Postoperative hyperglycemia in nondiabetic patients after gastric surgery for cancer: perioperative outcomes

Reality of post-gastrectomy stress hyperglycemia revealed by continuous glucose monitoring: a prospective study

PURPOSES

Postoperative stress hyperglycemia is reported to be associated with increased postoperative complications (PCs) following various surgical procedures. However, most reports of postoperative hyperglycemia are based on conventional, point blood glucose measurements. We sought to clarify trends in post-gastrectomy glucose levels using continuous glucose monitoring (CGM) and investigate the relationship between postoperative hyperglycemia and stress-related factors such as PCs and the degree of surgical invasiveness.

METHODS

The subjects of this prospective study were 40 patients who underwent gastrectomy between November, 2022 and September, 2023. We recorded their glucose levels by CGM immediately after surgery until discharge (up to 2 weeks postoperatively).

RESULTS

There was no increase in glucose levels caused by open gastrectomy, a strong inflammatory response, or PCs. Hyperglycemia, defined as the percentage of time that the glucose level was > 140 mg/dL, was associated only with the preoperative HbA1c value (P = 0.039). Patients with an HbA1c ≥ 6% had a significantly longer duration of hyper- and hypo-glycemia and greater glycemic variability than those with an HbA1c < 6% (glucose level < 70 mg/dL, P = 0.027; > 140 mg/dL, P = 0.001, coefficient of variation P = 0.024).

CONCLUSIONS

No association was observed between stress hyperglycemia during the acute phase following gastrectomy and PCs. Only patients with an elevated HbA1c had high rates of hypo- and hyper-glycemia and large glycemic variability, despite perioperative glucose management.

Analysis of postoperative complications and long term survival following radical gastrectomy for patients with gastric cancer

This study aimed to analyze the complications and long-term survival outcomes in patients who underwent radical gastrectomy for gastric cancer, as well as to identify the risk factors associated with postoperative complications. After conducting a comprehensive search within the medical records system, a total of 2508 patients who underwent radical gastrectomy and met the inclusion criteria were enrolled. Of the 2508 patients, 301 were diagnosed with postoperative complications. The pathological data, postoperative recovery, and survival outcome were compared between complication and control group. Subsequently, univariate and multivariate logistic regression analyses were conducted to identified the risk factors. According to the Clavien-Dindo grading criteria for postoperative complications, the proportions of grade I, II, III, IV, and V complications following radical gastrectomy were observed to be 28.2%, 42.9%, 19.6%, 8.0%, and 1.3%, respectively. The presence of postoperative complications significantly prolonged the duration of gastrointestinal decompression (P < 0.001), catheter retention (P < 0.001), fasting (P < 0.001), and hospitalization (P < 0.001). Additionally, it had a detrimental impact on survival outcomes. Age > 65years [odds ratio (OR) = 1.378, P = 0.020], presence of diabetes (OR = 2.042, P < 0.001), operative duration > 215 min (OR = 1.450, P = 0.006), intraoperative blood loss > 275 ml (OR = 1.474, P = 0.004), and Roux-en-Y anastomosis for both whole stomach (OR = 1.567, P = 0.021) and distal gastric cancer (OR = 2.083, P = 0.003) were identified as independent risk factors for postoperative complications. This study analyzed the complications and survival outcomes following radical gastrectomy, and investigated the predictors for postoperative complications, thereby providing valuable guidance on the prevention and management of surgical complications in gastric cancer.

Postoperative hyperglycemia among adult non-diabetic surgical patients at University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia

BACKGROUND

Postoperative hyperglycemia is associated with morbidity and mortality in non-diabetic surgical patients. However, there is limited information on the extent and factors associated with postoperative hyperglycemia. This study assessed the magnitude and associated factors of postoperative hyperglycemia among non-diabetic adult patients who underwent elective surgery at University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia.

METHODS

A facility-based cross-sectional study was conducted among 412 adult patients who underwent elective surgery at University of Gondar Comprehensive Specialized Hospital from April 14 to June 30, 2022 All consecutive postoperative non-diabetic elective surgical patients who were admitted to PACU during the data collection period and who fulfilled inclusion criteria were included in the study until the intended minimum sample size was achieved. And data were collected through interviews using a pretested semi-structured questionnaire. Postoperative hyperglycemia was defined as a blood glucose level of ≥ 140 mg/dl. Multivariable logistic regression was performed to identify the association between postoperative hyperglycemia and independent variables. Variables with a p-value less than 0.05 and a 95% confidence interval (CI) were considered statistically significant.

