Objective <p>This study aimed to assess the effect of preoperative carbohydrate (CHO) loading on perioperative insulin resistance (PIR) and outcomes after live donor hepatectomy. The primary objective of the trial was to compare PIR on postoperative day (POD) 2 between preoperative oral carbohydrate (CHO) loading and overnight fasting groups. The secondary objectives were to compare the functional recovery of the remnant liver, incidence of postoperative nausea and vomiting (PONV) up to 72&#xa0;h after surgery, inflammatory markers, and length of hospital stay (LOS) between both groups.</p> Background <p>Preoperative fasting increases perioperative insulin resistance (PIR). Insulin resistance has deleterious effects on liver regeneration following partial hepatectomy.</p> Methods <p>Single-center, open-label, randomized controlled trial. After exclusion, 70 donors were recruited (35 from each group). Donors in the intervention arm received 50&#xa0;g of maltodextrin at 10 PM the night before surgery and 25&#xa0;g of maltodextrin 2&#xa0;h before anesthesia induction on the day of surgery, whereas those in the control arm followed a minimum of 6&#xa0;h of overnight fasting. The PIR was assessed using the Homeostatic Model for Assessment of Insulin Resistance (HOMA-IR).</p> Results <p>Baseline and intraoperative parameters were comparable between the two groups. CHO loading provided better postoperative glycemic control (<i>p</i> &lt; 0.01) and reduced PIR by &gt; 50% (<i>p</i> &lt; 0.01) compared to preoperative fasting. Although postoperative complications, inflammatory markers, and LOS were comparable between the groups, there was a significant attenuation of postoperative nausea (<i>p</i> = 0.01) and vomiting (<i>p</i> = 0.013) with early soft diet tolerance (<i>p</i> = 0.002) in the CHO group. In addition, preoperative carbohydrate loading accelerated functional recovery of the remnant liver, with earlier normalization of serum bilirubin levels (<i>p</i> = 0.002).</p> Conclusion <p>CHO supplementation is safe and effective in shortening preoperative fasting during donor hepatectomy without significant postoperative risks. It can be considered a standard of care in donor surgery ERAS (Enhanced Recovery After Surgery) protocols for live&#xa0;donor liver transplantations.</p> Registration number <p>NCT05293444 (<a href="http://www.ClinicalTrials.gov">www.ClinicalTrials.gov</a>).</p>