Surg Endosc DOI 10.1007/s00464-015-4071-7
and Other Interventional Techniques
Effects of preoperative carbohydrates drinks on immediate postoperative outcome after day care laparoscopic cholecystectomy Basant Narayan Singh • Divya Dahiya • Dinesh Bagaria • Vikas Saini • Lileswar Kaman • Vivek Kaje • Ankur Vagadiya Shawashat Sarin • Roger Edwards • Vishal Attri • Kajal Jain
•
Received: 3 October 2014 / Accepted: 8 January 2015 Ó Springer Science+Business Media New York 2015
Abstract Background Postoperative nausea and vomiting is the most common cause for unexpected hospital admission of patients undergoing day care surgery. Overnight fasting changes patient metabolic state and influences their perioperative stress response. Preoperative carbohydrate loading may have accelerated recovery and better overall outcome after major abdominal surgery. The aim of the study was to investigate the effects of preoperative carbohydrate-rich drinks on postoperative nausea and vomiting and pain after day care laparoscopic cholecystectomy. Methods A total of 120 patients posted for day care laparoscopic cholecystectomy were included in the study and were randomized into three groups. Group A (Cases)—receiving the carbohydrate-rich drink before surgery (CHO), group B (placebo)—receiving the placebo drink before surgery and group C (controls)—fasting from midnight before surgery. Postoperative nausea and vomiting and visual analogue score for pain were noted and analyzed for 24 h. Results Mean score of nausea in 0–4 h in group A was significantly lower as compared to group B and group C (p = 0.001). Difference in mean score of nausea in 4–12 and 12–24 h between groups was not significant (p = 0.066), (p = 0.257). Mean score of vomiting in 0–4 and 4–12 h in group A was significantly less than that of B. N. Singh D. Dahiya D. Bagaria L. Kaman (&) V. Kaje A. Vagadiya S. Sarin R. Edwards V. Attri Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India e-mail: [email protected] V. Saini K. Jain Department of Anaesthesia, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India
group B and group C (p = 0.004), (p = 0.001). Mean score of pain in group A was significantly less when compared to group B and group C in 0–4 h (p = 0.001) and 4–12 h (0.005). Conclusion Perioperative consumption of a carbohydraterich drink can minimize postoperative nausea, vomiting and pain in patients undergoing outpatient cholecystectomy. Consumption of carbohydrate drinks up to 2 h prior to surgery is not associated with additional complications. Keywords Carbohydrate-rich drinks Day care laparoscopic cholecystectomy Postoperative nausea and vomiting Postoperative nausea and vomiting (PONV) continues to pose serious challenge to surgeons even after recent advances in anesthetic techniques, improved postoperative care and advances in operative techniques. It is defined as any episode of nausea, vomiting or retching during the first 24-h period after surgery [1]. Reported incidence of PONV in various studies has been reported to be about 20–30 % in adult patients [2, 3]. It is a serious problem especially in patients undergoing day care surgery as it leads to delay in hospital discharges, prolonged nursing care and overnight admissions, defeating very purpose of day care surgery [4]. In addition, it leads to complications such as aspiration, dehydration, electrolyte imbalance and incision site disruption [5]. Apfel et al. [6] identified four risk factors, which predict risks for development of PONV after major surgery. Risk factors include female gender, history of PONV, non-smoking status and use of postoperative opioids. Each risk factor increases the risk of developing PONV by about 18–20 % [6]. Multimodal approaches have been proposed to minimize the risk of PONV including use of prophylactic antiemetic
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therapy, oxygen supplementation, cannabinoids, acupuncture and herbal medicines (Zingiber officinale), but the optimal treatment still eludes the surgical community [7, 8]. In an attempt to find the optimal solution, the preoperative carbohydrate loading has been tried in the past [2]. It has been shown that preoperative carbohydrate loading leads to reduced postoperative catabolism and insulin resistance [9]. Decrease in postoperative insulin resistance leads to dampening of metabolic stress response, leading to favorable outcome such as decreased postoperative pain, anxiety, nausea and vomiting [9]. Carbohydraterich drink (CHO) does not alter the gastric acidity, neither does it reduce gastric emptying time [10]. It empties from stomach within 90 min and stimulates insulin release, which is equivalent to that seen after a normal meal [10]. Thus, it can be safely used in patients without risk of pulmonary aspiration. Cochrane review of 22 randomized controlled trials showed that fasting from midnight did not reduce gastric content, nor did it raise the pH of gastric fluids compared with patients who took clear liquids 2 h before surgery [11]. Many anesthesiology societies now recommend intake of clear liquids 2 h before surgery [12]. CHO has also been shown to improve preoperative wellbeing in patients in terms of decreased hunger, anxiety, nausea and discomfort [13]. In addition, a significant increase in preoperative nausea was found in placebo group but not in CHO or fasting group [13]. Carbohydrate treatment causes decrease in postoperative protein catabolism, improved voluntary muscle strength and better lean body mass [14]. Preoperative carbohydrate treatment has been advocated as part of multimodal fast- track surgery because of its favorable effect in reducing postoperative insulin resistance, thus hastening patient’s recovery [15]. Laparoscopic cholecystectomy is a commonly performed surgery in a day care setting. Reported incidence of PONV of up to 38–60 % has been reported within 24 h after laparoscopic surgery [16]. The report regarding the incidence of PONV after preoperative carbohydrate loading during laparoscopic cholecystectomy is contradictory [17, 18]. Very few studies have been done in the past to evaluate the role of preoperative carbohydrates in terms of postoperative nausea and vomiting in laparoscopic cholecystectomy. So this trial to further explore the effect of CHO-rich drinks on PONV in patients undergoing laparoscopic cholecystectomy was carried out.