RESULTS

A total of 405 patients' data were evaluated with a response rate of 98.3%. The median (IQR) age was 40 (28-52) years. The prevalence of postoperative hyperglycemia was 34.1% (95% CI: 29.4-39.0). Factors significantly associated with postoperative hyperglycemia included being overweight (AOR = 5.45, 95% CI: 2.46-12.0), American Society of Anesthesiologists (ASA) classification II and III (AOR = 2.37, 95% CI: 1.17-4.79), postoperative low body temperature (AOR = 0.18, 95% CI: 0.069-0.48), blood loss ≥ 500 ml (AOR = 2.33, 95% CI: 1.27-4.27), long duration of surgery, mild pain (AOR = 5.17, 95% CI: 1.32-20.4), and moderate pain (AOR = 7.63, 95% CI: 1.811-32.20).

CONCLUSION AND RECOMMENDATION

One-third of the study participants had postoperative hyperglycemia. Weight, ASA classification, postoperative body temperature, duration of surgery, intraoperative blood loss, and postoperative pain were identified as a modifiable risk factors. Maintaining normal body temperature throughout the procedure, treating postoperative pain, and monitoring and controlling blood glucose level in patients at risk of hyperglycemia is crucial.

Comparison of spinal versus general anesthesia on the perioperative blood glucose levels in patients undergoing lower abdominal and pelvic surgery: a prospective cohort study, Ethiopia

Surgery is linked with fear and stress that disrupt metabolic and neuroendocrine activities, which impair normal maintained glucose metabolism that leads to stress hyperglycaemia. This study aimed to compare the effect of general and spinal anaesthesia on perioperative blood glucose levels in patients undergoing lower abdominal and pelvic surgery.

Methods

This prospective observational cohort study recruits 70 adult patients who underwent lower abdominal and pelvic surgery under general and spinal anaesthesia; 35 in each group. A systematic random sampling technique was used to select study participants. Capillary blood glucose was measured at four perioperative times. An independent t-test, dependent t-test, and Manny-Whitney U test were used for statistical analysis, as appropriate. P values less than 0.05 were considered statistically significant.

Results

No statistically significant difference was observed in mean blood glucose levels at baseline and 5 min after induction of general anaesthesia and complete blocks of spinal anaesthesia. But at the end of surgery and 60 min after the end of surgery the mean blood glucose levels were statistically significantly higher in the general anaesthesia group compared with the spinal anaesthesia group (P<0.05). And the blood glucose level was significantly increased from baseline compared with the different time intervals in the general anaesthesia group.

Conclusion

The mean blood glucose levels were lower in patients undergoing surgery under spinal anaesthesia compared with general anaesthesia. The authors recommend spinal over general anaesthesia whenever possible for patients undergoing lower abdominal and pelvic surgery.

The association between fasting blood glucose and prognosis in gastrointestinal stromal tumor patients after curable resection

Blood glucose has been demonstrated to serve as prognostic indicators in various malignancies. This study aimed to explore the relationship between fasting blood glucose (FBG) levels and the prognosis in patients with gastrointestinal stromal tumor (GIST) undergoing complete resection. Data were retrospectively collected from 256 patients with primary GIST underwent complete surgical resection or endoscopic excision. Patients were stratified into euglycemic group and hyperglycemic group. Patients' characteristics between groups were compared. Cox regression model was conducted to identify independent prognostic factors of disease-free survival (DFS). Both univariate analysis and multivariate analyses revealed that FBG ≥ 100 mg/dl was associated with poor outcomes. Patients with FBG ≥ 100 mg/dl tended to have more adverse features, more likely to suffer recurrence and a worse 5-year DFS than patients with FBG < 100 mg/dl. Moreover, FBG levels helped distinguishing between patients with different survival outcomes in different risk categories defined by modified NIH systems. Our data provided the evidence that FBG is a useful prediction marker prognosis in patients with GIST undergoing curative surgery.

