Glycaemic control strategies in people with type 2 diabetes mellitus undergoing elective surgery

Abstract

People with diabetes mellitus (DM) undergo more elective surgery than those without DM; however, up to half of the patients are undiagnosed when referred for surgery. This is an opportunity to intervene and instigate a management plan. Preoperative strategies may vary based on coexisting medical diseases such as obesity and the availability of resources with the aim of achieving glycaemic control while also treating coexisting conditions. In the context of obesity, there is substantial overlap in some of the treatment strategies. Guidelines, such as those from the UK Centre for Perioperative Medicine, suggest target glycated haemoglobin levels, preoperative fasting blood glucose levels, and when to defer an elective operation or instigate treatment to proceed if deemed safe. Preoperatively glycaemic control is often achieved pharmacologically, and newer agents, including glucagon-like peptide one receptor agonists (GLP1-RA) and sodium-glucose co-transporter 2 (SGLT2) inhibitors, are emphasised in the preoperative management of diabetes mellitus, particularly if obesity is also present. A very low-energy diet is an underutilised but well-evidenced method of achieving both glycaemic control and weight loss with a particularly dominant effect on liver fat which is helpful for people who are due to undergo abdominal surgery. Bariatric-metabolic procedures are of growing interest as bridging interventions to surgery and are more commonly used for obesity, but they also have a well-recognized impact on the improvement and remission of DM. This review gives an overview of the necessity of preoperative identification of DM and strategies for management. Intra-operative glycaemic control is also discussed, and the role of stress hyperglycaemia perioperatively.

Keywords

Diabetes mellitus / surgery / perioperative / calorie restriction / very-low-energy diet

References

[1] Pournaras DJ,Barnett N.Assessing the quality of primary care referrals to surgery of patients with diabetes in the East of England: a multi-centre cross-sectional cohort study.Int J Clin Pract2017;71:e12971

[2] Meneghini LF.Perioperative management of diabetes: translating evidence into practice.Cleve Clin J Med2009;76 Suppl 4:S53-9

[3] Beckman JA.Vascular complications of diabetes.Circ Res2016;118:1771-85

[4] Stentz FB,Cuervo R.Proinflammatory cytokines, markers of cardiovascular risks, oxidative stress, and lipid peroxidation in patients with hyperglycemic crises.Diabetes2004;53:2079-86

[5] Marik PE.Stress hyperglycemia: an essential survival response!.Crit Care2013;17:305 PMCID:PMC3672537

[6] Finfer S,Su SY.NICE-SUGAR Study InvestigatorsIntensive versus conventional glucose control in critically ill patients.N Engl J Med2009;360:1283-97

[7] Fabbri A,Benazzi B.Stress hyperglycemia and mortality in subjects with diabetes and sepsis.Crit Care Explor2020;2:e0152 PMCID:PMC7365708

[8] Roberts GW,Valentine N.Relative hyperglycemia, a marker of critical Illness: introducing the stress hyperglycemia ratio.J Clin Endocrinol Metab2015;100:4490-7

[9] International Diabetes Federation. IDF atlas, 10th edition 2021. Available from: https://www.diabetesatlas.org/ [Last accessed on 1 Sep 2022]

[10] Dhatariya KK.Why the definitions used to diagnose diabetic ketoacidosis should be standardised.Diabetes Res Clin Pract2018;135:227-8

[11] Kwon S,Dellinger P,Farrohki E.Importance of perioperative glycemic control in general surgery: a report from the Surgical Care and Outcomes Assessment Program.Ann Surg2013;257:8-14 PMCID:PMC4208433

[12] Frisch A,Smiley D.Prevalence and clinical outcome of hyperglycemia in the perioperative period in noncardiac surgery.Diabetes Care2010;33:1783-8 PMCID:PMC2909062

[13] Rawshani A,Franzén S.Risk factors, mortality, and cardiovascular outcomes in patients with type 2 diabetes.N Engl J Med2018;379:633-44

[14] Centre for Perioperative Care. Guideline for perioperative care for people with diabetes mellitus undergoing elective and emergency surgery, 2021. Available from: https://diabetes-resources-production.s3.eu-west-1.amazonaws.com/resources-s3/public/2021-03/CPOC-Diabetes-Guideline2021.pdf [Last accessed on 1 Sep 2022]

[15] Gillis C,Carli F.Prehabilitation, enhanced recovery after surgery, or both?.Br J Anaesth2022;128:434-48

