Advertisement

Clinical significance of diabetes control before metabolic surgery

      Highlights

      • Is there an association between poor preoperative diabetes control with worse postoperative outcomes (serious complications, infectious complications, prolonged length of stay, reoperation, and readmission) in patients with obesity and diabetes undergoing metabolic surgery?
      • This retrospective cohort study of 26,674 patients did not demonstrate any association between higher preoperative glycated hemoglobin and worsening of five primary outcomes of interest after sleeve gastrectomy and gastric bypass.
      • Suboptimal preoperative diabetes control is not associated with increased postoperative adverse events and should not delay metabolic surgery.

      Abstract

      Background

      Even though observational studies have suggested that poor preoperative diabetes control increases risk after major abdominal surgery, it is unclear whether this effect is seen in metabolic surgery patients.

      Objectives

      To determine whether poor preoperative diabetes control is associated with worse outcomes in patients with obesity and diabetes undergoing metabolic surgery.

      Setting

      Metabolic and Bariatric Surgery Quality Improvement Project (MBSAQIP) database.

      Methods

      Using the MBSAQIP 2017 and 2018 database and preoperative glycated hemoglobin (HbA1C) as a diabetes control surrogate, we examined the association between diabetes control and major outcomes of primary laparoscopic sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) in patients with diabetes and obesity. Multivariate logistic regression modeling examined five 30-day postoperative outcomes: composite serious complications (composite of 10 adverse events), composite infection (composite of 7 infectious complications), length of stay >5 days, reoperation, and readmission. Models were adjusted for multiple covariates.

      Results

      In total, 26,674 patients with HbA1C data available within 30 days before metabolic surgery were included in the primary analysis and 35,884 patients with HbA1C data within 90 days before surgery were included in the sensitivity analysis. The mean body mass index (BMI) and preoperative HbA1C were 45.6 ± 8.2 kg/m2 and 8.2 ± 2.7%, respectively. The incidence of 30-day postoperative infections and serious complications were 1.62% and 1.35%, respectively. Neither primary analysis nor sensitivity analysis demonstrated any association between higher HbA1C and worsening of 5 primary outcomes of interest. The odds ratio of an overall effect for SG was 1.01 (95% CI .98–1.03; P = .58) and for RYGB was .99 (95% CI .96–1.02; P = .41).

      Conclusion

      Suboptimal preoperative diabetes control is not associated with increased adverse events and should not delay metabolic surgery, as metabolic surgery is generally a safe procedure and intrinsically improves diabetes control.

