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What Is the Best Way to Guarantee Postoperative Glycemic Control?
Vol. 212, No. 5, May 2011
REFERENCES 1. Butler PD, Britt LD, Green ML, et al. The Diverse Surgeons Initiative: an effective method for increasing the number of under-represented minorities in academic surgery. J Am Coll Surg 2010;211:561–566. 2. Butler PD, Longaker MT, Britt LD. Major deficit in the number of underrepresented minority academic surgeons persists. Ann Surg 2008;248:704–711.
Disclosure Information: Nothing to disclose.
What Is the Best Way to Guarantee Postoperative Glycemic Control? Kazuhiro Hanazaki, MD, PhD, Masaya Munekage, MD, Takehiro Okabayashi, MD, PhD Kochi, Japan We read with great interest the article by Murphy and colleagues.1 In a study of patients undergoing cardiac surgery, the authors found that the Surgical Care Improvement Project (SCIP) 6:00 AM blood sugar metric correlated with average blood sugar on postoperative day 1. Nonetheless, the duration of hyperglycemia (percentage of time with blood sugar ⬎200 mg/dL) was still 14% in the SCIPcompliant group. The authors concluded that the use of an insulin infusion protocol does not guarantee glycemic control, even with intensive use.1 Surgical stress-induced hyperglycemia often results in dysregulation of liver metabolism and immune function and increases the risk of postoperative infections,2 thus impairing postoperative recovery. In addition, a recent report by Kawahito and colleagues3 suggested that hyperglycemia during cardiovascular operations may be due to decreased insulin secretion in response to hypothermia and cardioplegia. It is possible that the 14% duration of hyperglycemia in the compliant group of the Murphy study1 may be due, at least in part, to the influence of hypothermia and cardioplegia during the cardiac operation. Conventional glycemic control must balance tight glycemic control, associated with the risk of hypoglycemia (⬍40 mg/dL) resulting in neurologic disorders, with loose glycemic control, associated with hyperglycemia and resultant infections. However, to improve morbidity and mortality in surgical patients, tight glycemic control in the ideal blood glucose range is essential to prevent postoperative infection, including surgical site infection.2-4 What was the clinical purpose and/or scientific evidence for a target blood glucose range of 100 to 140 mg/dL in this study,1
Letters
915
despite the accepted target blood glucose zone being 80 to 110 mg/dL for intensive insulin therapy?4 Unfortunately, conventional glycemic control using an openloop system, as in this study,1 is associated with the risk of hypoglycemia and hyperglycemia; therefore, we recommend the use of a closed-loop system.5 Since 2006, we have clinically used an artificial endocrine pancreas with a closed-loop system in more than 200 general operations (hepatic resection, pancreatic resection, esophageal resection, and emergency operations) under tight perioperative glycemic control with no incidents of hypoglycemia or periods of hyperglycemia.5-7 Because postoperative hyperglycemia occurs most frequently within 20 hours after operation,3,5-7 the most useful postoperative glycemic control to prevent hyperglycemia should be used during this time. To avoid hyperglycemia immediately after surgery, the closed-loop artificial pancreas system can perform continuous blood glucose monitoring and targeted blood glucose control simultaneously for 2 or 3 days.5-7 What is the best way to guarantee postoperative glycemic control? Currently an optimal blood glucose range is needed in patients to improve morbidity and mortality in various surgical settings. The closed-loop artificial endocrine pancreas is a safe and effective means of obtaining tight glycemic control without hypoglycemia or hyperglycemia according to the targeted blood glucose range. We propose that the use of the artificial pancreas will diminish the duration of hyperglycemia as shown in this study1 and also contribute to a future new insulin infusion protocol to guarantee postoperative glycemic control.
