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World Journal of Surgery

, Volume 35, Issue 1, pp 85–92 | Cite as

Intensive Versus Conventional Insulin Therapy in Type 2 Diabetes Patients Undergoing D2 Gastrectomy for Gastric Cancer: A Randomized Controlled Trial

  • Shou-Gen Cao
  • Jian-An Ren
  • Bo Shen
  • Dong Chen
  • Yan-Bing ZhouEmail author
  • Jie-Shou Li
Article

Abstract

Background

This study was to compare the effect of intensive insulin therapy (IIT) to conventional insulin therapy (CIT) on postoperative outcomes among type 2 diabetes mellitus (DM) patients who underwent D2 gastrectomy for gastric cancer.

Methods

We randomly assigned gastric cancer patients with type 2 DM who underwent radical gastrectomy to receive IIT (maintenance of blood glucose at a level between 4.4 and 6.1 mmol/l) with insulin infusion or CIT (maintenance of blood glucose at a level between 10 and 11.1 mmol/l) during the postoperative period.

Results

Of the 179 eligible patients, 92 patients were assigned to receive IIT and 87 patients to receive CIT. Mean blood glucose concentrations were lower in the intensive group (IG) than in the conventional group (CG) (5.5 ± 0.8 vs. 9.9 ± 1.0 mmol/l, P < 0.001). Hypoglycemia occurred in 6 patients (6.5%) in the IG (P = 0.029) versus in 1 patient (1.1%) in the CG. Hospital mortality did not differ significantly between two groups (4.3% vs. 5.7%, P = 0.742). However, IIT significantly reduced morbidity (from 18.4 to 7.6%, P = 0.031). Also, IIT shortened the days to suture removal, postoperative hospital stay, and postoperative duration of antibiotic use. The HOMA-IR score was lower at all time points in IG. Moreover, IIT increased the postoperative HLA-DR expression on monocytes on postoperative days 3 and 5.

Conclusions

IIT significantly reduced short-term morbidity but not mortality among type 2 DM patients who underwent D2 gastrectomy for gastric cancer. Furthermore, a possible mechanism of suppression of the insulin resistance and improvement of HLA-DR expression may partially explain the benefits of IIT.

Keywords

Gastric Cancer Hypoglycemia Diabetes Mellitus Patient Intensive Insulin Therapy Conventional Group 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Notes

Acknowledgment

This study was partially supported by the Health Science and Technology Development Project of Shandong (2005HZ024).

Conflict of interest

There is no potential and real conflict to any third party.

