Diabetes mellitus as a contraindication to plastic surgery. Postoperative Complications in Diabetes Mellitus – Don’t Watch for the Faint of Heart

In diabetes mellitus, it leads to metabolic changes that worsen glycemic control.

This occurs even regardless of whether the patient has diabetes. Surgical incisions lead to increased levels of stress hormones, relative insulin deficiency and insulin resistance. It has been documented that catecholamines, growth hormone, glucagon, adrenocorticotropic hormone and cortisol levels increase for several days after surgery. These changes lead to increased catabolism through glycogenolysis, lipolysis and proteolysis, ultimately leading to increased production of glucose, free fatty acids and ketone bodies. The anabolic effect of insulin decreases during this period, thereby reducing the uptake and use of glucose by the liver and skeletal muscles.

In addition to surgery, inhaled anesthetics also lead to a similar release of stress hormones even before the incision is made. A combination of factors leads to hyperglycemia in the postoperative period. Hyperglycemia negatively affects the outcome of surgical treatment. Hyperglycemic animal models have demonstrated a decrease in the rate of wound healing. A decrease in neutrophil activity in patients with hyperglycemia and an increase in the frequency of wound infection have been established.

Gastric paresis due to diabetic neuropathy increases the likelihood of aspiration of gastric contents. Tachycardia, apparently due to autonomic neuropathy, is associated with orthostatic hypotension after surgery. In surgical patients, the duration of diabetes, what diet the patient was following at the time of examination, the last dose of insulin prescribed, and clinical manifestations should be established. The feet should be examined for minor injuries, hygiene rules, and the adequacy of the blood supply.

The goal of therapeutic treatment for all patients suffering from diabetes is to maintain optimal glucose levels during surgery and in the postoperative period. At this time, insulin may be required even for patients whose diabetes was previously controlled by diet or oral medications. However, prescribing insulin increases the risk of hypoglycemia in situations in which the characteristic symptoms of this condition may be hidden - during anesthesia or taking analgesics. Maintaining blood glucose concentrations between 150 and 200 mg/dL reduces the negative effects of hyperglycemia on wound healing and infectious complications. Patients with poorly controlled diabetes and blood glucose levels above 250 mg/dL require increased intensity of therapy in the pre- and postoperative period to achieve target values.

Basic principles of diabetes surgery

The approach to performing operations for diabetes mellitus comes down to the following points.

• Patients who are instructed to abstain from eating or drinking after midnight the night before surgery for diabetes should reduce their morning dose of intermediate- or long-acting insulin by half the next morning.
• A continuous infusion of 5% dextrose is necessary to provide 10 g of glucose per hour. During surgery, it is necessary to constantly monitor the level of glucose in capillary blood, and in the postoperative period - at least every 6 hours. The schedule for administering long-acting insulin should be based on the glucose level (performed every 6 hours). In unstable patients with diabetes, it is preferable to administer continuous intravenous insulin at a rate of 1-3 units per hour.
• In the postoperative period, diabetic ketoacidosis may be inadvertently overlooked, since this condition often manifests only with nausea, vomiting, bloating, or polyuria. Therefore, after surgery for diabetes mellitus, it is necessary to monitor the level of ketones in the urine with a special sensor.

Many people know that in the presence of diabetes mellitus, healing processes in the human body proceed much slower and longer, and this is a certain risk when performing any surgical interventions. However, sometimes, under certain circumstances, people have a desire (or need) to seek help from a plastic surgeon in order to correct, harmonize or change their appearance. And this is where the question arises: can diabetics use the services of this branch of modern medicine, and what might be the risks and consequences of such an operation?

Plastic surgery and diabetes – does beauty need such sacrifices?

In general, this disease is a contraindication to plastic surgery, but some American doctors are quite optimistic. For example, Allan Parungao, an experienced surgeon and author of a popular book for women about cosmetology and plastic surgery, says: “Many of you have heard that any surgical intervention is contraindicated for diabetics, but if I am faced with the question of deciding whether to perform plastic surgery on a patient with diabetes or not, then the determining factor will be how well the illness she has is compensated. Before discussing all the details of the upcoming operation with a diabetic, I must personally talk with his endocrinologist and find out whether my future patient is taking good care of her health.”

