Enhanced recovery after surgery (ERAS) is the use of a series of evidence-based perioperative optimization measures to treat the patient’s disease while minimizing traumatic stress, reducing complications, and accelerating the patient’s recovery.
Since 1997, when the concept of ERAS was first introduced by Danish surgeon Kehlet, it has been gradually applied in various fields of surgery, including gastrointestinal surgery, obstetrics and gynecology, urology, orthopedics, cardiothoracic surgery, etc. The application of ERAS in hepatic surgery started later, but in recent years, more and more hepatobiliary surgeons have found that patients are recovering more quickly after the introduction of ERAS measures, and patients are experiencing less pain and satisfaction. experiencing less and less pain and higher satisfaction, the common laparoscopic procedures in our department according to the ERAS concept are discussed as follows.
How long should patients undergoing laparoscopic hepatobiliary surgery be fasted from food and water before surgery? To answer this question the following three questions need to be clarified.
- Why is fasting and water fasting required before surgery?
- What is the effect of fasting and water fasting on the patient before surgery?
- What are the special effects of laparoscopic hepatobiliary surgery on the patient?
First of all, let’s answer the first question: Why do we need to fast and water before surgery? Fasting and water fasting for 8-12 hours before surgery has been practiced for more than 150 years, mainly to prevent vomiting and aspiration during anesthesia and surgery leading to patient asphyxia or aspiration pneumonia. Because the anesthetic drugs into the body, will produce a series of side effects such as nausea, vomiting, etc., if the preoperative period consumed more food and water, easily lead to nausea, vomiting, food reflux into the trachea leading to death by asphyxiation. The time for stomach emptying of mixed food is 4-6 hours, and the time for stomach emptying of liquid food is 2 hours, so 6 hours of solid food fasting before surgery and 2 hours of water fasting before surgery can achieve the same purpose as 8-12 hours of food and water fasting before surgery.
In fact, the second question: what is the effect of preoperative fasting and water fasting on the patient? Long preoperative fasting and water fasting can easily lead to sympathetic excitement, making the patient irritable and anxious, while long-term fasting and water fasting can lead to an increased incidence of postoperative nausea and vomiting, prolonging the time of postoperative intestinal paralysis, and even hemodynamic disturbances, deficiency, and even shock.
Prolonged preoperative fasting and water fasting can directly lead to postoperative insulin resistance. Insulin resistance can increase the occurrence of postoperative complications such as bacteraemia and infection. At the same time, prolonged fasting and water fasting can lead to physiological and psychological discomfort of patients, which is not conducive to the cooperation and recovery of postoperative treatment. Therefore, it is important to find a reasonable duration of fasting and water fasting based on the patient’s surgical modality and physical status without increasing the risk of reflux aspiration for the patient’s recovery.
One last question: What are the special effects of laparoscopic hepatobiliary surgery on patients? Traditional gastrointestinal surgery requires gastrointestinal preparation, but laparoscopic hepatobiliary surgery has less impact on the gastrointestinal tract, so there are no RCT studies or evidence on the use of intestinal preparation in laparoscopic hepatectomy at this time. In the gastrointestinal surgery study, it was found that a 6-h preoperative solid food fast and a 2-h clear liquid food fast did not increase the incidence of postoperative complications.
Also eating liquid food 2 h before surgery reduced the incidence of insulin resistance. A Meta-analysis that included 17 RCTs with 1445 patients showed that patients who ate carbohydrates 2 h before surgery had a lower incidence of perioperative insulin resistance and significantly less thirst, nausea, anxiety and hunger, but there was no significant difference in the incidence of postoperative complications. The Chinese Expert Consensus on Accelerated Rehabilitation Surgery for Laparoscopic Hepatectomy (2017 edition) recommends that patients without gastrointestinal motility disorders should abstain from solid food for 6 h and clear liquid food for 2 h before laparoscopic hepatectomy. In patients without diabetes, 400 mL of 12.5% carbohydrate beverage orally 2 h before surgery.
In summary, the ERAS concept was implemented with the aim of treating the disease while reducing the patient’s perioperative stress response, accelerating the patient’s postoperative recovery, and thus shortening the length of hospital stay and saving social resources. The perioperative oral intake of 12.5% carbohydrate beverage not only relieves patients’ physical discomfort, but also reduces psychological discomfort, because “eating sugar makes people happy”.