Research, Chandigarh, India, from July 1, 2012, to December 31, 2013. A total of 120 patients undergoing elective laparoscopic cholecystectomy were enrolled in the study. Patients were prospectively randomized into three groups, each group containing 40 patients. Randomization was done by computer-generated randomized number table. Group A (Cases)—Receiving the carbohydrate-rich drink before surgery (CHO) Group B (Placebo)—Receiving the placebo drink before surgery Group C (Controls)—Fasting from midnight before surgery Patient’s selection Inclusion criteria All adult patients more than 18 years of age scheduled for elective laparoscopic cholecystectomy and giving a valid consent. Exclusion criteria Patients with conditions that impair gastrointestinal motility, such as gastro-esophageal reflux disease, diabetes mellitus, pregnancy, on medications which impair gastrointestinal motility and with jaundice or documented choledocholithiasis to allow standardization of surgical trauma and past history of PONV. Preoperative preparation
Materials and methods
The patients were assigned according to randomization to one of the three preoperative treatment groups: group A— preparation with CHO, group B—preparation with a placebo drink and group C—fasting from midnight. The patients, nursing staff, surgeons and anesthetist were blinded to the CHO and placebo treatments groups. During the evening before surgery (8:00–10:00 pm), patients in the CHO group ingested 400 ml of a clear carbohydrate-rich drink (12.5 % carbohydrates, 50 kcal/100 ml, 290 mOsm/ kg and pH 5.0). The placebo group consumed the same quantity of flavored water (0 kcal/100 ml, pH5.0). After midnight, nothing was allowed by mouth, except for a single morning dose (6:00 am) of 200 ml of the appropriate drink in the CHO and placebo groups. Morning drink was taken at least 2 h before premedication because of the opioid-induced slowing of gastric emptying.
Study design
Surgery
The study was conducted in the Department of General Surgery, Postgraduate Institute of Medical Education and
Laparoscopic cholecystectomy was performed by standard ‘‘American’’ technique with four ports. Carbon dioxide was
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used to create pneumoperitoneum by closed technique by Veress needle. Intra-abdominal pressure was maintained at 12–15 mm of Hg. Postoperatively, all patients were given analgesics diclofenac sodium 75 mg intravenously. Antiemetic was given on demand basis. Patients were allowed to take orally 6 h after surgery. Patients operated on day care basis were discharged on the same day after observation for 6–8 h. Patients with significant comorbidities (n = 5) such as coronary artery disease, asthma, uncontrolled hypertension were admitted and kept in ward for observation and discharged after 24 h. The nature of preanesthetic medication, anesthetic technique and surgical technique and postoperative medications was similar in all three groups.
Measurement of outcome The nursing staff/patient attendant objectively recorded episodes of PONV, defined as either spontaneous complaints of nausea or retching or vomiting for 0–4, 4–12 and 12–24 h after surgery. VAS scores for overall pain were obtained in parallel. Statistical analysis All quantitative data were estimated through mean, median and standard deviation. Nonparametric data were analyzed by Mann–Whitney U, Kruskal–Wallis and Wilcoxon Signed-Rank test. Categorical variables were analyzed by Chi-square test. All statistical analyses were performed at a significance level of a = 0.05. p \ 0.050 was considered statistically significant. Analysis was performed using Statistical Package for the Social Sciences Version 22.
Observation and results A total of 120 patients were enrolled in the study. They were randomized into cases (group A) receiving CHO drink (n = 40), placebo (group B) receiving flavored drink (n = 40) and controls (group C) who were fasting from midnight before surgery (n = 40). Number of episodes of nausea and vomiting were recorded in 0–4, 4–12 and 12–24 h after surgery. Pain score on VAS score was calculated in 0–4, 4–12 and 12–24 h after surgery. Patient characteristics Mean age in group A was 43.2 ± 15.85 years. Mean age in group B was 43.72 ± 15.40 years. Mean age in group C was 44.40 ± 11.45 years. In group A, 85 % of patients were female (n = 34), while 15 % (n = 6) were males. In group B, 75 % (n = 30) of patients were female, while
25 % were male (n = 10). In group C, 70 % (n = 30) were females, and 30 % (n = 10) were males. Incidence of nausea Incidence of nausea in group A was 52.5 % in 0–4 h, 55 % in 4–12 h and 25 % in 12–24 h after surgery. Incidence of nausea in group B was 87.5 % in 0–4 h, 67.5 % in 4–12 h and 42.5 % in 12–24 h after surgery. Incidence of nausea in C group was 80 % in 0–4 h, 75 % in 4–12 h and 53.8 % in 12–24 h after surgery (Table 1). There was significant decrease in incidence of nausea in 0–4 h (p = 0.0006) when group A was compared with group B. However, there was no significant difference in the incidence of nausea in 4–12 and 12–24 h after surgery. There was significant decrease in the incidence of nausea in 0–4 h (p = 0.009) when group A was compared with group C. However, there was no significant decrease in the incidence of nausea in 4–12 h (p = 0.06) and 12–24 h (p = 0.329) after surgery between two groups. In group A, the mean number of nausea episode in 0–4 h was 0.65 with SD of 0.7; in group B, the mean score of nausea in 0–4 h was 1.30 with SD of 0.853. In group C, mean score of nausea in 0–4 h was 1.23 with SD of 1.097. Thus, mean score of nausea in 0–4 h in group A was significantly lower as compared to group B and group C (p = 0.001). Difference in mean score of nausea in 4–12 and 12–24 h in group A as compared to group B and group C was not significant (p = 0.066), (p = 0.257). (Table 2). Incidence of vomiting In group A, the incidence of vomiting was 17.5 % in 0–4 h and 7.5 % in 4–12 h after surgery. No patient had vomiting in 12–24 h after surgery. In group B, the incidence of vomiting was 42.5 % in 0–4 h, 12.5 % in 4–12 h and 2.5 % in 12–24 h after surgery. In group C, the incidence of vomiting was 47.5 % in 0–4 h, 32.5 % in 4–12 h and 2.5 % in 12–24 h after surgery (Table 3). There was significant decrease in incidence of vomiting in 0–4 h (p = 0.0006) after surgery when group A was compared with group B. However, there was no significant decrease in the incidence of vomiting in 4–12 h (p = 0.459) and 12–24 h (p = 0.314) after surgery. There was significant decrease in the incidence of vomiting in Table 1 Comparison of incidence of nausea in different groups 0–4 h
