Perioperative Glucose Levels and Complications in

Microvascular Reconstruction Patients

Katherine K.S. Rieth,

1
MD ;

1
BS ;

Mark A. Miller,
Paul D. Allen,
1
Matthew C. Miller, MD
1University

ABSTRACT
Objective: To determine if elevated
perioperative blood glucose levels in
patients undergoing microvascular
reconstruction are associated with
increased complications, including flap
failure.
Study design: Retrospective case series
from a single institution of soft tissue
microvascular reconstruction procedures
completed between 2011-2014
Background: Glycemic control and
surgical outcomes in research outside of
otolaryngology suggest the importance
of perioperative glycemic control as a
risk factor for complications, with or
without a pre-existing diagnosis of
diabetes. A growing body of research
within the field of otolaryngology has
established the importance of diabetes
as a risk factor in head and neck cancer
patient outcomes and complications.
There remains an unexplored role for
closely controlled perioperative glucose
levels in all patients, with and without
diabetes, to reduce complications,
including flap failure.
Methods: 108 Head and Neck
microvascular reconstruction procedures
from 2011-2014 performed at a single
institution were identified and met
criteria with sufficient data for follow up.
Surgical outcomes, demographics, comorbidities and blood glucose
measurements recorded between postoperative day 0-7 were abstracted from
the patients medical records. Univariate
analyses were performed with average
glucose levels and the occurrence of
medical and surgical complications.
Patient demographics and comorbid
conditions were also investigated.
Results: Univariate analysis does not
indicate a statistically significant
increase in surgical complications
associated with increased perioperative
glucose levels. However, a history of
diabetes mellitus is correlated with an
increased risk of developing any surgical
complication, as well as any medical
complication.
Conclusion: These data do not indicate
an association between elevated blood
glucose levels in the perioperative
period and increased risk for
complications, including flap failure.
However, diabetic patients undergoing
free flap procedures may be at higher
risk of complications overall. This
suggests preoperative screening can
guide patient counseling and
expectations.

CONTACT
Katherine K.S. Rieth

University of Rochester Medical Center

Email:

katherine_rieth@urmc.rochester.edu

RESULTS

Research in the study of glycemic control and

surgical outcomes is accumulating in specialties
outside of otolaryngology. A study of patients
undergoing non-cardiac surgery found that, in
aggregate, higher rates of postoperative infection
were associated with mean 24-hour postoperative
serum glucose concentrations of >150 mg/dL1. In
addition, intraoperative glycemic control for
patients undergoing cardiac surgery has been
found to be an independent risk factor for postoperative complications, including death2. This
data, along with a growing body of evidence in the
specialties of cardiac and orthopaedic surgery,
suggest the importance of perioperative glycemic
control as a risk factor for complications, with or
without a pre-existing diagnosis of diabetes1,3,4.
There is also a growing body of research in the
field of otolaryngology establishing the importance
of glycemic control in head and neck cancer patient
outcomes. Diabetes mellitus was found to be a
significant predictor of complication, and patients
with diabetes mellitus were five times more likely to
develop complications associated with free flaps5.
While some evidence suggests the importance
of diabetes and perioperative glucose monitoring,
to date we find no clear evidence which would
suggest safe parameters for glucose monitoring
and control perioperatively in the field of head and
neck surgery.
Our aim is to retrospectively study whether
perioperative glycemic levels in head and neck
surgery affects morbidity and mortality outcomes
including flap complications and flap failure.

DISCUSSION

There were a total of 108 procedures identified that involved

surgical resection with soft tissue free flap reconstruction that
met criteria with sufficient data for follow up. Characteristics of
the study population are presented below.
In the univariate analysis, a history of diabetes mellitus was
associated with a nearly 2-fold risk for developing any surgical
complication, and a 2-fold risk for developing any medical
complication. There was no statistically significant association
identified between perioperative glucose levels and incidence
of surgical complications. Although not statistically significant,
there appears to be a trend toward development of wound
dehiscence in diabetics.
Characteristics

This is an exploration into the role of

glycemic control in patients undergoing
microvascular soft tissue reconstruction of
the head and neck. Diabetic patients
undergoing soft tissue microvascular
reconstruction procedures demonstrated an
overall elevation in daily blood glucose levels
when compared to non-diabetics. Despite
this, the data do not support a statistically
significant association between perioperative
glucose levels and risk of surgical
complication. However, there was a strong
association identified between a history of
diabetes mellitus and risk of surgical
complication. The relative risk of any surgical
complication is increased 1.61 times with
diabetic patients, with an odds ratio of 5.51.
The relative risk of any medical complication
for diabetics was 2.04, with an odds ratio of
3.29. While diabetic patients did demonstrate
a statistically significant risk in having daily
average blood glucose levels above 180 mg/
dL, the current data is insufficient to
determine if this is associated with the
morbidities identified in this study. In
addition, diabetics appear to develop wound
dehiscence more often than non-diabetics.
These are areas of future study that would
provide useful information in guiding
development of perioperative glycemic
control protocols in both diabetic and nondiabetic patients.
The retrospective nature of this study can be
flawed due to reliance on accurate records, as
well as the inconsistencies in the recording of
certain data.

