Preoperative Oral

Carbohydrate Beverages

A sweet deal for post-operative

outcomes in cholecystectomies?

By Carly Harris
Learning Objectives
ü Understand the role of pre-operative
oral carbohydrate beverages in ERAS
ü Determine how pre-operative oral
carbohydrate beverages work to
improve post-operative related
outcomes in cholecystectomies
ü Analyze current research on the
surgical outcomes when oral
carbohydrate beverages are used
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Have You Heard of
ERAS?
(ENHANCED RECOVERY
AFTER SURGERY)

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o ERAS= Enhanced Recovery
After Surgery
o Consensus
statements/guidelines for a
variety of surgical procedures
o Goal: improve surgical
outcomes
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Some Components of ERAS

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 Why give an oral
carbohydrate beverage
(POCB)?
Post-Operative Insulin Resistance

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Pre-operative
NPO status

Glycogen stores depleted,

amino acids used for energy

Patient undergoes procedure

Stress response by the body

Elevated stress hormones

Glucose Catabolism

Increased insulin
resistance/Hyperglycemia
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The more “major” the surgery the greater
the insulin resistance and hyperglycemia

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Post-operative hyperglycemia is actually
a survival measure for the body

However in modern day medical

procedures it may cause more problems
than solving
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 Complications of post-op insulin
resistance includes

Greater risk of infections

Longer length of stay

Decreased quality of recovery

Increased risk of mortality

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One Way We Can Prevent/Manage Post-op
Insulin Resistance

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What makes up a POCB?

50g corn maltodextrin

Selenium

Zinc

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What makes up a POCB?

50g corn maltodextrin

Limits osmolality and
empties readily from the
stomach unlike glucose
making it suitable for
pre-surgery

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 Instructions for the general
population

100g night before 50g 2hours before

surgery (consumed
surgery
between 5-10 mins)

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 How does a POCB work?

Stimulates endogenous insulin release that

ends the overnight fasting metabolic state
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 Less reliance on amino acids from fasting
therefore preserving whole body protein balance
and muscle function
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Pre-operative
NPO status

Glycogen stores depleted,

amino acids used for energy

Patient undergoes procedure

Stress response by the body

Elevated stress hormones

Can we lessen the burden? Glucose Catabolism

Increased insulin
resistance/Hyperglycemia
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 How else can oral carbohydrate
beverages improve outcomes?

• Less anxiety
• Less nausea/vomiting post-op
• Less discomfort related to prolonged NPO
status (thirst, hunger, dry mouth, etc.)

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 Notable Mentions..

Patients with delayed gastric emptying may not

be suitable to receive POCBs

There is limited research on the efficacy of

POCB for diabetic patients as they often will be
excluded from studies

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Many studies have been conducted on POCB
for colorectal cancer and major abdominal
surgery but today we are focusing on

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 Cholecystectomy
• Surgical removal of the gallbladder
• Preformed open surgery or laparoscopically

Open Surgery:
- 1-2 days post-op before discharge

Laparoscopically:
- Same day discharge

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Research on the clinical outcomes
of POCBs on cholecystectomies

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 Clinical outcome #1
Insulin Resistance

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 Control
Group:
NPO @ HOMA-IR
50 patients was used to
midnight
undergoing Experimental measure
insulin
elective group: received
resistance
Nutricia Preop
laparoscopic 800ml at
cholecystectomies midnight+400ml 2
hours prior to
surgery
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 Results/Conclusions

Preoperative Oral Carbohydrate

Beverages given before
laparoscopic cholecystectomy
lowers the postoperative stress
response and insulin resistance
and poses no risk at all
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 Control
Group: Water
placebo 2 HOMA-IR
40 patients hours prior to was used to
surgery measure
undergoing insulin
elective Experimental
resistance
group: received
laparoscopic Nutricia Preop
cholecystectomies 400ml 2 hours
prior to surgery

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 Right after surgery
24 hours post-op
Before Surgery

Group 1: Intervention
Group 2: Control 30
 Results/Conclusions

Preoperative Oral Carbohydrate

Beverages given before laparoscopic
cholecystectomy does not lower the
postoperative insulin resistance and
poses no risk at all

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 Clinical outcome #2
Post-Op Discomfort

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 Control
Group: Malaise,
Fasting Thirst,
60 patients for 8hrs Hunger,
undergoing Experimental Weakness
were
elective group: received
measured
Nutricia Preop
laparoscopic 800ml night
cholecystectomies before+400ml 2-3
hours prior to
surgery
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 Lower in Experimental Group
receiving POCB
2 hrs. Pre-OP 2 hrs. Post-Op 24 hrs. Post-Op

Malaise Malaise Malaise

Thirst Thirst Weakness
Hunger
Weakness

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 Results/Conclusions
Preoperative CHO delivery was found to
reduce thirst, malaise, hunger and
weakness; and make the patients feel
better postoperatively

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 Placebo
Group:
MN-NPO flavored
group: Fast water instead
of NO-NPO QoR-40
after
questionnaire
153 patients midnight
used to
undergoing NO-NPO group: measure
subjective
elective received NO-NPO
outcomes
beverage 400ml
laparoscopic night
cholecystectomies before+400ml 2
hours prior to
surgery
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Group No- Group Group MN-
NPO Placebo NPO
186.7+/- 17.5 182.8+/-17 194.5+/- 5.6

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 Results/Conclusions
Preoperative CHO delivery was found to
have no significant impact on overall
patients’ surgical experience

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 Clinical outcome #3
Hand-Grip Strength

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 Control
group: Fast Hand grip
for >8hrs strength
prior to Experimental pre/post
92 patients surgery group: received operative
undergoing NO-NPO were
measured
elective beverage 400ml 6
hrs before surgery
laparoscopic +200ml 2 hours
cholecystectomies prior to surgery
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 Dominant Hand Grip Strength
Preoperatively Postoperatively

Shortened Fasting 25.2 24.9

Prolonged Fasting 23.1 18.4

Non-Dominant Hand Grip Strength

Preoperatively Postoperatively

Shortened Fasting 24.8 22.9

Prolonged Fasting 22.4 17.0

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 Results/Conclusions
shortened fasting using
maltodextrin brought preserved
muscle strength when comparing
grip strength

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Overall consensus

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How can this help in
clinical practice?

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 Improved surgical
outcomes is good for
Everyone

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 From a Healthcare
Professional Standpoint

Implementing this protocol gives patients

a better surgical experience and reduces
potential complications
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 From a Financial Standpoint

2-3 beverages can prevent costly

post-operative complications and
shorten length of stay
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 From a Patient Standpoint

This minor surgery can avoid the

discomfort of prolonged fasting and
improve our experience to get back to
normal life ASAP 48
For POCB’s to work effectively
RDs can provide education and
assist in implementation

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 Further research is needed

• Larger populations
• Malnourished vs well
nourished patients
• In conjunction with
other ERAS protocols

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 Limitations to POCB
Implementation

Interdisciplinary acceptance

Cost

Patient adherence to protocol

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Questions?

Thank you!

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