Is glycosylated hemoglobin A1 c associated with increased risk for severe early postoperative complications in nondiabetics after laparoscopic gastric bypass?

Elevated Hb A1C level and revisional bariatric surgery complications

BACKGROUND

Elevated Hb A1C is a modifiable risk factor for postoperative complications. However, in bariatric surgery, as published by our group and others, elevated preoperative Hb A1C may not be associated with increased postoperative complications. Previous literature has focused on primary bariatric surgery and has excluded the higher-risk revisional surgery cohort.

OBJECTIVE

To assess the impact of Hb A1C on early postoperative outcomes in patients requiring revisional bariatric surgery.

SETTING

Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database.

METHODS

We undertook a retrospective review of patients undergoing revisional bariatric surgery between 2017 and 2018 from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. Two groups were studied, defined by Hb A1C cutoff, ≤8% versus >8% and ≤10% versus >10%. Early postoperative complications were compared at each threshold, with the primary outcome defined as a composite of all complications. Propensity score matching (PSM) was used with one-to-one matching for covariates, and the complication rates before and after PSM were calculated and assessed by Fisher's exact test and conditional logistic regression, respectively.

RESULTS

A total of 16,234 patients had undergone revisional bariatric surgery. After PSM, elevated Hb A1C was not associated with worse outcomes. No significant difference was seen in the composite outcomes for Hb A1C ≤8% versus Hb A1C >8% (P = .22) or for patients with Hb A1C ≤10% versus Hb A1C >10% (P < .46). There were no differences in individual outcomes such as surgical-site infections, cardiopulmonary complications, or readmissions/reinterventions.

CONCLUSION

In this study of revisional bariatric patients, elevated Hb A1C >8% or >10% was not associated with increased postoperative complications. Prospective studies are needed to investigate this further.

Preoperative Glycosylated Haemoglobin Screening to Identify Older Adult Patients with Undiagnosed Diabetes Mellitus-A Retrospective Cohort Study

More than 25% of older adults in Europe have diabetes mellitus. It is estimated that 45% of patients with diabetes are currently undiagnosed, which is a known risk factor for perioperative morbidity. We investigated whether routine HbA1c screening in older adult patients undergoing surgery would identify patients with undiagnosed diabetes. We included patients aged ≥65 years without a diagnosis of diabetes who visited the preoperative assessment clinic at the Amsterdam University Medical Center and underwent HbA1c screening within three months before surgery. Patients undergoing cardiac surgery were excluded. We assessed the prevalence of undiagnosed diabetes (defined as HbA1c ≥ 48 mmol·mol-1) and prediabetes (HbA1c 39-47 mmol·mol-1). Using a multivariate regression model, we analysed the ability of HbA1c to predict days alive and at home within 30 days after surgery. From January to December 2019, we screened 2015 patients ≥65 years at our clinic. Of these, 697 patients without a diagnosis of diabetes underwent HbA1c screening. The prevalence of undiagnosed diabetes and prediabetes was 3.7% (95%CI 2.5-5.4%) and 42.9% (95%CI 39.2-46.7%), respectively. Preoperative HbA1c was not associated with days alive and at home within 30 days after surgery. In conclusion, we identified a small number of patients with undiagnosed diabetes and a high prevalence of prediabetes based on preoperative HbA1c screening in a cohort of older adults undergoing non-cardiac surgery. The relevance of prediabetes in the perioperative setting is unclear. Screening for HbA1c in older adult patients undergoing non-cardiac surgery does not appear to help predict postoperative outcome.

Results from the Scandinavian Obesity Surgery Registry: A narrative review

In 2007, the Scandinavian Obesity Surgery Registry (SOReg) was started by the profession to monitor the results of bariatric surgery and to provide a high-quality database for research. In the end of August 2023, SOReg contains 88,379 patients (body mass index [BMI] 41.7 kg/m2 , 41.2 years, 77.1% females, gastric bypass 76.8%). In this narrative review, we demonstrate that preoperative weight loss is of value and that the laparoscopic double omega-loop technique is highly suitable for gastric bypass. Closing the mesenteric openings is, however, important. Swedish bariatric surgery has low mortality, and our results are comparative to those of other countries. Significant long-term improvements are found in common obesity-related diseases such as diabetes, hypertension, and sleep apnea. Furthermore, the risk for cardiac failure and major adverse cardiovascular events is significantly reduced. Pregnancy-related outcomes are also improved. Gastric bypass results in significant improvements in quality of life and seems to be cost saving. We have revealed that low socioeconomic status is associated with reduced chance of undergoing bariatric surgery and inferior outcomes. Of note, we have performed several randomized clinical trials within the registry database. In conclusion, high-quality national registry databases, such as SOReg, are important for maintaining high-quality care and present a platform for extensive research.

