The Effect of an Enhanced Recovery Protocol on Colorectal Surgery Patients With Diabetes

doi:10.1016/j.jss.2020.07.041

Journal of Surgical Research

Volume 257, January 2021, Pages 153-160

https://doi.org/10.1016/j.jss.2020.07.041 Get rights and content

Abstract

Background

The effect of an enhanced recovery protocol including preoperative carbohydrate loading on patients with diabetes is unclear. This study investigated the effect of both on perioperative glucose management and postoperative outcomes in patients with diabetes undergoing colorectal surgery.

Materials and methods

A retrospective study was conducted on patients undergoing elective colorectal surgery before and after implementation of an enhanced recovery protocol. Ninety-nine patients with type 2 diabetes (DM, 41 control versus 58 enhanced recovery) and 366 patients without diabetes (NDM, 158 control versus 158 enhanced recovery) were included. Multivariate analyses were run to compare mean peak perioperative serum glucose and postoperative outcomes in enhanced recovery and control cohorts with (DM) and without diabetes (NDM).

Results

Mean peak preoperative glucose was elevated in DM enhanced recovery compared with DM control patients (192.2 [72.2] versus 139.8 [41.4]; P < 0.001). Mean peak intraoperative (162.3 [43.1] versus 163.8 [39.6]; P = 0.869) and postoperative glucose (207.7 [75.8] versus 217.8 [78.5]; P = 0.523) were similar in DM enhanced recovery compared with DM control group. Enhanced recovery led to decreased LOS in DM (P = 0.001) and NDM enhanced recovery patients (P < 0.000) compared with their control groups.

Conclusions

An enhanced recovery protocol may lead to increased peak preoperative glucose levels and 30-d readmissions in patients with type 2 diabetes undergoing colorectal surgery. However, the ultimate clinical significance of transiently elevated preoperative glucose in DM patients is uncertain. Our results suggest that an enhanced recovery protocol and preoperative carbohydrate loading does not lead to poorer postoperative glycemic control overall in patients with diabetes undergoing colorectal surgery.

Introduction

Enhanced recovery after surgery (ERAS) uses a multimodal approach targeting improvement in surgical outcomes and cost reduction.¹ A systematic review of enhanced recovery studies validated these effects as these programs reduced patients’ length of hospital stays in comparison with traditional perioperative care programs after colon surgery.² Additional literature states enhanced recovery decreases infection rates, readmissions, mortality, and morbidity after colorectal surgery.3, 4, 5 Enhanced recovery has been identified as an international standard for certain procedures, but there is a paucity of studies investigating the theoretical problems the protocol may pose to certain patient populations, specifically, carbohydrate loading in patients with type 2 diabetes.

The colorectal enhanced recovery protocol specific to our institution includes opioid-sparing analgesia, carbohydrate loading, goal-directed fluid management, early postoperative oral feeding, and early ambulation. Patients are provided education including smoking cessation, limiting alcohol use, and encouraging exercise before surgery at a preoperative clinic visit. Further they are instructed to continue their regular diet and supplementation up until the day before surgery, when they may only consume clear liquids and complete a bowel prep (polyethylene glycol 3350 and bisacodyl for mechanical prep with neomycin and metronidazole tablets for GI tract decontamination). The bowel prep is provided along with two bottles of commercially prepared, maltodextrin-based drinks with 50 g of carbohydrate per bottle. All patients, including diabetics, were instructed to drink one bottle the evening before surgery and one 2 hours before surgery. Before surgery, patients scheduled for open procedures received thoracic epidural anesthesia, whereas laparoscopic cases received spinal analgesia with 200 mcg intrathecal morphine. Patients were medicated with acetaminophen, oxycodone, gabapentin, and a scopolamine patch (unless age 65 y or older). Intraoperatively, providers were encouraged to minimize use of opioids, use IV ketamine, and use goal-directed fluid management. Postoperatively, patients were given a clear liquid diet and advanced to regular diet as tolerated and started on scheduled multimodal analgesia with acetaminophen, ibuprofen, and gabapentin. IV fluids were stopped once patients were tolerating a diet. Early mobilization was promoted including ambulation to chair the day of surgery and ambulation in hallway starting postoperative day 1.

The primary clinical concern for preoperative carbohydrate loading in patients with diabetes is the risk of perioperative hyperglycemia and insulin resistance may pose to these patients. In general, a systematic review found that preoperative carbohydrate loading, independent of an enhanced recovery protocol, improves insulin resistance and indices of patient comfort without increasing the risk for adverse event such as aspirations.⁶ In addition, a statewide surgical outcomes study in Washington, conducted before enhanced recovery adoption, identified hyperglycemia as a significant risk for increased infection, reoperation, and mortality in both diabetic and nondiabetic patients.⁷ The study saw that the risk was mitigated with perioperative glucose evaluation and insulin administration. Furthermore, a retrospective review of a Canadian colorectal enhanced recovery program found diabetes mellitus to be an independent predictor of surgical site infections.⁸ From these studies, one can see that there exists both a theoretical basis and preliminary evidence to suggest either increased benefit or risk pertaining to preoperative carbohydrate loading in patients with diabetes.

