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The American Society of Anesthesiologists no longer recommends long fasts before surgery.
Research shows benefits from drinking a clear, carbohydrate-rich beverage 2 to 3 hours before surgery instead of a long fast.1Tebala GD, Gordon-Dixon A, Imtiaz M, Shrestha A, Toeima M. Enhanced recovery after rectal surgery: what we have learned so far. Mini-invasive Surgery. 2018;2:32.
- Improved insulin resistance, less nitrogen and protein loss, and shorter hospital stays after colorectal surgery among people given a clear, carbohydrate-rich beverage before midnight and 2 to 3 hours before surgery compared to no nutrition in a consensus review2Lassen K, Soop M et al. Enhanced Recovery After Surgery (ERAS) Group. Consensus review of optimal perioperative care in colorectal surgery: Enhanced Recovery After Surgery (ERAS) Group recommendations. Archives of Surgery. 2009 Oct;144(10):961-9; Ljungqvist J. Insulin resistance in surgery. Cirugía y Cirujanos. 2016;84(Supl 1):51-54.
- Less severe mouth dryness, thirst, hunger, pain, and insulin resistance (HOMA-IR), plus shorter hospitalization among adult surgical patients treated with oral carbohydrate before surgery compared to fasting in a meta-analysis of 57 RCTs3Cheng PL, Loh EW, Chen JT, Tam KW. Effects of preoperative oral carbohydrate on postoperative discomfort in patients undergoing elective surgery: a meta-analysis of randomized controlled trials. Langenbeck’s Archive of Surgeries. 2021 Jun;406(4):993-1005.
- Lower inflammatory response mediators; lower patient self-reported symptom burdens of thirst, hunger, anxiety, and nausea; faster gastrointestinal function return; and shorter hospital stays with liver resection (hepatectomy) among elderly people with hepatocellular carcinoma treated with oral carbohydrate before surgery and early oral feeding after surgery compared to conventional fasting in a mid-sized RCT4Feng J, Xu R et al. Effects of preoperative oral carbohydrate administration combined with postoperative early oral intake in elderly patients undergoing hepatectomy with acute-phase inflammation and subjective symptom burden: a prospective randomized controlled study. Asian Journal of Surgery. 2022 Jan;45(1):386-395.
- Lower insulin resistance, higher insulin sensitivity, better prognosis scores, and a lower marker of inflammation (IL-6), but a lower score of well-being, among people undergoing open colorectal surgery treated with oral carbohydrate before surgery compared to fasting in a small RCT5Rizvanović N, Nesek Adam V, Čaušević S, Dervišević S, Delibegović S. A randomised controlled study of preoperative oral carbohydrate loading versus fasting in patients undergoing colorectal surgery. International Journal of Colorectal Disease. 2019 Sep;34(9):1551-1561.
- No significant differences in side effects or recovery, but more nighttime urinations and less sleep time before radical gastrectomy among people with gastric cancer given a double dose of oral carbohydrates before surgery compared to a single dose in a mid-sized RCT6Chen X, Li K et al. Effects of preoperative oral single-dose and double-dose carbohydrates on insulin resistance in patients undergoing gastrectomy:a prospective randomized controlled trial. Clinical Nutrition. 2021 Apr;40(4):1596-1603.
Pain control during surgery
The type of anesthesia and pain control you use can affect many outcomes:
- Your experience of pain
- Your risk for infection
- Your appetite
- Your ability to urinate or have a bowel movement
- Your risk of cancer recurrence (limited data)
Every person is different, and your pain control needs to be tailored to your situation and needs. We strongly encourage you to explore all pain-management options with your surgeon and anesthesiologist. Then make choices that fit your situation and goals.