Elevated hemoglobin A1c level and bariatric surgery complications

INTRODUCTION

In cardiac and orthopedic surgery, elevated glycosylated hemoglobin (HbA1c) is a modifiable risk factor for postoperative complications. However, in bariatric surgery, there is insufficient evidence to assess the effectiveness of preoperative HbA1c assessment and its association with postoperative complications. The objective of this study was to assess the impact of HbA1c on early postoperative outcomes in bariatric surgery patients.

METHODS

Patients who underwent laparoscopic sleeve gastrectomy and laparoscopic Roux-En-Y Gastric Bypass between 2017 and 2018 were selected for a retrospective review from the metabolic and bariatric surgery accreditation and quality improvement program (MBSAQIP) database. The study population of 118,742 patients was analyzed for our primary outcome which was defined as a composite of any postoperative complications occurring within 30 days. Two groups were defined by HbA1c cutoff: comparison point A (≤ 8% vs > 8%) and comparison point B (≤ 10% vs > 10%). Procedure-related complications were also examined on subgroup analysis. Propensity score matching (PSM) was used with one-to-one matching. The complication rates before and after PSM were calculated and assessed by Fisher's exact test and conditional logistic regression, respectively.

RESULTS

After PSM, demographic and clinical characteristics were all balanced and elevated HbA1C was not associated with worse outcomes. After adjusting for underlying comorbidities, there was no statistically significant difference seen in the composite outcome for comparison point A HbA1C ≤ 8 and HbA1C > 8 (p = 0.22). For comparison point B, patients with HbA1C ≤ 10 had more composite complications compared to patients with HbA1C > 10 (p < 0.001). Also, on subgroup analysis after PSM for procedure-specific complications, patients above the cutoff threshold of 8 did not have worsened composite outcomes (p = 0.58 and 0.89 for sleeve and bypass, respectively). Again, at cutoff threshold of 10, patients in HbA1C ≤ 10 had more composite complications (p = 0.001 and 0.007 for sleeve and bypass, respectively).

CONCLUSION

In this study of bariatric patients, elevated HbA1c > 8% or 10% was not associated with increased postoperative complications. HbA1c lower than 10% was associated with some types of adverse outcomes in this bariatric dataset. More studies are needed to investigate these findings further. A high HbA1c alone may not disqualify a patient from proceeding with bariatric surgery.

Association of Preoperative Glycosylated Hemoglobin Level with 30-Day Outcomes Following Laparoscopic Roux-en-Y Gastric Bypass: an Analysis of the ACS-MBSAQIP Database

PURPOSE

Elevated glycosylated hemoglobin (HbA₁c) levels have been associated with increased morbidity and mortality following several cardiac, colorectal, orthopedic, and vascular surgery operations. The purpose of this study was to determine if there is a HgA₁c cut-point that can be used in patients undergoing laparoscopic Roux-en-Y gastric bypass to decrease the risk of 30-day wound events and additional 30-day morbidity and mortality.

MATERIALS AND METHODS

All patients undergoing first-time, elective Roux-en-Y gastric bypass in 2017 and 2018 with a diagnosis of diabetes mellitus (DM) and a preoperative HbA₁c level were identified within the American College of Surgeons Metabolic and Bariatric Surgery Accreditation Quality Improvement Program (ACS-MBSAQIP) database. The association of preoperative HbA₁c levels with 30-day morbidity and mortality was investigated.

RESULTS

A total of 13,806 patients met inclusion criteria. Two natural HbA₁c inflection points for composite wound events, including superficial, deep, and organ space surgical site infections (SSI) and wound dehiscence, were found. A HbA₁c level of ≤ 6.5% was associated with a decreased odds of experiencing the composite 30-day wound event outcome while a HbA₁c level of > 8.6% was associated with an increased odds of experiencing the composite 30-day wound event outcome. The differences in the incidence of the 30-day composite wound event outcomes were driven primarily by superficial and organ space SSI, including anastomotic leaks.

