Eur Surg Res , DOI: 10.

1159/000530124
Received: September 12, 2022
Accepted: March 6, 2023
Published online: March 20, 2023

Effects of preoperative oral carbohydrate loading on

Neutrophil/Lymphocyte Ratio and postoperative complications following
colorectal cancer surgery: a randomized controlled study
Rizvanović N, Nesek Adam V, Kalajdžija M, Čaušević S, Dervišević S, Smajić J

ISSN: 0014-312X (Print), eISSN: 1421-9921 (Online)

https://www.karger.com/ESR
European Surgical Research

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Effects of preoperative oral carbohydrate loading on neutrophil/lymphocyte ratio and postoperative
complications following colorectal cancer surgery: a randomised controlled study

Nermina Rizvanovića*, Višnja Nesek Adamc, Merlina Kalajdžijaa, Senada Čauševića, Senad Derviševićb, Jasmina
Smajićd

a
Department of Anaesthesiology, Resuscitation and Intensive Care, Cantonal Hospital Zenica, University of Zenica,
Faculty of Medicine, Zenica, Bosnia and Herzegovina
b
Department of Surgery, Cantonal Hospital Zenica, University of Zenica, Faculty of Medicine, Zenica, Bosnia and
Herzegovina
c
University Department for Anaesthesiology, Resuscitation and Intensive Care, Clinical Hospital Sveti Duh, Zagreb,
Faculty of Medicine J.J. Strossmayer, Osijek, Croatia
d
Clinic of Anaesthesiology, Resuscitation and Intensive Care, University Clinical Center Tuzla, University of Tuzla,
Faculty of Medicine, Tuzla, Bosnia and Herzegovina

Short Title: Preoperative carbohydrate drink, NLR and postoperative complications

Corresponding Author:
Nermina Rizvanović
Department of Anaesthesiology and Intensive Care Unit, Cantonal Hospital Zenica
The University of Zenica, Faculty of Medicine, Zenica, Bosnia and Herzegovina
67 Crkvice St, 72 000 Zenica, Bosnia and Herzegovina
Tel: 0038761806282
E-mail: rizvanovic.nermina@gmail.com

Number of Tables: 4
Number of Figures: 1
Word count: Abstract 249; Body text 2881

Keywords: Carbohydrate drink  Neutrophil-to-Lymphocyte  Postoperative complications  Colorectal surgery

Abstract
Introductionː Preoperative carbohydrate oral (CHO) drinks attenuate the surgical stress response; however, the
effects of CHO supplementation on the neutrophil-to-lymphocyte ratio (NLR) as an inflammatory and
immunology-based predictor remain unclear. This study evaluated the effects of preoperative CHO loading on
NLR values and complications following open colorectal surgery compared with a conventional fasting protocol.
Methodsː Sixty eligible participants having planned for routine and open colorectal cancer surgery from May 2020
to January 2022 were prospectively and randomly allocated to either the control (fasting) group, whose members
discontinued oral intake beginning the midnight before surgery, or the intervention (CHO), group, whose
members consumed a CHO solution the night before surgery and 2 h prior to anaesthesia. NLR was assessed at
06:00 h before surgery (baseline) and at 06:00 h on postoperative days 1, 3 and 5. The incidence and severity of
postoperative complications were assessed by Clavien-Dindo Classification up to postoperative day 30. All data
were analysed using descriptive statistics. Resultsː Postoperative NLR and delta NLR values were significantly
higher in controls (p < 0.001; p < 0.001). Control group participants also demonstrated grade IV (n = 5; 16.7%, p <
0.01) and grade V (n = 1; 3.3%, p < 0.313) postoperative complications. There were no major postoperative
complications in the CHO group. Discussion/Conclusion: Preoperative CHO consumption reduced postoperative
NLR values and the incidence and severity of postoperative complications following open colorectal surgery,
compared with a preoperative fasting protocol. Preoperative carbohydrate loading may improve recovery
following colorectal cancer surgery.