References

  1. 1.
    Ouattara A, Lecomte P, Le Manach Y et al (2005) Poor intraoperative blood glucose control is associated with a worsened hospital outcome after cardiac surgery in diabetic patients. Anesthesiology 103:687–694CrossRefPubMedGoogle Scholar
  2. 2.
    Furnary AP, Gao G, Grunkemeier GL et al (2003) Continuous insulin infusion reduces mortality in patients with diabetes undergoing coronary artery bypass grafting. J Thorac Cardiovasc Surg 125:1007–1021CrossRefPubMedGoogle Scholar
  3. 3.
    Lazar HL, Chipkin SR, Fitzgerald CA et al (2004) Tight glycemic control in diabetic coronary artery bypass graft patients improves perioperative outcomes and decreases recurrent ischemic events. Circulation 109:1497–1502CrossRefPubMedGoogle Scholar
  4. 4.
    van den Berghe G, Wouters P, Weekers F et al (2001) Intensive insulin therapy in the critically ill patients. N Engl J Med 345:1359–1367CrossRefPubMedGoogle Scholar
  5. 5.
    Ascione R, Rogers CA, Rajakaruna C et al (2008) Inadequate blood glucose control is associated with in-hospital mortality and morbidity in diabetic and nondiabetic patients undergoing cardiac surgery. Circulation 118:113–123CrossRefPubMedGoogle Scholar
  6. 6.
    van den Berghe G, Wilmer A, Hermans G et al (2006) Intensive insulin therapy in the medical ICU. N Engl J Med 354:449–461CrossRefPubMedGoogle Scholar
  7. 7.
    Finfer S, Chittock DR, Su SY et al (2009) Intensive versus conventional glucose control in critically ill patients. N Engl J Med 360:1283–1297CrossRefPubMedGoogle Scholar
  8. 8.
    Lipshutz AK, Gropper MA (2009) Perioperative glycemic control: an evidence-based review. Anesthesiology 110:408–421PubMedGoogle Scholar
  9. 9.
    Cao SG, Zhou YB, Zhang CK et al (2008) Effect of intensive insulin therapy on the clinical results of postoperative patients with gastric cancer. Chinese J Surg 46:918–920Google Scholar
  10. 10.
    World Health Organization (1999) Definition, diagnosis and classification of diabetes mellitus and its complications, part 1: diagnosis and classification of diabetes mellitus: report of the WHO consultation. WHO, Tech. Rep. Ser. No. WHO/NCD/NCS/99.2, GenevaGoogle Scholar
  11. 11.
    Furnary AP, Zerr KJ, Grunkemeier GL et al (1999) Continuous intravenous insulin infusion reduces the incidence of deep sternal wound infection in diabetic patients after cardiac surgical procedures. Ann Thorac Surg 67:352–360CrossRefPubMedGoogle Scholar
  12. 12.
    Kajitani T (1981) The general rules for the gastric cancer study in surgery and pathology. Part I. Clinical classification. Jpn J Surg 11:127–139CrossRefPubMedGoogle Scholar
  13. 13.
    Emoto M, Nishizawa Y, Maekawa K et al (1999) Homeostasis model assessment as a clinical index of insulin resistance in type 2 diabetic patients treated with sulfonylureas. Diabetes Care 22:818–822CrossRefPubMedGoogle Scholar
  14. 14.
    Bonora E, Targher G, Alberiche M et al (2000) Homeostasis model assessment closely mirrors the glucose clamp technique in the assessment of insulin sensitivity: studies in subjects with various degrees of glucose tolerance and insulin sensitivity. Diabetes Care 23:57–63CrossRefPubMedGoogle Scholar
  15. 15.
    Mohn A, Marcovecchio M, Chiarelli F (2006) Validity of HOMA-IR as index of insulin resistance in obesity. J Pediatr 148:565–566; author reply 566Google Scholar
  16. 16.
    Bonora E, Formentini G, Calcaterra F et al (2002) HOMA-estimated insulin resistance is an independent predictor of cardiovascular disease in type 2 diabetic subjects: prospective data from the Verona Diabetes Complications Study. Diabetes Care 25:1135–1141CrossRefPubMedGoogle Scholar
  17. 17.
    Bone RC, Sibbald WJ, Sprung CL (1992) The ACCP-SCCM consensus conference on sepsis and organ failure. Chest 101:1481–1483CrossRefPubMedGoogle Scholar
  18. 18.
    Yamashita S, Yamaguchi H, Sakaguchi M et al (2000) Longer-term diabetic patients have a more frequent incidence of nosocomial infections after elective gastrectomy. Anesth Analg 91:1176–1181CrossRefPubMedGoogle Scholar
  19. 19.
    van den Berghe G, Wilmer A, Milants I et al (2006) Intensive insulin therapy in mixed medical/surgical intensive care units: benefit versus harm. Diabetes 55:3151–3159CrossRefPubMedGoogle Scholar
  20. 20.
    Wiener RS, Wiener DC, Larson RJ (2008) Benefits and risks of tight glucose control in critically ill adults: a meta-analysis. JAMA 300:933–944CrossRefPubMedGoogle Scholar
  21. 21.
    Mesotten D, Swinnen JV, Vanderhoydonc F et al (2004) Contribution of circulating lipids to the improved outcome of critical illness by glycemic control with intensive insulin therapy. J Clin Endocrinol Metab 89:219–226CrossRefPubMedGoogle Scholar
  22. 22.
    Mesotten D, Delhanty PJ, Vanderhoydonc F et al (2002) Regulation of insulin-like growth factor binding protein-1 during protracted critical illness. J Clin Endocrinol Metab 87:5516–5523CrossRefPubMedGoogle Scholar
  23. 23.
    Wang QG, Lu LF, Zhou YB et al (2008) Effects of intensive insulin therapy on insulin resistance and serum proteins after radical gastrectomy. Chinese J Gastrointest Surg 11:444–447Google Scholar
  24. 24.
    Vanhorebeek I, De Vos R, Mesotten D et al (2005) Protection of hepatocyte mitochondrial ultrastructure and function by strict blood glucose control with insulin in critically ill patients. Lancet 365:53–59CrossRefPubMedGoogle Scholar
  25. 25.
    Hansen TK, Thiel S, Wouters PJ et al (2003) Intensive insulin therapy exerts antiinflammatory effects in critically ill patients and counteracts the adverse effect of low mannose-binding lectin levels. J Clin Endocrinol Metab 88:1082–1088CrossRefPubMedGoogle Scholar
  26. 26.
    Weekers F, Giulietti AP, Michalaki M et al (2003) Metabolic, endocrine, and immune effects of stress hyperglycemia in a rabbit model of prolonged critical illness. Endocrinology 144:5329–5338CrossRefPubMedGoogle Scholar
  27. 27.
    Thorell A, Nygren J, Hirshman MF et al (1999) Surgery-induced insulin resistance in human patients: relation to glucose transport and utilization. Am J Physiol 276:E754–E761PubMedGoogle Scholar
  28. 28.
    Bandyopadhyay G, De A, Laudanski K et al (2007) Negative signaling contributes to T-cell anergy in trauma patients. Crit Care Med 35:794–801CrossRefPubMedGoogle Scholar
  29. 29.
    Tschaikowsky K, Hedwig-Geissing M, Schiele A et al (2002) Coincidence of pro- and anti-inflammatory responses in the early phase of severe sepsis: longitudinal study of mononuclear histocompatibility leukocyte antigen-DR expression, procalcitonin, C-reactive protein, and changes in T-cell subsets in septic and postoperative patients. Crit Care Med 30:1015–1023CrossRefPubMedGoogle Scholar
  30. 30.
    Walsh DS, Thavichaigarn P, Pattanapanyasat K et al (2005) Characterization of circulating monocytes expressing HLA-DR or CD71 and related soluble factors for 2 weeks after severe, non-thermal injury. J Surg Res 129:221–230CrossRefPubMedGoogle Scholar
  31. 31.
    Mochiki E, Ohno T, Kamiyama Y et al (2005) Laparoscopy-assisted gastrectomy for early gastric cancer in young and elderly patients. World J Surg 29:1585–1591CrossRefPubMedGoogle Scholar
  32. 32.
    Huscher CG, Mingoli A, Sgarzini G et al (2005) Laparoscopic versus open subtotal gastrectomy for distal gastric cancer: five-year results of a randomized prospective trial. Ann Surg 241:232–237CrossRefPubMedGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2010

Authors and Affiliations

  • Shou-Gen Cao
    • 1
  • Jian-An Ren
    • 1
  • Bo Shen
    • 1
  • Dong Chen
    • 2
  • Yan-Bing Zhou
    • 2
    Email author
  • Jie-Shou Li
    • 1
  1. 1.Medical School of Nanjing University, Institute of General Surgery, Jinling HospitalNanjingChina
  2. 2.Department of General SurgeryAffiliated Hospital of Medical College Qingdao UniversityQingdaoChina

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