4–12 h
12–24 h
Group A (n = 40)
21 (52.5 %)
22 (55 %)
10 (25 %)
Group B (n = 40)
35 (87.5 %
27 (67.5 %)
17 (42.5 %)
Group C (n = 40)
32 (80 %)
30 (75 %)
14 (53.8 %)
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Surg Endosc Table 2 Comparison of MEAN ± SD value of nausea in 0–4, 4–12 and 12–24 h after surgery in different groups
Group A (n = 40)
Group B (n = 40)
Group C (n = 40)
Mean
Mean
Mean
SD
SD
p value
SD
Nausea 0–4 h
0.65
0.700
1.30
0.853
1.23
1.097
0.001
4–12 h
0.70
0.823
0.83
0.636
1.05
0.815
0.066
12–24 h
0.25
0.439
0.43
0.501
0.35
0.483
0.257
Table 3 Comparison of incidence of vomiting in different groups 0–4 h
4–12 h
12–24 h
Group A (n = 40)
7 (17.5 %)
3 (7.5 %)
Group B (n = 40)
17(42.5 %)
5 (12.5 %)
1 (2.5 %)
Group C (n = 40)
19(47.5 %)
13 (32.5 %)
1 (2.5 %)
0 (0 %)
0–4 h (p = 0.004) and 4–12 h (0.005) when group A was compared with group C. However, no difference in the incidence of vomiting was found in 12–24 (p = 0.314) h after surgery between two groups. Mean score of number of episodes of vomiting in group A was 0.15 in 0–4 h, 0.03 in 4–12 h and 0.00 in 12–24 h. In group B, mean score of number of episodes of vomiting was 0.43 in 0–4 h, 0.13 in 4–12 h and 0.05 in 12–24 h. In group C, mean score of number of episodes of vomiting was 0.50 in 0–4 h, 0.35 in 4–12 h and 0.03 in 12–24 h after surgery (Table 4). Thus, mean score of vomiting was less in group A as compared to group B and group C in 0–4, 4–12 and 12–24 h of surgery. Mean score of vomiting in 0–4 and 4–12 h in group A was significantly less than that of group B and group C (p = 0.004), (p = 0.001). Mean score of vomiting in 12–24 h in group A was not significantly less when compared to group B and group C (p = 0.362) (Table 4). Table 4 Comparison of Mean ± SD score of vomiting in 0–4, 4–12 and 12–24 h after surgery in different groups
Pain Mean score of pain on VAS in group A was 5.75 in 0–4 h, 3.53 in 4–12 h and 1.95 in 12–24 h. In group B, mean score of pain on VAS was 7.13 in 0–4 h, 4.08 in 4–12 h, and 2.08 in 12–24 h. In group C, the mean score of pain in 0–4 h was 6.95, 4.65 in 4–12 h, 2.25 in 12–24 h. Thus, the mean score of pain was less in group A when compared to group B and group C in 0–4, 4–12 and 12–24 h. Mean score of pain in group A was significantly less when compared to group B and group C in 0–4 h (p = 0.001) and 4–12 h (0.005) (Table 5).
Discussion PONV continues to be a common problem after surgery as the incidence ranges from 20–30 % in general population to 70–80 % in high-risk patients [2]. It has significant impact on patient well-being, quality of life, as well as increased health-care cost, resulting from unanticipated hospital admissions and prolonged nursing care. Despite several attempts in past, the optimal treatment of PONV still eludes medical fraternity. So there is a need to further explore the treatment options in the management of PONV. One of the options is preoperative carbohydrate loading. In
Group A (n = 40)
Group B (n = 40)
Group C (n = 40)
Mean
Mean
Mean
SD
SD
p value
SD
Vomiting 0–4 h
0.15
0.362
0.43
0.501
0.50
0.555
0.004
4–12 h
0.03
0.158
0.13
0.335
0.35
0.533
0.001
12–24 h
0.00
0.000
0.05
0.221
0.03
0.158
0.362
Table 5 Comparison of Mean ± SD score of pain (VAS) in different groups in 0–4, 4–12 and 12–24 h
Group A (n = 40)
Group B (n = 40)
Group C (n = 40)
p value
Mean
SD
Mean
SD
Mean
SD
0–4 h
5.75
1.918
7.13
1.067
6.95
0.959
0.001
4–12 h
3.53
1.633
4.08
1.289
4.65
1.442
0.005
12–24 h
1.95
0.714
2.08
0.656
2.25
0.809
0.223
Pain
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this study, it was found that the preoperative carbohydrate ingestion causes reduction in the incidence of PONV, and also there is a suggestion of reduced postoperative pain. All three groups were evenly matched with respect to age and sex distribution. There was significant decrease in the incidence of nausea (p = 0.0006) in CHO group when compared to fasting group in 0–4 h after surgery. Incidence of vomiting was significantly less in 0–4 h (p = 0.004) and 4–12 h (p = 0.005) after surgery in CHO group as compared to fasting group. When CHO group was compared with placebo group, it was found that there was significant decrease in incidence of nausea (p = 0.0006) and vomiting (p = 0.0006) in 0–4 h after surgery in the CHO group. In a similar study by Hausel et al., role of preoperative carbohydrates was evaluated in patients undergoing laparoscopic cholecystectomy [17]. Patients were randomized to either preoperative fasting, intake of CHO or placebo. It was shown that intake of preoperative carbohydrates reduces incidence of PONV in CHO group when compared to fasting group in 12–24 h after surgery (p = 0.039). Nausea scores in fasted and placebo groups were higher after surgery than before admission (p = 0.018) and p \ 0.001, respectively, whereas there was no significant change in CHO group. Surgical stress response is more in immediate postoperative period, and giving a carbohydrate load will most likely benefit in this setting rather than after 12–24 h as shown in our study, where there was reduction in the incidence in nausea and vomiting in 0–4 and 4–12 h after surgery. Moreover, patients after laparoscopic cholecystectomy are allowed orally after 6 h; hence, it is difficult to evaluate clinical benefit of oral carbohydrate solution, especially 12 h after surgery. In this study, the episodes of PONV were less in CHO group when compared to placebo group (p = 0.0006) in 0–4 h after surgery. Bisgaard et al. [18] evaluated ninety-four patients undergoing laparoscopic cholecystectomy but did not find any beneficial effect of preoperative carbohydrates in terms of general well-being, fatigue, appetite and PONV. The major limitation of that study was the absence of a control group that fasted overnight and ingested no preoperative solution. So it is difficult to interpret the results in the absence of comparison with a control group that fasted overnight. Lauwick et al. [19] studied the effect of oral carbohydrate on early postoperative outcome after thyroidectomy. They concluded that oral carbohydrate before thyroidectomy improves pre- and postoperative patient comfort, as well as postoperative analgesia but has no effect on PONV. In that study, 50 gm of CHO in 400 ml of water was given 2 h before surgery. In comparison, in our study, total of 600 ml of 12.5 % CHO was given: 400 ml at midnight followed by 200 ml 2 h before surgery. Thus, the amount of carbohydrate given in that study was less as compared to