Introduction
Colorectal cancer (CRC) is the third most frequent cancer worldwide and the second leading cause of cancer
related deaths. CRC is usually diagnosed between the ages of 65 and 74 [1]. Surgery is the main treatment for
patients with CRC; however, the risk of postoperative complications increases with age. Cancer often worsens a
patient’s preoperative nutritional status, which can predict unfavourable postoperative outcomes. Long-term
preoperative fasting further affects patient’s catabolic state and activates a network of inflammatory pathways
even before surgical tissue damage [2]. Perioperative interventions established in the Enhanced Recovery After
Surgery (ERAS) protocol aim to optimise nutritional status and reduce postoperative complications. As part of the
ERAS programme, a preoperative carbohydrate oral (CHO) drink consumed the evening before surgery and 2 h
before anaesthesia is recommended to alleviate harmful metabolic and inflammatory stress responses to fasting
and surgery [3]. Despite strong evidence, preoperative CHO solutions are not routinely administered, even in
modern healthcare systems [4]. In Bosnia and Herzegovina, preoperative fasting remains the rule rather than the
exception.
The neutrophil-to-lymphocyte Ratio (NLR), calculated as the neutrophil count divided by the lymphocyte count,
represents the balance between the non-specific inflammatory response and adaptive immunity to various
stimuli [5]. Neutrophils release cytokines and chemokines and recruit effector cells during the systemic
inflammatory response (SIRS). Lymphocytes participate in antigen-specific host response. NLR can accurately
predict early-stage sepsis and metabolic syndrome [5, 6]. Postoperative neutrophilia and lymphopenia denote
immunosuppression and favour the development of postoperative complications [7]. Delta NLR (Δ NLR), the
dynamic change between pre- and postoperative NLR values, reflects the intensity of the immune-inflammatory
response elicited by surgery [8] and is negatively associated with overall survival in patients who undergo CRC
resection [9].
The magnitude of the postoperative stress response increases with surgical invasiveness. Open CRC surgery as a
model of major abdominal procedures amplifies SIRS, metabolic and immunological changes, potentially
increasing the likelihood of postoperative adverse events. The detrimental effects of prolonged fasting are
expected to be greater for patients undergoing CRC surgery compared to less-invasive (i.e. “minor”) procedures.
Preoperative CHO loading was more beneficial in CRC surgery than prolonged fasting or placebo. These benefits
encompassed postoperative insulin resistance, glucose, cortisol and triglyceride levels [10], length of hospital
stay, hand grip strength [11] and postoperative well-being [12]. However, there is a lack of evidence on the
impact of preoperative CHO on NLR as an inflammation and immune-status predictor after CRC surgery.
This study focused exclusively on one element of the ERAS pathway: the effects of preoperative CHO loading,
hopefully to increase awareness of the benefits of shortened preoperative fasting. We hypothesised that
preoperative CHO loading would reduce inflammation and improve immune function in patients, as assessed by
NLR after open CRC surgery. We compared changes in NLR values between patients randomly assigned to either
preoperative CHO loading or a conventional preoperative fasting protocol. We then compared the incidence and
severity of postoperative complications between the two groups.

