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Journal of Visceral Surgery (2013) 150, 12

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EDITORIAL
Oral sweet liquids 2 hours before surgery,
chewing-gum and coffee after surgery. . . What else!
Surgeons have traditionally considered postoperative morbidity to be a direct result of
their surgical procedure or, rather, of the quality of the intervention. This is true indeed
[1,2]! But while the surgeon cannot be absolved of responsibility for technical errors, is
technical prociency alone sufcient to guarantee good quality outcomes after surgery (in
terms of patient comfort) and a reduction in postoperative morbidity? Surgeons should not
forget that other factors might be implicated in adverse postoperative outcomes including
patient related factors (age, diabetes, malnutrition) and also pre-, intra-, and postopera-
tive care. But we emphasize that evocation of non-surgical risk factors can never serve
as a pretext to justify poor surgical technique.
Consider, for example, the case of a patient who undergoes technically optimal surgery
with no intraoperative complications (a beautiful colorectal anastomosis with negative leak
testing, two perfect doughnuts on the anvil of the EEA stapler, excellent blood supply, and
a clean operative eld without contamination or bleeding); despite all these optimal condi-
tions, is the patient therefore free of risk of postoperative complications? The answer is no!
The patient is not even free of the risk of so-called surgical complications (anastomotic
leak, postoperative peritonitis, wound infection): if he(she) was malnourished preopera-
tively and did not receive preoperative immunonutrition, his chances of complications are
increased [3]; if he(she) was not kept warm intraoperatively, he(she) has increased risk of
surgical site infection [4]; if he(she) received excessive intravenous uids during surgery,
he(she) is at increased risk for both surgical and other complications [5]. And we could
multiply these examples. . .
A multidisciplinary approach to the results of the surgical procedure has the merit of
removing the surgeon from his pedestal; while still the captain of the ship, he(she) is not the
sole person responsible for the patients care. The surgeon thereby comes to consider his
role within a multidisciplinary team framework (anesthetists and other paramedical care-
givers). One of the merits of this new paradigm is an improvement in post-surgical recovery
(not merely rapid or accelerated recovery, since this approach also signicantly reduces
postoperative morbidity in addition to decreasing hospital stay) (Enhanced Recovery after
Surgery or Fast-track Surgery) [69]. This new multimodal approach has demonstrated
the efcacy of certain measures (some of which are astonishingly simple) and of other
approaches that contradict enshrined decades-old surgical dogma. This is the subject of
our editorial.
Several hours of preoperative fasting continues to be the rule in everyday surgi-
cal practice despite the recommendations of Learned Societies based on a high level
of evidence [1012]. It has been proved that, unless there is a history or impaired
gastric emptying, pregnancy, diabetes, gastro-esophageal reux, or neurologic abnormal-
ity, patients can safely drink clear liquids until two hours before anesthesia induction
with no increased risk of aspiration [13]. Allowing the patient to continue to drink
avoids the sensation of thirst and reduces the anxiety that precedes all surgical
interventions. In addition, robust surgical evidence since the 1990s has shown that
preoperative glucose loading decreases postoperative insulin resistance with its conse-
quent deleterious catabolic state, a typical concomitant phenomenon of all abdominal
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2 Editorial
surgery [14]. Thus, in addition to the ingestion of water or
clear liquid tea or juices, the provision of glucose-rich oral
liquids on the eve of surgery and up to 2 hours before induc-
tion reduces insulin resistance by 50%; two meta-analyses
have also demonstrated reduction in the duration of post-
operative hospitalization for major elective abdominal cases
such as colorectal surgery [15,16]. We therefore have data
with a good level of evidence showing that the simple pro-
vision of preoperative glucose-rich oral liquids results in
improved patient comfort and a shorter duration of hospi-
talization.
On another level, postoperative ileus is the princi-
pal non-infectious complication after colorectal and other
abdominal surgery, causing patient discomfort, prolongation
of hospital stay and increased cost. Prevention of ileus is
an integral component of fast-track post-surgical protocols.
Several meta-analyses have shown that gum chewing after
surgery results in a reduction in postoperative ileus [17,18].
Here then is a simple method to decrease ileus and hospital
stay at minimal cost. There has even been a study of gum
chewing after laparoscopy [19]. Measurable benets seem to
be limited to laparotomy; the gain was not statistically sig-
nicant after laparoscopy in the most recent meta-analysis
[18].
And nally, we come to coffee. . . The promotility intesti-
nal effects of coffee have been demonstrated in healthy
subjects, but little has been published regarding its efcacy
after surgery. A randomized study has been recently pub-
lished on this subject [20]; in 80 patients who underwent
open or laparoscopic colectomy, return of intestinal tran-
sit occurred signicantly earlier (14 hours) in patients who
drank coffee, but there was no signicant decrease in hos-
pital stay (the number of patients necessary to demonstrate
statistical signicance for this endpoint was not calculated).
Unfortunately, there was no sub-group analysis of laparo-
tomy and laparoscopy patients. Further studies will be
necessary to conrm these results.
It is easy to see that the post-laparoscopy surgical rev-
olution is not uniquely surgical [21], but includes a
combination of medical measures; some of these are very
simple (no colonic preparation, preoperative oral glucose
loading, intraoperative warming, avoidance of nasogastric
tube, early postoperative feeding) while others are more
technically complex (epidural anesthesia). Of course, imple-
mentation of all these simple measures will not sufce to
prevent the severe surgical complications dreaded by all sur-
geons if the operative technique and perioperative conduct
of anesthesia are not also optimal.
Disclosure of interest
The author declares that he has no conicts of interest con-
cerning this article.
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K. Slim
Service de chirurgie digestive, CHU Estaing, 63003
Clermont-Ferrand, France
E-mail address: kslim@chu-clermontferrand.fr
2013 Elsevier Masson SAS. Tous droits rservs. - Document tlcharg le 15/03/2013 par UNIV CLERMONT - (261120)