[16] Levy N.Pre-operative optimisation of the surgical patient with diagnosed and undiagnosed diabetes: a practical review.Anaesthesia2019;74 Suppl 1:58-66

[17] Rollins KE,Dhatariya K.Systematic review of the impact of HbA1c on outcomes following surgery in patients with diabetes mellitus.Clin Nutr2016;35:308-16

[18] Wang J,Jin X.Effects of preoperative HbA1c levels on the postoperative outcomes of coronary artery disease surgical treatment in patients with diabetes mellitus and nondiabetic patients: a systematic review and meta-analysis.J Diabetes Res2020;2020:3547491 PMCID:PMC7066407

[19] National Institute for Health and Care Excellence. Routine preoperative tests for elective surgery (NG45) 2016. Available from: https://www.nice.org.uk/guidance/ng45 [Last accessed on 1 Sep 2022]

[20] Garg R,Bader A.Effect of preoperative diabetes management on glycemic control and clinical outcomes after elective surgery.Ann Surg2018;267:858-62

[21] Juray S,Trasino SE.Remission of type 2 diabetes with very low-calorie diets-a narrative review.Nutrients2021;13:2086 PMCID:PMC8234895

[22] Kempf K,Banzer W.High-Protein, Low-glycaemic meal replacement decreases fasting insulin and inflammation markers-a 12-month subanalysis of the ACOORH trial.Nutrients2021;13:1433 PMCID:PMC8145939

[23] Pournaras DJ,Hagström-Toft E,le Roux CW.Improved glucose metabolism after gastric bypass: evolution of the paradigm.Surg Obes Relat Dis2016;12:1457-65

[24] Colles SL,Marks P,O'Brien PE.Preoperative weight loss with a very-low-energy diet: quantitation of changes in liver and abdominal fat by serial imaging.Am J Clin Nutr2006;84:304-11

[25] Ross LJ,Osland EJ.Commercial very low energy meal replacements for preoperative weight loss in obese patients: a systematic review.Obes Surg2016;26:1343-51

[26] Stefan N.A global view of the interplay between non-alcoholic fatty liver disease and diabetes.Lancet Diabetes Endocrinol2022;10:284-96

[27] Griffin SB,Burstow MJ,Palmer MA.Efficacy of a dietitian-led very low calorie diet (VLCD) based model of care to facilitate weight loss for obese patients prior to elective, non-bariatric surgery.J Hum Nutr Diet2021;34:188-98

[28] Ruggenenti P,Ruggiero B.CRE.S.O. Study Group. Renal and systemic effects of calorie restriction in patients with type 2 diabetes with abdominal obesity: a randomized controlled trial.Diabetes2017;66:75-86

[29] Holt RIG,Dritsakis G.OCTOPuS study groupDeveloping an intervention to optimise the outcome of cardiac surgery in people with diabetes: the OCTOPuS pilot study.Pilot Feasibility Stud2021;7:157 PMCID:PMC8368047

[30] Li S,Lytvyn L.SGLT-2 inhibitors or GLP-1 receptor agonists for adults with type 2 diabetes: a clinical practice guideline.BMJ2021;373:n1091

[31] Houlden RL,Moore S.Effectiveness of an interprofessional glycemic optimization clinic on preoperative glycated hemoglobin levels for adult patients with type 2 diabetes undergoing bariatric surgery.Can J Diabetes2018;42:514-9

[32] Frías JP,Rosenstock J.SURPASS-2 InvestigatorsTirzepatide versus semaglutide once weekly in patients with type 2 diabetes.N Engl J Med2021;385:503-15

[33] Jastreboff AM,Ahmad NN.SURMOUNT-1 InvestigatorsTirzepatide once weekly for the treatment of obesity.N Engl J Med2022;387:205-16

[34] Rubino F,Eckel RH.Delegates of the 2nd Diabetes Surgery SummitMetabolic surgery in the treatment algorithm for type 2 diabetes: a joint statement by international diabetes organizations.Surg Obes Relat Dis2016;12:1144-62

[35] Lee Y,Switzer N,Birch DW.Bridging interventions before bariatric surgery in patients with BMI ≥ 50 kg/m²: a systematic review and meta-analysis.Surg Endosc2019;33:3578-88

[36] Kotinda APST,Ribeiro IB.Efficacy of intragastric balloons for weight loss in overweight and obese adults: a systematic review and meta-analysis of randomized controlled trials.Obes Surg2020;30:2743-53

