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Preoperative carbohydrate loading before elective abdominal surgery: A systematic review and network meta-analysis of phase II/III randomized controlled trials.
Ricci, C, Ingaldi, C, Alberici, L, Serbassi, F, Pagano, N, De Raffele, E, Minni, F, Pironi, L, Sasdelli, AS, Casadei, R
Clinical nutrition (Edinburgh, Scotland). 2022;(2):313-320
Abstract
BACKGROUND & AIMS The preoperative use of carbohydrate loading (CHO) is recommended in patients undergoing abdominal surgery, even if the advantages remain debatable. The aim was to evaluate the CHO benefits in patients undergoing abdominal surgery. METHODS A systematic search of randomized clinical trials was made. A frequentist random-effects network meta-analysis was carried out, reporting the surface under the cumulative ranking (SUCRA). The primary endpoint regarded the morbidity rate. The secondary endpoints were aspiration/regurgitation rates, the length of stay (LOS), the rate of postoperative nausea and vomiting (PONV), the changes (Δ) in insulin sensitivity or resistance, and the postoperative C- reactive protein (CRP) values. RESULTS CHO loading and water administration had a similar probability of being the approach with a lower morbidity rate (SUCRA = 62.4% and 64.7%). CHO and clear water also had a similar chance of avoiding the PONV (SUCRA of 80.8% and 77%). The aspiration regurgitation rate was not relevant in non-fasting patients (0.06%). CHO administration was associated with the shorter hospitalization (SUCRA 86.9%), with the best metabolic profile (SUCRA values for insulin resistance and sensitivity were 81.1% and 76%). CHO enriched was the best approach for postoperative CRP values. Preoperative fasting was the worst approach for morbidity, PONV, insulin resistance and sensitivity, and CRP (SUCRA values of 32.1%, 21.7%, 10.2%, 3.2%, and 2.0%). CONCLUSION Both preoperative CHO loading and clear water use were superior to the fasting about morbidity. CHO drinks use could provide specific advantages, reduce the PONV rate, and improve carbohydrate homeostasis, inflammatory pathway, and hospitalization.
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Perioperative Probiotics or Synbiotics in Adults Undergoing Elective Abdominal Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Trials.
Chowdhury, AH, Adiamah, A, Kushairi, A, Varadhan, KK, Krznaric, Z, Kulkarni, AD, Neal, KR, Lobo, DN
Annals of surgery. 2020;(6):1036-1047
Abstract
OBJECTIVE To define the impact of perioperative treatment with probiotics or synbiotics on postoperative outcome in patients undergoing abdominal surgery. BACKGROUND Postoperative surgical infection accounts for a third of all cases of sepsis, and is a leading cause of morbidity and mortality. Probiotics, prebiotics, and synbiotics (preparations that combine probiotics and prebiotics) are nutritional adjuncts that are emerging as novel therapeutic modalities for preventing surgical infections. However, current evidence on their effects is conflicting. METHODS A comprehensive search of the PubMed, Embase, and WHO Global Index Medicus electronic databases was performed to identify randomized controlled trials evaluating probiotics or synbiotics in adult patients undergoing elective colorectal, upper gastrointestinal, transplant, or hepatopancreaticobiliary surgery. Bibliographies of studies were also searched. The primary outcome measure was incidence of postoperative infectious complications. Secondary outcomes included incidence of noninfectious complications, mortality, length of hospital stay, and any treatment-related adverse events. Quantitative pooling of the data was undertaken using a random effects model. RESULTS A total of 34 randomized controlled trials reporting on 2723 participants were included. In the intervention arm, 1354 patients received prebiotic or symbiotic preparations, whereas 1369 patients in the control arm received placebo or standard care. Perioperative administration of either probiotics or synbiotics significantly reduced the risk of infectious complications following abdominal surgery [relative risk (RR) 0.56; 95% confidence interval (CI) 0.46-0.69; P < 0.00001, n = 2723, I = 42%]. Synbiotics showed greater effect on postoperative infections compared with probiotics alone (synbiotics RR: 0.46; 95% CI: 0.33-0.66; P < 0.0001, n = 1399, I = 53% probiotics RR: 0.65; 95% CI: 0.53-0.80; P < 0.0001, n = 1324, I = 18%). Synbiotics but not probiotics also led to a reduction in total length of stay (synbiotics weighted mean difference: -3.89; 95% CI: -6.60 to -1.18 days; P = 0.005, n = 535, I = 91% probiotics RR: -0.65; 95% CI: -2.03-0.72; P = 0.35, n = 294, I = 65%). There were no significant differences in mortality (RR: 0.98; 95% CI: 0.54-1.80; P = 0.96, n = 1729, I = 0%) or noninfectious complications between the intervention and control groups. The preparations were well tolerated with no significant adverse events reported. CONCLUSIONS Probiotics and synbiotics are safe and effective nutritional adjuncts in reducing postoperative infective complications in elective abdominal surgery. The treatment effects are greatest with synbiotics.