CONCLUSION

Patients with DM being evaluated for RYGB surgery with a HbA₁c level > 8.6% are at an increased risk for 30-day wound events, including superficial and organ space SSI.

Clinical practice guideline: evidence, recommendations and algorithm for the preoperative optimization of anemia, hyperglycemia and smoking

Preoperative optimization has not been explored comprehensively in the surgical literature, as this responsibility has often been divided among surgery, anesthesia and medicine. We developed an evidence-based clinical practice guideline to summarize existing evidence and present diagnostic and treatment algorithms for use by surgeons caring for patients scheduled to undergo major elective surgery. We focus on 3 common comorbid conditions seen across surgical specialties - anemia, hyperglycemia and smoking - as these conditions increase complication rates in patients undergoing major surgery and can be optimized successfully as soon as 6-8 weeks before surgery. With the ability to address these conditions earlier in the patient journey, surgeons can positively affect patient outcomes. The aim of this guideline is to bring optimization in the preoperative period under the existing umbrella of evidence-based surgical care.

The Effect of Laparoscopic Gastric Bypass Surgery on Insulin Resistance and Glycosylated Hemoglobin A1c: a 2-Year Follow-up Study

BACKGROUND

Bariatric surgery improves insulin sensitivity and secretion in patients with type 2 diabetes, but the effect on patients with prediabetes or even normal glucose tolerance deserves further consideration.

METHODS

Cohort study including patients operated with laparoscopic Roux-en-Y gastric bypass surgery (LRYGB) between November 2012 and June 2017 at the Örebro University Hospital (n = 813) with follow-up of 742 patients 2 years after surgery. Fasting insulin, glucose, glycosylated hemoglobin (HbA1c), and homeostatic model assessment of insulin resistance (HOMA-IR) were analyzed at baseline and 2 years after surgery for patients with overt type 2 diabetes, prediabetes, or non-diabetes.

RESULTS

Fasting insulin levels improved for all groups (diabetics baseline 25.5 mIU/L, IQR 17.5-38.0, 2 years 7.6 mIU/L, IQR 5.4-11.1, p < 0.001; prediabetics baseline 25.0 mIU/L, IQR 17.5-35.0, 2 years 6.7mIU/L, IQR 5.3-8.8, p < 0.001; non-diabetics baseline 20.0 mIU/L, IQR 14.0-30.0, 2 years 6.4 mIU/L, IQR 5.0-8.5, p < 0.001). HbA1c improved in all groups (diabetics baseline 56 mmol/mol, IQR 49-74 [7.3%, IQP 6.6-8.9], 2 years 38 mmol/mol, IQR 36-47 [5.6%, IQR 5.4-6.4], p < 0.001; prediabetics baseline 40 mmol/mol, IQR 39-42 [5.8%, IQR5.7-6.0], 2 years 36 mmol/mol, IQR 34-38 [5.5%, IQR 5.3-5.6], p < 0.001; non-diabetics baseline 35 mmol/mol, IQR 33-37 [5.4%, IQR 5.2-5.5]; 2 years 34 mmol/mol, IQR 31-36 [5.3%, IQR 5.0-5.4], p < 0.001). HOMA-IR improved in all groups (diabetics baseline 9.3 mmol/mol, IQR 5.4-12.9, 2 years 1.9 mmol/mol, IQR 1.4-2.7, p < 0.001; prediabetics baseline 7.0 mmol/mol, IQR 4.3-9.9, 2 years 1.6 mmol/mol, IQR 1.2-2.1, p < 0.001; non-diabetics 4.9 mmol/mol, IQR 3.4-7.3, 2 years 1.4 mmol/mol, IQR 1.1-1.9, p < 0.001).

CONCLUSION

Insulin homeostasis and glucometabolic control improve in all patients after LRYGB, not only in diabetics but also in prediabetics and non-diabetic obese patients, and this improvement is sustained 2 years after surgery.

Costs Associated With Modifiable Risk Factors in Ventral and Incisional Hernia Repair

IMPORTANCE

Ventral and incisional hernia repair (VIHR) is an extremely common operation, after which complications are also fairly common. A number of preoperative risk factors are known to contribute to increased complications after surgical repair; however, the individual relative association of these risk factors with adverse outcomes and increased spending is unclear. Quantifying the association of individual risk factors may help surgeons implement targeted surgical optimization, improve outcomes, and reduce spending.

