The Metabolic Stress Response and Enhanced Recovery

  • Olle Ljungqvist
Part of the Enhanced Recovery book series (ER)


Injury and surgery immediately cause a series of stress responses in the body. The most important reactions involve the release of stress hormones and cytokines. The level of these reactions is related to the amount of stress inflicted. With greater stress, increasingly stronger reactions cause more marked catabolic reactions. Central to all these reactions is the loss of the normal anabolic actions of insulin, i.e., the development of insulin resistance [1]. Excessive catabolic reactions are generally not beneficial for the body and a state of catabolism continuously breaks down muscle tissue and prolongs recovery. Hence a key aspect of enhancing recovery after surgery is related to minimising the negative metabolic effects by reducing the catabolic responses and having the patient return to a balanced metabolism again.


Insulin Resistance Bowel Preparation Surgical Stress Elective Colorectal Surgery Catabolic Response 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Thorell A, Nygren J, Ljungqvist O. Insulin resistance: a marker of surgical stress. Curr Opin Clin Nutr Metab Care. 1999;2(1):69–78.PubMedCrossRefGoogle Scholar
  2. 2.
    Brandi LS et al. Insulin resistance after surgery: normalization by insulin treatment. Clin Sci (Lond). 1990;79(5):443–50.Google Scholar
  3. 3.
    Brownlee M. The pathobiology of diabetic complications: a unifying mechanism. Diabetes. 2005;54(6):1615–25.PubMedCrossRefGoogle Scholar
  4. 4.
    Witasp A et al. Increased expression of inflammatory pathway genes in skeletal muscle during surgery. Clin Nutr. 2009;28(3):291–8.PubMedCrossRefGoogle Scholar
  5. 5.
    Wang ZG et al. Randomized clinical trial to compare the effects of preoperative oral carbohydrate versus placebo on insulin resistance after colorectal surgery. Br J Surg. 2010;97(3):327–38.CrossRefGoogle Scholar
  6. 6.
    Witasp A et al. Expression of inflammatory and insulin signaling genes in adipose tissue in response to elective surgery. J Clin Endocrinol Metab. 2010;95(7):3460–9.PubMedCrossRefGoogle Scholar
  7. 7.
    Gore DC et al. Hyperglycemia exacerbates muscle protein catabolism in burn-injured patients. Crit Care Med. 2002;30(11):2438–42.PubMedCrossRefGoogle Scholar
  8. 8.
    van den Berghe G et al. Intensive insulin therapy in the critically ill patients. N Engl J Med. 2001;345(19):1359–67.PubMedCrossRefGoogle Scholar
  9. 9.
    Krinsley JS. Effect of an intensive glucose management protocol on the mortality of critically ill adult patients. Mayo Clin Proc. 2004;79(8):992–1000.PubMedCrossRefGoogle Scholar
  10. 10.
    Gustafsson UO et al. Haemoglobin A1c as a predictor of postoperative hyperglycaemia and complications after major colorectal surgery. Br J Surg. 2009;96(11):1358–64.PubMedCrossRefGoogle Scholar
  11. 11.
    Nygren J, Nair KS. Differential regulation of protein dynamics in splanchnic and skeletal muscle beds by insulin and amino acids in healthy human subjects. Diabetes. 2003;52(6):1377–85.PubMedCrossRefGoogle Scholar
  12. 12.
    Ferrando AA et al. A submaximal dose of insulin promotes net skeletal muscle protein synthesis in patients with severe burns. Ann Surg. 1999;229(1):11–8.PubMedCrossRefGoogle Scholar
  13. 13.
    Pierre EJ et al. Effects of insulin on wound healing. J Trauma. 1998;44(2):342–5.PubMedCrossRefGoogle Scholar
  14. 14.
    Schwegler I et al. Nutritional risk is a clinical predictor of postoperative mortality and morbidity in surgery for colorectal cancer. Br J Surg. 2010;97:92–7.PubMedCrossRefGoogle Scholar
  15. 15.
    Smedley F et al. Randomized clinical trial of the effects of preoperative and postoperative oral nutritional supplements on clinical course and cost of care. Br J Surg. 2004;91(8):983–90.PubMedCrossRefGoogle Scholar
  16. 16.
    Doenst T et al. Hyperglycemia during cardiopulmonary bypass is an independent risk factor for mortality in patients undergoing cardiac surgery. J Thorac Cardiovasc Surg. 2005;130(4):1144.PubMedCrossRefGoogle Scholar
  17. 17.
    Weimann A et al. ESPEN guidelines on enteral nutrition: surgery including organ transplantation. Clin Nutr. 2006;25(2):224–44.PubMedCrossRefGoogle Scholar
  18. 18.
    Buzby GP et al. Perioperative totalparenteral nutrition in surgical patients. N Engl J Med. 1991;325:525–32.CrossRefGoogle Scholar
  19. 19.
    Braga M et al. ESPEN Guidelines on Parenteral Nutrition: Surgery. Clin Nutr. 2009;28(4):378–86.PubMedCrossRefGoogle Scholar