[37] Abu Dayyeh BK,Rapaka B.Adjustable intragastric balloon for treatment of obesity: a multicentre, open-label, randomised clinical trial.Lancet2021;398:1965-73

[38] Zorron R,Adler A.Endoscopic sleeve gastroplasty using Apollo Overstitch as a bridging procedure for superobese and high risk patients.Endoscopy2018;50:81-3

[39] Abu Dayyeh BK,Vargas EJ.Endoscopic sleeve gastroplasty for treatment of class 1 and 2 obesity (MERIT): a prospective, multicentre, randomised trial.Lancet2022;400:441-51

[40] Albaugh VL,Tu C.Clinical significance of diabetes control before metabolic surgery.Surg Obes Relat Dis2021;17:1271-8

[41] Umpierrez G,Pasquel F.Randomized controlled trial of intensive versus conservative glucose control in patients undergoing coronary artery bypass graft surgery: GLUCO-CABG trial.Diabetes Care2015;38:1665-72 PMCID:PMC4542267

[42] Cardona S,Pasquel FJ.Sitagliptin for the prevention of stress hyperglycemia in patients without diabetes undergoing coronary artery bypass graft (CABG) surgery.BMJ Open Diabetes Res Care2019;7:e000703 PMCID:PMC6731905

[43] van den Boom W, Schroeder RA, Manning MW, Setji TL, Fiestan GO, Dunson DB. Effect of A1C and glucose on postoperative mortality in noncardiac and cardiac surgeries.Diabetes Care2018;41:782-8

[44] Chiang HY,Hsiao YL.Association between preoperative blood glucose level and hospital length of stay for patients undergoing appendectomy or laparoscopic cholecystectomy.Diabetes Care2021;44:107-15 PMCID:PMC7783940

[45] He T,Wang C.Relationship between pre-operative blood glucose level and length of hospital stay in patients with renal cell carcinoma undergoing laparoscopic nephrectomy.Front Surg2021;8:659365 PMCID:PMC8180589

[46] Domek N,Pinzur M,Rogers T.Association between hemoglobin a1c and surgical morbidity in elective foot and ankle surgery.J Foot Ankle Surg2016;55:939-43

[47] Gustafsson UO,Soop M,Nygren J.Haemoglobin A1c as a predictor of postoperative hyperglycaemia and complications after major colorectal surgery.Br J Surg2009;96:1358-64

[48] O'Sullivan CJ,Mahendran B.Haemoglobin A1c (HbA1C) in non-diabetic and diabetic vascular patients. Is HbA1C an independent risk factor and predictor of adverse outcome?.Eur J Vasc Endovasc Surg2006;32:188-97

[49] Vilar-Compte D,Martín-Onraet A,Sánchez-Hernández C.Hyperglycemia as a risk factor for surgical site infections in patients undergoing mastectomy.Am J Infect Control2008;36:192-8

[50] Makino H,Asakura K.Addition of low-dose liraglutide to insulin therapy is useful for glycaemic control during the peri-operative period: effect of glucagon-like peptide-1 receptor agonist therapy on glycaemic control in patients undergoing cardiac surgery (GLOLIA study).Diabet Med2019;36:1621-8

[51] Hulst AH,Godfried MB.GLOBE Study GroupLiraglutide for perioperative management of hyperglycaemia in cardiac surgery patients: a multicentre randomized superiority trial.Diabetes Obes Metab2020;22:557-65 PMCID:PMC7079116

[52] Kaneko S,Tahara Y.GLP1 receptor agonist liraglutide is an effective therapeutic option for perioperative glycemic control in type 2 diabetes within Enhanced Recovery After Surgery (ERAS) protocols.Eur Surg Res2018;59:349-60

[53] Draznin B,Bakris G.American Diabetes Association Professional Practice Committee, American Diabetes Association Professional Practice Committee:. 16. Diabetes care in the hospital: standards of medical care in diabetes-2022.Diabetes Care2022;45:S244-53

[54] Duggan E.Glycemic management in the operating room: screening, monitoring, oral hypoglycemics, and insulin therapy.Curr Diab Rep2019;19:134

[55] Clinical Pharmacy Association. Perioperative Handbook 2022. Available from: https://www.ukcpa-periophandbook.co.uk/ [Last accessed on 1 Sep 2022]

[56] Abdelmalak BB,Bonilla A.The intraoperative glycemic response to intravenous insulin during noncardiac surgery: a subanalysis of the DeLiT randomized trial.J Clin Anesth2016;29:19-29 PMCID:PMC4762183