Effects of preoperative carbohydrate loading on recovery after elective surgery: A systematic review and Bayesian network meta-analysis of randomized controlled trials

Enyu Tong, Yiming Chen, Yanli Ren, Yuanyuan Zhou, Chunhong Di, Ying Zhou, Shihan Shao, Shuting Qiu, Yu Hong, Lei Yang, Xiaohua Tan, Enyu Tong, Yiming Chen, Yanli Ren, Yuanyuan Zhou, Chunhong Di, Ying Zhou, Shihan Shao, Shuting Qiu, Yu Hong, Lei Yang, Xiaohua Tan

Abstract

Background: Preoperative carbohydrate loading is an important element of the enhanced recovery after surgery (ERAS) paradigm in adult patients undergoing elective surgery. However, preoperative carbohydrate loading remains controversial in terms of improvement in postoperative outcomes and safety. We conducted a Bayesian network meta-analysis to evaluate the effects and safety of different doses of preoperative carbohydrates administrated in adult patients after elective surgery.

Methods: MEDLINE (PubMed), Web of Science, EMBASE, EBSCO, the Cochrane Central Register of Controlled Trials, and China National Knowledge Infrastructure (CNKI) were searched to identify eligible trials until 16 September 2022. Outcomes included postoperative insulin resistance, residual gastric volume (RGV) during the surgery, insulin sensitivity, fasting plasma glucose (FPG), fasting serum insulin (Fin) level, the serum levels of C-reactive protein (CRP), postoperative scores of pain, patients' satisfaction, thirst, hunger, anxiety, nausea and vomit, fatigue, and weakness within the first 24 h after surgery and the occurrences of postoperative infection. The effect sizes were estimated using posterior mean difference (continuous variables) or odds ratios (dichotomous variables) and 95 credible intervals (CrIs) with the change from baseline in a Bayesian network meta-analysis with random effect.

Results: Fifty-eight articles (N = 4936 patients) fulfilled the eligibility criteria and were included in the meta-analysis. Both preoperative oral low-dose carbohydrate loading (MD: -3.25, 95% CrI: -5.27 to -1.24) and oral high-dose carbohydrate loading (MD: -2.57, 95% CrI: -4.33 to -0.78) were associated with postoperative insulin resistance compared to placebo/water. When trials at high risk of bias were excluded, association with insulin resistance was found for oral low-dose carbohydrate loading compared with placebo/water (MD: -1.29, 95%CrI: -2.26 to -0.27) and overnight fasting (MD: -1.17, 95%CrI: -1.88 to -0.43). So, there was large uncertainty for all estimates vs. control groups. In terms of safety, oral low-dose carbohydrate administration was associated with the occurrences of postoperative infection compared with fasting by 0.42 (95%Crl: 0.20-0.81). In the other outcomes, there was no significant difference between the carbohydrate and control groups.

Conclusion: Although preoperative carbohydrate loading was associated with postoperative insulin resistance and the occurrences of postoperative infection, there is no evidence that preoperative carbohydrate administration alleviates patients' discomfort.

Systematic review registration: [https://www.crd.york.ac.uk/PROSPERO/], identifier [CRD42022312944].

Keywords: Bayesian network meta-analysis; adults; elective surgery; insulin resistance; postoperative comfort and safety; preoperative carbohydrate loading.

Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Copyright © 2022 Tong, Chen, Ren, Zhou, Di, Zhou, Shao, Qiu, Hong, Yang and Tan.

Figures

FIGURE 1
FIGURE 1
Flow diagram of study identification, screening, eligibility assessment, and inclusion.
FIGURE 2
FIGURE 2
Risk of bias included RCTs. The colors in the bar next to each row/criteria represent the percentage of total studies falling within the high risk of bias/some concerns/low risk of bias.
FIGURE 3
FIGURE 3
Network plot of evidence comparing different interventions for the primary outcome.
FIGURE 4
FIGURE 4
Forest plot for the estimates of different interventions on IR of postoperative patients. Values are mean differences (MDs) with 95% confidence intervals (Crls).
FIGURE 5
FIGURE 5
Surface under the cumulative ranking curve (SUCRA) for HOMA-IR.
FIGURE 6
FIGURE 6
Forest plot for the estimates of different interventions on IR of postoperative patients that excluded trials at high risk of bias and data for the imputation methods. Values are mean differences (MDs) with 95% confidence intervals (CrIs).

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