our study, which might account for the difference in outcome. Preoperative carbohydrate loading has several other beneficial effects as shown in another study [20]. Multiple regression analysis of 52 elective patients who were randomized to carbohydrate beverage or placebo undergoing open cholecystectomy, hip replacement and colorectal surgery showed that preoperative carbohydrates could explain 71 % variation in length of hospital stay [20]. The existing data show that patient treated with carbohydrate drinks recorded less fatigue after colorectal surgery as compared to patients who fasted overnight [20]. Preoperative glucose treatment has also been shown to be beneficial in the preparation of patients with cardiac surgery [21, 22]. It has been shown in previous studies that intake of oral carbohydrates before surgery significantly reduces preoperative discomfort in terms of decreased anxiety, hunger, thirst and malaise [13]. The results of preoperative carbohydrate drink in surgery have got contradictory results. Our study showed decrease in number of episodes, as well as incidence of PONV after administration of preoperative carbohydrates. We have also found that there is decrease in pain score in patients taking carbohydrates as compared to placebo and fasting group. The exact pathophysiology of reduction in postoperative pain is difficult to explain. It may have something to do with the surgical stress. Surgical stress in the presence of fasting worsens the catabolic state, causing insulin resistance and may delay in recovery. Decrease in postoperative pain may be due to overall decrease in postoperative surgical stress response due to insulin resistance. Another possible explanation may be due to decrease in postoperative nausea, vomiting, thirst and anxiety; there may be feeling of general well-being in patients, which might be interpreted as decrease in pain. However, the exact cause of decrease in pain is still a subject of further investigations, and further studies are required in this regard. As already stated, all these beneficial effects of preoperative carbohydrate may be related to decrease in insulin resistance, resulting in dampening of metabolic stress response after surgery. It has been shown that intake of 12.5 % carbohydrates causes increase of approximately 50 % in whole body insulin sensitivity [23]. It has been proved that insulin sensitivity decreases by about 15–20 % even after minimally invasive procedure such as laparoscopic cholecystectomy [24]. Studies in animals have indicated that response to a given injury depends upon the metabolic state of animal at the time of the insult. This shows that there is a clear advantage in doing surgery in a fed state rather than a fasted state [25]. This is the most likely mechanism behind action of the carbohydrate-rich drink in the immediate preoperative period.
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Conclusion To conclude from our study, preoperative carbohydraterich drink has a beneficial effect in reducing the incidence of postoperative nausea and vomiting. There is also suggestion of reduction in postoperative pain. It is cheap, easily available and safe. Further studies are needed to validate these findings to establish the beneficial effect of preoperative carbohydrate loading. Disclosures Basant Narayan Singh, Divya Dahiya, Dinesh Bagaria, Vikas Saini, Lileswar Kaman, Vivek Kaje, Ankur Vagadiya, Roger Edwards, Vishal Attri, Kajal Jain have no conflict of interests or financial ties to disclose.
References 1. Palazzo M, Evans R (1993) Logistic regression analysis of fixed patient factor for post operative sickness: a model for risk assessment. Br J Anaesth 70:135–140 2. Gan TJ, Meyer T, Apfel CC, Chung F, Davis PJ, Eubanks S et al (2003) Consensus guidelines for managing postoperative nausea and vomiting. Anesth Analg 97:62–71 3. Tramer MR (2001) A rational approach to control of postoperative nausea and vomiting: evidence from systematic reviews. Part I. Efficacy and harm of antiemetic interventions and methodological issues. Acta Anaesthesiol Scand 45:4–13 4. Leeder PC, Mathews T, Krzeminska K, Dehn TC (2004) Routine day case laparoscopic cholecystectomy. Br J Surg 91:312–316 5. Mc Kay WP, Yip RW (2000) Distribution of randomized controlled trials of drugs for postoperative nausea and vomiting. Can J Anaesth 47:421–426 6. Apfel CC, Laara E, Koivuranta M, Greim CA, Roever N (1999) A simplified risk score for prediction of postoperative nausea and vomiting:conclusion form cross-validations between two centres. Anaesthesiology 91:693–700 7. Tramer MR, Carroll D, Cambell FA, Reynolds DJ, Moore RA, McQuay HJ (2001) Cannabinoid for control of chemotherapy induced nausea and vomiting. BMJ 321:116–121 8. Eberhart M, Mayer R, Betz O, Tsolakidis S, Hilpert W, Morin AM et al (2003) Ginger does not prevent PONV after laparoscopic surgery. Anaesth Analg 96:945–998 9. Ljungqvist O, Nygren J, Thorell A (2002) Modulation of postoperative insulin resistance by preoperative carbohydrate loading. Proc Nutr Soc 61:329–336 10. Nygren J, Thorell A, Jacobsson H, Larsson S, Schnell PO, Hylen L et al (1995) Preoperative gastric emptying. Effects of anxiety and oral carbohydrate administration. Ann Surg 222:728–734