      Graphical abstract

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Surgery for Obesity and Related Diseases
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Haines D.
        • Miranda H.G.
        • Flynn B.C.
        The role of hemoglobin A1c as a biomarker and risk assessment tool in patients undergoing non-cardiac and cardiac surgical procedures.
        J Cardiothorac Vasc Anesth. 2018; 32: 488-494
        • Goodenough C.J.
        • Liang M.K.
        • Nguyen M.T.
        • et al.
        Preoperative glycosylated hemoglobin and postoperative glucose together predict major complications after abdominal surgery.
        J Am Coll Surgeons. 2015; 221: 854-861.e1
        • Hikata T.
        • Iwanami A.
        • Hosogane N.
        • et al.
        High preoperative hemoglobin A1c is a risk factor for surgical site infection after posterior thoracic and lumbar spinal instrumentation surgery.
        J Orthop Sci. 2014; 19: 223-228
        • Underwood P.
        • Askari R.
        • Hurwitz S.
        • Chamarthi B.
        • Garg R.
        Preoperative A1C and clinical outcomes in patients with diabetes undergoing major noncardiac surgical procedures.
        Diabetes Care. 2014; 37: 611-616
        • Frisch A.
        • Chandra P.
        • Smiley D.
        • et al.
        Prevalence and clinical outcome of hyperglycemia in the perioperative period in noncardiac surgery.
        Diabetes Care. 2010; 33: 1783-1788
        • Ramos M.
        • Khalpey Z.
        • Lipsitz S.
        • et al.
        Relationship of perioperative hyperglycemia and postoperative infections in patients who undergo general and vascular surgery.
        Ann Surg. 2008; 248: 585-591
        • Meister K.M.
        • Hufford T.
        • Tu C.
        • et al.
        Clinical significance of perioperative hyperglycemia in bariatric surgery: evidence for better perioperative glucose management.
        Surg Obes Relat Dis. 2018; 14: 1725-1731
        • Dunn J.P.
        • Abumrad N.N.
        • Breitman I.
        • et al.
        Hepatic and peripheral insulin sensitivity and diabetes remission at 1 month after Roux-en-Y gastric bypass surgery in patients randomized to omentectomy.
        Diabetes Care. 2012; 35: 137-142
        • Isbell J.M.
        • Tamboli R.A.
        • Hansen E.N.
        • et al.
        The importance of caloric restriction in the early improvements in insulin sensitivity after Roux-en-Y gastric bypass surgery.
        Diabetes Care. 2010; 33: 1438-1442
        • Bradley D.
        • Conte C.
        • Mittendorfer B.
        • et al.
        Gastric bypass and banding equally improve insulin sensitivity and β cell function.
        J Clin Invest. 2012; 122: 4667-4674
        • Bradley D.
        • Magkos F.
        • Eagon J.C.
        • et al.
        Matched weight loss induced by sleeve gastrectomy or gastric bypass similarly improves metabolic function in obese subjects.
        Obesity (Silver Spring). 2014; 22: 2026-2031
        • Schauer P.R.
        • Bhatt D.L.
        • Kirwan J.P.
        • et al.
        Bariatric surgery versus intensive medical therapy for diabetes — 5-year outcomes.
        N Engl J Med. 2017; 376: 641-651
        • Salminen P.
        • Helmiö M.
        • Ovaska J.
        • et al.
        Effect of laparoscopic sleeve gastrectomy vs laparoscopic Roux-en-Y gastric bypass on weight loss at 5 years among patients with morbid obesity: the SLEEVEPASS randomized clinical trial.
        JAMA. 2018; 319: 241-254
        • Peterli R.
        • Wölnerhanssen B.K.
        • Peters T.
        • et al.
        Effect of laparoscopic sleeve gastrectomy vs laparoscopic Roux-en-Y gastric bypass on weight loss in patients with morbid obesity: the SM-BOSS randomized clinical trial.
        JAMA. 2018; 319: 255-265
        • Flum D.R.
        • Belle S.H.
        • King W.C.
        • et al.
        • Longitudinal Assessment of Bariatric Surgery Consortium
        Perioperative safety in the longitudinal assessment of bariatric surgery.
        N Engl J Med. 2009; 361: 445-454
        • Rubino F.
        • Nathan D.M.
        • Eckel R.H.
        • et al.
        Metabolic surgery in the treatment algorithm for type 2 diabetes: a joint statement by international diabetes organizations.
        Diabetes Care. 2016; 39: 861-877
        • Mascha E.J.
        • Sessler D.I.
        Statistical grand rounds: design and analysis of studies with binary- event composite endpoints.
