Preoperative Fasting: An Outdated Concept?

Abstract

Recent studies have shown that fasting during the preoperative period for elective surgery induces a metabolic state that seems unfavorable for patients. Results from animal studies indicate that rapid depletion of liver glycogen before surgery leads to mobilization of muscle glycogen after surgery, in turn leading to reduced muscle strength. Depletion of liver glycogen also influences the function of the mononuclear phagocytic system (MPS), which is located predominantly in the liver. The MPS is essential in restricting endotoxin, which may translocate from the gut. In addition, surgery per se puts a substantial physical strain on the patient, and fasting may adversely affect the metabolic response to surgery. This paper presents experimental and clinical data that, when combined together, prove that fasting before surgery has adverse consequences for the patient.

Recent information indicates that fasting before surgery changes the metabolic state in such a way that it may have adverse effects on the patient’s recovery. Animal and human studies are accumulating that preoperative feeding with specialized clinical nutrition may improve this recovery.

Get full access to this article

View all access options for this article.

References

Watson K, Rinomhota S. Preoperative fasting: we need a new consensus. Nurs Times. 2002 ;98:36– 37.

Scarlett M, Crawford-Sykes A, Nelson M. Preoperative starvation and pulmonary aspiration. New perspectives and guidelines. West Indian Med J. 2002;51:241– 245.

Ljungqvist O, Soreide E. Preoperative fasting. Br J Surg. 2003;90:400– 406.

Soreide E, Fasting S, Raeder J. New preoperative fasting guidelines in Norway. Acta Anaesthesiol Scand. 1997 ;41:799 .

Eriksson LI, Sandin R. Fasting guidelines in different countries.Acta Anaesthesiol Scand. 1996 ;40:971– 974.

Fasting S, Soreide E, Raeder JC. Changing preoperative fasting policies. Impact of a national consensus. Acta Anaesthesiol Scand. 1998;42:1188– 1191.

Munro H, Chalmers M. Fracture metabolism at different levels of protein intake. Br J Exp Path. 1945 ;16:396– 404.

Quiros G, Ware J. Cardiovascular and metabolic alterations caused by hemorrhage in fed and starved rats. Acta Physiol Scand. 1983 ;117:397– 403.

Quiros G, Ware J. Modification of cardiovascular responses to hemorrhage by induced hyperosmolality in the rat. Acta Physiol Scand. 1983;117:391– 396.

10.

Ljungqvist O, Jansson E, Ware J. Effect of food deprivation on survival after hemorrhage in the rat. Circ Shock. 1987 ;22:251– 260.

11.

Alibegovic A, Ljungqvist O. Pretreatment with glucose infusion prevents fatal outcome after hemorrhage in food deprived rats. Circ Shock. 1993;39:1– 6.

12.

Nettelbladt CG, Alibergovic A, Ljungqvist O. Pre-stress carbohydrate solution prevents fatal outcome after hemorrhage in 24-hour food-deprived rats. Nutrition. 1996 ;12:696– 699.

13.

Friberg B. Food deprivation prior to stress stimulates muscle force both before and after hemorrhage in the rat. Surg Res Comm. 1994 ;16:131– 137.

14.

Esahili AH, Boija PO, Ljungqvist O, Rubio C, Ware J. Twenty-four hour fasting increases endotoxin lethality in the rat. Eur J Surg. 1991;157:89– 95.

15.

Nettelbladt CG, Katouli M, Volpe A, et al. Starvation increases the number of coliform bacteria in the caecum and induces bacterial adherence to caecal epithelium in rats. Eur J Surg. 1997 ;163:135– 142.

16.

Bark T, Katouli M, Svenberg T, Ljungqvist O. Food deprivation increases bacterial translocation after non-lethal haemorrhage in rats.Eur J Surg. 1995;161:67– 71.

17.

Tanigawa K, Kim YM, Lancaster JR Jr., Zar HA. Fasting augments lipid peroxidation during reperfusion after ischemia in the perfused rat liver. Crit Care Med. 1999 ;27:401– 406.

18.

Ilhan N, Halifeoglu I, Ozercan HI. Tissue malondialdehyde and adenosine triphosphatase level after experimental liver ischaemia-reperfusion damage. Cell Biochem Funct. 2001 ;19:207– 212.

19.

Akcakaya A, Alimoglu O, Sahin M, Abbasoglu SD. Ischemia-reperfusion injury following superior mesenteric artery occlusion and strangulation obstruction. J Surg Res. 2002 ;108:39– 43.

20.

Qayumi AK, Godin DV, Jamieson WR, Ko KM, Poostizadeh A. Correlation of red cell antioxidant status and heart-lung function in swine pretreated with allopurinol (a model of heart-lung transplantation).Transplantation. 1993;56:37– 43.

21.

Van Hoorn EC, Middelaar-Voskuilen MC, van Limpt CJ, et al. Preoperative supplementation with a carbohydrate mixture decreases organ dysfunction-associated risk factors. Clin Nutr. 2005 ;24:114– 123.

22.

Van Hoorn EC, Boelens PG. Pre-operative feeding preserves heart function and decreases oxidative injury in rasts. Nutrition. 2005 ; in press.

23.

Nijveldt RJ, Teerlink T, Van Der Hoven B, et al. Asymmetrical dimethylarginine (ADMA) in critically ill patients: high plasma ADMA concentration is an independent risk factor of ICU mortality. Clin Nutr. 2003;22:23– 30.

24.

Nijveldt RJ, Teerlink T, van Leeuwen PA. The asymmetrical dimethylarginine (ADMA)-multiple organ failure hypothesis. Clin Nutr. 2003;22:99– 104.