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11. Brady M, Kinn S, Stuart P (2003) Preoperative fasting for adults to prevent perioperative complications. Cochrane Database Syst Rev 4:CD004423 12. Soreide E, Ljungqvist O (2006) Modern preoperative fasting guidelines. A summary of present recommendations and remaining questions. Best Pract Res Clin Anesthesiol 20:483–491 13. Hausel J, Nygren J, Lagerkranser M, Hellstorm PM, Hammarqvist F, Almstorm C et al (2001) A carbohydrate rich drink reduces preoperative discomfort in elective surgery patients. Anesth Analg 93:1344–1350 14. Henrisksen MG, Hessov I, Dela F, Hansen HV, Haraldsred V, Rodt SA (2003) Effects of preoperative oral carbohydrates and peptides on postoperative endocrine response, mobilization, nutrition and muscle function in abdominal surgery. Acta Anaesthesiol Scand 47:191–199 15. Melnyk M, Casey RG, Black P, Koupparis AJ (2011) Enhanced recovery after surgery (ERAS) protocols: time to change practice. Can Urol Assoc J 5:342–348 16. Bisgaard T, Klarskov B, Kehlet H, Rosenberg J (2002) Recovery after uncomplicated laparoscopic cholecystectomy. Surgery 132:817–825 17. Hausel J, Nygren J, Thorell A, Lagerkranser M, Ljungqvist O (2005) Randomized clinical trial of the effects of oral preoperative carbohydrates on postoperative nausea and vomiting after laparoscopic cholecystectomy. Br J Surg 92:415–421 18. Bisgaard T, Kristiansen VB, Hjortso NC, Jacobsen LS, Rosenberg J, Kehlet H (2004) Randomized clinical trial comparing an oral carbohydrate beverage with placebo before laparoscopic cholecystectomy. Br J Surg 91:151–158 19. Lauwick M, Kaba A, Maweja S, Hamoir EE, Jolis JL (2009) Effects of preoperative carbohydrates on early postoperative outcome after thyroidectomy. Act Anaesthesiol Belg 60:67–73 20. Nygren J, Thorell A, Ljungqvist O (2001) Preoperative oral carbohydrate nutrition: an update. Curr Opin Clin Nutr Metab Care 4:255–259 21. Jones C, Badger SA, Hannon R (2011) The role of carbohydrate drinks in preoperative nutrition for elective colorectal surgery. Ann R Coll Surg Engl 93:504–507 22. Lazar HL, Phillipides G, Fitzgerald C, Lancaster D, Shemin RJ, Apstein C (1997) Glucose insulin potassium solutions enhance recovery after urgent artery bypass surgery. J Thorac Cardiovasc Surg 113:354–362 23. Ljungqvist O, Thorell A, Gutnaik M, Haggmark T, Efendic S (1994) Glucose infusion instead of preoperative fasting reduces postoperative insulin resistance. J Am Coll Surg 178:329–336 24. Thorell A, Nygren J, Essen P, Gutnaik M, Loftenius A, Andersson B et al (1996) The metabolic response to cholecystectomy: insulin resistance after open compared to laparoscopic operation. Eur J Surg 162:187–191 25. Jarhult J, Holmberg J, Lundvall J, Mellander S (1976) Hyperglycemic and hyperosmolar responses to graded hemorrhage. Acta Physiol Scand 97:470–475
and Other Interventional Techniques
Effects of preoperative carbohydrates drinks on immediate postoperative outcome after day care laparoscopic cholecystectomy Basant Narayan Singh • Divya Dahiya • Dinesh Bagaria • Vikas Saini • Lileswar Kaman • Vivek Kaje • Ankur Vagadiya Shawashat Sarin • Roger Edwards • Vishal Attri • Kajal Jain
•
Received: 3 October 2014 / Accepted: 8 January 2015 Ó Springer Science+Business Media New York 2015
Abstract Background Postoperative nausea and vomiting is the most common cause for unexpected hospital admission of patients undergoing day care surgery. Overnight fasting changes patient metabolic state and influences their perioperative stress response. Preoperative carbohydrate loading may have accelerated recovery and better overall outcome after major abdominal surgery. The aim of the study was to investigate the effects of preoperative carbohydrate-rich drinks on postoperative nausea and vomiting and pain after day care laparoscopic cholecystectomy. Methods A total of 120 patients posted for day care laparoscopic cholecystectomy were included in the study and were randomized into three groups. Group A (Cases)—receiving the carbohydrate-rich drink before surgery (CHO), group B (placebo)—receiving the placebo drink before surgery and group C (controls)—fasting from midnight before surgery. Postoperative nausea and vomiting and visual analogue score for pain were noted and analyzed for 24 h. Results Mean score of nausea in 0–4 h in group A was significantly lower as compared to group B and group C (p = 0.001). Difference in mean score of nausea in 4–12 and 12–24 h between groups was not significant (p = 0.066), (p = 0.257). Mean score of vomiting in 0–4 and 4–12 h in group A was significantly less than that of B. N. Singh D. Dahiya D. Bagaria L. Kaman (&) V. Kaje A. Vagadiya S. Sarin R. Edwards V. Attri Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India e-mail: [email protected] V. Saini K. Jain Department of Anaesthesia, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India
group B and group C (p = 0.004), (p = 0.001). Mean score of pain in group A was significantly less when compared to group B and group C in 0–4 h (p = 0.001) and 4–12 h (0.005). Conclusion Perioperative consumption of a carbohydraterich drink can minimize postoperative nausea, vomiting and pain in patients undergoing outpatient cholecystectomy. Consumption of carbohydrate drinks up to 2 h prior to surgery is not associated with additional complications. Keywords Carbohydrate-rich drinks Day care laparoscopic cholecystectomy Postoperative nausea and vomiting Postoperative nausea and vomiting (PONV) continues to pose serious challenge to surgeons even after recent advances in anesthetic techniques, improved postoperative care and advances in operative techniques. It is defined as any episode of nausea, vomiting or retching during the first 24-h period after surgery [1]. Reported incidence of PONV in various studies has been reported to be about 20–30 % in adult patients [2, 3]. It is a serious problem especially in patients undergoing day care surgery as it leads to delay in hospital discharges, prolonged nursing care and overnight admissions, defeating very purpose of day care surgery [4]. In addition, it leads to complications such as aspiration, dehydration, electrolyte imbalance and incision site disruption [5]. Apfel et al. [6] identified four risk factors, which predict risks for development of PONV after major surgery. Risk factors include female gender, history of PONV, non-smoking status and use of postoperative opioids. Each risk factor increases the risk of developing PONV by about 18–20 % [6]. Multimodal approaches have been proposed to minimize the risk of PONV including use of prophylactic antiemetic