REFERENCES 1. Murphy MA, Whitman I, Campfield A, et al. Intense implementation of a strict insulin infusion protocol does not guarantee postoperative glycemic control. J Am Coll Surg 2010;211:465–469. 2. Ramos M, Khalpey Z, Lipsitz S, et al. Relationship of perioperative hyperglycemia and postoperative infections in patients who undergo general and vascular surgery. Ann Surg 2008;248:585– 591. 3. Kawahito S, Kitahata H, Kitagawa T, Oshita S. Intensive insulin therapy during cardiovascular surgery. J Med Invest 2010;57: 191–204. 4. Van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in critically ill patients. N Engl J Med 2001;345:1359– 1367. 5. Hanazaki K, Maeda H, Okabayashi T. Tight perioperative glycemic control using an artificial endocrine pancreas. Surg Today 2010;40:1–7. 6. Okabayashi T, Nishimori I, Maeda H, et al. Effect of intensive insulin therapy using a closed-loop glycemic control system in hepatic resection patients: a prospective randomized clinical trial. Diabetes Care 2009;32:1425–1427. 7. Hanazaki K, Okabayashi T, Maeda H. Tight glycemic control using an artificial pancreas to control perioperative hyperglycemia
916
Letters
decreases surgical site infection in pancreatectomized or hepatectomized patients. Ann Surg 2009;250:351–352.
Disclosure Information: Nothing to disclose.
Oncologically Safe Suture Retraction in Single-Incision Laparoscopic Surgery John R Frederick, MD, FACS Lancaster, PA With the trend toward developing surgical techniques that are less invasive, one criterion for acceptance of a new procedure is the respect of proven standards of safety. For the single-incision laparoscopic cholecystectomy, routine identification of the critical view of safety guards against an increase in iatrogenic bile duct injury. The respect of the oncological point of view is also important, as identified by Giulio Belli and colleagues in their letter “Laparoendoscopic Single–Site Cholecystectomy: A Word of Concern.”1 This concern is raised by the placement of a suture for retraction of the gallbladder, a placement through the gallbladder wall that risks spillage of bile and, therefore, potential tumor spread. A modification of the technique of suture retraction is proposed that does not risk spillage of bile and is technically easier to achieve. This modification involves placement of the retraction suture through a peritoneal cuff on the liver bed and not through the gallbladder wall. To accomplish this placement, the dissection starts at the fundus of the gallbladder in the same manner as a dome down approach. Care is taken to incise the peritoneum at least 1 cm from the liver, leaving an attached cuff strong enough to hold the traction suture. Holding the peritoneal rim on the liver side upward, the gallbladder is separated from the peritoneum and the liver bed, creating a space large enough to pass the needle through safely. Continuing to hold this peritoneal cuff upward, a straight needle is then passed percutaneously through the abdominal wall at the point closest to the liver bed. In most cases, the needle can be passed directly through this cuff of peritoneum in the same motion; the tip of the needle is then grasped in the open space between the gallbladder and liver bed. The needle is then pulled through and pierced through the abdominal wall. This suture now allows traction of the liver upward. A traction suture placed in this location has the following advantages: minimal risk of bile leakage, less time for placement, and facilitation of a dome down approach if advanta-
J Am Coll Surg
geous. In some cases, it also allows for better exposure of the triangle of Calot, with upward traction of the liver and simultaneous inferior traction of the gallbladder now possible. A disadvantage of this placement is that the fundus of the gallbladder is free to flop back and forth, occasionally requiring additional maneuvering for adequate exposure. This technique is not always necessary and not always possible, depending on the patient’s anatomy. It does provide an oncologically safe option when additional traction is necessary.
REFERENCE 1. Belli G, Limongelli P, Belli A, et al. Laparoendoscopic single-site cholecystectomy: a word of concern. J Am Coll Surg 2010;211: 689–690.
Disclosure Information: Nothing to disclose.
Business Course for Residents Stephen M Cohn, MD, FACS, Clint Baisden, MD, FACS San Antonio, TX We read with interest the article by Hauge and colleagues1 regarding their “web-based curriculum” for health care business. Some years ago we initiated a business leadership course for our surgical chief residents to prepare them to deal with the business challenges of private or academic surgical practice. Sunday evening dinner lectures were conducted monthly for our chief residents and their significant others at the home of faculty members by surgeon experts from both academia and the community sector. (Child care was provided.) We found that this venue improved attendance, decreased interruptions, and allowed for spousal participation. Topics included personal finance; differences between private and academic practice; searching for a job; legal issues; contracts; insurance; when, how, and where to borrow money; office organization; hiring and firing office staff; coding; billing; collecting; and time management. Evaluations have remained universally highly positive.
REFERENCE 1. Hauge LS, Frischknecht AC, Gauger PG, et al. Web-based curriculum improves residents’ knowledge of health care business. J Am Coll Surg 2010;211;777–783.