Treatment of Severe Hyperglycemia in Patients Without Diabetes After Colorectal Surgery

Background: Several studies have suggested that intravenous insulin therapy for post-operative hyperglycemia improves outcomes after colorectal surgery. Despite the potential benefit, there is a reluctance to use this approach in patients without diabetes mellitus because of an unproven benefit and the potential for hypoglycemia. In this study, we examined whether sliding-scale insulin is sufficient to improve outcomes or if stricter glucose control is necessary. Patients and Methods: Of 1,064 consecutive colorectal surgery patients between August 2016 and December 2021, 478 patients without diabetes mellitus had an average of 6.4 ± 3.1 glucose samples taken within 48 hours after surgery. Sixty-six percent of patients with severe hyperglycemia (glucose ≥180 mg/dL) received sliding-scale insulin. Complication rates and effects of insulin were examined. Results: Severe hyperglycemia was associated with a higher total infection rate (p < 0.002), National Healthcare Safety Network-reported infections (NHSN; p < 0.026), total complications (p < 0.001), and length of stay (LOS; p < 0.000). Sliding-scale insulin did not lower the risk of infection or other complications. Hypoglycemia (glucose <70 mg/dL) occurred in 3.5% of patients, but was not related to insulin use, and was predictable with clinical variables: albumin (p < 0.032), operative duration (p < 0.012), and average post-operative glucose (p < 0.002; area under the curve [AUC], 0.86). Conclusions: Our data confirm that severe post-operative hyperglycemia in patients without diabetes mellitus after colorectal surgery is associated with complications. Sliding-scale insulin was safe but not effective. Treatment before severe hyperglycemia is reached, not after its occurrence, may be beneficial.

The efficacy of intraoperatie continuous glucose monitoring in patients undergoing liver transplantation: a study protocol for a prospective randomized controlled superiority trial

BACKGROUND

The high incidence of intraoperative glucose dysregulations in liver transplantation (LT) is related to the lack of highly orchestrated control of intraoperative blood glucose. Glucose monitoring based on a single arterial blood gas test can only provide a simple glucose profile and is insufficient in monitoring intraoperative glycemic variability (GV), which is not conducive to controlling GV and may have a lag in the management of hyper/hypoglycemia. Continuous glucose monitor (CGM), which has been successfully applied in the management of chronic disease in diabetes, provides more detailed blood glucose records and reflect GV parameters such as coefficient of variation (CV%). However, its effectiveness and accuracy for guiding blood glucose management in major surgeries remains unclear.

METHODS

This is a single-center, randomized, controlled, superiority trial. One hundred and eighty patients scheduled for orthotopic LT will be recruited and randomized into two groups. All patients are monitored for intraoperative glucose using CGM combined with arterial blood gas (ABG). In the intervention group (group CG), ABG will be performed when CGM value is < 6.1 mmol/L or > 10.0 mmol/L, or the rate of change of CGM value > 1.67 mmol/(L·min). In the control group (group G), intraoperative ABG tests will be performed every 2 h, and the frequency of ABG tests will be adjusted based on the previous arterial glucose result. Patients in both groups will have their blood glucose adjusted according to arterial glucose values and a uniform protocol. Surgical and other anesthetic management is completed according to standard LT practices.

DISCUSSION

This study intends to investigate the effectiveness of CGM-based intraoperative glucose management and its impact on the prognosis of LT patients by comparing the GV, mean glucose values, and the incidence of hypo/hypoglycemic events guided by the above two glucose monitoring methods.

TRIAL REGISTRATION

This study is registered at www.chictr.org.cn on January 4, 2022, under the registration number ChiCTR2200055236.

Hyperglycemia is associated with worse 3-year survival in older patients admitted to the intensive care unit after non-cardiac surgery: Post hoc analysis of a randomized trial

Objective

Hyperglycemia is common in critically ill patients after surgery and is associated with worse perioperative outcomes. Yet, the impact of postoperative hyperglycemia on long-term outcomes remains unclear. We therefore analyzed the association between early postoperative hyperglycemia and 3-year overall survival in older patients who were admitted to the intensive care unit after surgery.

Methods

This was a post hoc analysis of database obtained from a previous randomized trial and 3-year follow-up. The underlying trial enrolled 700 patients aged 65 years or older who were admitted to the intensive care unit after elective non-cardiac surgery. Early postoperative time-weighted average blood glucose was calculated and was divided into three levels, i.e., <8.0 mmol/L, from 8.0 to 10.0 mmol/L, and >10.0 mmol/L. The primary outcome was 3-year overall survival. The association between time-weighted average blood glucose level and 3-year overall survival was analyzed with Cox proportional hazard regression models. Subgroup analyses were also performed in patients with or without diabetes, and in patients following cancer or non-cancer surgery.