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therapy, oxygen supplementation, cannabinoids, acupuncture and herbal medicines (Zingiber officinale), but the optimal treatment still eludes the surgical community [7, 8]. In an attempt to find the optimal solution, the preoperative carbohydrate loading has been tried in the past [2]. It has been shown that preoperative carbohydrate loading leads to reduced postoperative catabolism and insulin resistance [9]. Decrease in postoperative insulin resistance leads to dampening of metabolic stress response, leading to favorable outcome such as decreased postoperative pain, anxiety, nausea and vomiting [9]. Carbohydraterich drink (CHO) does not alter the gastric acidity, neither does it reduce gastric emptying time [10]. It empties from stomach within 90 min and stimulates insulin release, which is equivalent to that seen after a normal meal [10]. Thus, it can be safely used in patients without risk of pulmonary aspiration. Cochrane review of 22 randomized controlled trials showed that fasting from midnight did not reduce gastric content, nor did it raise the pH of gastric fluids compared with patients who took clear liquids 2 h before surgery [11]. Many anesthesiology societies now recommend intake of clear liquids 2 h before surgery [12]. CHO has also been shown to improve preoperative wellbeing in patients in terms of decreased hunger, anxiety, nausea and discomfort [13]. In addition, a significant increase in preoperative nausea was found in placebo group but not in CHO or fasting group [13]. Carbohydrate treatment causes decrease in postoperative protein catabolism, improved voluntary muscle strength and better lean body mass [14]. Preoperative carbohydrate treatment has been advocated as part of multimodal fast- track surgery because of its favorable effect in reducing postoperative insulin resistance, thus hastening patient’s recovery [15]. Laparoscopic cholecystectomy is a commonly performed surgery in a day care setting. Reported incidence of PONV of up to 38–60 % has been reported within 24 h after laparoscopic surgery [16]. The report regarding the incidence of PONV after preoperative carbohydrate loading during laparoscopic cholecystectomy is contradictory [17, 18]. Very few studies have been done in the past to evaluate the role of preoperative carbohydrates in terms of postoperative nausea and vomiting in laparoscopic cholecystectomy. So this trial to further explore the effect of CHO-rich drinks on PONV in patients undergoing laparoscopic cholecystectomy was carried out.
Research, Chandigarh, India, from July 1, 2012, to December 31, 2013. A total of 120 patients undergoing elective laparoscopic cholecystectomy were enrolled in the study. Patients were prospectively randomized into three groups, each group containing 40 patients. Randomization was done by computer-generated randomized number table. Group A (Cases)—Receiving the carbohydrate-rich drink before surgery (CHO) Group B (Placebo)—Receiving the placebo drink before surgery Group C (Controls)—Fasting from midnight before surgery Patient’s selection Inclusion criteria All adult patients more than 18 years of age scheduled for elective laparoscopic cholecystectomy and giving a valid consent. Exclusion criteria Patients with conditions that impair gastrointestinal motility, such as gastro-esophageal reflux disease, diabetes mellitus, pregnancy, on medications which impair gastrointestinal motility and with jaundice or documented choledocholithiasis to allow standardization of surgical trauma and past history of PONV. Preoperative preparation
Materials and methods
The patients were assigned according to randomization to one of the three preoperative treatment groups: group A— preparation with CHO, group B—preparation with a placebo drink and group C—fasting from midnight. The patients, nursing staff, surgeons and anesthetist were blinded to the CHO and placebo treatments groups. During the evening before surgery (8:00–10:00 pm), patients in the CHO group ingested 400 ml of a clear carbohydrate-rich drink (12.5 % carbohydrates, 50 kcal/100 ml, 290 mOsm/ kg and pH 5.0). The placebo group consumed the same quantity of flavored water (0 kcal/100 ml, pH5.0). After midnight, nothing was allowed by mouth, except for a single morning dose (6:00 am) of 200 ml of the appropriate drink in the CHO and placebo groups. Morning drink was taken at least 2 h before premedication because of the opioid-induced slowing of gastric emptying.
Study design
Surgery
The study was conducted in the Department of General Surgery, Postgraduate Institute of Medical Education and
Laparoscopic cholecystectomy was performed by standard ‘‘American’’ technique with four ports. Carbon dioxide was
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used to create pneumoperitoneum by closed technique by Veress needle. Intra-abdominal pressure was maintained at 12–15 mm of Hg. Postoperatively, all patients were given analgesics diclofenac sodium 75 mg intravenously. Antiemetic was given on demand basis. Patients were allowed to take orally 6 h after surgery. Patients operated on day care basis were discharged on the same day after observation for 6–8 h. Patients with significant comorbidities (n = 5) such as coronary artery disease, asthma, uncontrolled hypertension were admitted and kept in ward for observation and discharged after 24 h. The nature of preanesthetic medication, anesthetic technique and surgical technique and postoperative medications was similar in all three groups.
Measurement of outcome The nursing staff/patient attendant objectively recorded episodes of PONV, defined as either spontaneous complaints of nausea or retching or vomiting for 0–4, 4–12 and 12–24 h after surgery. VAS scores for overall pain were obtained in parallel. Statistical analysis All quantitative data were estimated through mean, median and standard deviation. Nonparametric data were analyzed by Mann–Whitney U, Kruskal–Wallis and Wilcoxon Signed-Rank test. Categorical variables were analyzed by Chi-square test. All statistical analyses were performed at a significance level of a = 0.05. p \ 0.050 was considered statistically significant. Analysis was performed using Statistical Package for the Social Sciences Version 22.