Materials and Methods

Study Design, Sample Size and Setting
This study followed the Consolidated Standards of Reporting Trials (CONSORT) 2010 Statement: an updated
guideline for reporting parallel-group randomised controlled trials [13]. This prospective, single-centre, hospital-
based, parallel-group randomised, controlled trial was carried out between May 2020 and January 2022 in the
Department of Anaesthesiology, Intensive Care Unit and Department of Surgery at Cantonal Hospital in Zenica,
Bosnia and Herzegovina. The study included 60 patients, aged 18–70 years, diagnosed with CRC, scheduled for
elective open CRC surgery and with American Society of Anaesthesiologists (ASA) physical status of I–III.
Nutritional status was assessed preoperatively. Patients with a body mass index ≤20 or ≥30 kg/m2 and an overall
Nutritional Screening (NRS-2002) score ≥3 were considered to be at elevated nutritional risk and were excluded
from the study. We also excluded patients with recurrent CRC, metastatic disease, histories of emergency surgery,
preoperative radiotherapy or chemotherapy, diabetes mellitus, haematological disease, psychiatric illness,
systemic inflammation, immunomodulatory therapy, those with increased risk of gastric aspiration and those who
refused to participate in the study.
Since there were no previously published data on the effects of preoperative CHO drink on postoperative NLR
values, we conducted a pilot study with 10 patients per group to estimate the sample size. Postoperative NLR was
8.67 ± 4.98 in the control group versus 4.76 ± 2.83 in the CHO group. Power analysis with a 95% confidence
interval and power of 80% was used. Statistical significance was considered at p <0.05. Power analysis indicated
that 27 patients per group would be sufficient for detecting a clinically relevant difference of 3.91 and a standard
deviation of ±1.16 for the primary outcome. Assuming dropout, the sample size was 60 patients. G*Power 3.1.9.7
programme for Windows was used for analysis.
Randomisation and Intervention
Eligible patients were randomly allocated into one of two groups, 30 patients in each. Block randomisation was
used with a block size of six and a 1:1 group ratio. Computer-generated random numbers indicating group
assignment were sealed in opaque envelopes. The night before surgery, the nurse, who performed randomisation
and was blinded to the experimental protocol, opened the envelopes and managed patients according to the
group allocation. The anaesthesiologists, surgeons and the staff who collected the data did not participate in
other aspects of the trial and were blinded to the treatment allocation. In the fasting (control) group, patients
observed a conventional preoperative fasting protocol, consisting of stopping all oral intake beginning the
midnight before surgery. Patients assigned to the CHO group consumed 400 mL of a CHO solution (12.5%
carbohydrate: 10 g polysaccharides, 2.1 g sugars, and <0.025 g lactose per 100 mL; electrolytes: sodium 50 mg,
potassium 122 mg, chloride 6 mg, magnesium 1 mg, phosphorus 1 mg, calcium 6 mg per 100 mL; 240 mOsm/kg;
0.5 kcal/mL; pH 4.9; lemon-flavoured; Nutricia preOp solution; Nutricia, Zoetermeer, The Netherlands) at 22 h,
the night before surgery and 200 mL of the same solution, 2 h before anaesthesia induction, according to the
institutional protocol.
Anaesthesia Management
Open radical resection of CRC was performed in all patients under general endotracheal anaesthesia.
Thromboprophylaxis was started the night before surgery with low-molecular-weight heparin. Before
anaesthesia, a prophylactic dose of second-generation cephalosporin was administered. The anaesthesia regimen
was the same for both groups. Fentanyl 3 µg/kg, propofol 2–3 mg/kg and pancuronium-bromide 0.1 mg/kg was
used for anaesthesia induction. After endotracheal intubation, anaesthesia was maintained with sevoflurane at a
minimum alveolar concentration of 1 ‰ and 65% nitrous oxide in 35% oxygen at a flow rate of 3 L/min.
Intermittent bolus doses of fentanyl 50 µg and pancuronium 1 mg were added to maintain intraoperative
