Enhanced Recovery after Surgery Carbohydrate Loading Does Not Increase Aspiration Risk in Bariatric Patients

Abstract

INTRODUCTION: Enhanced recovery after surgery (ERAS) pathways have been developed to improve perioperative outcomes; however, there is ongoing concern for aspiration with recent oral intake in obese patients, who may be predisposed to impaired gastrointestinal motility and greater gastric volume. We aim to study the safety of preoperative carbohydrate loading before bariatric surgery. METHODS: Data was collected prospectively from patients undergoing primary bariatric surgery. All bariatric patients at our institution undergo a screening preoperative esophagogastroduodenoscopy (EGD) before operation with a traditional 8-hour fast (NOCARB), followed by an intraoperative day-of-surgery EGD with carbohydrate loading (CARB) 2 to 4 hours before incision. Gastric volume and pH were measured after being endoscopically suctioned via direct visualization during both settings. RESULTS: We identified 121 patients: 64 patients (52.9%) in the CARB group, and 57 patients (47.1%) in the NOCARB group. The patients were 81.1% female with a mean age of 43 years (range 19 to 71) and average BMI of 41.9 kg/m2. CARB patients had lower gastric volume with a mean of 15.7 vs 41.8 mL in the NOCARB patients (p = 0.0084). There was no significant difference in pH between the 2 groups, 3.9 CARB vs 3.4 NOCARB (p = 0.25). Subset analysis of 18 patients who had measurements on both screening and intraoperative EGD revealed lower gastric volume in CARB patients (14.4 vs 57.8 mL, p = 0.085). CONCLUSION: Preoperative carbohydrate loading 2 to 4 hours before bariatric surgery does not increase aspiration risk based on gastric volume and pH and should be the standard of care in all eligible bariatric patients.