The Role of Perioperative Glucose Management In At Risk Surgical Closures: The Case for Tighter Glycemic Control

Purpose: Despite the recognition that tight glycemic control has received for patients in diseased states, the exact risk that poor control plays in patients undergoing surgical closure has yet to be fully defined. As such, the decision to perform primary closure in patients with hyperglycemia or to wait until better control has been achieved can be difficult especially in patients at high risk for complications.   We therefore sought to determine the increased risk poor glycemic control introduces to surgical closures in a high risk patient population.

Materials and Methods: We performed a retrospective chart review of high risk patients seen regularly at our wound center who underwent surgical closure of a variety of wounds.  Blood glucose levels taken regularly during their hospital stay were recorded for five days before and after surgical closure. Primary endpoints recorded included rates of healing, dehiscence, infection and reoperation. Univariate and multivariate analysis were performed. 

Results: 93 patients who underwent primary closure of their wounds, the majority of which occurred in the lower extremity (89%), were included for analysis.  Average follow up was 113 days.  Preoperative and postoperative hyperglycemia (defined as any blood glucose measurement recorded above 200) were significantly associated with increased rates of dehiscence (Odds ratio 3.46, p=0.028 and Odds ratio 3.46 and p=0.022 respectively) and trended toward significance with increased rates of reoperation (p=0.09 and 0.09).  There was no association between preoperative or postoperative hyperglycemia and rates of infection (p=0.457 and p=0.52).  Variability in preoperative glucose (as defined as a range of glucose measurements exceeding 200 points) was significantly associated with increased rates of reoperation (p=0.008) and trended toward a significant association with increased rates of dehiscence (p=0.075). On regression analysis of glycemic control, patient demographics, postoperative dressing and preoperative co-morbidities, including any history of diabetes, only perioperative hyperglycemia was significantly associated with increased rates of dehiscence and trended toward increased rates of reoperation.

Conclusions: When considering primary closure of surgical wounds in high risk patients, the importance of tight glycemic control cannot be underestimated.  Glucose levels above 200 and large swings in glucose levels increase rates of dehiscence and reoperation whether present in the preoperative or postoperative period.  The reconstructive surgeon must therefore insist on tight glycemic control before and after surgical closure for better results.