Perioperative management of the patient with diabetes mellitus: update and overview

Correlation between organ-specific co-morbidities and complications in bladder cancer patients undergoing radical cystectomy

OBJECTIVE

To evaluate the association between patients' organ-specific co-morbidities and post-operative complications following radical cystectomy for bladder cancer.

PATIENTS AND METHODS

All patients who underwent radical cystectomy at Aarhus University Hospital during the period from January 2006 to February 2014 were included retrospectively. A total of 40 comorbidities and 59 complications were registered meticulously. Univariate and multivariate analyses were used to detect associations between the individual comorbidities and specific post-operative complications.

RESULTS

Ninety-two per cent (575/625) of patients experienced one or more complications following radical cystectomy. Clavien-Dindo grade 3-5 complications were observed in 40.8% of patients, and 6.2% had severe complications (Clavien-Dindo grade 4-5). The mortality rate was 2.2%. High BM, previous myocardial infarction and chronic obstructive pulmonary disease were noted to be associated with moderate-to-severe post-operative complications (Clavien-Dindo grade 3-5), while diabetes and lymphoproliferative disorders were significantly associated with severe complications (Clavien-Dindo grade 4-5).

CONCLUSION

This study demonstrates that overall complications to radical cystectomy are high (92%). The associations between specific comorbidities and complications need to be further investigated in order to evaluate whether pre-operative assessment can be more optimally used in a prevention strategy tailored to the individual patient.

PROACTIVE PROTOCOL-BASED MANAGEMENT OF HYPERGLYCEMIA AND DIABETES IN COLORECTAL SURGERY PATIENTS

OBJECTIVE

The management of diabetic patients undergoing elective abdominal surgery continues to be unsystematic, despite evidence that standardized perioperative glycemic control is associated with fewer postoperative surgical complications. We examined the efficacy of a pre-operative diabetes optimization protocol implemented at a single institution in improving perioperative glycemic control with a target blood glucose of 80 to 180 mg/dL.

METHODS

Patients with established and newly diagnosed diabetes who underwent elective colorectal surgery were included. The control group comprised 103 patients from January 1, 2011, through December 31, 2013, before protocol implementation. The glycemic-optimized group included 96 patients following protocol implementation from January 1, 2014, through July 31, 2016. Data included demographic information, blood glucose levels, insulin doses, hypoglycemic events, and clinical outcomes (length of stay, re-admissions, complications, and mortality).

RESULTS

Patients enrolled in the glycemic optimization protocol had significantly lower glucose levels intra-operatively (145.0 mg/dL vs. 158.1 mg/dL; P = .03) and postoperatively (135.6 mg/dL vs. 145.2 mg/dL; P = .005). A higher proportion of patients enrolled in the protocol received insulin than patients in the control group (0.63 vs. 0.48; P = .01), but the insulin was administered less frequently (median [interquartile range] number of times, 6.0 [2.0 to 11.0] vs. 7.0 [5.0 to 11.0]; P = .04). Two episodes of symptomatic hypoglycemia occurred in the control group. There was no difference in clinical outcomes.

CONCLUSION

Improved peri-operative glycemic control was observed following implementation of a standardized institutional protocol for managing diabetic patients undergoing elective colorectal surgery.

ABBREVIATIONS

HbA1c = glycated hemoglobin A1c; IQR = interquartile range.