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Surgical management of the diabetic patient
BOOK REVIEWS John M. Porter, Surgical
management
MD, Book Review Section Editor of the diabetic
patient
Michael Bergman, Gregorio A. Sicard, eds. New York, 1991, Raven Press,427 pages, $90.00. This text by many authors is intended to be a blueprint for the convergence of various medical specialistsinto an effective team to deal with surgical problems in patients with diabetes. More than 15 authors have contributed 29 chapters -more than 400 pages. General organization is in the form of five introductory chapters followed in sequence by sections dealing with “Special Medical Considerations” and the last 200 pages dealing with ‘Special Surgical Considerations.” The first of these dealswith either various end organ diseases,for example, nephropathy, or general problems such as infections and their complicating influence in surgical patients. The surgical section is comprised of chapters dealing with particular anatomic problems such as diabetic foot management and renal transplantation. The introductory chapters range from a tedious review of the intermediary metabolism of carbohydrates to a very informative review of the available experimental and clinical data that relate to deficient wound healing in diabetics. The latter is the type of resource that one is apt to refer to when challenged to provide evidence about problems with healing in diabetics. As might be anticipated, much attention is given to the medical management of diabetes in the perioperative period. Indeed a fair amount of repetition existswith respect to this topic, with individual chapters dealing with emergency, outpatient, and/or pediatric and adolescent surgery. A position is strongly voiced throughout these chapters in favor of continuous intravenous glucose/insulin or insulin alone infLsi0n.s for the perioperative management of diabetes. These sections, written by diabetologists, reflect the prevailing bias for rather tight blood glucose control in the long-term management of diabetes. Most surgeons would likely opt for less stringent control in the perioperative period fearing hypoglycemic events and potential cardiac morbidity. Furthermore, I suspect continuous infusion techniques for perioperative insulin administration are not widely used, although this method is popular in Great Britain. Certainly, diabetologists in our hospital and at a sister institution in Boston with a nationally recognized diabetes group continue to use subcutaneous insulin administration for most diabetics undergoing surgery. Completing the first section of the book is a chapter on “Hospital Discharge Planning,” which should prove useful to nurse specialistsand socialworkers involved in discharge planning. The section on “SpeciIic Surgical Considerations” begins with a series of chapters on lower extremity problems in diabetes. Individual chapters are devoted to diabetic foot care, management, and cutaneous ulcers and amputations, supplemented by a lengthy chapter on vascular surgery. These are variably written by surgeons,
internists, and podiatrists. In an apparent effort to give each discipline its sounding board, there is much repetition and some conflict with respect to the issue of diabetic “microangiopathy.” There is a curious omission of any focused discussion of diabetic peripheral neuropathy. Indeed, an earlier chapter entitled “Diabetic Neuropathy” is concerned only with visceralneuropathic syndromes. Conspicuously lacking in the book is a discussionof the pathogenesis, diagnosis, and medical management options for symptomatic peripheral neuropathy, although its contribution to foot problems is appropriately emphasized. Certain chapters seem out of place in this text because the disease processesthey deal with have little specific relevance to diabetic patients, such as the sections on carotid artery disease and pancreatitis. Indeed, the latter chapter becomes a discussion of the surgical therapy of chronic pancreatitis. The final chapters cover a wide range of clinical circumstancesthat entail surgery in the diabetic. In an effort to appeal to medical and surgical audiences, the depth of certain topics becomes overbearing. For example, a chapter on the urologic complications of diabetes runs 30 pages and contains technical information on the merits of various models of penile prostheses,information that seems out of place in this setting. However, balancing the sections with limited focus are excellent chapters on renal and pancreas transplantation, pregnancy in diabetes, and management of diabetic retinopathy. This book belongs in the collection of practitioners seeing large numbers of diabetic patients. Principally this would be the diabetologist, but surgeons whose practices are afliliated with large diabetic clinics may also find it useful. The editors could have been more ruthless with their contributors and produced a more streamlined text. Yet that is the perspective of one who has read 400 consecutive pages dealing with a broad range of clinical problems. Clearly this is a reference text with major value because contained in this single volume is information relevant to the treatment of diabetics that would ordinarily require reference to an entire shelf of subspecialty text books. Richard P. Cmti, MD Mizssachsetts Generd Hospital
Clinical
epidemiology
of stroke
Shah Ebrahim, Qxford, 1990, Oxford University Press,227 pages, $59.95. This book by Shah Ebrahim, Professor of Health Care of the Elderly, represents a very thorough study of established stroke. For the vascular surgeon, the lesions described herein do not correspond to the classicindications for carotid surgery. As a result, the book’s value for vascular surgeons residesprimarily in providing information about prognostic factors and patient rehabilitation. 133