OBJECTIVE

To identify the attributable association of modifiable risk factors for adverse outcomes after VIHR on outcomes and episode-of-care payments.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study was performed using a population-based sample of adult patients and episode spending data from January 1, 2012, to December 31, 2018, from a statewide multipayer registry. A multilevel mixed-effects logistic regression model was used to examine the contribution of patient-specific risk factors to adverse outcomes. Attributable risk and population attributable risk fraction were calculated to estimate the additional spending attributable to individual risk factors. Data were analyzed from April 2018 to September 2018.

MAIN OUTCOMES AND MEASURES

Any complications, serious complication, discharge not to home, 30-day emergency department utilization, and 30-day readmission. Episode-of-care spending was calculated for these outcomes.

RESULTS

This study included 22 664 patients (median [interquartile range] age, 55 [44-64] years; 10 496 [46.3%] women) undergoing VIHR with identified significant preoperative risk factors. Fourth-quartile body mass index (BMI), calculated as weight in kilograms divided by height in meters squared and defined as a mean (SD) BMI of 43 (6), was associated with increased risk of any complication (odds ratio [OR], 1.64; 95% CI, 1.30-2.06; P < .001) and serious complication (OR, 1.67; 95% CI, 1.22-2.31; P = .002). Insulin-dependent diabetes was associated with increased risk of any complication (OR, 1.34; 95% CI, 1.03-1.73; P = .03), serious complication (OR, 1.51; 95% CI, 1.08-2.12; P = .02), discharge not to home (OR, 1.49; 95% CI, 1.12-1.98; P = .005), and 30-day readmission (OR, 1.68; 95% CI, 1.32-2.14; P < .001). Median (interquartile range) additional episode spending for any complication was $9934 ($9224-$11 851), of which $1304 ($1208-$1552) was attributable to fourth-quartile BMI. Median (interquartile range) additional episode spending for a serious complication was $26 648 ($20 632-$33 166), of which $3638 ($2827-$4544) was attributable to fourth-quartile BMI, $650 ($495-$796) was attributable to insulin-dependent diabetes, and $567 ($433-$696) was attributable to unhealthy alcohol use.

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, modifiable risk factors, such as obesity, insulin-dependent diabetes, and unhealthy alcohol use, were associated with adverse outcomes after VIHR. These factors were significantly associated with increased health care spending; therefore, preoperative optimization may improve outcomes and decrease episode-of-care costs.

Risk Prediction Model for Severe Postoperative Complication in Bariatric Surgery

Background

Factors associated with risk for adverse outcome are important considerations in the preoperative assessment of patients for bariatric surgery. As yet, prediction models based on preoperative risk factors have not been able to predict adverse outcome sufficiently.

Objective

This study aimed to identify preoperative risk factors and to construct a risk prediction model based on these.

Methods

Patients who underwent a bariatric surgical procedure in Sweden between 2010 and 2014 were identified from the Scandinavian Obesity Surgery Registry (SOReg). Associations between preoperative potential risk factors and severe postoperative complications were analysed using a logistic regression model. A multivariate model for risk prediction was created and validated in the SOReg for patients who underwent bariatric surgery in Sweden, 2015.

Results

Revision surgery (standardized OR 1.19, 95% confidence interval (CI) 1.14–0.24, p < 0.001), age (standardized OR 1.10, 95%CI 1.03–1.17, p = 0.007), low body mass index (standardized OR 0.89, 95%CI 0.82–0.98, p = 0.012), operation year (standardized OR 0.91, 95%CI 0.85–0.97, p = 0.003), waist circumference (standardized OR 1.09, 95%CI 1.00–1.19, p = 0.059), and dyspepsia/GERD (standardized OR 1.08, 95%CI 1.02–1.15, p = 0.007) were all associated with risk for severe postoperative complication and were included in the risk prediction model. Despite high specificity, the sensitivity of the model was low.

Conclusion

Revision surgery, high age, low BMI, large waist circumference, and dyspepsia/GERD were associated with an increased risk for severe postoperative complication. The prediction model based on these factors, however, had a sensitivity that was too low to predict risk in the individual patient case.

Association of Elevated Pre-operative Hemoglobin A1c and Post-operative Complications in Non-diabetic Patients: A Systematic Review

IMPORTANCE

Pre-operative hyperglycemia is associated with post-operative adverse outcomes in diabetic and non-diabetic patients. Current pre-operative screening includes random plasma glucose, yet plasma glycated hemoglobin (HbA1c) is a better measure of long-term glycemic control. It is not clear whether pre-operative HbA1c can identify non-diabetic patients at risk of post-operative complications.