Disclosure Information: Nothing to disclose
REFERENCES 1. Butler PD, Britt LD, Green ML, et al. The Diverse Surgeons Initiative: an effective method for increasing the number of under-represented minorities in academic surgery. J Am Coll Surg 2010;211:561–566. 2. Butler PD, Longaker MT, Britt LD. Major deficit in the number of underrepresented minority academic surgeons persists. Ann Surg 2008;248:704–711.
Disclosure Information: Nothing to disclose.
What Is the Best Way to Guarantee Postoperative Glycemic Control? Kazuhiro Hanazaki, MD, PhD, Masaya Munekage, MD, Takehiro Okabayashi, MD, PhD Kochi, Japan We read with great interest the article by Murphy and colleagues.1 In a study of patients undergoing cardiac surgery, the authors found that the Surgical Care Improvement Project (SCIP) 6:00 AM blood sugar metric correlated with average blood sugar on postoperative day 1. Nonetheless, the duration of hyperglycemia (percentage of time with blood sugar ⬎200 mg/dL) was still 14% in the SCIPcompliant group. The authors concluded that the use of an insulin infusion protocol does not guarantee glycemic control, even with intensive use.1 Surgical stress-induced hyperglycemia often results in dysregulation of liver metabolism and immune function and increases the risk of postoperative infections,2 thus impairing postoperative recovery. In addition, a recent report by Kawahito and colleagues3 suggested that hyperglycemia during cardiovascular operations may be due to decreased insulin secretion in response to hypothermia and cardioplegia. It is possible that the 14% duration of hyperglycemia in the compliant group of the Murphy study1 may be due, at least in part, to the influence of hypothermia and cardioplegia during the cardiac operation. Conventional glycemic control must balance tight glycemic control, associated with the risk of hypoglycemia (⬍40 mg/dL) resulting in neurologic disorders, with loose glycemic control, associated with hyperglycemia and resultant infections. However, to improve morbidity and mortality in surgical patients, tight glycemic control in the ideal blood glucose range is essential to prevent postoperative infection, including surgical site infection.2-4 What was the clinical purpose and/or scientific evidence for a target blood glucose range of 100 to 140 mg/dL in this study,1
Letters
915
despite the accepted target blood glucose zone being 80 to 110 mg/dL for intensive insulin therapy?4 Unfortunately, conventional glycemic control using an openloop system, as in this study,1 is associated with the risk of hypoglycemia and hyperglycemia; therefore, we recommend the use of a closed-loop system.5 Since 2006, we have clinically used an artificial endocrine pancreas with a closed-loop system in more than 200 general operations (hepatic resection, pancreatic resection, esophageal resection, and emergency operations) under tight perioperative glycemic control with no incidents of hypoglycemia or periods of hyperglycemia.5-7 Because postoperative hyperglycemia occurs most frequently within 20 hours after operation,3,5-7 the most useful postoperative glycemic control to prevent hyperglycemia should be used during this time. To avoid hyperglycemia immediately after surgery, the closed-loop artificial pancreas system can perform continuous blood glucose monitoring and targeted blood glucose control simultaneously for 2 or 3 days.5-7 What is the best way to guarantee postoperative glycemic control? Currently an optimal blood glucose range is needed in patients to improve morbidity and mortality in various surgical settings. The closed-loop artificial endocrine pancreas is a safe and effective means of obtaining tight glycemic control without hypoglycemia or hyperglycemia according to the targeted blood glucose range. We propose that the use of the artificial pancreas will diminish the duration of hyperglycemia as shown in this study1 and also contribute to a future new insulin infusion protocol to guarantee postoperative glycemic control.