management
MD, Book Review Section Editor of the diabetic
patient
Michael Bergman, Gregorio A. Sicard, eds. New York, 1991, Raven Press,427 pages, $90.00. This text by many authors is intended to be a blueprint for the convergence of various medical specialistsinto an effective team to deal with surgical problems in patients with diabetes. More than 15 authors have contributed 29 chapters -more than 400 pages. General organization is in the form of five introductory chapters followed in sequence by sections dealing with “Special Medical Considerations” and the last 200 pages dealing with ‘Special Surgical Considerations.” The first of these dealswith either various end organ diseases,for example, nephropathy, or general problems such as infections and their complicating influence in surgical patients. The surgical section is comprised of chapters dealing with particular anatomic problems such as diabetic foot management and renal transplantation. The introductory chapters range from a tedious review of the intermediary metabolism of carbohydrates to a very informative review of the available experimental and clinical data that relate to deficient wound healing in diabetics. The latter is the type of resource that one is apt to refer to when challenged to provide evidence about problems with healing in diabetics. As might be anticipated, much attention is given to the medical management of diabetes in the perioperative period. Indeed a fair amount of repetition existswith respect to this topic, with individual chapters dealing with emergency, outpatient, and/or pediatric and adolescent surgery. A position is strongly voiced throughout these chapters in favor of continuous intravenous glucose/insulin or insulin alone infLsi0n.s for the perioperative management of diabetes. These sections, written by diabetologists, reflect the prevailing bias for rather tight blood glucose control in the long-term management of diabetes. Most surgeons would likely opt for less stringent control in the perioperative period fearing hypoglycemic events and potential cardiac morbidity. Furthermore, I suspect continuous infusion techniques for perioperative insulin administration are not widely used, although this method is popular in Great Britain. Certainly, diabetologists in our hospital and at a sister institution in Boston with a nationally recognized diabetes group continue to use subcutaneous insulin administration for most diabetics undergoing surgery. Completing the first section of the book is a chapter on “Hospital Discharge Planning,” which should prove useful to nurse specialistsand socialworkers involved in discharge planning. The section on “SpeciIic Surgical Considerations” begins with a series of chapters on lower extremity problems in diabetes. Individual chapters are devoted to diabetic foot care, management, and cutaneous ulcers and amputations, supplemented by a lengthy chapter on vascular surgery. These are variably written by surgeons,
internists, and podiatrists. In an apparent effort to give each discipline its sounding board, there is much repetition and some conflict with respect to the issue of diabetic “microangiopathy.” There is a curious omission of any focused discussion of diabetic peripheral neuropathy. Indeed, an earlier chapter entitled “Diabetic Neuropathy” is concerned only with visceralneuropathic syndromes. Conspicuously lacking in the book is a discussionof the pathogenesis, diagnosis, and medical management options for symptomatic peripheral neuropathy, although its contribution to foot problems is appropriately emphasized. Certain chapters seem out of place in this text because the disease processesthey deal with have little specific relevance to diabetic patients, such as the sections on carotid artery disease and pancreatitis. Indeed, the latter chapter becomes a discussion of the surgical therapy of chronic pancreatitis. The final chapters cover a wide range of clinical circumstancesthat entail surgery in the diabetic. In an effort to appeal to medical and surgical audiences, the depth of certain topics becomes overbearing. For example, a chapter on the urologic complications of diabetes runs 30 pages and contains technical information on the merits of various models of penile prostheses,information that seems out of place in this setting. However, balancing the sections with limited focus are excellent chapters on renal and pancreas transplantation, pregnancy in diabetes, and management of diabetic retinopathy. This book belongs in the collection of practitioners seeing large numbers of diabetic patients. Principally this would be the diabetologist, but surgeons whose practices are afliliated with large diabetic clinics may also find it useful. The editors could have been more ruthless with their contributors and produced a more streamlined text. Yet that is the perspective of one who has read 400 consecutive pages dealing with a broad range of clinical problems. Clearly this is a reference text with major value because contained in this single volume is information relevant to the treatment of diabetics that would ordinarily require reference to an entire shelf of subspecialty text books. Richard P. Cmti, MD Mizssachsetts Generd Hospital
Clinical
epidemiology
of stroke
Shah Ebrahim, Qxford, 1990, Oxford University Press,227 pages, $59.95. This book by Shah Ebrahim, Professor of Health Care of the Elderly, represents a very thorough study of established stroke. For the vascular surgeon, the lesions described herein do not correspond to the classicindications for carotid surgery. As a result, the book’s value for vascular surgeons residesprimarily in providing information about prognostic factors and patient rehabilitation. 133