OBJECTIVE

The systematic review summarizes the evidence pertaining to the association of suboptimal pre-operative HbA1c on post-operative outcomes in adult surgical patients with no history of diabetes mellitus.

EVIDENCE REVIEW

A detailed search strategy was developed by a librarian to identify all the relevant studies to date from the major online databases.

FINDINGS

Six observational studies met all the eligibility criteria and were included in the review. Four studies reported a significant association between pre-operative HbA1c levels and post-operative complications in non-diabetic patients. Two studies reported increased post-operative infection rates, and two reported no difference. Of four studies assessing the length of stay, three did not observe any association with HbA1c level and only one study observed a significant impact. Only one study found higher mortality rates in patients with suboptimal HbA1c.

CONCLUSIONS AND RELEVANCE

Based on the limited available evidence, suboptimal pre-operative HbA1c levels in patients with no prior history of diabetes predict post-operative complications and represent a potentially modifiable risk factor.

[Quality indicators for metabolic and bariatric surgery in Germany : Evidence-based development of an indicator panel for the quality of results, indications and structure]

An expert committee was appointed by the German Society for General and Visceral Surgery to develop a panel of appropriate quality indicators to collate the quality of results, indications and structure in metabolic and bariatric surgery. This entailed assimilating the available evidence (systematic literature search), results from the national registry of the society (StuDoQ|MBE) and specific socioeconomic aspects (e. g. severely limited access to metabolic and bariatric surgery in Germany). These quality parameters were to be incorporated into the national guidelines and the rules of procedure for certification in the future. The committee concluded that mortality, MTL30 and severe complications needing intervention (Clavien-Dindo ≥ 3b) are suitable indicators to measure surgical outcome quality due to their relevance, scientific soundness and practicability. As a systematic follow-up is mandatory after bariatric surgery, a minimum follow-up quota is now required using reported quality of life data as an indicator of process quality. As intestinal bypass procedures have been shown to be superior in the treatment of type 2 diabetes, these procedures should be offered to eligible patients and also be performed. The proposed threshold values based on the results of the available literature and StuDoQ registry are to be considered as preliminary and need to be validated and adjusted if necessary in the future. The StuDoQ|MBE is considered a valuable tool to gather this information and also represents the appropriate infrastructure for the collation of relevant risk adjustors.

Bariatric Surgery Registries: Can They Contribute to Improved Outcomes?

PURPOSE OF REVIEW

Clinical registries systematically collect prospective information about patients with a particular medical condition, who have had a medical device implanted or who have undergone a particular procedure. When these variables are collected with pre-defined quality indices included, the benched-marked risk-adjusted data may be a valuable resource for providing feedback on outcomes, including performance, to practitioners, patients, health services and device manufacturers.

RECENT FINDINGS

There are examples of feedback from clinical registries positively influencing patient care. The Australian National Joint Registry identified a poorly performing hip prosthesis which was ultimately withdrawn from the market. Feedback from the Victorian State Prostate Cancer Registry has contributed to improved patient care and fewer positive surgical margins noted over a 5-year reporting period. There are several national and regional registries collecting information on patients undergoing bariatric surgery, however, few currently focus on quality outcome measures. Whilst, current bariatric registries have contributed to improved understanding of some of the clinical situations relating to bariatric surgery, as well as developing composite risk scores and measuring quality cultures, they have not as yet demonstrably directly influenced patient care. This may reflect the fact that many of the registries do not hold data that are mature enough for proper analysis, but may also reflect problems with systematic data collection, bias from missing results and lack of appropriate funding. It will be important in the future that bariatric surgery registries actively seek to measure and validate their contribution to patient outcomes.

Ventral Hernia Management: Expert Consensus Guided by Systematic Review

OBJECTIVE

To achieve consensus on the best practices in the management of ventral hernias (VH).

BACKGROUND

Management patterns for VH are heterogeneous, often with little supporting evidence or correlation with existing evidence.

METHODS

A systematic review identified the highest level of evidence available for each topic. A panel of expert hernia-surgeons was assembled. Email questionnaires, evidence review, panel discussion, and iterative voting was performed. Consensus was when all experts agreed on a management strategy.

