A Comparison of the most common complications after different general surgical procedures for diabetic and non-diabetic patients in Jordanian military sector hospitals

Frequency of diabetes mellitus increases with age and is strongly correlated with patients admitted for surgical purposes.⁽³⁾ In patients with diabetes mellitus, electrolyte or metabolic disorders and immunological problems may pre-exist or occur during surgical management. Diabetic patients scheduled for different types of surgical intervention have a high risk of peri-surgical complications, such as increased infection, delayed wound healing, ischemic events and difficulty in controlling blood sugar levels.⁽⁴⁾Optimum diagnosis, good clinical assessment and peri-surgical control are the pathways for adequate operative procedures in medical care.⁽⁵⁾Insulin dependent diabetic patients have a higher risk for any morbidity than those that are non-diabetic or oral hypoglycemic dependent diabetic in the general surgery group. .

The aim of our investigation was to compare the complications after different general surgical procedures for diabetic and non-diabetic patients.

METHODS 

This retrospective and observational investigation included 35 diabetic(type II) patients (Group I, GI) and 108 non-diabetic patients(Group II, GII).These 143 patients, aged 35-63 years, of both genders, were assigned for different elective and emergency general surgical procedures for different causes at Prince Hashim hospital, Zarqa, Jordan and King Hussein hospital, King Hussein medical center, Amman, Jordan, during the periods Oct 2015 - Sep 2016 and Sep 2016-Sep 2017, respectively. Written informed consent was obtained from all patients. Approval for this study was also obtained from the local ethical and research board review committee of the Jordanian Royal Medical Services. On admission, the blood sugar levels of patients were determined. All participants were followed up for blood sugar levels and complications after surgery. The frequency of complications and their association with blood sugar level after surgery were recorded for each Jordanian patient group. Diabetes was diagnosed according to the American Diabetic Association and World Health Organization classification: a random blood sugar > 200ml/dl, and a fasting (8 hours) blood sugar > 125mg/dl.⁽⁶⁾

Complications after different elective and emergency general surgical procedures were recorded for 7 days. The following complications were investigated: hypoglycemia (blood sugar levels < 55mg/dl);wound infection, as determined by drainage of serosanguinous fluid from the incision or erythema around the incision; urinary tract infection (UTI), determined by the presence of bacteriuria in culture or pus cells in routine urine analysis;⁽⁷⁾post-operative ileus,indicated by not passing stools, no appreciable flatus or absence of bowel sounds by day 3 post-surgery;⁽⁸⁾ electrolyte disorders, such as hypo or hypernatremia, and hypo or hyperkalemia; Stress induced hyperglycemia ,based on raised sugar levels > 250 mg/dl, an acidic pH < 7.3 and presence of urine ketones;⁽⁸⁾and pneumonia, as indicated by3or more of the following, new or changing infiltrate on chest radiograph, fever, purulent sputum or increased lung secretions, white blood cell count > 11,000 or hypoxia and aspiration pneumonia with X-ray findings of bilateral diffuse pneumonitis.⁽⁸⁾

STATISTICS

Student's t test and Mann-Whitney U test were used for normality. For homogeneity between proportions, we used the chi-square test or Fisher's test. A p-value < 0.05 was considered statistically significant.

RESULTS

  There was an increase in complications after different general surgical procedures with increasing age in diabetic patients. Wound infection accounted for 5.7%⁽⁵⁾of the complications in patients of 35-40 years of age, and 14.3%⁽⁸⁾ in patients of 55-63 years of age. Ileus was commonly found in patients 35-40 years and 55 - 63 years of age, in (11.4%) and 20% of patients, respectively.⁽⁷⁾UTIs were more common in females (5/17, 29.4%) than in males (3/18, 16.7%), while lung complications were found in more males (5/18 27.8%) than females (3/17, 17.6%).

The overall most frequent complication was post-operative ileus (27.3%),followed by wound infection (26.6%) and electrolyte disorders (18.9%; Table I). Diabetic patients experienced more complications after surgery than non-diabetic patients, with the most frequent being post-operative ileus (42.9%) in GI and wound infection (24.1%) in G II. The second most frequent complications were wound infection (34.3%) in GI and post-operative ileus (22.2%) in GII. The third most frequent complications were electrolyte disorders, both in GI (31.4%) and in GII (14.8%; Table II). The total number of complications was 62 in 35 diabetic patients, indicating that some patients had more than 1 issue; on average, every diabetic patient had 1.8 complications. By contrast, the total number of complications in non-diabetic patients was 92 in 108 individuals, meaning they had single issues, with an average of 0.9 complications per patient.

Wound and infection complications were more common in diabetic patients, even after elective surgery (Table III). Even so, most of the complications were found in diabetics after emergency surgery. Infective complications were significantly increased in diabetic patients. Stress induced hyperglycemia was higher in diabetic patients after emergency surgery; however, it was higher in non-diabetic patients after elective surgery.

