Association of Postoperative Hyperglycemia With Outcomes Among Patients With Complex Ventral Hernia Repair

Abstract

IMPORTANCE Patients with medically complex conditions undergoing repair of large or recurrent hernia of the abdominal wall are at risk for early postoperative hyperglycemia, which may serve as an early warning for delays in recovery and for adverse outcomes. OBJECTIVE To evaluate postoperative serum glucose level as a predictor of outcome after open ventral hernia repair in patients with major medical comorbidities. DESIGN, SETTING, AND PARTICIPANTS We performed a retrospective medical record review of 172 consecutive patients who underwent open ventral hernia repair at Penn State Milton S. Hershey Medical Center, an academic tertiary referral center, from May 1, 2011, through November 30, 2013. We initially identified patients by medical complexity and repair requiring a length of stay of longer than 1 day. MAIN OUTCOMES AND MEASURES Postoperative recovery variables, including time to the first solid meal, length of stay, total costs of hospitalization, and surgical site occurrence. RESULTS Postoperative serum glucose values were available for 136 patients (79.1%), with 130 (95.6%) obtained within 48 hours of surgery. Among these patients, Ventral Hernia Working Group grade distributions included 8 patients with grade 1, 79 with grade 2, 41 with grade 3, and 8 with grade 4. Fifty-four patients (39.7%) had a postoperative glucose level of at least 140 mg/dL, and 69 patients (50.7%) required insulin administration. Both outcomes were associated with delays in the interval to the first solid meal (glucose level, Ն140 vs <140 mg/dL: mean [SD] delay, 6.4 [5.3] vs 5.6 [8.2] days; P = .01; Ն2 insulin events vs <2: 6.5 [5.5] vs 5.4 [8.4] days; P = .02); increased length of stay (glucose level, Ն140 vs <140 mg/dL: mean [SD], 8.0 [6.0] vs 6.9 [8.2] days; P = .008; Ն2 insulin events vs <2: 8.3 [6.1] vs 6.5 [8.4] days; P < .001); increased costs of hospitalization (glucose level, Ն140 vs <140 mg/dL: mean [SD], $31 307 [$20 875] vs $22 508 [$22 531]; P < .001; Ն2 insulin events vs <2: $31 943 [$22 224] vs $20 651 [$20 917]; P < .001); and possibly increased likelihood of surgical site occurrence (glucose level, Ն140 vs <140 mg/dL: 37.5% [21 of 56 patients] vs 22.5% [18 of 80 patients]; P = .06; Ն2 insulin events vs <2: 36.4% [24 of 66 patients] vs 21.4% [15 of 70 patients]; P = .06). Not all patients with diabetes mellitus developed postoperative hyperglycemia or needed more intense insulin therapy; however, 46.4% of the patients who developed postoperative hyperglycemia were not previously known to have diabetes mellitus, although most had at least 1 clinical risk factor for a prediabetic condition. CONCLUSIONS AND RELEVANCE Postoperative hyperglycemia was associated with outcomes in patients in this study who underwent complex ventral hernia repair and may serve as a suitable target for screening, benchmarking, and intervention in patient groups with major comorbidities.

Continuous Glucose Monitoring in Bariatric Patients Undergoing Laparoscopic Sleeve Gastrectomy and Laparoscopic Roux-En-Y Gastric Bypass

“…Prior to conducting surgery on patients with DM2, preoperative assessment and planning is required to establish a suitable treatment regimen that will minimize the risk of complications [50,51]. Previous studies, in addition to our data, have shown that the period following a surgical procedure is often characterized by hyperglycemia, which results in a greater incidence of complications and higher costs connected to hospitalization [52][53][54].…”

Abdominal wall procedures: the benefits of prehabilitation

“…Glycemic control pre-, intra-, and postoperatively has been proven essential for reducing complications in elective surgery, particularly infection [35][36][37] . Hyperglycemia has been shown to have numerous adverse effects at the cellular level including altered chemotaxis, phagocytosis, pseudopod formation, and oxidative burst, all of which prevent neutrophils from functioning optimally [38] .…”

“…Currently, perioperative blood sugar control in both diabetic and non-diabetic patients should aim for 120-160 mg/dL to minimize complication risks [40][41][42] . Postoperative hyperglycemia remains a significant risk factor for the development of surgical site occurrences; it has been reported that even one episode of serum glucose of > 200 mg/dL increases the risk of wound dehiscence [37,43] . Strict protocols for preventing hyperglycemia and glycemic interventions have effectively reduced rates of hyperglycemia and improved outcomes [43,44] .…”

Incidence, risk factors and outcomes of early postoperative hyperglycemia in surgical patients: a protocol for a systematic review and meta-analysis

“…Early postoperative hyperglycemia (POHG) is recognized as a major cause of delays in convalescence, higher rates of complications, and increased costs of care. [1][2][3][4] The incidence of stress hyperglycemia is more likely in patients with a preoperative diagnosis of type 2 diabetes (T2D) and impaired glucose metabolism and control. [3] Strikingly, POHG has been observed among patients who are not known to have T2D.…”

“…[3] Strikingly, POHG has been observed among patients who are not known to have T2D. [1,2,[5][6][7][8] In such a cohort of patents, adverse outcomes occurring in association with POHG may be as or more consequential [1,5,7,9] than in patients with a diagnosis of T2D. Moreover, a recent study has provided seemingly paradoxical evidence that higher levels of hemoglobin A1C may be associated with a lower likelihood of post-operative complications and readmissions.…”