Pain is one of the main contributors to the stress response during surgery—especially major surgery. The experience of pain can promote the release of stress hormones. A longer stress response after surgery is linked to worse outcomes, such as stress-related insulin resistance, greater risk of functional decline after surgery, and impaired organ function.7Tebala GV, Gordon-Dixon A, Imtiaz M, Shrestha A, Toeima M. Enhanced recovery after rectal surgery: what we have learned so far. Mini-invasive Surgery. 2018;2:32; Minnella EM, Carli F. Prehabilitation and functional recovery for colorectal cancer patients. European Journal of Surgical Oncology. 2018;44(7):919-926.
But on the other side of this equation, some types of anesthetic drugs and delivery methods are linked to higher risk of recurrence.8Biki B, Mascha E et al. Anesthetic technique for radical prostatectomy surgery affects cancer recurrence: a retrospective analysis. Anesthesiology. 2008 Aug;109(2):180-7; Brand JM, Kirchner H, Poppe C, Schmucker P. The effects of general anesthesia on human peripheral immune cell distribution and cytokine production. Clinical Immunology and Immunopathology. 1997 May;83(2):190-4. A balance between pain control benefits and risks is the goal. We encourage controlling pain with the safest and most effective methods available in each situation.
Medications to manage pain
Examples of pain-control options during surgery, sometimes started before surgery:
- Continuous surgical wound infiltration with local anesthetics: local anesthetic medication is pumped into the surgical site
- Multimodal pain management protocol: an approach using non-opioid analgesic techniques is an integral component of enhanced recovery after surgery protocols described on Preparing for surgery ›
- Local nerve blocks, a direct injection in a nerve or space around a nerve to block pain:
- Transversus abdominis plane block (TAP): a nerve injection designed to anesthetize the nerves in your abdominal wall. This can be helpful if you are going to have an incision on your abdomen.
- Quadratus lumborum block (QLB): a variant of the transversus abdominis plane block (TAP) (above) to anesthetize the posterior (back) abdominal wall
- Neuraxial anesthesia: an anesthetic is injected near the spinal cord
- Ketorolac: a nonsteroidal anti-inflammatory drug (NSAID) that is given intravenously
- Oral medications: opioids, NSAIDs such as Motrin, acetaminophen (Tylenol), and other medications; be sure to ask your team about the purpose of any medication you are given and its side effects.
Pain control: connection to survival and reducing cancer proliferation or recurrence
Preliminary evidencesignificant effects in small or poorly designed clinical studies OR conflicting results in adequate studies but a preponderance of evidence of an effect (this is the CancerChoices definition; other researchers and studies may define this differently) of lower risk of recurrence among men with prostate cancer treated with epidural analgesia compared to opioids in addition to general anesthesia
Insufficient and conflicting evidencepreclinical evidence only OR clinical studies with such poor or unclear methodology that no conclusion can be drawn OR conflicting findings across clinical studies with no preponderance of evidence in one direction; conflicting evidence occurs when studies find conflicting effects (positive effect vs no effect or negative effect) with the same treatment and the same general study population (same cancer type, for example) (this is the CancerChoices definition; other researchers and studies may define this differently) of any effect on recurrence or survival after surgery among people, mostly with cancer, treated with regional anesthesia (epidural, paravertebral blocks, neuraxial anesthesia)
Our note: regional anesthesia is not linked to worse outcomes other than one report of higher risk of low blood pressure during surgery.
- 57% lower risk of biochemical cancer recurrence among men with prostate cancer undergoing surgery using epidural plus general anesthesia compared to general anesthesia plus opioids in an observationala type of study in which individuals are observed or certain outcomes are measured, but no attempt is made to affect the outcome (for example, no treatment is given); an example is a study that records people’s diets, but doesn’t try to alter their diets, and looks for patterns of disease or other outcomes related to different foods study9Biki B, Mascha E et al. Anesthetic technique for radical prostatectomy surgery affects cancer recurrence: a retrospective analysis. Anesthesiology. 2008;109(2):180-187.
