Preoperative Oral Carbohydrate and Postoperative Recovery in Diabetic Patients

Studies show that avoiding long-time fasting by oral carbohydrates 2 hours before surgery attenuates discomfort and anxiety; it also reduces stress, insulin resistance and catabolism in patients undergoing gastrointestinal surgery, resulting in earlier recovery of gastrointestinal function and short length of hospital stay after surgery. However, for diabetic patients scheduled to undergo gastrointestinal surgery, the risks and benefits of preopertive oral carbohydrate remain unclear. The purpose of this pilot study is to investigate the impact of preoperative oral carbohydrate (outfast®) on the recovery in diabetic patients after gastrointestinal surgery.

• Oral carbohydrate (Outfast) (Dietary supplement): For all patients, 2 bottles of oral carbohydrate (Outfast, 710 ml) is provided between 22:00-24:00 on the day before surgery. Subcutaneous insulin is administered before drinking. The dose of insulin is calculated by an endocrinologist according to patients' daily glucose controlling plan. For patients who entered operating room before 12:00, 1 bottle of oral carbohydrate (Outfast) is provided at 6:00 on the day of surgery. For patients who enter the operating room after 12:00, another bottle of oral carbohydrate (Outfast) is provided at least 2 hours before entering the operating room. Subcutaneous insulin is administered before drinking. The dose of insulin is calculated is the same way as described above.
• Routine fasting (Other): For all patients, routine fasting (water drinking allowed) begin from 22:00 on the day before surgery until entering the operating room on the day of surgery. For patients who enter the operating room before 12:00, no oral or intravenoous fluid is provided. For patients who enter the operating room after 12:00, 5% glucose (500-1000 ml) is provided by intravenous infusion from 6:00 on the day of surgery. Intravenous insulin is added in the 5% glucose (glucose:insulin=4-6:1). Electrolytes (such as sodium chloride, potasium chloride, and magnesium sulfate) are added when considered necessary.

Primary outcomes

• Recovery of gastrointestinal function [From end of surgery until the time of first flatus and defecation, assessed up to 7 days after surgery.]: Time to first flatus and defecation after surgery.

Secondary outcomes

• Subjective feelings [Before anesthesia induction and at 4-6 hours after surgery.]: Four subjective feelings, including the degree of being thirsty, hungry, tired and anxious, are assessed with Numeric Rating Scale (NRS, an 11-point scale where 0 = no feeling at all and 10 = the worst feeling).
• Blood glucose variation [From 22:00 on the day before surgery until 24 hours after surgery.]: Difference between the highest and the lowest blood glucose levels.
• Insulin resistance (in part of patients) [Assessed at 24 hours after surgery.]: Insulin resistance is calculated with the Homeostatic model assessment-insulin resistance (HOMA-IR) equation.
• Length of stay in hospital after surgery. [From end of surgery until hospital discharge, up to 30 days after surgery.]: Length of stay in hospital after surgery.
• Incidence of postoperative complications [From end of surgery until 30 days after surgery]: Postoperative complications are defined as newly occurred medical conditions that have harmful effects on patients' recovery and require therapeutic intervention.
• Time to first walking in the ground and distance of walking after surgery. [During the first 5 days after surgery]: Time to first walking in the ground and distance of walking after surgery.
• All cause 30-day mortality [At 30 days after surgery]: All cause 30-day mortality

Sex: All, ages: 18 Years to any

Inclusion Criteria:

1. Age of 18 years and beyond;
2. Diagnosed with type 2 diabetes before surgery;
3. Scheduled to undergo elective gastrointestinal surgery with anticipated duration of 2 hours or more;
4. Provide signed writen informed consents.

Exclusion Criteria:

1. Refuse to participate in the study;
2. Diagnosed with diaphragmatic hernia, gastric esophageal reflux disease or pregnancy;
3. Previous history of total or partial gastrectomy;
4. Preoperative New York Heart Assocition (NYHA) class IV, renal failure (requirement of renal replacement therapy), severe hepatic disease (Child-Pugh class C), or American Society of Anesthesiologists (ASA) class IV or higher;
5. Preoperative pyloric and/or intestinal obstruction;
6. Combined surgery on other intra-abdominal organs or other parts of the body.

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• Dong-Xin Wang, MD, PhD, Principal investigator, Peking University First Hospital