However, there remains a paucity of studies that directly investigate the effect of preoperative carbohydrate loading in patients with diabetes. One study that did so identified that patients with well-controlled type 2 diabetes who received a preoperative carbohydrate-rich drink exhibited no signs of delayed gastric emptying, and no increased risk of preoperative hyperglycemia or aspiration if the drink was delivered 3 hours before anesthesia care.⁹ The study was limited by notably small sample size, comparing the outcomes of twenty-five patients with diabetes to ten healthy subjects. By contrast, there has been a call for a moratorium on preoperative carbohydrate drinks in surgical patients with diabetes until both the safety and efficacy of their use can be proven.¹⁰ Thus, further investigation is needed to quantify the risk an enhanced recovery protocol poses to patients with diabetes.

This retrospective study offers a focused analysis of the impact of using preoperative carbohydrate loading on perioperative glucose control in patients with and without diabetes as well as postoperative outcomes before and after implementation of an enhanced recovery program. Our hypothesis is that an enhanced recovery protocol with preoperative carbohydrate loading does not lead to increased morbidity and mortality in colorectal surgery patients with diabetes.

Section snippets

Data collection and sample

After obtaining Institutional Review Board approval that included a waiver of consent, a retrospective cohort study was conducted on patients aged more than 18 y undergoing an elective partial or total colectomy before (January 2016 to January 2017) and after the implementation of an enhanced recovery protocol (February 2017 to December 2018). A waiver of consent was obtained from the institutional review board to conduct the study. Patients were verified as being on the enhanced recovery

Study demographics

The study included patients between the years of 2016 through 2018. Table 1 details the study population's demographics including age, BMI, gender, race, and comorbidities broken down by patient population and treatment groups. Based on the records available during the study period, the population had increased proportions of Caucasian patients and those with multiple comorbidities, especially in patients with pre-existing diabetes. Of the 415 patients included in the study, 199 patients were

Discussion

Enhanced recovery after surgery has become widely adopted internationally and is implemented across many centers and service lines worldwide.¹ Studies have demonstrated that enhanced recovery protocols achieve the goal of reducing length of stay.2, 3, 4, 5^,¹² Our analysis demonstrated a significant reduction in LOS in DM and NDM enhanced recovery cohorts compared with their control counterparts. This is an important finding as it demonstrates that the benefit of reduced LOS in an enhanced

Conclusions

Patients with type 2 diabetes undergoing elective colorectal surgery on an enhanced recovery protocol experienced a reduced length of stay compared with those patients with diabetes not on an enhanced recovery protocol. Perioperative glucose control was not markedly worse in enhanced recovery patients with diabetes compared with control patients. An enhanced recovery protocol may reduce the number of postoperative hyperglycemic episodes in diabetic patients. Patients without diabetes on the

Acknowledgment

The authors thank the Association of Academic Surgery and Society of University Surgeons for providing platforms for academic advancement at their annual Academic Surgical Congress. This work was initially presented as an oral presentation at the 15^th Annual Academic Surgical Congress in Orlando, FL, Session 92–Clinical/Outcomes: Colorectal Oral Session II on Thursday, February 06, 2020.

The authors also thank the Medical Student Research program, the Ohio State University College of Medicine

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Cited by (9)

