A Carbohydrate-Rich Beverage Prior to Surgery Prevents Surgery-Induced Immunodepression: A Randomized,Controlled,Clinical Trial

Abstract

Background: Fasting before surgery is still common care in a lot of western hospitals. Overnight fasting can induce postoperative insulin resistance. Insulin resistance has been shown to be related to infectious morbidity. It was shown that postoperative insulin resistance can be attenuated by preoperative intake of a clear carbohydrate-rich beverage. The aim of this study was to investigate whether preoperative intake of carbohydrate-rich beverages could postoperatively influence the immune system. Methods: In this randomized, controlled study, we investigated the effect of surgery on the postoperative immune response in 10 preoperatively fasted patients (control) and 2 groups of 10 patients receiving 2 different carbohydrate-rich beverages preoperatively, by measuring human leukocyte antigen (HLA)-DR expression on monocytes on the day before and on the day after surgery. Furthermore, we studied perioperative fluid homeostasis and preoperative well-being of the patients. Results: HLA-DR expression decreased significantly after surgery in the control group. Patients receiving any of the 2 carbohydrate-rich beverages did not show this postoperative decrease. Fluid homeostasis was not affected in any of the groups, and well-being tended to be better in patients receiving carbohydrate-rich beverages compared with controls. Conclusion: This study suggests that preoperative intake of a carbohydrate-rich beverage can prevent surgery-induced immunodepression and thus might reduce the risk of infectious complications.

The results from this study show that human leukocyte antigen-DR expression decreased significantly after surgery in patients who were fasted before surgery. Patients who received a carbohydrate-rich beverage did not show this postoperative decrease.

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References

Mendelson CL. The aspiration of stomach contents into the lungs during obstetric anesthesia. Am J Obstet Gyneacol. 1946 ;52:191– 205.

Roberts RB, Shirley MA. Reducing the risk of acid aspiration during cesarean section. Anesth Analg. 1974 ;53:859– 868.

Agarwal A, Chari P, Singh H. Fluid deprivation before operation: the effect of a small drink. Anaesthesia. 1989 ;44:632– 634.

Sutherland AD, Maltby JR, Sale JP, Reid CR. The effect of preoperative oral fluid and ranitidine on gastric fluid volume and pH.Can J Anaesth. 1987;34:117– 121.

Hutchinson A, Maltby JR, Reid CR. Gastric fluid volume and pH in elective inpatients, part I: coffee or orange juice versus overnight fast.Can J Anaesth. 1988;35:12– 15.

Maltby JR, Lewis P, Martin A, Sutheriand LR. Gastric fluid volume and pH in elective patients following unrestricted oral fluid until three hours before surgery. Can J Anaesth. 1991 ;38:425– 429.

Maltby JR, Reid CR, Hutchinson A. Gastric fluid volume and pH in elective inpatients, part II: coffee or orange juice with ranitidine.Can J Anaesth. 1988;35:16 –19.

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

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.

10.

Bang P, Nygren J, Carlsson-Skwirut C, Thorell A, Ljungqvist O. Postoperative induction of insulin-like growth factor binding protein-3 proteolytic activity: relation to insulin and insulin sensitivity. J Clin Endocrinol Metab. 1998;83:2509 –2515.

11.

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

12.

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

13.

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

14.

Zerr KJ, Furnary AP, Grunkemeier GL, Bookin S, Kanhere V, Starr A. Glucose control lowers the risk of wound infection in diabetics after open heart operations. Ann Thorac Surg. 1997 ;63: 356– 361.

15.

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.

16.

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

17.

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.

18.

Soop M, Nygren J, Myrenfors P, Thorell A, Ljungqvist O. Preoperative oral carbohydrate treatment attenuates immediate postoperative insulin resistance. Am J Physiol Endocrinol Metab. 2001 ;280:E576– E583.

19.

Sietses C, Wiezer MJ, Eijsbouts QA, et al. A prospective randomized study of the systemic immune response after laparoscopic and conventional Nissen fundoplication. Surgery. 1999 ;126:5– 9.

20.

Johnston RB Jr. Current concepts: immunology: monocytes and macrophages. N Engl J Med. 1988 ;318:747– 752.

21.

Cheadle WG, Hershman MJ, Wellhausen SR, Polk HC Jr. HLA-DR antigen expression on peripheral blood monocytes correlates with surgical infection.Am J Surg. 1991;161:639– 645.

22.

Hershman MJ, Cheadle WG, Wellhausen SR, Davidson PF, Polk HC Jr. Monocyte HLA-DR antigen expression characterizes clinical outcome in the trauma patient. Br J Surg. 1990 ;77: 204– 207.

23.

Wakefield CH, Carey PD, Foulds S, Monson JR, Guillou PJ. Changes in major histocompatibility complex class II expression in monocytes and T cells of patients developing infection after surgery. Br J Surg. 1993 ;80:205– 209.

24.

Rose BD. Clinical Physiology of Acid-Base and Electrolyte Disorders. New York, NY: McGraw-Hill Information Services Company;1989 .

25.

Nygren J, Thorell A, Jacobsson H, et al. Preoperative gastric emptying: effects of anxiety and oral carbohydrate administration. Ann Surg. 1995;222:728 –734.

26.

Walrand S, Moreau K, Caldefie F, et al. Specific and nonspecific immune responses to fasting and refeeding differ in healthy young adult and elderly persons. Am J Clin Nutr. 2001 ;74:670– 678.

27.

Reichert S, Stein J, Gautsch A, Schaller HG, Machulla HK. Gender differences in HLA phenotype frequencies found in German patients with generalized aggressive periodontitis and chronic periodontitis. Oral Microbiol Immunol. 2002;17:360– 368.

28.

Czaja AJ, Donaldson PT. Gender effects and synergisms with histocompatibility leukocyte antigens in type 1 autoimmune hepatitis.Am J Gastroenterol. 2002 ;97:2051– 2057.

29.

Sole CC, Noakes TD. Faster gastric emptying for glucose-polymer and fructose solutions than for glucose in humans. Eur J Appl Physiol Occup Physiol. 1989;58:605– 612.

30.

Ljungqvist O, Nygren J, Thorell A, Brodin U, Efendic S. Preoperative nutrition: elective surgery in the fed or the overnight state.Clin Nutr. 2001;20(suppl 1): 167–171.

31.

Sietses C, Beelen RH, Meijer S, Cuesta MA. Immunological consequences of laparoscopic surgery, speculations on the cause and clinical implications. Langenbecks Arch Surg. 1999 ;384: 250– 258.

32.

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.