Results

A total of 677 patients (mean age 74 years, 60% male sex) were included in the final analysis. Within 3 years after surgery, deaths occurred in 22.1% (30/136) of patients with time-weighted average blood glucose <8.0 mmol/L, compared with 35.7% (81/227) of those from 8.0 to 10.0 mmol/L (unadjusted hazard ratio 1.75, 95% CI 1.15 to 2.67, P = 0.009), and 36.9% (116/314) of those >10.0 mmol/L (unadjusted hazard ratio 1.91, 95% CI 1.28 to 2.85, P = 0.002). After adjustment for confounding factors, the risk of 3-year mortality remained higher in patients with time-weighted average blood glucose from 8.0 to 10.0 mmol/L (adjusted hazard ratio 2.28, 95% CI 1.47 to 3.54, P < 0.001) and in those >10.0 mmol/L (adjusted hazard ratio 2.00, 95% CI 1.29 to 3.10, P = 0.002). Similar results were obtained in the subgroups of patients without diabetes and patients following cancer surgery.

Conclusion

For older patients admitted to the intensive care unit after elective non-cardiac surgery, high early blood glucose (time-weighted average blood glucose ≥ 8.0 mmol/L) was associated with poor 3-year overall survival. The impact of moderate glycemic control on long-term survival deserves further investigation.

The Impact and Clinical Prediction of Hyperglycemia During Parenteral Nutrition for Nondiabetic Patients After Gastrectomy for Gastric Cancer

Background and Purpose

Hyperglycemia (HG) is associated with increased postoperative complications. This study aims to evaluate the effect of HG during supplemental parenteral nutrition (SPN) on short-term prognosis in non-diabetic patients undergoing gastrectomy for cancer and to analyse the risk factors and prevention methods for HG.

Methods

A total of 359 patients were divided into three groups according to blood glucose (BG) during SPN: normoglycemic patients ( ≤ 125 mg/dL), mild HG (125~200 mg/dL), and severe HG (>200 mg/dL). The effect of BG on postoperative short-term outcomes was analyzed. Multivariate regression was performed to investigate influencing factors for severe HG. The safety and efficacy of insulin addition to total nutrient admixture (TNA) for the prevention and management of HG were assessed by propensity score matching (PSM). In addition, regression analysis was performed in the noninsulin group to investigate the predictive factors of severe HG, and a nomogram was plotted.

Results

The postoperative complication rate was 18.9%, but it was significantly higher in patients with severe HG than in mild HG and normoglycemic patients (25.2, 15.0, and 10.0%, respectively, p < 0.05). Multivariate logistic regression analysis showed that anemia, myosteatosis, higher postoperative capillary blood glucose (CBG) before TNA infusion, and insulin in the TNA were independent influencing factors for severe HG. Based on the above factors, 75 pairs of patients (insulin group and non-insulin group) with comparable baseline data were successfully matched by PSM. The HG incidence and the glycemic fluctuation were significantly improved through 1 U insulin/6 g glucose (1/6 scheme) to TNA. A nomogram containing hemoglobin, skeletal muscle radiodensity, pre-SPN CBG, and pTNM stage with good predictive efficacy (C-index: 0.750) was constructed based on the noninsulin group.

Conclusion

Poor postoperative glycemic control was related to worse outcomes in non-diabetic patients undergoing gastrectomy for cancer. Pre-operative anemia, myosteatosis, and high postoperative CBG before TNA infusion are risk factors for severe HG. Insulin in TNA can improve the blood glucose control of patients. Our proposed nomogram rendered an individualized predictive tool for HG during SPN, which helps screen high-risk patients requiring insulin therapy. Future studies with larger samples are needed to develop a complete insulin application protocol for SPN.

High glucose: an emerging association between diabetes mellitus and cancer progression

The association of cancer and diabetes mellitus (DM) has been studied for decades. Hyperglycemia and the imbalance of hormones are factors that contribute to the molecular link between DM and carcinogenesis and cancer progression. Hyperglycemia alone or in combination with hyperinsulinemia are key factors that promote cancer aggressiveness. Many preclinical studies suggest that high glucose induces abnormal energy metabolism and aggressive cancer via several mechanisms. As evidenced by clinical studies, hyperglycemia is associated with poor clinical outcomes in patients who have comorbid DM. The prognoses of cancer patients with DM are improved when their plasma glucose levels are controlled. This suggests that high glucose level maybe be involved in the molecular mechanism that causes the link between DM and cancer and may also be useful for prognosis of cancer progression. This review comprehensively summarizes the evidence from recent pre-clinical and clinical studies of the impact of hyperglycemia on cancer advancement as well as the underlying molecular mechanism for this impact. Awareness among clinicians of the association between hyperglycemia or DM and cancer progression may improve cancer treatment outcome in patients who have DM.