Enhanced recovery after surgery: Preoperative carbohydrate loading and insulin management in type 2 diabetes
2024, Surgery Open Science
We assessed our institutional practice of individualized insulin dosing for patients with type 2 diabetes receiving preoperative carbohydrate loading (CHO-L) within an enhanced recovery after surgery (ERAS®) protocol. Patients enrolled in an ERAS® protocol with concomitant type 2 diabetes received rapid acting insulin (Novolog®[insulin aspart]) prior to 50 g CHO-L on the day of surgery. Following CHO-L and the administration of insulin, no hypoglycemic episodes occurred with preoperative POC glucose values between 6.8 and 12.3 mmol/L (123 and 221 mg/dL). Our experience demonstrates that administering rapid acting insulin prior to CHO-L in patients with type 2 diabetes is feasible and targets the potentially negative influence CHO-L may impose on preoperative glycemia in this population. Important considerations of this approach are highlighted and an insulin dosing algorithm designed for non-specialty providers is suggested.
Investigating glycemic control in patients undergoing lower extremity bypass within an enhanced recovery pathway at a single institution
2023, Journal of Vascular Surgery
Enhanced recovery pathways (ERPs) aim to lower perioperative stress to facilitate recovery. Limited fasting combined with carbohydrate loading is a common ERP element. The effect of limited fasting has not been elucidated in patients with diabetes. Given the known deleterious effects of poor glycemic control in the perioperative period, such as increased rates of surgical site infection, the associations of preoperative limited fasting with perioperative glycemic control and early outcomes after lower extremity bypass (LEB) were investigated.
A single institutional retrospective review of patients who underwent infrainguinal LEB from 2016 to 2022 was performed. The ERP was initiated in May 2018. Patients were stratified by diabetes diagnosis and preoperative hemoglobin A1C (HbA1C) levels. Perioperative glycemic control was compared between the limited fasting and traditional fasting patients (nil per os at midnight). Limited fasting was defined as a clear liquid diet until 2 hours before surgery with recommended carbohydrate loading consisting of 400 cc of a clear sports drink (approximately 30 g of carbohydrates). All limited fasting patients were within the ERP. Early perioperative hyperglycemia (EPH) was defined as blood glucose of >180 mg/dL within the first 24 hours of surgery. Perioperative outcomes such as surgical site infection, readmission, reinterventions, and complications were also compared.
A total of 393 patients were included (limited fasting patients N = 135; traditional fasting patients N = 258). A trend toward EPH was seen in all limited fasting groups. Evaluating limited fasting within diabetic patients revealed that 74.5% of limited fasting-diabetic patients had EPH compared with 49.6% of traditional fasting-diabetic patients (P = .001). When stratified by the HbA1C level, a significantly higher rate of EPH was seen in the HbA1c >8.0% groups, with 90.5% in the limited fasting patients compared with 67.9% in traditional fasting patients (P = .05). Limited fasting-diabetic patients experience a longer postoperative length of stay at 5.0 days (interquartile range: 3, 9) vs 4.0 days (2, 6) in nondiabetic patients (P = .016).
ERP limited fasting was associated with early perioperative hyperglycemia after LEB, particularly in patients with HbA1C >8.0%. Due to the high prevalence of diabetic patients undergoing LEB under ERP, the role of limited fasting and common glycemic elements of ERP may need to be re-evaluated in this subpopulation.
Postoperative morbidity and mortality in patients with diabetes after colorectal surgery with an enhanced recovery program: A monocentric retrospective study
2023, Journal of Visceral Surgery
Diabetes mellitus may increase the risk of adverse perioperative outcomes and prolong hospital stay. An enhanced recovery program (ERP) reduces surgical stress and its metabolic consequences, so attenuating the impact of preoperative risk factors. We tested the hypothesis that diabetes would have only a minor impact on outcome after colorectal surgery with an ERP.
The data for patients scheduled for colorectal surgery between 2015 and 2021, were analyzed (n = 769). All the patients were managed with the same protocol. Demographic data, preoperative risk factors, postoperative complications, and length of stay were compared between patients with and without diabetes.
In all, 124 patients (16.1%) had diabetes, of whom 30 (24.1%) required insulin. The following preoperative risk factors for postoperative complications were significantly more frequent in the patients with diabetes: age > 70 years, ASA score ≥ III, renal failure, cardiac disease, BMI > 30 kg/m², anemia, and cancer as indication for surgery. Despite more risk factors, patients with diabetes did not experience more overall postoperative complications than controls (OR (95%IC): 0.9 [0.6–1.5], p = 0.85). Length of hospital stay was not significantly longer in patients with diabetes than in those without (4 [2–7] vs. 3 [2–7] days; p = 0.45).
Despite more risk factors, patients with diabetes did not experience more complications or longer length of stay after colorectal surgery with an ERP. The multimodal, multidisciplinary approach of ERP to reducing surgical stress may thus help mitigate the reported deleterious effects of diabetes.
Preoperative carbohydrate loading with individualized supplemental insulin in diabetic patients undergoing gastrointestinal surgery: A randomized trial
2022, International Journal of Surgery
Citation Excerpt :