REFERENCES 1. Murphy MA, Whitman I, Campfield A, et al. Intense implementation of a strict insulin infusion protocol does not guarantee postoperative glycemic control. J Am Coll Surg 2010;211:465–469. 2. Ramos M, Khalpey Z, Lipsitz S, et al. Relationship of perioperative hyperglycemia and postoperative infections in patients who undergo general and vascular surgery. Ann Surg 2008;248:585– 591. 3. Kawahito S, Kitahata H, Kitagawa T, Oshita S. Intensive insulin therapy during cardiovascular surgery. J Med Invest 2010;57: 191–204. 4. Van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in critically ill patients. N Engl J Med 2001;345:1359– 1367. 5. Hanazaki K, Maeda H, Okabayashi T. Tight perioperative glycemic control using an artificial endocrine pancreas. Surg Today 2010;40:1–7. 6. Okabayashi T, Nishimori I, Maeda H, et al. Effect of intensive insulin therapy using a closed-loop glycemic control system in hepatic resection patients: a prospective randomized clinical trial. Diabetes Care 2009;32:1425–1427. 7. Hanazaki K, Okabayashi T, Maeda H. Tight glycemic control using an artificial pancreas to control perioperative hyperglycemia
916
Letters
decreases surgical site infection in pancreatectomized or hepatectomized patients. Ann Surg 2009;250:351–352.
Disclosure Information: Nothing to disclose.
Oncologically Safe Suture Retraction in Single-Incision Laparoscopic Surgery John R Frederick, MD, FACS Lancaster, PA With the trend toward developing surgical techniques that are less invasive, one criterion for acceptance of a new procedure is the respect of proven standards of safety. For the single-incision laparoscopic cholecystectomy, routine identification of the critical view of safety guards against an increase in iatrogenic bile duct injury. The respect of the oncological point of view is also important, as identified by Giulio Belli and colleagues in their letter “Laparoendoscopic Single–Site Cholecystectomy: A Word of Concern.”1 This concern is raised by the placement of a suture for retraction of the gallbladder, a placement through the gallbladder wall that risks spillage of bile and, therefore, potential tumor spread. A modification of the technique of suture retraction is proposed that does not risk spillage of bile and is technically easier to achieve. This modification involves placement of the retraction suture through a peritoneal cuff on the liver bed and not through the gallbladder wall. To accomplish this placement, the dissection starts at the fundus of the gallbladder in the same manner as a dome down approach. Care is taken to incise the peritoneum at least 1 cm from the liver, leaving an attached cuff strong enough to hold the traction suture. Holding the peritoneal rim on the liver side upward, the gallbladder is separated from the peritoneum and the liver bed, creating a space large enough to pass the needle through safely. Continuing to hold this peritoneal cuff upward, a straight needle is then passed percutaneously through the abdominal wall at the point closest to the liver bed. In most cases, the needle can be passed directly through this cuff of peritoneum in the same motion; the tip of the needle is then grasped in the open space between the gallbladder and liver bed. The needle is then pulled through and pierced through the abdominal wall. This suture now allows traction of the liver upward. A traction suture placed in this location has the following advantages: minimal risk of bile leakage, less time for placement, and facilitation of a dome down approach if advanta-
J Am Coll Surg
geous. In some cases, it also allows for better exposure of the triangle of Calot, with upward traction of the liver and simultaneous inferior traction of the gallbladder now possible. A disadvantage of this placement is that the fundus of the gallbladder is free to flop back and forth, occasionally requiring additional maneuvering for adequate exposure. This technique is not always necessary and not always possible, depending on the patient’s anatomy. It does provide an oncologically safe option when additional traction is necessary.
REFERENCE 1. Belli G, Limongelli P, Belli A, et al. Laparoendoscopic single-site cholecystectomy: a word of concern. J Am Coll Surg 2010;211: 689–690.
Disclosure Information: Nothing to disclose.
Business Course for Residents Stephen M Cohn, MD, FACS, Clint Baisden, MD, FACS San Antonio, TX We read with interest the article by Hauge and colleagues1 regarding their “web-based curriculum” for health care business. Some years ago we initiated a business leadership course for our surgical chief residents to prepare them to deal with the business challenges of private or academic surgical practice. Sunday evening dinner lectures were conducted monthly for our chief residents and their significant others at the home of faculty members by surgeon experts from both academia and the community sector. (Child care was provided.) We found that this venue improved attendance, decreased interruptions, and allowed for spousal participation. Topics included personal finance; differences between private and academic practice; searching for a job; legal issues; contracts; insurance; when, how, and where to borrow money; office organization; hiring and firing office staff; coding; billing; collecting; and time management. Evaluations have remained universally highly positive.
REFERENCE 1. Hauge LS, Frischknecht AC, Gauger PG, et al. Web-based curriculum improves residents’ knowledge of health care business. J Am Coll Surg 2010;211;777–783.
Disclosure Information: Nothing to disclose