- No evidence of an effectoverall, one or more studies did not demonstrate that a treatment or intervention led to an expected outcome; this does not always mean that there is no effect in clinical practice, but that the studies may have been underpowered (too few participants) or poorly designed. Larger, well-designed studies provide more confidence in making assessments. on survival (cancer-specific, overall, recurrence-free, or event-free) after major noncardiac thoracic or abdominal surgeries among people treated with combined epidural-general anesthesia with postoperative epidural analgesia compared to general anesthesia alone with postoperative intravenous analgesia in a large RCTrandomized controlled trial, a study design in which people are randomly assigned to either an experimental group or a control group to compare the outcomes from different treatments; an RCT is considered a strong design for determining a therapy’s effects10Du YT, Li YW et al; Peking University Clinical Research Program Study Group. Long-term survival after combined epidural-general anesthesia or general anesthesia alone: follow-up of a randomized trial. Anesthesiology. 2021 Aug 1;135(2):233-245.
- No evidence of an effect on recurrence, incisional pain, or neuropathic pain over 36 months after potentially curative primary breast cancer resections among women younger than 85 years treated with regional anesthesia-analgesia (paravertebral blocks and propofol) compared to general anaesthesia (sevoflurane) and opioid analgesia in a large RCT11Sessler DI, Pei L et al; Breast Cancer Recurrence Collaboration. Recurrence of breast cancer after regional or general anaesthesia: a randomised controlled trial. Lancet. 2019 Nov 16;394(10211):1807-1815.
- No evidence of an effect on survival (recurrence-free, overall, or cancer-specific)over 32 months after lung cancer surgery, although a higher risk of low blood pressure (hypotension) during surgery. among people treated with combined epidural-general anesthesia and epidural analgesia compared to general anesthesia and intravenous opioid analgesia in a mid-sized RCT12Xu ZZ, Li HJ et al. Epidural anesthesia-analgesia and recurrence-free survival after lung cancer surgery: a randomized trial. Anesthesiology. 2021 Sep 1;135(3):419-432.
- No evidence of an effect on recurrence-free survival or biochemical recurrence-free survival after surgery among people treated with regional anesthesia compared to general anesthesia in a meta-analysisa statistical analysis that combines the results of two or more research studies; the results of smaller research studies addressing the same or similar questions can be analyzed as though they are one bigger, more powerful study of 28 clinical trials13Grandhi RK, Lee S, Abd-Elsayed A. The relationship between regional anesthesia and cancer: a metaanalysis. Ochsner Journal. 2017 Winter;17(4):345-361.
- No evidence of an effect on recurrence and metastasis of cancer as a whole or colorectal cancer after surgery, although lower risks among people with prostate cancer or with risk within 2 years of surgery, among people with cancer treated with general-epidural anesthesia compared to general anesthesia in a meta-analysis of 10 observationala type of study in which individuals are observed or certain outcomes are measured, but no attempt is made to affect the outcome (for example, no treatment is given); an example is a study that records people’s diets, but doesn’t try to alter their diets, and looks for patterns of disease or other outcomes related to different foods studies14Pei L, Tan G et al. Comparison of combined general-epidural anesthesia with general anesthesia effects on survival and cancer recurrence: a meta-analysis of retrospective and prospective studies. PLoS One. 2014 Dec 30;9(12):e114667.
- Better overall survival mostly with colorectal cancer, and better recurrence-free survival after cancer surgery among people treated with neuraxial anesthesia either combined with or without general anesthesia compared to no neuraxial anesthesia in a meta-analysis of 21 clinical trials15Weng M, Chen W et al. The effect of neuraxial anesthesia on cancer recurrence and survival after cancer surgery: an updated meta-analysis. Oncotarget. 2016 Mar 22;7(12):15262-73.
- No evidence of an effect on biochemical recurrence-free survival, although better overall survival among studies reporting propensity score matching, after radical prostatectomy among people treated with neuraxial anesthesia/analgesia compared to other pain management approaches in a large meta-analysis of 10 clinical trials16Lee BM, Singh Ghotra V et al. Regional anesthesia/analgesia and the risk of cancer recurrence and mortality after prostatectomy: a meta-analysis. Pain Management. 2015 Sep;5(5):387-95.
