Discussion
hypoglycemia, UC
STILL, POSTOPERATIVE COMPLICATIONS, TYPE 1 DIABETES, HYPOGLYCEMIA, COMPLICATIONS
In this exploratory post hoc analysis, we compared the perioperative glycemic efficacy and insulin requirements of SC FCL insulin delivery with UC insulin therapy in patients undergoing pancreatic surgery. We observed that FCL substantially improved glycemic control by increasing time spent in the glycemic target range and lowering mean sensor glucose without increasing the risk of hypoglycemia.Although we have recently shown the feasibility and superior performance of the FCL approach over UC insulin regimes in various types of elective surgery, the present analysis provides evidence that an FCL insulin-only approach effectively controls glucose levels in clinical situations with maximum glycemic lability as is the case after total pancreatectomy (five out of six patients in the FCL group received total pancreatectomy in this study). The absolute insulin deficiency that is also the pathophysiological hallmark of type 1 diabetes makes these two populations comparable in terms of complexity of their glucose control.However, the concomitant lack of glucagon secretion is mainly pertinent to patients with total pancreatectomy, thereby further challenging glucose management in this population. In this context, the present results are encouraging as previous efforts to control glucose levels by an FCL approach in people with type 1 diabetes have shown insufficient performanceHowever, it is important to note that the algorithm used in this study has a considerably enhanced adaptivity to allow for more responsive insulin dosing compared with currently available hybrid closed-loop systems for the treatment of type 1 diabetes. In addition, the amount of oral dietary intake in the perioperative setting is likely lower than in usual outpatient conditions.We are not aware of any other study that analyzed the use of an SC FCL insulin-only system to manage perioperative glucose levels in patients undergoing pancreatic surgery. Nevertheless, observational studies and a nonrandomized clinical trial investigated the efficacy of STG-55 (Nikkiso, Inc.) FCL that uses the intravenous route for both glucose sensing and insulin delivery.Although these small studies reported benefits in terms of reducing postoperative complications in pancreatic surgery patients, evidence from randomized controlled trials is still lacking. The advantages in terms of facilitation of care by FCL systems, however, are more apparent. Pancreatic resections are high-risk procedures with frequently experienced complications (30%–73%) and high complexity of postoperative care.FCL insulin therapy may, therefore, not only contribute to improved quality and safety of blood glucose control in this challenging population, but also reduce the work load of hospital staff. Of note, a recently published study reported increased time in euglycemia and reduced time in hypoglycemia using a bihormonal SC FCL system modulating both insulin and glucagon compared with UC in 12 outpatients after total pancreatectomy.We acknowledge the limitations that are inherent to any post hoc analysis and the fact that the FCL insulin treatment was managed by the study team rather than the hospital staff. In addition, the small sample size needs to be considered. Still, we believe that these early findings provide an important steppingstone for future larger and well-designed studies in the field of perioperative and possibly postoperative glucose management in patients undergoing pancreatic surgery.