According to the chi-square test, differences between diabetic and non-diabetic patients for post-operative ileus, UTI, lung infection and electrolyte disorders were highly significant (p <0.005) while wound infection was only significant (p <0.05).In terms of Fisher’s test; differences in levels of hypoglycemia and Stress induced hyperglycemia were highly significant.

          Table I: Overall complication incidence after surgery (%, n)

      Table II: Comparison of complications between diabetic and non-diabetic patients(n, %)

     Table III: Comparison of complications between diabetic and non-diabetic patients in different elective and emergency general surgical procedures (n, %).

DISCUSSION

 Diabetic patients are subject to increased risk from many operative techniques, major and minor. Inadequate blood sugar control is increasingly common in underdeveloped countries.⁽⁴⁾ The current study investigated complications in diabetic patients after different elective and emergency general surgical procedures, compared with those without diabetes.⁽⁷⁾  The major complications considered in this study were wound, metabolic, neuropathic and infective.⁽⁷⁾ 

There was an increase in complication frequency after surgery with an increase in age in diabetic patients.⁽³⁾  This was especially the case for wound infection and urinary infection, and was likely caused by prolonged end organ damage, such as nephropathy and autonomic neuropathy.⁽⁷⁾    Increased age was a significant risk factor for infective complications and wound infection.⁽⁹⁾However, in our investigation, ileus was more common in older patients.⁽⁸⁾

Many wound infections were more common after emergency than elective surgery, because of its imperative nature.⁽¹⁰⁾ The risk of infections was greater in diabetic patients after emergency surgery. In our investigation, wound infection was also more common in diabetic patients, mainly after emergency surgery with inadequate blood sugar control. ⁽⁷⁾  A serum sugar level >140mg/dl was the only significant indicator of operative wound infection.⁽¹¹⁾ Patients with blood sugar levels of 220 mg/dL had an incidence of infection 2.7 times greater than for patients with lower blood sugar levels (31.3% and 11.5%, respectively).⁽⁷⁾  Poor sugar control, particularly for diabetic patients after emergency surgery, increased insulin resistance and hyperglycemia, and Stress induced hyperglycemia was also more common in diabetic patients after emergency laparotomy . Three among the diabetic patients had ketoacidosis, with more after emergency surgery than after elective surgery.⁽⁷⁾

A high frequency of morbidity in diabetic individuals with poor blood sugar control has been reported worldwide. ⁽¹⁶⁾ Establishing normal blood sugar levels in this group of patients has been recommended. After surgery, stress is reduced, sepsis is decreased, insulin resistance is reduced, and insulin needs decrease with the changed physiological stress response.⁽¹²⁾If sugar level is not followed up, hypoglycemia will be more common. In our investigation, 5 patients experienced hypoglycemia, and they had uncontrolled diabetes with severe sepsis. Hypoglycemia occurred more often after emergency surgery than after elective surgery in diabetic patients. ⁽⁷⁾ Before surgery, sugar levels were optimized. Diabetic patients have more electrolyte and acid-base disorders. Urinary infections were also found more often in diabetic than non-diabetic patients. In a previous study, the frequency of UTIs was 5.91% and 2.52%, respectively.⁽⁷⁾ Diabetes was one of the risk factors for UTIs. Post-operative ileus can be caused by pathologically impaired neural conduction. ⁽⁸⁾ It was recorded more often in diabetic patients than in non-diabetic patients after surgery. Diabetic gastroparesis is found in 25% of those with diabetes.⁽⁷⁾

Diabetes is an immunosuppressed condition and diabetic patients have increased numbers of infections, such as lung infections and UTIs.⁽⁷⁾ In our investigation, diabetic patients had significantly more UTIs than non-diabetic patients. Diabetic females have a higher incidence of bacteriuria.⁽¹³⁾Prevalence of UTIs in diabetic males and females was 43% and 46%, respectively.⁽⁷⁾Diabetic patients have been reported to have 2-3 times more UTIs than non-diabetic patients.⁽⁷⁾In addition, diabetic patients have a higher risk of lung complications due to their reduced immunological status, and also more gastro paresis.⁽¹⁴⁾This was consistent with our investigation with regard to lung complications. The influence of insulin may be more advantageous as reaction to the acute insult of surgery dissipates. During the acute onset of stressful stimuli such as surgery, treatment with insulin can actually be harmful ⁽¹⁵⁾.Improved outcomes have been seen in patients with strict blood sugar control during surgery. In fact, minimal alterations in blood sugar level are correlated with bad outcomes.⁽¹⁶⁾Similar investigations to this study have been performed in other groups, such as orthopedic, cardiac, vascular and plastic surgery patients, which with a few differences showed consistent results.⁽¹⁷⁾

CONCLUSIONS

Diabetic patients had significantly more operative complications than those that were non-diabetic. The most frequent issues were post-operative ileus and wound infection, followed by lung complications. Stringent blood sugar control may reduce diabetes-correlated complications.

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