RESULTS

Experts agreed that complications with VH repair (VHR) increase in obese patients (grade A), current smokers (grade A), and patients with glycosylated hemoglobin (HbA1C) ≥ 6.5% (grade B). Elective VHR was not recommended for patients with BMI ≥ 50 kg/m (grade C), current smokers (grade A), or patients with HbA1C ≥ 8.0% (grade B). Patients with BMI= 30-50 kg/m or HbA1C = 6.5-8.0% require individualized interventions to reduce surgical risk (grade C, grade B). Nonoperative management was considered to have a low-risk of short-term morbidity (grade C). Mesh reinforcement was recommended for repair of hernias ≥ 2 cm (grade A). There were several areas where high-quality data were limited, and no consensus could be reached, including mesh type, component separation technique, and management of complex patients.

CONCLUSIONS

Although there was consensus, supported by grade A-C evidence, on patient selection, the safety of short-term nonoperative management, and mesh reinforcement, among experts; there was limited evidence and broad variability in practice patterns in all other areas of practice. The lack of strong evidence and expert consensus on these topics has identified gaps in knowledge where there is need of further evidence.

Bleeding during laparoscopic gastric bypass surgery as a risk factor for less favorable outcome. A cohort study from the Scandinavian Obesity Surgery Registry

BACKGROUND

Intraoperative adverse events are known to be associated with postoperative complications; however, little is known about whether or not blood loss during laparoscopic gastric bypass surgery affects the outcome.

OBJECTIVE

To see if intraoperative bleeding was associated with a less favorable outcome, and to identify patient-specific risk factors for intraoperative bleeding.

SETTING

Nationwide, Sweden.

METHODS

Patients who underwent laparoscopic gastric bypass surgery between January 8, 2007, and September 15, 2015, were included in the study. The volume of intraoperative blood loss was compared with data from follow-up at day 30 and 1 and 2 years after surgery. Patient-specific factors were analyzed as potential risk factors for intraoperative bleeding.

RESULTS

The study included 43,157 patients. Intraoperative bleeding was associated with an increased risk for postoperative complication (100-499 mL, odds ratio [OR] 2.97, 95% confidence interval [95%CI] 2.53-3.50;>500 mL OR 3.34, 95%CI 2.05-5.44), lower weight loss (<100 mL, 82.4±24.19% excess body mass index-loss [%EBMIL]; 100-499 mL, 76.9±24.24 %EBMIL, P<.0001;>500 mL 76.9±23.89 %EBMIL, P = .063) and lower reported quality-of-life 2 years after surgery (<100 mL, Obesity-related Problem scale (OP) 21.1±24.46; 100-499 mL, OP 25.0±26.62, P = .008;>500 mL, OP 25.2±24.46, P = .272). Diabetes (OR 1.30, 95%CI 1.08-1.58), age (OR 1.02, 95%CI 1.02-1.03), and body mass index (OR 1.03, 95%CI 1.02-1.05) were patient-specific risk factors for intraoperative bleeding≥100 mL, whereas intentional preoperative weight loss was associated with a lower risk (OR .50, 95%CI .43-.57).

CONCLUSION

Intraoperative bleeding was associated with less favorable outcome after laparoscopic gastric bypass surgery. Age, body mass index, and diabetes were risk factors for intraoperative bleeding, while preoperative weight reduction seems to be protective.

Incidência e fatores de complicações pulmonares pós-operatórias em pacientes submetidos à cirurgias de tórax e abdome

RESUMO Objetivos: avaliar a incidência de complicações pulmonares pós-operatórias em pacientes submetidos à cirurgias de tórax e abdome e os principais fatores envolvidos. Métodos: estudo analítico observacional prospectivo dos pacientes submetidos à cirurgias de tórax e abdome no Hospital Santo Antônio de Blumenau, SC. Os dados foram coletados dos prontuários eletrônicos e através de entrevistas estruturadas com os pacientes. Foram avaliados dados relativos às características dos pacientes e da cirurgia. A variável de desfecho foi a ocorrência de complicações pulmonares pós-operatórias. Resultados: foram estudados 314 pacientes, 65,6% do sexo feminino, com média de idade de 46,61 anos, 51,6% classificados como ASA II. Cirurgias por vídeo foram realizadas em 55,7% dos casos, abdominais em 85,4% e 61,5% dos procedimentos foram classificados como potencialmente contaminadas e de porte médio. O tempo médio de cirurgia foi de 126,65 minutos e os pacientes ficaram internados em média por 2,59 dias. A incidência de complicações pulmonares pós-operatórias foi de 11,5%. As complicações mais comuns foram a insuficiência respiratória, o derrame pleural e a pneumonia. Os fatores de risco mais importantes para estas complicações foram diabetes, internação hospitalar por mais de cinco dias e presença de doença pulmonar prévia. Os pacientes submetidos às cirurgias por vídeo apresentaram menor incidência de complicações. Conclusão: as complicações pulmonares pós-operatórias são frequentes e os fatores associados a maior risco foram diabetes, internação prolongada e presença de doença pulmonar prévia.

