Targeting Peri-Operative Hyperglycemia in Patients Undergoing Complex Ventral Hernia Repair

Early post-operative hyperglycemia is associated with greater costs in patients who have undergone complex ventral hernia repair, independent of comorbid diabetes, according to findings recently reported in the Journal of the American Medical Association (JAMA) Surgery.1

David Soybel, M.D., along with colleagues from Penn State Hershey Endocrinology, conducted a retrospective medical record review of 136 consecutive patients for whom complex ventral hernias were repaired and serum glucose levels were measured within 48 hours of surgery. In the subset of patients with post-operative elevated glucose (greater than or equal to 140 mg/ mL, n=54) or those who required insulin administration (n=69) compared to patients without these outcomes, time to first solid meal was significantly delayed and significant increases were observed for length-of-stay and hospital costs. A trend toward greater risk of surgical site occurrence was also observed (P=0.06). These findings were further supported by a sub-analysis of patients in the two most common Ventral Hernia Working Group grades 2 and 3 (Figure 1).

Post-Operative Hyperglycemia

A: Comparison between groups with postoperative serum glucose levels of less than 140 mg/dL vs greater than or equal to 140 mg/dL. B: Comparison between groups with zero or one vs two or more insulin events, defined as the number of times insulin was administered postoperatively during the hospital stay. Comparisons were performed using Fisher exact test. SSO=surgical site occurrence, including seroma, hematoma, surgical site infection, a non-healing wound, or a hernia recurrence; LOS=length-of-stay.

Soybel notes, “A really interesting finding is that nearly half of the patients [46.4 percent] who developed hyperglycemia had no history of diabetes. This supports the notion that post-operative hyperglycemia and insulin resistance are part of the metabolic response to surgery itself, and are often transient.”

A major implication of these findings is the need to change current standards of care to include post-operative glucose monitoring within 48 hours for patients who undergo complex ventral hernia repair, regardless of their diabetic status. Soybel further explains, “This might also be applied to patients undergoing any type of complex abdominal surgery. Hyperglycemia may be a response to the physiological stress of such procedures.”

The potential use of post-operative glucose monitoring could be paired with preventive steps to manage risks associated with elevated blood glucose. Soybel notes, “As part of our multi-disciplinary team, a diabetologist [Ariana Pichardo- Lowden, M.D.] plays a key role in managing patients with post-op hyperglycemia. In some cases, the use of a long-acting insulin can more effectively manage blood sugar levels, while minimizing risk of hypoglycemia, particularly in hernia repair patients who are not eating.” According to Pichardo-Lowden2 there are currently no clearly defined glycemic targets for the general surgical patient population outside of the intensive care unit setting, but rather guidance to maintain “reasonable, achievable, and safe” glucose levels, aiming for pre-prandial blood glucose less than 140 mg/mL and administering insulin to reduce random glucose levels greater than 180 mg/dL.

Post-operative hyperglycemia has previously been linked to poor patient outcomes and increased costs across multiple inpatient populations.2 The phenomenon is considered to arise from a variety of genetic, medication-related, and patient-related factors that influence chronic and acute systemic inflammatory processes, immune responses and metabolic homeostasis. Many ventral hernia repair patients also exhibit pre-diabetic risk factors. In these patients, pre-operative hemoglobin A1C screening may be performed with appropriate measures taken to optimize HbA1C prior to surgery.


David I. Soybel, M.D.David I. Soybel, M.D.
Professor of Surgery
Phone: 717-531-5272 | E-mail: dsoybel@hmc.psu.edu
Residency: General Surgery, Washington University in St. Louis – Barnes Jewish Hospital, St. Louis, Missouri
Medical School: The University of Chicago-Pritzker School of Medicine, Chicago, Illinois

 


References:

  1. Won EJ, Lehman EB, Geletzke AK, Tangel MR, Matsushima K, Brunke-Reese D, Pichardo-Lowden AR, Pauli EM, Soybel DI. 2015. Association of Postoperative Hyperglycemia With Outcomes Among Patients With Complex Ventral Hernia Repair. JAMA Surg. March 18, Epub ahead of print.
  2. Pichardo-Lowden A, Gabbay RA. 2012. Management of hyperglycemia during the perioperative period. Curr Diab Rep. 12:108-18.

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