Observation and results A total of 120 patients were enrolled in the study. They were randomized into cases (group A) receiving CHO drink (n = 40), placebo (group B) receiving flavored drink (n = 40) and controls (group C) who were fasting from midnight before surgery (n = 40). Number of episodes of nausea and vomiting were recorded in 0–4, 4–12 and 12–24 h after surgery. Pain score on VAS score was calculated in 0–4, 4–12 and 12–24 h after surgery. Patient characteristics Mean age in group A was 43.2 ± 15.85 years. Mean age in group B was 43.72 ± 15.40 years. Mean age in group C was 44.40 ± 11.45 years. In group A, 85 % of patients were female (n = 34), while 15 % (n = 6) were males. In group B, 75 % (n = 30) of patients were female, while
25 % were male (n = 10). In group C, 70 % (n = 30) were females, and 30 % (n = 10) were males. Incidence of nausea Incidence of nausea in group A was 52.5 % in 0–4 h, 55 % in 4–12 h and 25 % in 12–24 h after surgery. Incidence of nausea in group B was 87.5 % in 0–4 h, 67.5 % in 4–12 h and 42.5 % in 12–24 h after surgery. Incidence of nausea in C group was 80 % in 0–4 h, 75 % in 4–12 h and 53.8 % in 12–24 h after surgery (Table 1). There was significant decrease in incidence of nausea in 0–4 h (p = 0.0006) when group A was compared with group B. However, there was no significant difference in the incidence of nausea in 4–12 and 12–24 h after surgery. There was significant decrease in the incidence of nausea in 0–4 h (p = 0.009) when group A was compared with group C. However, there was no significant decrease in the incidence of nausea in 4–12 h (p = 0.06) and 12–24 h (p = 0.329) after surgery between two groups. In group A, the mean number of nausea episode in 0–4 h was 0.65 with SD of 0.7; in group B, the mean score of nausea in 0–4 h was 1.30 with SD of 0.853. In group C, mean score of nausea in 0–4 h was 1.23 with SD of 1.097. Thus, mean score of nausea in 0–4 h in group A was significantly lower as compared to group B and group C (p = 0.001). Difference in mean score of nausea in 4–12 and 12–24 h in group A as compared to group B and group C was not significant (p = 0.066), (p = 0.257). (Table 2). Incidence of vomiting In group A, the incidence of vomiting was 17.5 % in 0–4 h and 7.5 % in 4–12 h after surgery. No patient had vomiting in 12–24 h after surgery. In group B, the incidence of vomiting was 42.5 % in 0–4 h, 12.5 % in 4–12 h and 2.5 % in 12–24 h after surgery. In group C, the incidence of vomiting was 47.5 % in 0–4 h, 32.5 % in 4–12 h and 2.5 % in 12–24 h after surgery (Table 3). There was significant decrease in incidence of vomiting in 0–4 h (p = 0.0006) after surgery when group A was compared with group B. However, there was no significant decrease in the incidence of vomiting in 4–12 h (p = 0.459) and 12–24 h (p = 0.314) after surgery. There was significant decrease in the incidence of vomiting in Table 1 Comparison of incidence of nausea in different groups 0–4 h
4–12 h
12–24 h
Group A (n = 40)
21 (52.5 %)
22 (55 %)
10 (25 %)
Group B (n = 40)
35 (87.5 %
27 (67.5 %)
17 (42.5 %)
Group C (n = 40)
32 (80 %)
30 (75 %)
14 (53.8 %)
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Group A (n = 40)
Group B (n = 40)
Group C (n = 40)
Mean
Mean
Mean
SD
SD
p value
SD
Nausea 0–4 h
0.65
0.700
1.30
0.853
1.23
1.097
0.001
4–12 h
0.70
0.823
0.83
0.636
1.05
0.815
0.066
12–24 h
0.25
0.439
0.43
0.501
0.35
0.483
0.257
Table 3 Comparison of incidence of vomiting in different groups 0–4 h
4–12 h
12–24 h
Group A (n = 40)
7 (17.5 %)
3 (7.5 %)
Group B (n = 40)
17(42.5 %)
5 (12.5 %)
1 (2.5 %)
Group C (n = 40)
19(47.5 %)
13 (32.5 %)
1 (2.5 %)
0 (0 %)
0–4 h (p = 0.004) and 4–12 h (0.005) when group A was compared with group C. However, no difference in the incidence of vomiting was found in 12–24 (p = 0.314) h after surgery between two groups. Mean score of number of episodes of vomiting in group A was 0.15 in 0–4 h, 0.03 in 4–12 h and 0.00 in 12–24 h. In group B, mean score of number of episodes of vomiting was 0.43 in 0–4 h, 0.13 in 4–12 h and 0.05 in 12–24 h. In group C, mean score of number of episodes of vomiting was 0.50 in 0–4 h, 0.35 in 4–12 h and 0.03 in 12–24 h after surgery (Table 4). Thus, mean score of vomiting was less in group A as compared to group B and group C in 0–4, 4–12 and 12–24 h of surgery. Mean score of vomiting in 0–4 and 4–12 h in group A was significantly less than that of group B and group C (p = 0.004), (p = 0.001). Mean score of vomiting in 12–24 h in group A was not significantly less when compared to group B and group C (p = 0.362) (Table 4). Table 4 Comparison of Mean ± SD score of vomiting in 0–4, 4–12 and 12–24 h after surgery in different groups
Pain Mean score of pain on VAS in group A was 5.75 in 0–4 h, 3.53 in 4–12 h and 1.95 in 12–24 h. In group B, mean score of pain on VAS was 7.13 in 0–4 h, 4.08 in 4–12 h, and 2.08 in 12–24 h. In group C, the mean score of pain in 0–4 h was 6.95, 4.65 in 4–12 h, 2.25 in 12–24 h. Thus, the mean score of pain was less in group A when compared to group B and group C in 0–4, 4–12 and 12–24 h. Mean score of pain in group A was significantly less when compared to group B and group C in 0–4 h (p = 0.001) and 4–12 h (0.005) (Table 5).