The Relationship between Diabetes Mellitus and Gastric Cancer and the Potential Benefits of Metformin: An Extensive Review of the Literature

The objective of this review is to summarize the findings of published research that investigated the relationship between diabetes mellitus and gastric cancer (GCa) and the potential benefits of metformin on GCa. Related literature has been extensively reviewed, and findings from studies investigating the relationship between diabetes mellitus and GCa suggest that hyperglycemia, hyperinsulinemia and insulin resistance are closely related to the development of GCa. Although not supported by all, most observational studies suggest an increased risk of GCa in patients with type 2 diabetes mellitus, especially in women and in Asian populations. Incidence of second primary malignancy diagnosed after GCa is significantly higher in diabetes patients. Diabetes patients with GCa may have more complications after gastrectomy or chemotherapy and they may have a poorer prognosis than patients with GCa but without diabetes mellitus. However, glycemic control may improve in the diabetes patients with GCa after receiving gastrectomy, especially after procedures that bypass the duodenum and proximal jejunum, such as Roux-en-Y gastric bypass or Billroth II reconstruction. The potential links between diabetes mellitus and GCa may involve the interactions with shared risk factors (e.g., obesity, hyperglycemia, hyperinsulinemia, insulin resistance, high salt intake, smoking, etc.), Helicobacter pylori (HP) infection, medications (e.g., insulin, metformin, statins, aspirin, proton pump inhibitors, antibiotics, etc.) and comorbidities (e.g., hypertension, dyslipidemia, vascular complications, heart failure, renal failure, etc.). With regards to the potential benefits of metformin on GCa, results of most observational studies suggest a reduced risk of GCa associated with metformin use in patients with T2DM, which can be supported by evidence derived from many in vitro and animal studies. Metformin use may also reduce the risk of HP infection, an important risk factor of GCa. In patients with GCa, metformin users may have improved survival and reduced recurrence. More studies are required to clarify the pathological subtypes/anatomical sites of GCa associated with type 2 diabetes mellitus or prevented by metformin, to confirm whether GCa risk can also be increased in patients with type 1 diabetes mellitus and to explore the possible role of gastric microbiota in the development of GCa.

Impact of preoperative muscle quality on postoperative severe complications after radical gastrectomy for gastric cancer patients

BACKGROUND

Preoperative sarcopenia is an important risk factor for postoperative complications in patients with gastric cancer. However, the relationship between muscle quality and postoperative complications in patients with gastric cancer is inadequately studied. Therefore, we investigated the impact of preoperative muscle quality on severe postoperative complications after radical gastrectomy.

METHODS

A total of 840 patients who underwent radical gastrectomy for p-stages I-III primary gastric cancer between April 2008 and June 2018 with preoperative computed tomography (CT) scans and body composition analysis were included. We measured intramuscular adipose tissue content (IMAC) as an indicator of muscle quality. A higher IMAC signified a poorer quality. All statistical analyses were performed with EZR, and a P-value < 0.05 was considered statistically significant.

RESULTS

The low-IMAC and high-IMAC groups had 422 (50.2%) and 418 (49.8%) patients, respectively. The latter were older (P < 0.001), had higher body mass index (BMI) (P < 0.001), and higher rates of chronic kidney disease (CKD) (P = 0.002) and diabetes (P < 0.001). They had lower skeletal muscle indexes (SMI) (P = 0.011) and higher visceral fat areas (VFA) (P < 0.001). They also experienced more intraoperative blood loss (P < 0.001) and greater complications (P = 0.016). Multivariate analysis showed that high-IMAC was an independent risk factor for severe complications (odds ratio: 2.260, 95% confidence interval: 1.220-4.190, P = 0.010).

CONCLUSIONS

Poor preoperative muscle quality is an independent risk factor for severe postoperative complications after radical gastrectomy in patients with gastric cancer.

