Omiya Keisuke, Koo Bon-Wook, Sato Hiroaki, Sato Tamaki, Kandelman Stanislas, Nooh Abdulwahaab, Schricker Thomas
Department of Anesthesia, McGill University Health Centre Glen Site, Royal Victoria Hospital, Montreal, Canada.
Ann Transl Med. 2023 Mar 15;11(5):205. doi: 10.21037/atm-22-3721.
While avoidance of preoperative fasting followed by hyperinsulinemic-normoglycemic clamp (HNC) reduced postoperative hepatic dysfunction and surgical site infection (SSI), the effect of HNC restricted to the intraoperative period is unknown. This study examined whether HNC restricted to the intraoperative period has similar effects in patients undergoing elective liver resections.
This study is a post hoc exploratory analysis of a randomized-controlled trial in patients undergoing hepatobiliary surgery and receiving the HNC as a potential preventative intervention to reduce infectious morbidity postoperatively. Patients (>18 years old) undergoing elective transabdominal resection of liver malignancy were enrolled. We implemented the random allocation by labelling cards. Consenting patients were randomly assigned to receive the HNC during surgery or standard metabolic care. The HNC was initiated by insulin (2 mU/kg/min) followed by 20% dextrose infusion titrated to keep blood glucose between 4.0 and 6.0 mmol/L until the end of surgery. In the control group, glycemia >10.0 mmol/L prompted insulin treatment according to a standardized sliding scale. The primary outcome was hepatic function on postoperative day (POD) one, assessed by Schindl score. Secondary outcome was the incidence of SSIs within 30 days after surgery. The Schindl score was analyzed by Mann-Whitney U test and the incidence of SSIs was analyzed by Fisher's exact test. Two-sided P values <0.05 were considered statistically significant.
From October 2018 to May 2022, 32 patients in the control group and 34 patients in the HNC group were analyzed. Patient characteristics were similar in the two groups. There was no significant difference in the mean Schindl score on POD1 between the HNC group and the control group (0.8±0.9 1.2±1.6, P=0.61). However, the incidence of SSIs in the HNC group was significantly lower than in the control group (6% 31%, P=0.01).
The HNC restricted to the intraoperative period did not improve postoperative hepatic function but reduced SSIs. Preoperative carbohydrate loading may contribute to the preservation of hepatic function.
ClinicalTrials.gov NCT01528189.
虽然避免术前禁食并采用高胰岛素-正常血糖钳夹术（HNC）可减少术后肝功能障碍和手术部位感染（SSI），但仅限于术中期进行HNC的效果尚不清楚。本研究探讨了仅限于术中期进行HNC对接受择期肝切除术患者是否有类似效果。
本研究是一项对接受肝胆手术并接受HNC作为降低术后感染发病率潜在预防性干预措施的患者进行的随机对照试验的事后探索性分析。纳入接受择期经腹肝恶性肿瘤切除术的患者（年龄>18岁）。我们通过标记卡片进行随机分配。同意参与的患者被随机分配在手术期间接受HNC或标准代谢护理。HNC通过胰岛素（2 mU/kg/分钟）启动，随后输注20%葡萄糖并进行滴定，以将血糖维持在4.0至6.0 mmol/L之间直至手术结束。在对照组中，血糖>10.0 mmol/L时根据标准化的胰岛素剂量调整表进行胰岛素治疗。主要结局是术后第1天（POD1）的肝功能，通过辛德尔评分评估。次要结局是术后30天内SSI的发生率。辛德尔评分采用曼-惠特尼U检验分析，SSI发生率采用费舍尔精确检验分析。双侧P值<0.05被认为具有统计学意义。
2018年10月至2022年5月，分析了对照组的32例患者和HNC组的34例患者。两组患者的特征相似。HNC组和对照组在POD1时的平均辛德尔评分无显著差异（0.8±0.9对1.2±1.6，P=0.61）。然而，HNC组SSI的发生率显著低于对照组（6%对31%，P=0.01）。
仅限于术中期进行HNC并不能改善术后肝功能，但可降低SSI。术前碳水化合物负荷可能有助于肝功能的保留。
ClinicalTrials.gov NCT01528189。