An Elevated HbA1c Level Is Associated With Short-Term Adverse Outcomes in Patients With Gastrointestinal Cancer and Type 2 Diabetes Mellitus

Background

Although an elevated hemoglobin A1c (HbAc1) level is an independent predictor of worse survival in patients with both digestive cancer and diabetes mellitus, its relationship to short-term prognosis in these patients has not been addressed. This study assessed this relationship in gastrointestinal cancer (GIC) patients with type 2 diabetes mellitus (T2DM).

Methods

A retrospective review of patients with GIC with or without T2DM from 2004 to 2014 was performed. Patients with T2DM were grouped according to HbA1c level, either normal (mean < 7.0%) or elevated (mean ≥ 7.0%). Age- and sex-matched GIC patients without T2DM served as controls.

Results

One hundred and eighteen patients aged 33 - 81 years with T2DM met the study eligibility criteria; 51 were in the normal HbA1c group, and 67 were in the elevated HbA1c group. The 91 patients in the non-T2DM group were randomly selected and matched to the T2DM group in terms of admittance date, age, and sex. There was a trend toward a higher 180-day mortality rate in the T2DM group compared with the non-T2DM group (15.3% vs. 7.7%, P = 0.095) and in the elevated HbA1c group compared with the normal HbA1c group (19.4% vs. 9.8%, P = 0.151); however, the differences were not significant. The duration of the hospital stay was longer in patients with T2DM than in those without T2DM (13.2 vs. 8.9 days, P < 0.05) and in patients with elevated versus normal HbA1c levels (14.5 vs. 11.4 days, P < 0.05). Diabetic GIC patients with elevated HbA1c levels had significantly more total postoperative complications than those with normal HbA1c levels (25.4% vs. 9.8%, P < 0.05). In multivariate regression analyses, short-term adverse outcomes were strongly associated with elevated HbA1c levels (odds ratio (OR): 5.276; 95% confidence level (CI): 1.73 - 16.095; P < 0.05) and no strict antidiabetic treatment (OR: 7.65; 95% CI: 2.49 - 23.54; P < 0.001).

Conclusion

An elevated level of HbA1c significantly correlated with and was an independent predictor of short-term adverse outcomes in GIC patients with T2DM.

Formation of the Scandinavian Obesity Surgery Registry, SOReg

BACKGROUND

Obesity surgery is expanding, the quality of care is ever more important, and learning curve assessment should be established. A large registry cohort can show long-term effects on obesity and its comorbidities, complications, and long-term side effects of surgery, as well as changes in health-related quality of life (QoL). Sweden is ideally suited to the task of data collection and audit, with universal use of personal identification numbers, nation-wide registries permitting cross-matching to analyze causes of death, in-hospital care, and health-related absenteeism.

METHOD

In 2004, the Scandinavian Obesity Surgery Registry (SOReg) was initiated and government financing secured. A project group created a national database covering all public as well as private hospitals. Data entry was to be made online, operative definitions of comorbidity were formed, and complication severity scored. Several forms of audit were devised.

RESULTS

After pilot studies, the system has been running in its present form since 2007. Since 15 January 2013, SOReg covers all bariatric surgery centers in Sweden. The number of operations in the database exceeded 40,000 (March 2014), with a median follow-up of 2.94 years. Audit shows that >98% of data are correct. All results are publicized annually on the Internet.

COMMENTS

Using this systematic approach, it has been possible to cover >99% of all bariatric surgery, cross-matching our data with nation-wide registries for in-hospital care, cause of death, and permitting regular nation-wide audit. Several scientific studies have used, or are using, what seems to be the most comprehensive database in obesity surgery.