Who can Dr. Parungao refuse? “I will certainly refuse help to people with diabetes who are clearly obese or who have no idea what a normal blood glucose level is.” However, not all plastic surgeons, unfortunately, have the same approach to this issue.

Surgery for diabetes - a real-life incident

An American resident, Holly, with type 1 diabetes, regularly takes insulin and at a certain point, at the age of thirty-six, she decided to see doctors to slightly correct her appearance. The first of them immediately refused her, without any clarification of the circumstances, explaining only that plastic surgery for diabetes is absolutely contraindicated. The next surgeon Holly contacted agreed to perform plastic surgery on the woman without further ado and offered to perform it the next day, without even asking about her insulin regimen and blood sugar levels. And only the third doctor was Dr. Parungao, who, after carefully studying the patient’s medical history and condition, agreed to help. Six months later, the mother of three, who had liposuction, a tummy tuck and a bust augmentation, is amazed at how quickly she has recovered.

Take care of your health

Uncompensated diabetes is a serious contraindication for such operations, but if the patient’s condition is stable and glycemia is within normal limits, then an experienced plastic surgeon will be able to satisfy his patient’s request. It is very important to decide whether this operation is really necessary for you or whether this desire to change is some kind of whim. It is easy to understand people who strive to get rid of some obvious defect in appearance, received as a result of injury or accident, or from congenital defects. Before going under the knife, try talking to a psychologist or psychotherapist, and be sure to also discuss your wishes with family members and, of course, with your doctor.

Is surgery performed for diabetes? Yes, they do, but the patient requires more careful preparation for surgery. The difficulty lies in the fact that the disease entails disturbances in carbohydrate and metabolic processes, which can provoke serious consequences.

Wound healing after surgery in diabetes mellitus takes much longer than in patients without diabetes. Additionally, the risk of developing an inflammatory process increases, which can prolong the rehabilitation period and worsen overall health. If the patient suffers from a form of diabetes, then after surgery a transition to the open form may occur.

So is surgery done for diabetes? If there are direct indications for radical therapy, then they do it. But the patient is required to undergo special preparation that will reduce health risks.

Preparing for surgery

The key to the success of an operation of any complexity is a set of measures aimed at compensating for the disease. Due to the nature of the course of the disease, even the simplest surgical interventions must be performed in the operating room; manipulations in the outpatient clinic are unacceptable.

If we are talking about a planned operation, then it will be postponed until good compensation for diabetes is achieved. In the event of an emergency, an analysis of the risks to life is carried out and a decision is made based on it.

The main principles of radical therapy:

• the operation cannot be delayed - the patient must be stabilized and operated on as quickly as possible;
• It is not recommended to perform the operation in the hot season;
• All operations are performed under the protection of antibiotics.

In general, patient preparation always begins with glucose. Immediately before surgery, hormonal therapy is needed - over the previous day, the patient is given the required dose of hormones in 3-4 injections. In advanced forms of the disease, a fifth injection of a hormonal drug may be necessary.

When preparing a patient with diabetes for surgery, it is advisable to use short-acting insulin, because immediately before the procedure, adjustment of the hormone level in orgasm will be required. A mandatory component of preparation is a therapeutic diet.

Immediately before the operation, the following actions are performed:

• administration of 0.5 doses of insulin;
• administration of glucose no earlier than half an hour after the injection of insulin.

The following indicators indicate that the patient is ready for surgery for type 2 diabetes:

• the blood glucose level is 8-9 units. The exception is for patients who have been diagnosed with diabetes mellitus for a long time; in this case, 10 units are allowed;
• blood pressure is normal or slightly below normal;
• urine test does not have positive responses to acetone and sugar.

Pancreatic surgery for diabetes

A diabetic may undergo surgery to improve his overall condition. This decision is made when other methods of treating the disease are ineffective or impossible. And it is radical therapy that today is considered the most modern and effective.

In order for the attending physician to make a decision on switching from conservative therapy to radical therapy, there must be clear indications. The reasons for surgical intervention are:

• pathological metabolic disorder that poses a direct threat to the patient’s life;
• identification of serious complications of diabetes mellitus;
• low effectiveness of conservative treatment;
• contraindications to subcutaneous injections of the hormone.