analgesia and muscle relaxation. Moderately liberal intraoperative fluid management with a balanced crystalloid
solution of 8–10 mL/kg/h was allowed. Fluid boluses (200 mL) and vasoactive drugs were given to ensure
hemodynamic variables of heart rate <100 bpm, MAP >65 mmHg, and urine output >0.5 mL/kg/h. Corticosteroids
were not administered during the surgery. A haematocrit value of 0.26 L/L was used to indicate the need for
blood transfusion. Postoperative analgesia was achieved with a combination of tramadol hydrochloride 100 mg
and paracetamol 1 g every 8 h during the first 24 h and later at the patient’s request. The postoperative fluid
replacement was approximately 25–30 mL/kg/day of balanced crystalloid solutions, considering the electrolyte
balance, the sufficient amount of glucose, ongoing losses and the patient’s condition. Early mobilisation was
encouraged.The timing of postoperative oral intake and removal of abdominal drainage tubes was determined by
surgeons. Patients who achieved pain control with an oral analgesic, acceptable postoperative oral intake, good
bowel motility, with no evidence of laboratory interferences (white blood cell (WBC) <10 × 109/L, neutrophils <7.5
× 109/L) or postoperative complications and able to independent mobilise were discharged from the hospital.
Outcome Measures and Definitions
Demographic and clinical data included: sex, age, body weight, body mass index, NRS-2002, Charlson Comorbidity
Index, ASA physical status class, tumour localisation, duration of surgery, intraoperative blood loss, intraoperative
transfusions and the length of postoperative hospital stay. The NRS-2002 was used to assess the patients’
preoperative nutritional statuses and predict malnutrition risk. The Charlson Comorbidity Index predicts10 y
mortality based on the patient’s comorbidities. The ASA classification system assessed patients’ functional and
physical fitness before anaesthesia and surgery.
The primary outcome was between-group differences in postoperative NLR and ΔNLR values. The NLR and ΔNRL
values were estimated using the WBC count with automated differential determination via fluorescence flow
cytometry. Peripheral venous blood samples were collected at 06:00 on the day of surgery (baseline) and
repeated at 06:00 on postoperative day 1 (POD1), 3 (POD3) and 5 (POD5). The NLR was calculated as the absolute
neutrophil count/the absolute lymphocyte count. ΔNRL was defined as the dynamic change from preoperative to
maximal postoperative NLR value and calculated as the maximal postoperative NLR value minus the preoperative
NLR value.
The secondary outcome was between-group differences in the incidence and severity of postoperative
complications. Postoperative complications were graded for incidence and severity, up to postoperative day 30
(POD30), using the Clavien-Dindo Classification of Surgical Complications. Grade I (requires additional monitoring
without medication) and grade II (requires pharmacological treatment) were considered minor complications.
Grade III (IIIa requires endoscopic or radiological intervention; IIIb requires surgical intervention), grade IV
(requires intensive care treatment) and grade V (death of a patient) were considered major complications. After
discharge, patients were called by phone weekly and on POD30.
We assessed the number of patients with complications, number of patients without complications, number of
patients with one, two or more than two complications and readmission rate by POD30.
Statistical Analysis
Data distribution normality was confirmed using the Kolmogorov-Smirnov test. Qualitative variables are
presented as frequencies and compared using Pearson’s x2 test. Quantitative variables are presented as means ±
standard deviations and tested using Student’s t test and Levene’s Test for equality of variances for repeated
measurements. Statistical significance was considered at p <0.05. Statistical analysis was performed using the
Statistical Package for the Social Sciences (SPSS v23.0; IBM Corp., Armonk, NY, USA).