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Is abdominal vascular calcification score valuable in predicting the occurrence of colorectal anastomotic leakage? A meta-analysis.
Tong, L, Xie, D, Song, X, Wu, X, Wen, S, Liu, A
International journal of colorectal disease. 2020;(4):641-653
Abstract
OBJECTIVE Anastomotic leakage (AL) is a catastrophic surgical complication affecting the prognosis of patients after colorectal surgery. We aimed to determine the value of the arterial calcification (AC) score in predicting AL. METHODS Medline and Embase were searched through November 2019. The odds ratio (OR) and 95% confidence interval (CI) were used to estimate the association between AC and AL after colorectal surgery. The fixed-effects model or random-effects model was adopted for data pooling. Subgroup analyses were conducted to assess the effect of different aortoiliac trajectories. RESULTS Four studies involving 496 patients were included. The calcium volume and calcium score measurements of different trajectories revealed a significant difference with regard to the left and right common iliac arteries, the superior mesenteric artery, and the left common iliac artery. Calcification of the internal iliac artery significantly increased the risk of AL compared with no AL (OR = 1.005; 95% CI 1.002-1.009; P = 0.005), as did calcification of the left internal iliac artery (OR = 1.009; 95% CI 1.002-1.016; P = 0.011), but not of the common iliac artery (OR = 1.001; 95% CI 1.000-1.001; P = 0.317) or common and internal iliac artery (OR = 1.000; 95% CI 1.000-1.000; P = 1.000). CONCLUSIONS AC is associated with increased risk of AL following colorectal surgery. TRIAL REGISTRATION CRD42019141236.
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Safety and efficacy of laxatives after major abdominal surgery: systematic review and meta-analysis.
Dudi-Venkata, NN, Seow, W, Kroon, HM, Bedrikovetski, S, Moore, JW, Thomas, ML, Sammour, T
BJS open. 2020;(4):577-586
Abstract
BACKGROUND Recovery of gastrointestinal function is often delayed after major abdominal surgery, leading to postoperative ileus (POI). Enhanced recovery protocols recommend laxatives to reduce the duration of POI, but evidence is unclear. This systematic review aimed to assess the safety and efficacy of laxative use after major abdominal surgery. METHODS Ovid MEDLINE, Embase, Cochrane Library and PubMed databases were searched from inception to May 2019 to identify eligible RCTs focused on elective open or minimally invasive major abdominal surgery. The primary outcome was time taken to passage of stool. Secondary outcomes were time taken to tolerance of diet, time taken to flatus, length of hospital stay, postoperative complications and readmission to hospital. RESULTS Five RCTs with a total of 416 patients were included. Laxatives reduced the time to passage of stool (mean difference (MD) -0·83 (95 per cent c.i. -1·39 to -0·26) days; P = 0·004), but there was significant heterogeneity between studies for this outcome measure. There was no difference in time to passage of flatus (MD -0·17 (-0·59 to 0·25) days; P = 0·432), time to tolerance of diet (MD -0·01 (-0·12 to 0·10) days; P = 0·865) or length of hospital stay (MD 0·01(-1·36 to 1·38) days; P = 0·992). There were insufficient data available on postoperative complications for meta-analysis. CONCLUSION Routine postoperative laxative use after major abdominal surgery may result in earlier passage of stool but does not influence other postoperative recovery parameters. Better data are required for postoperative complications and validated outcome measures.
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Effect of perioperative goal-directed hemodynamic therapy on postoperative recovery following major abdominal surgery-a systematic review and meta-analysis of randomized controlled trials.
Sun, Y, Chai, F, Pan, C, Romeiser, JL, Gan, TJ
Critical care (London, England). 2017;(1):141
Abstract
BACKGROUND Goal-directed hemodynamic therapy (GDHT) has been used in the clinical setting for years. However, the evidence for the beneficial effect of GDHT on postoperative recovery remains inconsistent. The aim of this systematic review and meta-analysis was to evaluate the effect of perioperative GDHT in comparison with conventional fluid therapy on postoperative recovery in adults undergoing major abdominal surgery. METHODS Randomized controlled trials (RCTs) in which researchers evaluated the effect of perioperative use of GDHT on postoperative recovery in comparison with conventional fluid therapy following abdominal surgery in adults (i.e., >16 years) were considered. The effect sizes with 95% CIs were calculated. RESULTS Forty-five eligible RCTs were included. Perioperative GDHT was associated with a significant reduction in short-term mortality (risk ratio [RR] 0.75, 95% CI 0.61-0.91, p = 0.004, I 2 = 0), long-term mortality (RR 0.80, 95% CI 0.64-0.99, p = 0.04, I 2 = 4%), and overall complication rates (RR 0.76, 95% CI 0.68-0.85, p < 0.0001, I 2 = 38%). GDHT also facilitated gastrointestinal function recovery, as demonstrated by shortening the time to first flatus by 0.4 days (95% CI -0.72 to -0.08, p = 0.01, I 2 = 74%) and the time to toleration of oral diet by 0.74 days (95% CI -1.44 to -0.03, p < 0.0001, I 2 = 92%). CONCLUSIONS This systematic review of available evidence suggests that the use of perioperative GDHT may facilitate recovery in patients undergoing major abdominal surgery.