Provided that the patient’s other organs and systems do not have serious pathologies, the pancreas functions normally just a day after the operation. The full rehabilitation course takes about two months.

Ophthalmic surgeries

Surgeries for vision loss due to diabetes are no exception, since damage to the smallest vessels of the eye is one of the complications of the disease. Patients with a long history of “sweet illness” are more at risk of partially or completely losing their vision.

Therefore, it is extremely important to have regular routine checkups with your eye doctor. A complete eye examination includes fundus examination, visual acuity testing and eye pressure measurement.

But a decrease in visual acuity is not always directly related to a chronic disease. There are other reasons when surgery is required to maintain the ability to see.

There is such a thing as clouding of the lens of the eye due to the progression of the disease. For patients without a diagnosis of diabetes, cataract treatment can occur on an outpatient basis.

But people with metabolic disorders should definitely undergo a full medical examination, preoperative preparation and perform the operation under conditions of increased caution. Permission to perform the operation is issued by the attending physician, who compares the risk of loss of vision with the risk of loss of life.

Prostatitis and diabetes mellitus

Diabetes mellitus and prostatitis are diseases that are quite closely related to each other. The first negatively affects the human immune system, and the second manifests itself against the background of a decrease in local immunity. Due to the constant inflammatory process in the prostate gland, which is difficult to localize due to restrictions on antibiotic therapy, both diseases often begin to progress.

It is not uncommon for prostatitis to become the cause of a more serious illness - a malignant neoplasm. For prostate cancer with diabetes, surgery is associated with many risks and can only be performed when full compensation of diabetes mellitus is achieved.

Spine surgery in diabetic patients

Spinal surgery for diabetes, even with today's level of development of science and medicine, remains very problematic. Moreover, problems begin to arise not precisely during the operation, but during the rehabilitation period. It is most difficult for patients with insulin-dependent diabetes - 78% of those operated on had complications of one form or another.

In conclusion, we can say that any surgical operations on patients diagnosed with diabetes are quite possible. And the success of radical treatment largely depends on the correct medication adjustment of the patient’s condition and the results of diabetes compensation.

In addition, both the surgical team and the anesthesiologist must have a sufficient level of professionalism to work with diabetics.

In the life of every person there may be a need for surgery, diabetics are no exception. There is no need to talk about the possibility of an emergency operation, because These types of manipulations are performed according to vital indications. As for planned operations, they are possible, but require certain actions on the part of both the patient and the medical staff.

People with diabetes undergo surgery to varying degrees. The number of diseases for which surgical treatment may be indicated is very large. However, the features of preparing a diabetic patient for surgery, its course and the course of the postoperative period differ significantly from healthy people. Let us consider the features of surgical intervention for diabetes mellitus.

What are the conditions for the operation?

Remember that the disease itself is not a contraindication to surgery. Moreover, in some cases it is carried out out of vital necessity.

The most important condition for a successful operation is compensation for the disease. And one more thing: even the smallest interventions that are performed on healthy patients on an outpatient basis (for example, removing an ingrown nail or opening an abscess) should only be done in a surgical department.

If diabetes mellitus is poorly compensated, elective surgery cannot be performed. First, you need to take measures aimed at compensating for diabetes. Of course, this does not apply to cases where the operation is performed for vital reasons.

An absolute contraindication to the intervention is diabetic coma. In such cases, measures are immediately taken to remove the patient from a dangerous condition. Only after them can surgery be performed.

Preparing the patient for surgery

The main thing is that patients undergoing intervention, and especially urgent ones, need testing for sugar! Patients before abdominal interventions require insulin administration. The drug treatment regimen is standard. The patient needs to administer this drug three to four times throughout the day. In severe cases and with labile diabetes mellitus, five-time administration of insulin is allowed. Careful monitoring of blood glucose throughout the day is essential.

It is not advisable to use long-acting insulin preparations. One injection of intermediate-acting insulin is allowed at night. This caution is explained by the fact that before surgery, a dose adjustment of the medication is necessary. And, of course, constant measurement of glucose levels is necessary.