Total procedures

108

Female

26 (24%)

Male

82 (76%)

Mean age

63.7

Medical History
alcohol use (active)

49 (45%)

alcohol use (former)

5 (5%)

tobacco use (active)

18 (17%)

tobacco use (former)

59 (55%)

Diabetes mellitus

22 (20%)

Hypertension

61 (56%)

Donor site
anterolateral thigh

52 (48%)

radial forearm

50 (46%)

latissimus dorsi

2 (2%)

lateral thigh

2 (2%)

scapula

2 (2%)

Previous chemo/radiation therapy

chemotherapy

9 (8%)

radiation therapy

22 (20%)

Table 1. Characteristics of sample population

METHODS AND MATERIALS

This retrospective analysis was done at the Department
of Otolaryngology, University of Rochester Medical
Center. Department surgical records were used to select
head and neck reconstructions involving free soft tissue
transfer with microvascular anastomosis between 2011
and 2014. Reconstruction of defects due to recurrent or
secondary primary head/neck cancers were also
included.
Variables: Patient data was collected via review of the
electronic medical records. Demographic information
included nicotine use, alcohol use, chemo/radiotherapy,
and medical comorbidities. Surgical data was also
collected, which included anatomic site, histopathology
of malignancy, and donor site. Outcome variables were
comprised of complications, distinguishing between
medical and surgical complications. Medical
complications included cardiovascular, pulmonary,
sepsis, and death. Surgical complications were defined
as adverse events involving the flap, recipient site, or
donor site. Perioperative blood glucose levels (mg/dL)
were identified from post-operative day 0-3, with a
mean value calculated for each day.
Statistical analysis: Univariate analysis, odds ratio and
relative risk were calculated using R (version 3.2.3).
Surgical
Complication

n (overall)

Wound dehiscence

31 (29%)

n (diabetics)
10 (45%)

n (nondiabetic)

RR

21 (24%)

1.86

2.58

4 (18%)

14 (16%)

1.12

1.14

Wound infection

13 (12%)

3 (14%)

10 (12%)

1.17

1.2

10 (9%)

4 (18%)

6 (7%)

2.61

2.96

10 (9%)

1 (5%)

9 (10%)

0.43

0.41

Complete flap
failure

7 (6%)

3 (14%)

4 (5%)

2.93

3.24

Partial flap failure

7 (6%)

1 (5%)

6 (7%)

0.65

0.63

Donor site
complication

5 (5%)

2 (9%)

3 (3%)

2.61

2.77

65 (60%)

19 (86%)

46 (53%)

1.61*

5.51*

Total

225

CONCLUSIONS

150

75

0
POD0

POD1

Overall

POD2

Diabetic

POD3

Non-diabetic

Figure 1. Mean daily blood glucose value (mg/dL)

0

25

50

75

100

Wound dehiscence
Fistula
Hematoma

The complexity of patient history, pathology,

and operative procedure contribute to the
significant number of patients who develop
surgical complications after soft tissue free flap
reconstruction in head and neck surgery. The
current data do not support perioperative blood
glucose levels as a predictor of surgical
complications. There is, however, a significant
risk associated with a history of diabetes
mellitus and increased risk of any surgical
complication, as well as any medical
complication. This suggests preoperative
screening can guide patient counseling and
expectations. Diabetics are also more likely to
have higher glycemic levels overall after surgery.
Whether or not this is associated with surgical
complications is an area for future
consideration.

REFERENCES

OR

18 (17%)

Seroma

300

Partial flap failure

Fistula

Hematoma

Mark A. Merkley, MD,

1
PhD ;

of Rochester Medical Center

INTRODUCTION

Table 2. Occurrence of surgical complications

Monday, January 18, 16

1
PhD ;

Complete flap failure

1King,

Donor site complication

Pneumonia*
Any surgical complication*
Any medical complication*

Overall

Diabetic

Non-diabetic

*statistically significant

Figure 2. Complications within sample populations (%)

J. T.,Jr, Goulet, J. L., Perkal, M. F., & Rosenthal, R. A. Glycemic control

and infections in patients with diabetes undergoing noncardiac surgery.
Annals of Surgery 2011;253(1):158-165.
2Gandhi GY, Nuttall GA, Abel MD, et al. Intraoperative hyperglycemia and
perioperative outcomes in cardiac surgery patients. Mayo Clin Proc
2005;80:8626.
3Garcia, C et al. (2013) Intensive glycemic control after heart transplantation is
safe and effective for diabetic and non-diabetic patients. Clin Transplant
2013;27: 444454
4LaPar, D. J., Isbell, J. M., Kern, J. A., Ailawadi, G., & Kron, I. L. Surgical care
improvement project measure for postoperative glucose control should not be
used as a measure of quality after cardiac surgery. The Journal of Thoracic and
Cardiovascular Surgery 2014;147(3):1041-1048.
5Bozikov, K. Arnez, Z.M. Factors predicting free flap complications in head and
neck reconstruction. J Plast Reconstr Aesthet Surg 2006;59(7):737-42.
6Khouri, et al. A prospective study of microvascular free-flap surgery and
outcome. Plastic and Reconstructive Surgery 1998;Sep;102(3):711-21.