Results
All 60 patients completed the study, and data were analysed on an intent-to-treat basis (Fig. 1). The groups were
homogeneous and comparable at baseline with no significant between-group differences in demographic and
surgical data. The length of postoperative hospital stay was 9.86 ± 3.47 in the control group versus 7.61 ± 2.34 in
the CHO group (p < 0.01) (Table 1).
Preoperative mean WBC, neutrophil, lymphocyte and NLR values did not significantly differ between the groups.
Significantly higher mean WBC (p < 0.001), neutrophil (p < 0.001) and NLR (p < 0.001) values, and significantly
lower mean lymphocytes values (p < 0.001) were noted in the control group during the postoperative period.
Postoperatively, mean WBC and neutrophil values increased in both groups, peaking on POD1 then declining.
Neutrophils peaked at 12.39 ± 1.40 in the control group versus 9.50 ± 1.16 in the CHO group. Leukocytosis and
neutrophilia receded on POD3 in the CHO group; meanwhile, the control group never returned to baseline.
Postoperative lymphopenia was documented on POD1 in the control group. The lowest lymphocyte value in the
CHO group was registered on POD1; however, there was no lymphopenia. The CHO group returned to baseline on
POD3; the control group never returned to baseline.
Postoperative NLR values increased in both groups, peaking on POD1; 9.47 ± 1.06 in the control group versus 5.34
± 0.69 in the CHO group. Although NLR values eventually declined in both groups, there was no return to baseline.
The ΔNRL value was 7.97 ± 0.28 in the control group versus 3.15 ± 0.11 in the CHO group (p < 0.001) (Table 2).
Thirty-seven postoperative complications were registered in the control group versus five in the CHO group (p <
0.01). Significantly higher incidence of Clavien-Dindo grade I (p < 0.015), II (p < 0.002), III (p < 0.01) and IV (p <
0.01) complications were seen in the control group. Minor postoperative complications (grades I–II) were
registered in the CHO group. Minor and major complications (grades I–V) were recorded in the control group.
Two patients in the control group required reoperation: one due to ileus and the other due to anastomosis
leakage. Both patients were admitted to the intensive care unit and mechanically ventilated. One patient with an
anastomosis leakage suffered multi-organ failure and died (Table 3).
There were 43.3% of patients with complications in the control group and 16.7% in the CHO group (p < 0.01).
Group characteristics for postoperative complications are summarised in Table 4.

