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• W4210996988 abstract "Dear Editor, We took great interest in reading the article titled “Preoperative carbohydrate loading with individualized supplemental insulin in diabetic patients undergoing gastrointestinal surgery: A randomized trial” by Xue Li et al. [1]. Using a prospective study of 63 patients, the authors reported that preoperative carbohydrate loading with individualized supplemental insulin did not promote gastrointestinal recovery but improved perioperative well-being in diabetic patients undergoing gastrointestinal surgery. However, we came across what we believed as flaws in the study methodology, and we would like to discuss them with the authors. In the “randomization and intervention” section, the authors asked patients to ingest the carbohydrate drink at 22:00 p.m. the night before surgery and before 6:00 a.m. in the morning of surgery. However, the operation time of these patients was not fixed, which led to the carbohydrate loading at a time not fixed with the operation time. The standard definition of carbohydrate loading for the American Society of Anesthesiologists (ASA) is at least 45 g administered <4 h before surgery [2]. The preoperative carbohydrate drink for some patients in the present study seemed to us to be much over this time range. We are not sure whether the expected effects after using carbohydrate drink for more than 4 hours before operation can be achieved, such as improving perioperative health, reducing insulin resistance, and shortening hospital stay [3]. The most important mechanism of carbohydrate drinking is to reduce insulin resistance [4]. For patients undergoing surgery in the prolonged fasted state, insulin resistance may begin even before surgery [5]. Patients in the present study were given carbohydrate drink before 6:00 a.m. in the morning of surgery would have prolonged fasting when they had surgery in the afternoon or even in the evening, and this would have affected the results of this study. In addition, an unfixed timing of preoperative carbohydrate drink could have biased the results. After reading this paper online, we conducted an observational study in our center. From January 20 to January 28, 13 patients who underwent either primary total knee or hip arthroplasty by the same surgeon were included in the study. We divided the patients into two groups according to the time they carbohydrate drinks preoperatively. The durations between drinks and start of operation in one group (7 patients) was 4 h ± 10 min and in another group (6 patients) 2 h ± 10 min. The enrolled patients were all operated on before noon. We found that when compared with the 4-h group, the 2-h group had higher blood glucose levels on the first day after operation, higher insulin levels and stronger insulin resistance on the first and second days after operation (Table 1). Despite our small sample size, the use of carbohydrate drinks at different preoperative time points had different results. As different time intervals between carbohydrate consumption and surgery were used in this study, the degrees of insulin resistance would change and would affect treatment outcomes, such as time to first flatus, subjective feelings of patients, fluctuations in blood glucose, and other indicators in this study.Table 1: Mean values of insulin resistance parameters according to the groups and study time points.In the “results” section, the authors reported that three patients in the carbohydrate group had protocol deviation as they only took the carbohydrate drink the night before surgery but not in the morning of surgery due to patients’ concerns of a full stomach. However, in their Table 3 (outcomes for all patients), the authors included these patients to compare the two groups. As these 3 patients are equivalent to patients undergoing routine preoperative fasting if no carbohydrate drink was used on the day of surgery, they should have been excluded from the carbohydrate group. Finally, to our knowledge, this is the first study to include time to first flatus as a primary outcome measure. However, several high-quality meta-analyses [3,4,6,7] did not use this indicator. The primary outcomes in previous prospective randomized controlled studies have generally been using insulin resistance or the degree of variability in blood glucose [8,9]. In addition, the authors stated in the original article that the time to first flatus defecation is widely used variables indicating the return of gastrointestinal function and cited the study by Short et al. [10]. However, the factors reported by Short et al. that affected the time of the first flatus/defecation after surgery include the degree of bowel manipulation, the degree of surgical trauma, the effect of anesthesia and other postoperative modifiers including increasing age, high body mass index, and ethnic minority [10]. Given the multitude of contributing factors that influence the time to the first flatus/defecation postoperatively, and the types of procedures and surgical approaches employed in the authors’ study varied, we were concerned that the preoperative carbohydrate drink cannot ultimately be shown to affect the time to the first flatus/defecation. We respectfully appreciate that Xue Li et al. provided us with an important study focusing on the effects of carbohydrate loading with individualized supplemental insulin in diabetic patients undergoing gastrointestinal surgery. This study can provide a guide to clinicians for decision-making. However, more studies with a large sample size and good scientific design should be carried out to clarify this issue. Please state any conflicts of interest None. Please state any sources of funding for your research None. Please state whether ethical approval was given, by whom and the relevant Judgement’s reference number Not applicable. Research registration unique identifying number (UIN) Not applicable. Author contribution Yahao Lai: Conceptualisation, Writing; Original Draft. Mingcheng Yuan: Conceptualisation, Writing; Review and Editting. Hong Xu: Review and Editing. Zongke Zhou: Conceptualisation, Writing; Review and Editting. Guarantor Zongke Zhou. Provenance and peer review Commentary, internally reviewed." @default.
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• W4210996988 date "2022-03-01" @default.
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• W4210996988 title "A Commentary on “Preoperative carbohydrate loading with individualized supplemental insulin in diabetic patients undergoing gastrointestinal surgery: A randomized trial” (Int. J. Surg. 2022;98:106215)" @default.
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