25.

Arnault I, Bao YM, Dimicoli JL, Lemoine A, Sebagh M, Adam R. Combined effects of fasting and alanine on liver function recovery after cold ischemia. Transpl Int. 2002 ;15:89– 95.

26.

Thorell A, Alston-Smith J, Ljungqvist O. The effect of preoperative carbohydrate loading on hormonal changes, hepatic glycogen, and glucoregulatory enzymes during abdominal surgery. Nutrition. 1996 ;12:690– 695.

27.

van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in the critically ill patients. N Engl J Med. 2001 ;345:1359– 1367.

28.

Thorell A, Nygren J, Ljungqvist O. Insulin resistance: a marker of surgical stress. Curr Opin Clin Nutr Metab Care. 1999 ;2:69– 78.

29.

Kmiec Z. Cooperation of liver cells in health and disease.Adv Anat Embryol Cell Biol. 2001 ;161:1– 151.

30.

Khaodhiar L, McCowen K, Bistrian B. Perioperative hyperglycemia, infection or risk? Curr Opin Clin Nutr Metab Care. 1999 ;2:79– 82.

31.

Thorell A, Nygren J, Hirshman MF, et al. Surgery-induced insulin resistance in human patients: relation to glucose transport and utilization.Am J Physiol. 1999;276:E754– E761.

32.

Nygren J, Soop M, Thorell A, Efendic S, Nair KS, Ljungqvist O. Preoperative oral carbohydrate administration reduces postoperative insulin resistance. Clin Nutr. 1998 ;17:65– 71.

33.

Crowe PJ, Dennison A, Royle GT. The effect of pre-operative glucose loading on postoperative nitrogen metabolism. Br J Surg. 1984 ;71:635– 637.

34.

Berggren H, Ekroth R, Hjalmarson A, et al. Enhanced myocardial protection from preoperative carbohydrate infusion in addition to maintained beta-blockade. J Cardiovasc Surg. 1985 ;26:454– 456.

35.

Ljungqvist O, Thorell A, Gutniak M, Haggmark T, Efendic S. Glucose infusion instead of preoperative fasting reduces postoperative insulin resistance. J Am Coll Surg. 1994 ;178:329– 336.

36.

Gutniak M, Grill V, Efendic S. Effect of composition of mixed meals—low- versus high-carbohydrate content—on insulin, glucagon, and somatostatin release in healthy humans and in patients with NIDDM.Diabetes Care. 1986;9:244– 249.

37.

Nygren J, Sammann M, Malm M, et al. Distributed anabolic hormonal patterns in burned patients: the relation to glucagon. Clin Endocrinol (Oxf). 1995;43:491– 500.

38.

Nygren J, Soop M, Thorell A, Sree Nair K, Ljungqvist O. Preoperative oral carbohydrates and postoperative insulin resistance.Clin Nutr. 1999;18:117– 120.

39.

Hausel J, Nygren J, Lagerkranser M, et al. A carbohydrate-rich drink reduces preoperative discomfort in elective surgery patients.Anesth Analg. 2001;93:1344– 1350.

40.

Bisgaard T, Kristiansen VB, Hjortso NC, Jacobsen LS, Rosenberg J, Kehlet H. Randomized clinical trial comparing an oral carbohydrate beverage with placebo before laparoscopic cholecystectomy. Br J Surg. 2004 ;91:151– 158.

41.

Hausel J, Thorell A, Nygren J, Ljungqvist O. Preoperative carbohydrates reduce postoperative nausea and vomiting after elective laparoscopic cholecystectomy. Br J Surg. 2005 ;92:415– 421.

42.

Yuill KA, Richardson RA, Davidson HI, Garden OJ, Parks RW. The administration of an oral carbohydrate containing fluid prior to major elective upper gastrointestinal surgery preserves skeletal muscle mass postoperatively- a randomised clinical trial. Clin Nutr. 2005 ;24:32– 37.

43.

Ljungqvist O, Nygren J, Thorell A. Modulation of post-operative insulin resistance by pre-operative carbohydrate loading. Proc Nutr Soc. 2002;61:329– 336.

44.

Henriksen MG, Hessov I, Dela F, Hansen HV, Haraldsted V, Rodt SA. Effects of preoperative oral carbohydrates and peptides on postoperative endocrine response, mobilization, nutrition and muscle function in abdominal surgery. Acta Anaesthesiol Scand. 2003 ;47:191– 199.

45.

Soop M, Nygren J, Thorell A, et al. Preoperative oral carbohydrate treatment attenuates endogenous glucose release 3 days after surgery.Clin Nutr. 2004;23:733– 741.

46.

Fearon KC, Luff R. The nutritional management of surgical patients: enhanced recovery after surgery. Proc Nutr Soc. 2003 ;62:807– 811.

47.

Thorell A, Efendic S, Gutniak M, Haggmark T, Ljungqvist O. Development of postoperative insulin resistance is associated with the magnitude of operation. Eur J Surg. 1993 ;159:593– 599.

48.

Thorell A, Efendic S, Gutniak M, Haggmark T, Ljungqvist O. Insulin resistance after abdominal surgery. Br J Surg. 1994 ;81:59– 63.

49.

Nygren J, Thorell A, Brismar K, Karpe F, Ljungqvist O. Short-term hypocaloric nutrition but not bed rest decrease insulin sensitivity and IGF-1 bioavailability in healthy subjects: the importance of glucagon.Nutrition. 1997;13:945– 951.