We read with interest the study by Nersessian et al., which explores the relationship between peri-operative semaglutide use and increased residual gastric content as assessed by gastric ultrasound [1]. This prospective study contributes to the emerging literature on GLP-1 receptor agonists (GLP-1 RAs) and delayed gastric emptying, raising important considerations for peri-operative management [2]. However, these findings prompt a need for greater specificity within clinical guidelines, particularly regarding the differing needs of patients using GLP-1 RAs for weight loss and to those prescribed these drugs for type 2 diabetes.

Although it is relevant that data are now available on volume of pre-operative gastric contents in patients using GLP-1 RA for weight loss, there are several methodological limitations that hinder the applicability. The study employs a small sample size without formal power calculations, using convenience sampling that undermines the statistical robustness of the findings. In addition, only a small number of baseline variables is presented, making it difficult to assess the validity of comparing the study groups. Factors such as dose of semaglutide, duration of use and the presence of gastrointestinal symptoms are missing. All can significantly influence the risk of increased pre-operative residual gastric contents [3]. Moreover, although BMI is reported, it remains unclear whether the semaglutide group represents patients with formerly higher BMIs, reduced following semaglutide treatment, being compared with a possibly healthier control group with distinct gastric function. Finally, the authors propose using gastric ultrasound as a pre-operative tool to evaluate gastric content. While valuable, the variability inherent in this subjective technique, which is also highlighted by the authors, limits its broad application.

Nersessian et al. suggest extending the pre-operative discontinuation period of GLP-1 RAs from 1 to 2–3 weeks. This recommendation, however, is not substantiated by their results, nor by the current literature. There is limited evidence supporting the efficacy of discontinuation in reducing volume of gastric content, which calls into question the proposed cessation periods for peri-operative settings. In addition, recent studies have suggested that GLP-1 RA use does not necessarily correlate with a clinically significant aspiration risk [4]. Furthermore, GLP1 RAs with even longer half-lives than semaglutide are expected, which will be challenging to discontinue promptly and may not prevent delayed gastric emptying effectively even if cessation is attempted.

In addition, prolonged discontinuation in patients with type 2 diabetes, who rely on GLP-1 RAs for glycaemic control, could risk peri-operative hyperglycaemia, which itself may contribute to delayed gastric emptying [5], further complicating peri-operative management and potentially increasing the risk of postoperative wound infection [6]. In contrast, patients on GLP-1 RAs solely for weight loss may tolerate a longer discontinuation without the same risks, supporting a more targeted approach within guidelines that consider the primary indication for GLP-1 RA use.

In conclusion, while the study by Nersessian et al. underscores the need for cautious use of GLP-1 RAs peri-operatively, it is important to distinguish between GLP-1 RA use for weight loss and for glycaemic control in future guidelines. While a longer cessation period may be feasible for patients using these drugs for weight loss, patients with type 2 diabetes require careful consideration of the potential for hyperglycaemia. In addition, the effectiveness of different cessation periods of GLP1 RAs on gastric emptying has not been studied adequately. The evidence required to support withholding GLP-1 RAs are trials comparing pre-operative cessation vs. continuation of GLP-1 RAs. Such research should evaluate the volume of residual gastric content and quality of glycaemic control in patients with and without type 2 diabetes.

我们饶有兴趣地阅读了 Nersessian 等人的研究，该研究探讨了围手术期使用 semaglutide 与胃超声评估的残余胃内容物增加之间的关系 [1]。这项前瞻性研究有助于关于 GLP-1 受体激动剂 （GLP-1 RAs） 和延迟胃排空的新兴文献，为围手术期管理提出重要考虑 [2]。然而，这些发现促使临床指南需要更大的特异性，特别是关于使用 GLP-1 RAs 减肥的患者和使用这些药物治疗 2 型糖尿病的患者的不同需求。

尽管现在有关于使用 GLP-1 RA 减肥的患者术前胃内容物体积的数据是相关的，但存在一些阻碍适用性的方法学限制。该研究采用小样本量，没有正式的功效计算，使用方便的抽样破坏了研究结果的统计稳健性。此外，仅提供了少量基线变量，因此难以评估比较研究组的有效性。缺少 semaglutide 的剂量、使用持续时间和胃肠道症状等因素。所有这些都可以显着影响术前残余胃内容物增加的风险 [3]。此外，尽管报告了 BMI，但尚不清楚 semaglutide 组是否代表先前 BMI 较高、在 semaglutide 治疗后降低的患者，与具有不同胃功能可能更健康的对照组进行比较。最后，作者建议使用胃超声作为评估胃内容物的术前工具。虽然很有价值，但这种主观技术固有的可变性（作者也强调了这一点）限制了它的广泛应用。

Nersessian 等人建议将 GLP-1 RA 的术前停药期从 1 周延长至 2-3 周。然而，这一建议并未得到他们的结果和当前文献的证实。支持停药在减少胃内容量方面的疗效的证据有限，这让人对围手术期建议的停药期提出质疑。此外，最近的研究表明，GLP-1 RA 的使用不一定与临床上显著的误吸风险相关 [4]。此外，预计 GLP1 RA 的半衰期甚至比索马鲁肽更长，这将具有挑战性，并且即使尝试停止，也可能无法有效阻止延迟胃排空。

此外，依赖GLP-1 RA控制血糖的2型糖尿病患者长期停药可能会有围手术期高血糖的风险，这本身就可能导致胃排空延迟[5]，使围手术期管理进一步复杂化，并可能增加术后伤口感染的风险[6].相比之下，仅以减轻体重为目的接受 GLP-1 RAs 的患者可以耐受更长时间的停药而没有相同的风险，这支持在考虑 GLP-1 RA 使用主要适应症的指南中采用更有针对性的方法。

总之，虽然 Nersessian 等人的研究强调了围手术期谨慎使用 GLP-1 RA 的必要性，但在未来的指南中区分 GLP-1 RA 用于减肥和血糖控制非常重要。虽然使用这些药物减肥的患者可能需要更长的停药期，但 2 型糖尿病患者需要仔细考虑高血糖的可能性。此外，GLP1 RAs 的不同停药期对胃排空的有效性尚未得到充分研究。支持拒绝 GLP-1 RA 所需的证据是比较术前停止与继续使用 GLP-1 RA 的试验。此类研究应评估 2 型糖尿病患者和非 2 型糖尿病患者的残余胃内容量和血糖控制质量。