        Anesth Analg. 2011; 112: 1461-1471
        • Tsuruta R.
        • Miyauchi K.
        • Yamamoto T.
        • et al.
        Effect of preoperative hemoglobin A1c levels on long-term outcomes for diabetic patients after off-pump coronary artery bypass grafting.
        J Cardiol. 2011; 57: 181-186
        • Endara M.
        • Masden D.
        • Goldstein J.
        • Gondek S.
        • Steinberg J.
        • Attinger C.
        The role of chronic and perioperative glucose management in high-risk surgical closures.
        Plast Reconstr Surg. 2013; 132: 996-1004
        • Knapik P.
        • Cieśla D.
        • Filipiak K.
        • Knapik M.
        • Zembala M.
        Prevalence and clinical significance of elevated preoperative glycosylated hemoglobin in diabetic patients scheduled for coronary artery surgery.
        Eur J Cardiothorac Surg. 2011; 39: 484-489
        • Bradley D.
        • Magkos F.
        • Klein S.
        Effects of bariatric surgery on glucose homeostasis and type 2 diabetes.
        Gastroenterology. 2012; 143: 897-912
        • King A.B.
        • Spann M.D.
        • Jablonski P.
        • Wanderer J.P.
        • Sandberg W.S.
        • McEvoy M.D.
        An enhanced recovery program for bariatric surgical patients significantly reduces perioperative opioid consumption and postoperative nausea.
        Surg Obes Relat Dis. 2018; 14: 849-856
        • Aminian A.
        • Brethauer S.A.
        • Kirwan J.P.
        • Kashyap S.R.
        • Burguera B.
        • Schauer P.R.
        How safe is metabolic/diabetes surgery?.
        Diabetes Obes Metab. 2015; 17: 198-201
        • Daigle C.R.
        • Brethauer S.A.
        • Tu C.
        • et al.
        Which postoperative complications matter most after bariatric surgery? Prioritizing quality improvement efforts to improve national outcomes.
        Surg Obes Relat Dis. 2018; 14: 652-657
        • Kuwada T.S.
        • Richardson S.
        • Chaar M.E.
        • et al.
        Insurance-mandated medical programs before bariatric surgery: do good things come to those who wait?.
        Surg Obes Relat Dis. 2011; 7: 526-530
        • Kim J.J.
        • Rogers A.M.
        • Ballem N.
        • Schirmer B.
        • Metabolic A.S.
        • Issues B.S.C.
        ASMBS updated position statement on insurance mandated preoperative weight loss requirements.
        Surg Obes Relat Dis. 2016; 12: 955-959
        • van den Boom W.
        • Schroeder R.A.
        • Manning M.W.
        • Setji T.L.
        • Fiestan G.-O.
        • Dunson D.B.
        Effect of A1C and glucose on postoperative mortality in noncardiac and cardiac surgeries.
        Diabetes Care. 2018; 41: 782-788
        • Jones C.E.
        • Graham L.A.
        • Morris M.S.
        • et al.
        Association between preoperative hemoglobin A 1c levels, postoperative hyperglycemia, and readmissions following gastrointestinal surgery.
        JAMA Surgery. 2017; 152: 1031-1038
        • Rawlins L.
        • Rawlins M.P.
        • Brown C.C.
        • Schumacher D.L.
        Effect of elevated hemoglobin A1c in diabetic patients on complication rates after Roux-en-Y gastric bypass.
        Surg Obes Relat. 2012; 9: 749-752
      1. Hart A, Goffredo P, Carroll R, et al. Optimizing bariatric surgery outcomes: the impact of preoperative elevated hemoglobin A1c levels on composite perioperative outcome measures. Surg Endosc. Epub 2020 Aug 12.

        • Senn S.
        Statistical pitfalls of personalized medicine.
        Nature. 2018; 563: 619-621
        • Fedorov V.
        • Mannino F.
        • Zhang R.
        Consequences of dichotomization.
        Pharm Stat. 2009; 8: 50-61
        • Cancienne J.M.
        • Werner B.C.
        • Browne J.A.
        Is there a threshold value of hemoglobin A1c that predicts risk of infection following primary total hip arthroplasty?.
        J Arthroplasty. 2017; 32: S236-S240
        • Rollins K.E.
        • Varadhan K.K.
        • Dhatariya K.
        • Lobo D.N.
        Systematic review of the impact of HbA1c on outcomes following surgery in patients with diabetes mellitus.
        Clin Nutri. 2016; 35: 308-316
        • Aminian A.
        • Kashyap S.R.
        • Burguera B.
        • et al.
        Incidence and clinical features of diabetic ketoacidosis after bariatric and metabolic surgery.
        Diabetes Care. 2016; 39: e50-e53