Preoperative management algorithm for endoscopic or surgical interventions in patients receiving incretin mimetics

The widespread use of GIP and/or GLP-1 receptor agonists for the treatment of type 2 diabetes mellitus and obesity has introduced new challenges in the perioperative period. These agents induce delayed gastric emptying, rendering traditional preoperative fasting protocols less effective and significantly increasing the risk of pulmonary aspiration of residual gastric contents. Suppression of the migrating motor complex leads to the retention of solids and liquids in the stomach far beyond standard physiological durations. Current recommendations regarding the pre-procedural prophylactic withdrawal of these drugs carry the risk of losing glycemic and metabolic control, as the long half-life of weekly formulations would require a treatment hiatus exceeding 4–5 weeks. Based on a literature review and clinical experience, this article proposes a novel perioperative management approach that avoids interrupting targeted incretin mimetic therapy. This strategy is based on preliminary aspiration risk stratification: Low-risk group (patients on stable, asymptomatic therapy): Validates a preventive combined preparation consisting of a 24-hour clear liquid diet in conjunction with prophylactic prokinetics to actively overcome gastric atony and stimulate emptying. High-risk group (presence of dyspepsia, initiation or dose escalation phase, morbid obesity): This pharmacological and dietary preparation is mandatory and must be supplemented by Point-of-Care Ultrasound (POCUS) of the stomach on the day of the intervention. The implementation of this dual strategy – pharmacological/dietary motility correction and ultrasound monitoring – reliably minimizes delayed gastric emptying and the risk of bronchopulmonary aspiration without depriving patients of the positive effects of weight-loss and cardiometabolic therapy.