Discussion
CRC surgery interrupts complete enteral intake postoperatively and activates demanding endocrine and immune
changes. The ongoing metabolic response results in insulin resistance (IR), hyperglycaemia, glycogenolysis, and
gluconeogenesis [14]. Surgical trauma stimulates WBC and endothelial cells to release proinflammatory cytokines
that disrupt insulin signalling pathways, potentiating SIRS and predisposing postoperative complications [15].
Conventional preoperative fasting aims to minimise the risk of pulmonary aspiration but increases catabolic shift
and acute-phase inflammatory markers [16]. Evidence suggests the beneficial effects of preoperative CHO loading
on reducing IR [10] and cytokine levels [17] and improving bowel function [18]; however, the impact of
preoperative CHO loading on postoperative NLR as an inflammatory and immunology-based predictor remains
unclear.
Consumption of a preoperative CHO drink resulted in significantly lower postoperative NLR values compared to
controls. NLR is a simple, inexpensive parameter accessible from the WBC differential count. Postoperative
changes in WBC, leucocytosis, neutrophilia and lymphopenia are expected on POD1, caused by the activities of
endogenous cortisol, catecholamines and cytokines in response to surgery, anaesthesia and bleeding [19]. In the
control group, leucocytosis and neutrophilia persisted at all observed time points. Lymphopenia lasted until POD3
with resultant increases in postoperative NLR. In the CHO group, leucocytosis and neutrophilia receded until
POD3, while lymphopenia was not registered, so the postoperative NLR was significantly lower in the CHO group
compared to controls. These findings indicate an attenuated inflammatory response and preserved cell-mediated
immune function after CHO treatment. Increased NLR is significantly associated with IR [20] and can predict
postoperative complications from CRC surgery [21].
ΔNRL reflects the intensity of the immune-inflammatory response elicited by surgery [8]. In this study,
preoperative CHO treatment decreased ΔNLR by more than half compared to the control group. Cytokines
released during surgery activate multiple inflammatory cells. IL-6 has been identified as a B-cell differentiation
factor. TNF-α and IL-8 activate neutrophils, monocytes, macrophages and CD4 T lymphocytes resulting in cell
recruitment, chemotaxis, proliferation, adhesion and microvascular disturbances [22]. Hu et al. found that
administration of a preoperative CHO drink decreased IL-6, IL-8 and TNF levels suggesting an immune-
inflammatory effect [17]. The researchers reported that preoperative CHO loading preserved preoperative levels
of human leukocyte antigen (HLA)-DR expression on monocytes after surgery. Meanwhile, preoperative fasting
reduced HLA-DR expression [23].
Consumption of a preoperative CHO drink significantly reduced the incidence and severity of postoperative
complications after open CRC surgery compared to controls. The reported rate of postoperative complications in
CRC surgery is 10–37% [24]. In this study, the rate was 43.3% in the control group and 16.7% in the CHO group.
Many factors associated with the incidence of postoperative complications were controlled by sampling criteria.
Our patients’ demographic and surgical data were very similar at baseline, with preoperative fasting being the
main between-group difference. The deleterious consequences of prolonged preoperative fasting are well
recognised. Bicudo-Salomão et al. reported that a shortened preoperative fasting period of <4 h reduced the risk
of postoperative complications [25]. Another study showed that preoperative CHO administration reduced the
incidence of wound infections and paralytic ileus after CRC surgery [10]. In contrast, a meta-analysis by Awad et
al. found that preoperative CHO loading had no effect on postoperative complications [26]. Importantly, the
subgroup analysis revealed the studies to be heterogeneous in terms of the type and magnitude of surgical
procedures, type and timing of CHO intervention, anaesthesia technique, definition of postoperative
complications and follow-up duration.
Preoperative fasting and surgery trigger postoperative IR and hyperglycaemia and expose insulin-independent
cells (e.g. neurons, immunocytes, renal, endothelial and blood cells) to glucotoxicity, mitochondrial dysfunction,
oxygen free radicals and cytokines, causing complications [27]. Preoperative CHO loading is an effective method
to maintain postoperative normoglycaemia [28] stimulating the phosphatidylinositol-3 kinase/protein kinase B
(PI3K/PKB) pathways that improve entry of pyruvate into the Krebs citrate cycle and govern the interplay
between metabolic and anti-inflammatory insulin pathways [29]. In addition, preoperative CHO supplementation
alleviates the metabolic and inflammatory stress response to fasting and surgery, thus accelerating clinical
recovery.
The present study reinforces prior evidence as to the benefits of shortened preoperative fasting. Our
homogeneous study sample, simple intervention and limited focus on patients undergoing open CRC surgery are
study strengths, we would like to highlight.
There are some limitations to our research. This single-centre study had a relatively small sample size, and further
multi-centre investigations are needed to validate our findings. Study participants were not blinded due to the
nature of the evaluated intervention. Although patients with recurrent CRC, metastatic disease, preoperative
radiotherapy or chemotherapy were not included in the sample, we did not assess tumour stages.
In conclusion, a shortening preoperative fasting time and consuming a CHO drink the evening before elective
open CRC surgery and 2 h before anaesthesia reduced postoperative NLR values, ΔNLR value and the incidence
and severity of postoperative complications. Preoperative CHO loading may improve outcomes following CRC
surgery.

