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174

VOLUME 11 NUMBER 4 • NOVEMBER 2014

LEARNING FROM PRACTICE

SA JOURNAL OF DIABETES & VASCULAR DISEASE

was first challenged in the 1980s and, as a result, many patients

were allowed clear fluids up until two hours prior to surgery. The

development of low osmolality carbohydrate drinks during the mid-

1990s opened up the opportunity of providing surgical patients

with a carbohydrate load two to three hours prior to anaesthesia.

In a comparative study of 14 patients undergoing colorectal surgery

Nygren

et al

. halved post-operative insulin resistance by the use of

such oral therapy.

15

In a meta-analysis of three small prospective

studies, Ljungqvist’s team showed that such an approach can

lead to a reduction in hospital stay by about 20%.

16

However, a

randomised study in Toronto of 26 patients undergoing coronary

artery bypass grafting and 12 patients having spinal surgery who

received oral carbohydrate supplements in the evening and two

hours before surgery showed no improvement in post-operative

insulin sensitivity. The patients who received the carbohydrate

supplements did, however, have lower blood glucose and higher

insulin levels than the traditionally fasted patients, although these

differences were not significant.

17

In contrast, in a randomised

study from Brazil of gastrointestinal surgery, the addition of whey

protein to the carbohydrate drink appeared to have some added

value in terms of reduced inflammatory response and lesser insulin

resistance.

18

The benefits of the ERAS approach to colorectal surgery have

been confirmed in several reports.

19-21

It can extend for a significant

period after surgery.

22

The role of pre-operative carbohydrate

supplementation has been assessed in a number of trials. The

mechanism by which it acts includes a reduction in catabolism of

fat and protein. This was shown in a study of 40 patients who

underwent an elective laparoscopic colectomy.

23

However, most

studies on the role of pre-operative carbohydrate supplementation

have excluded diabetic patients. Clearly the concept of giving a

patient with inherent insulin resistance a carbohydrate load prior to

surgery is seen by many as ‘a step too far’. Indeed, in 2011 the Joint

British Diabetes Societies guideline on the management of adults

with diabetes undergoing surgery stated:

‘The Enhanced Recovery

Partnership Programme recommends the administration of high-

carbohydrate drinks prior to surgery. This may compromise blood

glucose control and is not recommended for people with insulin-

treated diabetes.’

24

However, such a blanket recommendation against the use of

high-carbohydrate drinks prior to surgery requires re-evaluation.

Concerns about potential delays in gastric emptying among

patients with diabetes and, therefore, the re-introduction of the

risk of aspiration, appear unfounded. In a study of 25 patients

with type 2 diabetes Gustaffson

et al.

found no delay in gastric

emptying compared to healthy volunteers among patients given a

carbohydrate drink.

25

In 2011, in a study from Poland, Jodlowski

et

al.

investigated the benefit of such drinks in 48 patients who were

to undergo elective colorectal surgery. Seven had type 2 diabetes.

Their conclusion was that a pre-operative oral carbohydrate load

was safe and well tolerated by them, although realistically this is

much too small a sample from which to make an inference. Overall

for both diabetic and non-diabetic patients it improved peri-

operative well-being, reduced hunger and reduced insulin blood

levels and insulin resistance on day two after surgery.

26

This study

is of particular importance against the background of a report

from Michigan which investigated risk factors for anastamotic leak

following a colectomy amongst 5 123 patients.

27

The occurrence of

a leak was not directly associated with the presence of diabetes but,

when it did happen, patients with diabetes had a four-fold mortality

of 26.3% compared with 6% for patients without diabetes. Other

evidence would suggest that the use of pre-operative carbohydrate

loading might reduce this difference in mortality subsequent to an

anastamotic leak.

20,21

Unfortunately none of these studies included

any reference to whether these patients’ diabetes was well

controlled or whether they had complications of their diabetes.

The importance of insulin resistance as an independent factor

associated with prolonged hospital stay cannot be over emphasised.

The potential benefits of carbohydrate loading for patients with

diabetes have been shown in the field of cardiac surgery. A

randomised, double-blind, placebo-controlled trial in Germany

among 160 patients undergoing elective cardiac surgery, including

31 with non-insulin-treated type 2 diabetes, reported that blood

glucose levels, gastric fluid volume and insulin requirement did not

differ between groups. However, patients receiving a carbohydrate

load required less intra-operative inotropic support after initiation of

cardiopulmonary bypass weaning (

p

< 0.05).

28

This study provided

no details on how well controlled the patients were or the presence

of complications, but did specifically exclude patients with type 1

diabetes after initial recruitment.

Conclusions

Although patients with diabetes have been excluded from most

trials looking at the role of carbohydrate loading as part of an ERAS

programme, there is certainly a need to stimulate a call for a properly

conducted large-scale, randomised, controlled trial of its efficacy in

this group of patients. There is some evidence, albeit from small

studies, to suggest that carbohydrate loading pre-operatively can

be safe in patients with diabetes. Naturally there will be a need to

carefully monitor and support such patients – but this is integral

to the ERAS approach. Clearly, its potential to shorten hospital

stay, give a more rapid return to normal activities and reduce the

frequency of serious complications would be of particular benefit.

Conflict of interest

None.

Funding

None.

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