The diet is prescribed taking into account the disease for which the operation is being performed. To prevent the development of acidosis, the patient is limited in fat. If there are no contraindications, then drinking in large quantities is prescribed (alkaline water is best).

If an operation is scheduled, after which the patient will be prohibited from eating normally, a half dose of insulin is administered immediately before the operation. After half an hour, it is necessary to introduce a glucose solution (20–40 milliliters at a concentration of 40%).

The diet before surgery is based on the following recommendations:

• reducing caloric intake;
• frequent meals (up to six times a day);
• exclusion of any saccharides;
• limiting saturated fats;
• limiting cholesterol-containing foods;
• inclusion of foods containing dietary fiber in the diet;
• excluding alcohol.

Correction of hemodynamic pathologies is also necessary. After all, patients with this disease significantly increase the risk of heart attack. In patients with diabetes, the painless type of coronary heart disease is several times more common.

The patient's readiness criteria for surgery are:

• normal or close to normal glucose level (in patients who have been ill for a long time, such indicators should not be higher than 10 mmol);
• elimination of glucosuria (sugar in urine);
• elimination of ketoacidosis;
• lack of acetone urine;
• elimination of hypertension.

Surgery for decompensated diabetes

There are cases when a patient needs to be operated on in conditions of insufficient compensation for the disease. In this case, surgery is prescribed against the backdrop of measures aimed at eliminating ketoacidosis. This can only be achieved with adequate administration of strictly defined doses of insulin. The introduction of alkalis is undesirable, since it leads to adverse consequences:

• increase in hypokalemia;
• intracellular acidosis;
• calcium deficiency in the blood;
• hypotension;
• danger of cerebral edema.

Sodium bicarbonate can only be administered when the blood acid level is below 7.0. It is important to ensure sufficient oxygen supply to the body. Antibiotic therapy is prescribed, especially if the body temperature is elevated.

It is important to administer insulin (also fractional), with mandatory monitoring of sugar levels. Long-term insulin is also administered, but glycemic control should in any case be maintained.

Surgery and nephropathy

Nephropathy is the main cause of disability and death in patients with diabetes. It occurs mainly due to a disorder of the humoral regulation of glomerular vascular tone. Before surgery, it is necessary to eliminate kidney dysfunction as much as possible. Therapeutic measures include several points.

1. Correction of carbohydrate metabolism (it must be carefully correlated with insulin therapy, since as renal failure progresses, renal insulinase is inhibited and the need for this hormone decreases).
2. Careful correction and control of blood pressure.
3. Elimination of glomerular hypertension (ACE inhibitors are prescribed).
4. A diet with limited animal proteins (for proteinuria).
5. Correction of lipid metabolism disorders (it is advisable to carry out with the help of appropriate medications).

Such measures make it possible to achieve successful surgery and the course of the postoperative period in patients with complications of diabetes.

Features of anesthesia for diabetes

When carrying out anesthesia, it is extremely important to control the level of glycemia; the appropriate parameters are selected individually for each patient. There is no need to strive to completely normalize it, since hypoglycemia is much more dangerous than hyperglycemia.

Against the background of modern anesthesia, signs of low blood sugar are smoothed out or completely distorted. In particular, phenomena such as agitation, coma, and convulsions do not appear. In addition, during anesthesia, hypoglycemia is difficult to distinguish from inadequate anesthesia. All this suggests that the anesthesiologist requires enormous experience and caution in the management of anesthesia.

In general terms, the following features of pain relief can be identified.

1. During surgery, you need to administer glucose with insulin depending on the severity of diabetes. Sugar control should be constant: its increase is corrected by fractional injections of insulin.
2. It must be remembered that inhaled anesthetic drugs increase glycemia.
3. The patient can be given injections of drugs for local anesthesia: they have a slight effect on glycemia. Intravenous anesthesia is also used.
4. It is imperative to monitor the adequacy of anesthesia.
5. Local anesthesia can be used for short-term interventions.
6. It is imperative to monitor hemodynamics: patients do not tolerate a drop in pressure well.
7. For long-term interventions, multicomponent anesthesia can be used: it has the least effect on sugar.