In retrospective studies, although preoperative carbohydrate loading increased blood glucose level in patients with type 2 diabetes, there were no differences regarding postoperative complications [14]; on the contrary, enhanced recovery protocol including preoperative carbohydrate loading shortened hospital stay [15]. In the above studies investigating the effects of oral carbohydrate loading in diabetic patients, no specifically designed insulin regimen was provided to control blood glucose [13–15]; the resulting hyperglycemia might have counteracted some of the potentially beneficial effects by, for example, driving intestinal barrier dysfunction [16]. Whereas return of gastrointestinal function is an important sign of postoperative recovery.
Preoperative carbohydrate drink is used to improve patients’ comfort and recovery, but evidence remains limited in diabetic patients. Herein we investigated the effects of preoperative carbohydrate loading with individualized supplemental insulin regimen in diabetic patients undergoing gastrointestinal surgery.
A total of 63 adult patients with type 2 diabetes mellitus undergoing major gastrointestinal surgery were randomized to receive either carbohydrate loading with individualized supplemental insulin (Carbohydrate group) or routine management (Control group). The primary outcome was time to first flatus after surgery. Among secondary outcomes, subjective feelings of thirsty, hunger and fatigue were assessed with the Visual Analogue Scale (scores range from 0 to 100, where 0 indicate no discomfort and 100 the most severe discomfort) before and after surgery. Adverse events were monitored until 24 h after surgery.
All patients were included in the intention-to-treat analysis. Time to first flatus did not differ between groups (median 41 h [IQR 18–69] in the Control group vs. 43 h [27–54] in the Carbohydrate group; hazard ratio 1.24 [95% CI 0.74–2.07]; P = 0.411). The VAS score of preoperative subject feeling of thirsty (median difference −33 [95% CI -50 to −15], P < 0.001), hunger (−25 [-40 to −10], P < 0.001), and fatigue (−5 [-30 to 0], P = 0.004), as well as postoperative subject feeling of thirsty (−50 [-60 to −30], P < 0.001), hunger (−20 [-40 to 0], P = 0.003), and fatigue (0 [-20 to 0], P = 0.020) were all significantly lower in the Carbohydrate group than in the Control group. Intraoperative hypotension (40.6% [13/32] vs. 16.1% [5/31], P = 0.031) and postoperative nausea and vomiting within 24 h (31.3% [10/32] vs. 9.7% [3/31], P = 0.034) occurred less in patients given carbohydrate drink.
In diabetic patients undergoing gastrointestinal surgery, preoperative carbohydrate loading with individualized supplemental insulin did not promote gastrointestinal recovery but improved perioperative well-being.
Preoperative carbohydrate loading in surgical patients with type 2 diabetes: Are concerns supported by data?
2021, Clinical Nutrition ESPEN
Citation Excerpt :
The generalizability of this conclusion is unknown due to small sample size and omitted details such as the type of DM and HbA1C range of these patients with DM. In summary, preoperative blood glucose was reported to be 12.5–52.4 mg/dL higher in patients with T2DM who consume carbohydrate load than those who do not [40,41]. Data from non-surgical patients with T2DM suggests that blood glucose returns to baseline at approximately 3 h after consumption [30,32].
Currently, there is a lack of consensus on the provision of preoperative carbohydrate loading in patients with type 2 diabetes mellitus (T2DM) due to theoretical concerns including the possibility of delayed gastric emptying, perioperative hyperglycemia, and poor surgical outcomes. This narrative review summarizes the accumulating evidence on preoperative carbohydrate loading in this population and whether these concerns are supported by preliminary evidence. In general, the available research suggests that carbohydrate loading may be implemented in those with T2DM without increased risk for intra- and postoperative hyperglycemia or surgical complications. However, there is strong justification for future research to definitively study this highly debated and timely topic. Ultimately, the inclusion of preoperative carbohydrate loading for surgical patients with DM should be guided by the surgical team's clinical judgment and individualized based on patient needs and characteristics.
Perioperative nutrition for gastrointestinal surgery: On the cutting edge
2023, Nutrition in Clinical Practice

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GastrointestinalThe Effect of an Enhanced Recovery Protocol on Colorectal Surgery Patients With Diabetes

Abstract

Background

Materials and methods

Results

Conclusions

Introduction

Section snippets

Data collection and sample

Study demographics

Discussion

Conclusions

Acknowledgment

Surgery

J Am Coll Surg

Enhanced recovery after surgery: a review

JAMA Surg

Guidelines for perioperative care in elective colorectal surgery: enhanced recovery after surgery (ERAS((R))) Society recommendations: 2018

World J Surg

Reduced length of hospital stay in colorectal surgery after implementation of an enhanced recovery protocol

Anesth Analg

An enhanced-recovery protocol improves outcome after colorectal resection already during the first year: a single-center experience in 168 consecutive patients

Dis Colon Rectum

Role of preoperative carbohydrate loading: a systematic review

Ann R Coll Surg Engl

Importance of perioperative glycemic control in general surgery: a report from the Surgical Care and Outcomes Assessment Program

Ann Surg

Surgical site infection rates following implementation of a colorectal closure bundle in elective colorectal surgeries

Dis Colon Rectum

Gastrointestinal
The Effect of an Enhanced Recovery Protocol on Colorectal Surgery Patients With Diabetes