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Meta-analysis of immunonutrition in major abdominal surgery.
Probst, P, Ohmann, S, Klaiber, U, Hüttner, FJ, Billeter, AT, Ulrich, A, Büchler, MW, Diener, MK
The British journal of surgery. 2017;(12):1594-1608
Abstract
BACKGROUND The objective of this study was to evaluate the potential benefits of immunonutrition in major abdominal surgery with special regard to subgroups and influence of bias. METHODS A systematic literature search from January 1985 to July 2015 was performed in MEDLINE, Embase and CENTRAL. Only RCTs investigating immunonutrition in major abdominal surgery were included. Outcomes evaluated were mortality, overall complications, infectious complications and length of hospital stay. The influence of different domains of bias was evaluated in sensitivity analyses. Evidence was rated according to the GRADE Working Group grading of evidence. RESULTS A total of 83 RCTs with 7116 patients were included. Mortality was not altered by immunonutrition. Taking all trials into account, immunonutrition reduced overall complications (odds ratio (OR) 0·79, 95 per cent c.i. 0·66 to 0·94; P = 0·01), infectious complications (OR 0·58, 0·51 to 0·66; P < 0·001) and shortened hospital stay (mean difference -1·79 (95 per cent c.i. -2·39 to -1·19) days; P < 0·001) compared with control groups. However, these effects vanished after excluding trials at high and unclear risk of bias. Publication bias seemed to be present for infectious complications (P = 0·002). Non-industry-funded trials reported no positive effects for overall complications (OR 1·13, 0·88 to 1·46; P = 0·34), whereas those funded by industry reported large effects (OR 0·66, 0·48 to 0·91; P = 0·01). CONCLUSION Immunonutrition after major abdominal surgery did not seem to alter mortality (GRADE high quality of evidence). Immunonutrition reduced overall complications, infectious complications and shortened hospital stay (GRADE low to moderate). The existence of bias lowers confidence in the evidence (GRADE approach).
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Enteral nutrition versus parenteral nutrition after major abdominal surgery in patients with gastrointestinal cancer: a systematic review and meta-analysis.
Zhao, XF, Wu, N, Zhao, GQ, Liu, JF, Dai, YF
Journal of investigative medicine : the official publication of the American Federation for Clinical Research. 2016;(5):1061-74
Abstract
To clarify the benefits of enteral nutrition (EN) versus total parenteral nutrition (TPN) in patients with gastrointestinal cancer who underwent major abdominal surgery. Medline, Cochrane, EMBASE, and Google Scholar were searched for studies published until July 10, 2015, reporting outcomes between the two types of postoperative nutritional support. Only randomized controlled trials (RCTs) were included. A χ(2)-based test of homogeneity was performed using Cochran's Q statistic and I(2) A total of 2540 patients (1268 who received EN and 1272 who received TPN; average age range: 58.3-67.7 years) from 18 RCTs were included for assessment. Patients who received EN had shorter lengths of hospital stay (pooled difference in mean=-1.74, 95% CI -2.41 to -1.07, p<0.001, shorter time to flatus (pooled difference in mean=-1.27, 95% CI -1.69 to -0.85, p<0.001), and significantly greater increases in albumin levels (pooled difference in mean=-1.33, 95% CI -2.18 to -0.47, p=0.002) compared with those who received TPN after major abdominal surgery, based on a random-effects model of analysis. EN after major abdominal surgery provided better outcomes compared with TPN in patients with gastrointestinal cancer.