Discussion PONV continues to be a common problem after surgery as the incidence ranges from 20–30 % in general population to 70–80 % in high-risk patients [2]. It has significant impact on patient well-being, quality of life, as well as increased health-care cost, resulting from unanticipated hospital admissions and prolonged nursing care. Despite several attempts in past, the optimal treatment of PONV still eludes medical fraternity. So there is a need to further explore the treatment options in the management of PONV. One of the options is preoperative carbohydrate loading. In
Group A (n = 40)
Group B (n = 40)
Group C (n = 40)
Mean
Mean
Mean
SD
SD
p value
SD
Vomiting 0–4 h
0.15
0.362
0.43
0.501
0.50
0.555
0.004
4–12 h
0.03
0.158
0.13
0.335
0.35
0.533
0.001
12–24 h
0.00
0.000
0.05
0.221
0.03
0.158
0.362
Table 5 Comparison of Mean ± SD score of pain (VAS) in different groups in 0–4, 4–12 and 12–24 h
Group A (n = 40)
Group B (n = 40)
Group C (n = 40)
p value
Mean
SD
Mean
SD
Mean
SD
0–4 h
5.75
1.918
7.13
1.067
6.95
0.959
0.001
4–12 h
3.53
1.633
4.08
1.289
4.65
1.442
0.005
12–24 h
1.95
0.714
2.08
0.656
2.25
0.809
0.223
Pain
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this study, it was found that the preoperative carbohydrate ingestion causes reduction in the incidence of PONV, and also there is a suggestion of reduced postoperative pain. All three groups were evenly matched with respect to age and sex distribution. There was significant decrease in the incidence of nausea (p = 0.0006) in CHO group when compared to fasting group in 0–4 h after surgery. Incidence of vomiting was significantly less in 0–4 h (p = 0.004) and 4–12 h (p = 0.005) after surgery in CHO group as compared to fasting group. When CHO group was compared with placebo group, it was found that there was significant decrease in incidence of nausea (p = 0.0006) and vomiting (p = 0.0006) in 0–4 h after surgery in the CHO group. In a similar study by Hausel et al., role of preoperative carbohydrates was evaluated in patients undergoing laparoscopic cholecystectomy [17]. Patients were randomized to either preoperative fasting, intake of CHO or placebo. It was shown that intake of preoperative carbohydrates reduces incidence of PONV in CHO group when compared to fasting group in 12–24 h after surgery (p = 0.039). Nausea scores in fasted and placebo groups were higher after surgery than before admission (p = 0.018) and p \ 0.001, respectively, whereas there was no significant change in CHO group. Surgical stress response is more in immediate postoperative period, and giving a carbohydrate load will most likely benefit in this setting rather than after 12–24 h as shown in our study, where there was reduction in the incidence in nausea and vomiting in 0–4 and 4–12 h after surgery. Moreover, patients after laparoscopic cholecystectomy are allowed orally after 6 h; hence, it is difficult to evaluate clinical benefit of oral carbohydrate solution, especially 12 h after surgery. In this study, the episodes of PONV were less in CHO group when compared to placebo group (p = 0.0006) in 0–4 h after surgery. Bisgaard et al. [18] evaluated ninety-four patients undergoing laparoscopic cholecystectomy but did not find any beneficial effect of preoperative carbohydrates in terms of general well-being, fatigue, appetite and PONV. The major limitation of that study was the absence of a control group that fasted overnight and ingested no preoperative solution. So it is difficult to interpret the results in the absence of comparison with a control group that fasted overnight. Lauwick et al. [19] studied the effect of oral carbohydrate on early postoperative outcome after thyroidectomy. They concluded that oral carbohydrate before thyroidectomy improves pre- and postoperative patient comfort, as well as postoperative analgesia but has no effect on PONV. In that study, 50 gm of CHO in 400 ml of water was given 2 h before surgery. In comparison, in our study, total of 600 ml of 12.5 % CHO was given: 400 ml at midnight followed by 200 ml 2 h before surgery. Thus, the amount of carbohydrate given in that study was less as compared to
our study, which might account for the difference in outcome. Preoperative carbohydrate loading has several other beneficial effects as shown in another study [20]. Multiple regression analysis of 52 elective patients who were randomized to carbohydrate beverage or placebo undergoing open cholecystectomy, hip replacement and colorectal surgery showed that preoperative carbohydrates could explain 71 % variation in length of hospital stay [20]. The existing data show that patient treated with carbohydrate drinks recorded less fatigue after colorectal surgery as compared to patients who fasted overnight [20]. Preoperative glucose treatment has also been shown to be beneficial in the preparation of patients with cardiac surgery [21, 22]. It has been shown in previous studies that intake of oral carbohydrates before surgery significantly reduces preoperative discomfort in terms of decreased anxiety, hunger, thirst and malaise [13]. The results of preoperative carbohydrate drink in surgery have got contradictory results. Our study showed decrease in number of episodes, as well as incidence of PONV after administration of preoperative carbohydrates. We have also found that there is decrease in pain score in patients taking carbohydrates as compared to placebo and fasting group. The exact pathophysiology of reduction in postoperative pain is difficult to explain. It may have something to do with the surgical stress. Surgical stress in the presence of fasting worsens the catabolic state, causing insulin resistance and may delay in recovery. Decrease in postoperative pain may be due to overall decrease in postoperative surgical stress response due to insulin resistance. Another possible explanation may be due to decrease in postoperative nausea, vomiting, thirst and anxiety; there may be feeling of general well-being in patients, which might be interpreted as decrease in pain. However, the exact cause of decrease in pain is still a subject of further investigations, and further studies are required in this regard. As already stated, all these beneficial effects of preoperative carbohydrate may be related to decrease in insulin resistance, resulting in dampening of metabolic stress response after surgery. It has been shown that intake of 12.5 % carbohydrates causes increase of approximately 50 % in whole body insulin sensitivity [23]. It has been proved that insulin sensitivity decreases by about 15–20 % even after minimally invasive procedure such as laparoscopic cholecystectomy [24]. Studies in animals have indicated that response to a given injury depends upon the metabolic state of animal at the time of the insult. This shows that there is a clear advantage in doing surgery in a fed state rather than a fasted state [25]. This is the most likely mechanism behind action of the carbohydrate-rich drink in the immediate preoperative period.
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Conclusion To conclude from our study, preoperative carbohydraterich drink has a beneficial effect in reducing the incidence of postoperative nausea and vomiting. There is also suggestion of reduction in postoperative pain. It is cheap, easily available and safe. Further studies are needed to validate these findings to establish the beneficial effect of preoperative carbohydrate loading. Disclosures Basant Narayan Singh, Divya Dahiya, Dinesh Bagaria, Vikas Saini, Lileswar Kaman, Vivek Kaje, Ankur Vagadiya, Roger Edwards, Vishal Attri, Kajal Jain have no conflict of interests or financial ties to disclose.
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