Statement of Ethic
This a prospective, randomized, controlled trial was approwed by the Ethics Committee of the Cantonal Hospital
Zenica (aproval number: 00-03-35-1487-11/20) and registered in ClinicalTrials.gov (number: NCT05301985). All
study procedures were in accordance with the ethical standards of the Declaration of Helsinki. The study report
adheres to the applicable CONSORT guidelines. A voluntary written informed consent was obtained from each
patient before enrollment in the study.

Conflict of Interest Statement

The authors have no related conflicts of interest to declare.

Funding Sources
No funding was received for this study.

Author Contributions Statement

Nermina Rizvanović and Višnja Nesek Adam contributed to the conception and design of the study, the
acquisition, analysis and interpretation of the data, writing first draft of the manuscript and revision. Merlina
Kalajdžija, Senada Čaušević, Senad Dervišević and Jasmina Smajić gave substantial contributions to patient
recruitment, data collection and analysis, and manuscript revision. All authors read and approved the final version
of manuscript. This manuscript is not being considered by any other journal.

Data Availability Statement

All data generated or analyzed during this study are included in this article. Further enquiries can be directed to
the corresponding autor.

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10.1159/000505515

Fig. 1. Study flowchart diagram.

Table 1. Demographic profile, nutritional status and clinical parameters of the participants
Fasting group CHO group p value
(n = 30) (n = 30)
Sex, n (%) 0.795a
Male 16 (53.3) 17 (56.7)
Female 14 (46.7) 13 (43.3)
Age, years (mean ± SD) 59.93±9.31 60.90±6.80 0.648b
Body weight, kg (mean ± SD) 79.31±7.82 82.41±4.26 0.562b
BMI, kg/m2 (mean ± SD) 24.70±1.68 23.56±1.51 0.873b
NRS-2002, n (%) 0.605a
I 17 (56.7) 15 (50)
II 13 (43.3) 15 (50)
ASA, n (%) 0.948a
I 9 (30) 8 (26.7)
II 10 (33.3) 11(36.7)
III 11(36.7) 11 (36.7)
CCI (mean ± SD) 3.95±2.29 4.29±2.93 0.696b
Tumor localisation n (%) 0.953a
Colon 9 (30) 10 (33.3)
Rectum 12 (40) 11 (36.7)
Rectosygmoid 9 (30) 9 (30)
Duration of surgery, minutes 141.40±28.32 153.20±36.59 0.814b
(mean ± SD)
Blood loss, mL (mean ± SD) 230.46±61.13 205.34±43.20 0.307 b
Blood transfusions n (%) 8 (26.7) 7 (23.3) 0.554 b
Postoperative hospital stay, days 9.86±3.47 7.61±2.34 0.01b
(mean ± SD)
p value <0.05 considered statistically significant; a, p values according x2 test; b, p values according t test; CHO, preoperative
carbohydrate loading group; SD, standard deviation; BMI, Body Mass Index; NRS-2002, Nutrition Risk Score-2002; ASA,
American Society of Anesthesiologists; CCI, Charlson Comorbidity Index.
Table 2. Hematological parameters and their changes after surgery with time
Time Fasting group CHO group p value p*value
(n = 30) (n = 30)
WBC, x109/L Preop 6.55±4.59 6.44±2.23 0.276 0.533
(mean ± SD) POD1 15.23±1.71 11.81±1.43 0.001 0.000
POD3 12.59±1.42 9.90±1.35 0.001 0.01
POD5 10.91±1.22 8.22±1.17 0.001 0.05
Neutrophil, x109/L Preop 3.64±0.32 3.71±0.14 0.760 0.486
(mean ± SD) POD1 12.38±1.40 9.50±1.16 0.001 0.001
POD3 10.07±1.11 7.31±1.07 0.001 0.05
POD5 8.72±0.96 5.19±0.59 0.001 0.006
Lymphocyte, x109/L Preop 2.08±0.18 2.12±0.14 0.489 0.355
(mean ± SD) POD1 1.31±0.39 1.77±0.91 0.001 0.000
POD3 1.53±0.57 2.15±0.95 0.001 0.001
POD5 1.82±0.53 2.38±0.10 0.001 0.006
NLR Preop 1.80±0.30 1.89±0.15 0.921 0.565
(mean ± SD) POD1 9.47±1.06 5.34±0.69 0.001 0.01
POD3 6.55±0.69 3.72±0.48 0.001 0.03
POD5 4.78±0.52 2.22±0.19 0.001 0.03
Delta NLR 7.97±0.28 3.15±0.11 0.001 0.001
(mean ± SD)
p value <0.05 considered statistically significant according t test; p* value <0.05 considered statistically significant according
ANOVA; CHO, preoperative carbohydrate loading group; WBC, white blood cell; SD, standard deviation; Preop, 06:00 h on
the day of surgery; POD1, 06:00 h on postoperative day 1; POD3, 06:00 h on postoperative day 3; POD5, 06:00 h on
postoperative day 5; NLR, neutrophil-to-lymphocyte ratio.
Table 3. Postoperative complications based on Clavien-Dindo classification
Fasting group CHO group p value
(n = 30) (n = 30)
Grade I, n (%) 11 (36.7) 3 (10) 0.015
Elevated serum creatinine 8 (26.7) 2 (6.7) 0.03
Confusion 3 (10) 1 (3.3) 0.68
Grade II, n (%) 15 (50) 2 (6.7) 0.002
Pneumonia 6 (20) 1 (3.3) 0.05
Delirium 4 (13.3) 0 (0) 0.05
Uroinfection 2 (6.7) 1 (3.3) 0.554
Wound infection 2 (6.7) 0 (0) 0.150
Deep vein thrombosis 1 (3.3) 0 (0) 0.313
Grade III, n (%) 5 (16.7) 0 (0) 0 01
Anastomotic leakage 1 (3.3) 0 (0) 0.313
Ileus 1 (3.3) 0 (0) 0.313
Abdominal wall dehiscence 1 (3.3) 0 (0) 0.313
Reoperation 2 (6.7) 0 (0) 0.150
Grade IV, n (%) 5 (16.7) 0 (0) 0.01
Respiratory failure 2 (6.7) 0 (0) 0.150
Renal failure 1 (3.3) 0 (0) 0.313
Septic schock 1 (3.3) 0 (0) 0.313
Multi-organ failure 1 (3.3) 0 (0) 0.313
Grade V, n (%) 1 (3.3) 0 (0) 0.313
Death of patient 1 (3.3) 0 (0) 0.313
p value <0.05 considered statistically significant according x2 test; CHO, preoperative carbohydrate loading group.
Table 4. Frequency of postoperative complications
Fasting group CHO group p value
(n = 30) (n = 30)
Patients with complications, n (%) 13 (43.3) 5 (16.7) 0.01
Patients without complications, n (%) 17 (56.7) 25 (83.3) 0.01
Patients with 1 complication, n (%) 7 (23.4) 3 (10.0) 0.05
Patients with 2 complications, n (%) 8 (26.7) 2 (6.7) 0.01
Patients with >2 complications, n (%) 2 (6.7) 0 (0) 0.150
Readmission rate within 30 days, n (%) 0 (0) 0 (0) /
2
p value <0.05 considered statistically significant according x test; CHO, preoperative carbohydrate loading group.