  20. 20.
    Holte K et al. Physiologic effects of bowel preparation. Dis Colon Rectum. 2004;47(8):1397–402.PubMedCrossRefGoogle Scholar
  21. 21.
    Slim K et al. Updated systematic reveiw and meta-analysis of randomized clincial trials on the role of mechanical bowel preparatyion before colorectal surgery. Ann Surg. 2009;249:203–9.PubMedCrossRefGoogle Scholar
  22. 22.
    Fatal applications of chloroform. Section on legal medicine. Edinburgh Med J. 1848;69:498–503.Google Scholar
  23. 23.
    Maltby JR. Fasting from midnight - the history behind the dogma. Best Pract Res Clin Anaesthesiol. 2006;20(3):363–78.PubMedCrossRefGoogle Scholar
  24. 24.
    Soreide E et al. Pre-operative fasting guidelines: an update. Acta Anaesthesiol Scand. 2005;49(8):1041–7.PubMedCrossRefGoogle Scholar
  25. 25.
    Powell-Tuck J et al. British consensus guidelines on intravenous fluid therapy for adult surgical patients. Journal of the Intensive Care Society. 2009;10(1):13–5.Google Scholar
  26. 26.
    Ljungqvist O. Modulating postoperative insulin resistance by preoperative carbohydrate treatment. Best Pract Res Clin Anaesthesiol. 2009;23:401–9.PubMedCrossRefGoogle Scholar
  27. 27.
    Svanfeldt M et al. Effect of “preoperative” oral cardohydrate treatment on insulin action - a randomized cross-over unblinded study in healthy subjects. Clin Nutr. 2005;24:815–21.PubMedCrossRefGoogle Scholar
  28. 28.
    Nygren J et al. Site of insulin resistance after surgery: the contribution of hypocaloric nutrition and bed rest. Clin Sci (Lond). 1997;93(2):137–46.Google Scholar
  29. 29.
    Soop M et al. Preoperative oral carbohydrate treatment attenuates immediate postoperative insulin resistance. Am J Physiol Endocrinol Metab. 2001;280(4):E576–83.PubMedGoogle Scholar
  30. 30.
    Soop M et al. Preoperative oral carbohydrate treatment attenuates endogenous glucose release 3 days after surgery. Clin Nutr. 2004;23(4):733–41.PubMedCrossRefGoogle Scholar
  31. 31.
    Henriksen MG et al. Effects of preoperative oral carbohydrates and peptides on postoperative endocrine response, mobilization, nutrition and muscle function in abdominal surgery. Acta Anaesthesiol Scand. 2003;47(2):191–9.PubMedCrossRefGoogle Scholar
  32. 32.
    Schricker T et al. Anticatabolic effects of avoiding preoperative fasting by intravenous hypocaloric nutrition: a randomized clinical trial. Ann Surg. 2008;248(6):1051–9.PubMedCrossRefGoogle Scholar
  33. 33.
    Svanfeldt M et al. Randomized clinical trial of the effect of preoperative oral carbohydrate treatment on postoperative whole-body protein and glucose kinetics. Br J Surg. 2007;94(11):1342–50.PubMedCrossRefGoogle Scholar
  34. 34.
    Yuill KA et al. The administration of an oral carbohydrate-containing fluid prior to major ­elective upper-gastrointestinal surgery preserves skeletal muscle mass postoperatively-a ­randomised clinical trial. Clin Nutr. 2005;24(1):32–7.PubMedCrossRefGoogle Scholar
  35. 35.
    Oldfield GS, Commerford PJ, Opie LH. Effects of preoperative glucose-insulin-potassium on myocardial glycogen levels and on complications of mitral valve replacement. J Thorac Cardiovasc Surg. 1986;91(6):874–8.PubMedGoogle Scholar
  36. 36.
    Lolley DM et al. Clinical experience with preoperative myocardial nutrition management. J Cardiovasc Surg (Torino). 1985;26(3):236–43.Google Scholar
  37. 37.
    Breuer JP et al. Preoperative oral carbohydrate administration to ASA III-IV patients undergoing elective cardiac surgery. Anesth Analg. 2006;103(5):1099–108.PubMedCrossRefGoogle Scholar
  38. 38.
    Uchida I et al. Effect of epidural analgesia on postoperative insulin resistance as evaluated by insulin clamp technique. Br J Surg. 1988;75(6):557–62.PubMedCrossRefGoogle Scholar
  39. 39.
    Greisen J et al. Acute pain induces insulin resistance in humans. Anesthesiology. 2001;95(3):578–84.PubMedCrossRefGoogle Scholar
  40. 40.
    Soop M et al. Randomized clinical trial of the effects of immediate enteral nutrition on metabolic responses to major colorectal surgery in an enhanced recovery protocol. Br J Surg. 2004;91:1138–45.PubMedCrossRefGoogle Scholar
  41. 41.
    Gustafsson UO et al. Pre-operative carbohydrate treatment may be used in type 2 diabetes patients. Acta Anaesthesiol Scand. 2008;52(7):946–51.PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag London Limited 2012

Authors and Affiliations

  • Olle Ljungqvist
    • 1
  1. 1.Department of SurgeryÖrebro University HospitalÖrebroSweden

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