Increased Rates of Wound Complications in Type II Diabetes Mellitus and Pre-Diabetes Following Ventral Hernia Repair and Abdominal Wall Reconstruction
Joshua A. David, BS, Lauren K. Rangel, BA, Jasmine Lee, BA, Salma A. Abdou, BA, WIlliam J. Rifkin, BA, Sonali Sharma, HS, Alyssa R. Golas, MD, Daniel J. Ceradini, MD, Steven M. Cohen, DO, Jaime P. Levine, MD.
New York University Langone Medical Center, New York, NY, USA.
PURPOSE: Impaired wound healing is a well-known complication of type II diabetes mellitus (TIIDM). While TIIDM is considered a risk factor for surgery, the extent to which it affects outcomes in hernia repair, specifically as it relates to wound healing, remains unknown. Furthermore, pre-diabetes (HbA1c 5.7-6.4%) is a growing epidemic of impaired glucose tolerance that has been largely overlooked in surgery. We present a retrospective comparison of outcomes and complications between these groups following ventral hernia repair, with and without abdominal wall reconstruction (AWR), and between plastic surgeons and general surgeons. METHODS: A retrospective review was performed of patients who underwent ventral hernia repair over a 2-year period at a single institution. Patient demographics, operative details, and surgical outcomes were analyzed between groups. Student t-tests, adjusted odds ratios, ROC curves, and linear regression were performed depending on the variable of interest by an independent biostatistician. RESULTS: 399 patients underwent ventral hernia repair during the study period. 59 (14.7%) had TIIDM, and 19 (5%) had pre-diabetes. No differences existed between the three groups with regard to sex, ethnicity, race, age, length of follow-up, emergent or recurrent nature of hernia repair, mesh placement, type of surgical repair (open vs. laparoscopic vs. robotic), or wound class. Patients with pre-diabetes and TIIDM had increased BMI and average ASA score. Even when adjusting for ASA status, patients with TIIDM had significantly greater odds of any complications (OR: 3.848, p=0.002), minor complications (3.726, p=0.001), and wound complications (4.152, p=0.001), regardless of whether AWR was performed or not. Similarly, pre-diabetics had increased odds of minor complications and wound complications (13.256 and 14.829, respectively, p=0.001) when compared to non-diabetic patients, even when adjusting for ASA status. Patients with TIIDM and pre-diabetes both independently had significantly increased hospital readmission rates when compared to non-diabetics (36.1% and 57.1% vs 14.2%, p=0.001). Additionally, length of hospital stay was longer in patients with TIIDM (1.114 days, p=0.018). When the AWR cohort was further stratified by procedures performed by plastic surgery versus those performed by general surgery, there were no differences in hernia recurrence rate or major complications between patients with TIIDM, pre-diabetes, or non-diabetics. However, minor complications and readmission rates were greater in diabetics when plastic surgeons performed the AWR. There were no associations seen between HbA1c values prior to surgery and outcomes in any of the groups. CONCLUSIONS: Here, we demonstrate significant surgical outcome disparities in patients with TIIDM and pre-diabetes following hernia repair, regardless of whether AWR was performed or not. Furthermore, when AWR is performed, certain outcomes are dependent on the surgical specialty performing the procedure. These findings underscore the importance of diligent pre-, peri-, and post-operative management in patients who are known to have dysfunctional glucose tolerance, regardless of HbA1c level or co-morbidities.
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