Preliminary (conflicting) evidence of better survival with either total intravenous anesthesia (TIVA) or regional anesthesia compared to volatile anesthetics
- Better overall survival, but not recurrence-free survival with propofol-based total intravenous anesthesia (TIVA) during cancer surgery compared to volatile anesthetics in meta-analyses of 1917Chang CY, Wu MY et al. Anesthesia and long-term oncological outcomes: a systematic review and meta-analysis. Anesthesia & Analgesia. 2021 Mar 1;132(3):623-634. and 1018Yap A, Lopez-Olivo MA, Dubowitz J, Hiller J, Riedel B; Global Onco-Anesthesia Research Collaboration Group. Anesthetic technique and cancer outcomes: a meta-analysis of total intravenous versus volatile anesthesia. Canadian Journal of Anesthesia/Journal canadien d’anesthésie. 2019 May;66(5):546-561. Erratum in: Canadian Journal of Anesthesia. 2019 Aug;66(8):1007-1008. observational studies
- No clear evidence that the use of regional analgesia is associated with improved recurrence-free survival or overall survival in people with gastrointestinal cancer in a review of observational studies19Cata JP, Hernandez M, Lewis VO, Kurz A. Can regional anesthesia and analgesia prolong cancer survival after orthopaedic oncologic surgery? Clinical Orthopaedics and Related Research. 2014 May;472(5):1434-41.
Better survival among people with breast cancer, kidney cancer, or lung cancer treated with ketorolac around the time of surgery (preliminary evidencesignificant effects in small or poorly designed clinical studies OR conflicting results in adequate studies but a preponderance of evidence of an effect (this is the CancerChoices definition; other researchers and studies may define this differently))
Pain control: connection to body terrain
Preliminary evidencesignificant effects in small or poorly designed clinical studies OR conflicting results in adequate studies but a preponderance of evidence of an effect (this is the CancerChoices definition; other researchers and studies may define this differently) of lower stress responses and pain among people with esophageal cancer receiving TEA-IVA, TIVA, or PCIA during surgery
- Slower increase in cortisol levels during open thoracotomy among people with esophageal cancer receiving thoracic epidural anesthesia with intravenous general anesthesia (TEA-IVA) compared to TIVA in a mid-sized RCTrandomized controlled trial, a study design in which people are randomly assigned to either an experimental group or a control group to compare the outcomes from different treatments; an RCT is considered a strong design for determining a therapy’s effects20Li Y, Dong H, Tan S, Qian Y, Jin W. Effects of thoracic epidural anesthesia/analgesia on the stress response, pain relief, hospital stay, and treatment costs of patients with esophageal carcinoma undergoing thoracic surgery: a single-center, randomized controlled trial. Medicine (Baltimore). 2019 Feb;98(7):e14362.
- Lower surgical stress response and less pain after surgery among people undergoing elective radical esophagectomy with total intravenous anesthesia (TIVA) combined with thoracic epidural anesthesia and analgesia compared to TIVA alone in a small RCT21Wang J, Yin Y et al. Thoracic epidural anaesthesia and analgesia ameliorates surgery-induced stress response and postoperative pain in patients undergoing radical oesophagectomy. Journal of International Medical Research. 2019 Dec;47(12):6160-6170.
- Quicker return to baseline plasma cortisol levels after open thoracotomy among people with esophageal cancer treated with patient-controlled epidural analgesia compared to patient-controlled intravenous analgesia in a mid-sized RCT22Li Y, Dong H, Tan S, Qian Y, Jin W. Effects of thoracic epidural anesthesia/analgesia on the stress response, pain relief, hospital stay, and treatment costs of patients with esophageal carcinoma undergoing thoracic surgery: a single-center, randomized controlled trial. Medicine (Baltimore). 2019 Feb;98(7):e14362.
Keep reading about integrative approaches to surgery