Features of the postoperative period

The volume of surgical care for patients with diabetes mellitus is quite large. Approximately every second person with diabetes undergoes at least one surgical operation during their lifetime. Diabetes mellitus, especially in a state of compensation, should not be considered a contraindication to surgery.

The main condition for any planned surgery is to achieve diabetes compensation. Even minor surgical interventions (removal of atheroma, ingrown nail, opening of an abscess, etc.), which can be performed on an outpatient basis in people without diabetes, must be performed in a surgical hospital in patients with diabetes. Moreover, if a patient has stable compensation of diabetes while taking tablet drugs, during surgical interventions of this kind there is no strict need to switch to insulin. Patients receiving biguanides, in order to avoid acidosis and the development of lactic acidosis, should be transferred to insulin with the abolition of biguanides.

Before major planned abdominal operations, the patient, regardless of previous therapy, needs to be switched to insulin according to the usual rules for prescribing the drug. The patient is recommended 3-4 times (in severe labile forms of diabetes - 5 times) administration of simple insulin under the control of blood sugar and glycosuria during the day. The use of long-acting drugs before surgery is not advisable (an evening injection of intermediate-acting insulin can be allowed), as this complicates insulin correction. The diet should take into account the characteristics of the disease for which the patient is undergoing surgery. To prevent acidosis, especially in the period after surgery, fats should be limited in the diet; in the absence of contraindications, abundant alkaline drinks should be prescribed.

The regimen of insulin administration and nutrition in patients who are undergoing minor surgery under local anesthesia, which does not interfere with food intake, does not need to be changed. After administering insulin and breakfast, the patient is taken to the operating room, and after 1.5-2 hours he is given a second breakfast.

Patients who are undergoing abdominal surgery or any operation that excludes oral food intake, as well as patients undergoing surgery under anesthesia, should take approximately half of their morning dose of insulin before the intervention. 30 minutes after the insulin injection, 20 to 40 ml of a 40% glucose solution is administered intravenously, followed by a constant drip of a 5% glucose solution. Further administration of glucose and insulin is adjusted according to the level of glycemia determined every 2 hours. Metabolic stress accompanying general anesthesia and surgery usually leads to an increase in the need for insulin. The time of administration and dose of insulin is controlled by the sugar content in the blood and urine. Usually, until the patient’s condition is completely stabilized, simple insulin is administered 2 to 6 times or more per day.

It is unacceptable to discontinue insulin in the postoperative period in a patient who previously received insulin. This threatens the development of acidosis. In cases where normal glycemia levels persist during the day (very rarely!), patients are administered fractional doses of insulin (6-8 units 2-3 times a day) under the cover of a 5% glucose solution. During the postoperative period, patients are required to monitor daily urine (or several daily portions) for acetone.

After 3-6 days (sometimes more), provided the general condition is stabilized and diabetes compensation is maintained, the patient can be transferred to his usual insulin administration regimen. When it becomes possible to eat per os in the postoperative period, a mechanically and chemically gentle diet is prescribed and insulin treatment is continued. It is possible to cancel insulin and transfer the patient to sulfonylureas 3-4 weeks after surgery, provided that the wound is completely healed, there are no inflammatory phenomena, diabetes compensation is maintained, and there are no contraindications for taking sulfonamides.

For urgent, emergency surgical interventions, it is difficult to give a specific insulin administration regimen. It is set purely individually based on the initial level of sugar in the blood and urine, subsequently monitored every 1-2 hours, as well as taking into account the daily dose of insulin received by the patient before surgery and the patient’s sensitivity to insulin in case of newly diagnosed diabetes.

Every patient undergoing urgent surgery should have their blood sugar levels checked!

In case of decompensated diabetes mellitus with signs of ketoacidosis, the patient should be operated on against the background of measures aimed at eliminating ketoacidosis, with fractional administration of simple insulin under glycemic control. If surgery can be delayed, ketoacidosis must be treated first. Patients who received long-acting insulin on the eve of urgent surgery may require (under glycemic control!) additional correction with plain insulin.

Diabetic coma is a contraindication for surgery. First, urgent measures are taken to remove the patient from a comatose state, and only after that can surgery be performed.

A.Efimov, N.Skrobonskaya, A.Cheban

“Preparation of diabetic patients for surgery” - article from the section