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Enhanced recovery pathways in abdominal gynecologic surgery: a systematic review and meta-analysis.
de Groot, JJ, Ament, SM, Maessen, JM, Dejong, CH, Kleijnen, JM, Slangen, BF
Acta obstetricia et gynecologica Scandinavica. 2016;(4):382-95
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Abstract
INTRODUCTION Enhanced recovery pathways have been widely accepted and implemented for different types of surgery. Their overall effect in abdominal gynecologic surgery is still underdetermined. A systematic review and meta-analysis were performed to provide an overview of current evidence and to examine their effect on postoperative outcomes in women undergoing open gynecologic surgery. MATERIAL AND METHODS Searches were conducted using Embase, Medline, CINAHL, and the Cochrane Library up to 27 June 2014. Reference lists were screened to identify additional studies. Studies were included if at least four individual items of an enhanced recovery pathway were described. Outcomes included length of hospital stay, complication rates, readmissions, and mortality. Quantitative analysis was limited to comparative studies. Effect sizes were presented as relative risks or as mean differences (MD) with 95% confidence intervals (CI). RESULTS Thirty-one records, involving 16 observational studies, were included. Diversity in reported elements within studies was observed. Preoperative education, early oral intake, and early mobilization were included in all pathways. Five studies, with a high risk of bias, were eligible for quantitative analysis. Enhanced recovery pathways reduced primary (MD -1.57 days, 95% CI CI -2.94 to -0.20) and total (MD -3.05 days, 95% CI -4.87 to -1.23) length of hospital stay compared with traditional perioperative care, without an increase in complications, mortality or readmission rates. CONCLUSION The available evidence based on a broad range of non-randomized studies at high risk of bias suggests that enhanced recovery pathways may reduce length of postoperative hospital stay in abdominal gynecologic surgery.
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A meta-analysis of randomised controlled trials on preoperative oral carbohydrate treatment in elective surgery.
Awad, S, Varadhan, KK, Ljungqvist, O, Lobo, DN
Clinical nutrition (Edinburgh, Scotland). 2013;(1):34-44
Abstract
BACKGROUND & AIMS Whilst preoperative carbohydrate treatment (PCT) results in beneficial physiological effects, the effects on postoperative clinical outcomes remain unclear and were studied in this meta-analysis. METHODS Prospective studies that randomised adult non-diabetic patients to either PCT (≥50 g oral carbohydrates 2-4 h pre-anaesthesia) or control (fasted/placebo) were included. The primary outcome was length of hospital stay. Secondary outcomes included development of postoperative insulin resistance, complications, nausea and vomiting. Methodological quality was assessed using GRADEpro® software. RESULTS Twenty-one randomised studies of 1685 patients (733 PCT: 952 control) were included. No overall difference in length of stay was noted for analysis of all studies or subgroups of patients undergoing surgery with an expected hospital stay ≤2 days or orthopaedic procedures. However, patients undergoing major abdominal surgery following PCT had reduced length of stay [mean difference, 95% confidence interval: -1.08 (-1.87 to -0.29); I² = 60%, p = 0.007]. PCT reduced postoperative insulin resistance with no effects on in-hospital complications over control (risk ratio, 95% confidence interval, 0.88 (0.50-1.53), I² = 41%; p = 0.640). There was significant heterogeneity amongst studies and, therefore, quality of evidence was low to moderate. CONCLUSIONS PCT may be associated with reduced length of stay in patients undergoing major abdominal surgery, however, the included studies were of low to moderate quality.
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Chewing gum reduces postoperative ileus following abdominal surgery: a meta-analysis of 17 randomized controlled trials.
Li, S, Liu, Y, Peng, Q, Xie, L, Wang, J, Qin, X
Journal of gastroenterology and hepatology. 2013;(7):1122-32
Abstract
BACKGROUND AND AIM Chewing gum proposal has been used in surgery to reduce postoperative ileus for more than 10 years; however, the efficacy remains imprecise. The aim of this study was to accurately assess whether the use of the chewing gum could reduce duration of postoperative ileus following the abdominal surgery. METHODS A systematic review was conducted in Medline, EMBASE, and the Cochrane Library through December 2012 to identify randomized controlled trials comparing with and without the use of chewing gum in patients undergoing abdominal surgery. The outcome of interest was time to flatus, time to bowel movement, and length of stay. Subgroup analyses were performed to examine the impact of different studies structural design. Cumulative meta-analyses were used to examine how the evidence has changed over time. RESULTS Seventeen randomized controlled trials involving 1374 participants were included. Overall time (in days) for the patients to pass flatus (weighted mean difference [WMD], -0.31; 95% confidence interval [CI], -0.43 to -0.19; P = 0.000); time to bowel movement (WMD, -0.51; 95% CI, -0.73 to -0.29; P = 0.000); and length of stay (WMD, -0.72; 95% CI, -1.02 to -0.43; P = 0.000) were significantly reduced in the treatment group. However, both of these results demonstrated significant heterogeneity. No evidence of publication bias was observed. Cumulative meta-analysis showed that chewing gum reduces duration of postoperative ileus that has been available for over 6 years. CONCLUSIONS Results of the meta-analysis suggest that chewing gum following abdominal surgery offers benefits in reducing the time of postoperative ileus.