The effect of glucose control in liver surgery on glucose kinetics and insulin resistance

BACKGROUND & AIMS

Clinical outcome is negatively correlated to postoperative insulin resistance and hyperglycemia. The magnitude of insulin resistance can be modulated by glucose control, preoperative nutrition, adequate pain management and minimal invasive surgery. Effects of glucose control on perioperative glucose kinetics in liver surgery is less studied.

METHODS

18 patients scheduled for open hepatectomy were studied per protocol in this prospective, randomized study. In the treatment group (n = 9), insulin was administered intravenously to keep arterial blood glucose between 6 and 8 mmol/l during surgery. The control group (n = 9) received insulin if blood glucose >11.5 mmol/l. Insulin sensitivity was measured by an insulin clamp on the day before surgery and immediately postoperatively. Glucose kinetics were assessed during the clamp and surgery.

RESULTS

Mean intraoperative glucose was 7.0 mM (SD 0.7) vs 9.1 mM (SD 1.9) in the insulin and control group respectively (p < 0.001; ANOVA). Insulin sensitivity decreased in both groups but significantly (p = 0.03, ANOVA) more in the control group (M value: 4.6 (4.4-6.8) to 2.1 (1.2-2.6) and 4.6 (4.1-5.0) to 0.6 (0.1-1.8) mg/kg/min in the treatment and control group respectively). Endogenous glucose production (EGP) increased and glucose disposal (WGD) decreased significantly between the pre- and post-operative clamps in both groups, with no significant difference between the groups. Intraoperative kinetics demonstrated that glucose control decreased EGP (p = 0.02) while WGD remained unchanged (p = 0.67).

CONCLUSION

Glucose control reduces postoperative insulin resistance in liver surgery. EGP increases and WGD is diminished immediately postoperatively. Insulin seems to modulate both reactions, but mostly the WGD is affected. Intraoperative EGP decreased while WGD remained unaltered.

REGISTRATION NUMBER OF CLINICAL TRIAL

ANZCTR 12614000278639.

Prognostic impact of the preoperative hemoglobin A1c levels in patients with gastric cancer surgery depends on postoperative complications

Purpose

The long-term prognostic impact of the hemoglobin A1c levels has not yet been evaluated in patients with gastric cancer. The present study investigated the clinical significance of the hemoglobin A1c levels in patients with gastric cancer.

Methods

We enrolled 294 patients with stage II, III, or IV gastric cancer who underwent gastrectomy. The patients were divided into high preoperative hemoglobin A1c (> 6.0%) and low preoperative hemoglobin A1c (≤ 6.0%) groups.

Results

In patients with stage III gastric cancer with severe postoperative complications, the high preoperative hemoglobin A1c group had a significantly worse prognosis than the low preoperative hemoglobin A1c group (p = 0.0409). In patients without severe postoperative complications, the high preoperative hemoglobin A1c group had a significantly favorable prognosis compared with the low preoperative hemoglobin A1c group (p = 0.0348).

Conclusion

The prognosis of patients with stage III gastric cancer having high preoperative hemoglobin A1c levels greatly depended on the presence or absence of postoperative complications. To avoid postoperative complications, optimal perioperative management and personalized treatments are critical, particularly for these patients.

Use of a Low-carbohydrate Enteral Nutrition Formula with Effective Inhibition of Hypoglycemia and Post-infusion Hyperglycemia in Non-diabetic Patients Fed via a Jejunostomy Tube

Objective As direct jejunal feeding often causes great fluctuation in glucose levels, continuous or slow infusion is recommended for jejunal tube-fed patients. However, continuous feeding results in prolonged immobility and the loss of activities of daily living. We investigated whether or not intermittent feeding of a low-carbohydrate high-monounsaturated fatty acid (LC/HM) nutrient formula reduces glucose fluctuation in patients who have undergone jejunotomy. Methods Ten bed-ridden non-diabetic patients receiving enteral feeding via a jejunostomy tube were enrolled in this study. LC/HM formula and standard control formula were infused in cross-over order for each patient at a speed of 160 kcal/h. Blood glucose levels were monitored by a continuous glucose monitoring system during the investigation period. Results The mean and standard deviation of the glucose concentrations and mean amplitude of glucose excursion (MAGE) were markedly lower while receiving LC/HM formula than while receiving control standard formula (104 vs. 136 mg/dL, 18.1 vs. 58.1 mg/dL, 50.8 vs. 160 mg/dL, respectively). The post-infusion hyperglycemia [area under the curve (AUC) >140 mg/dL] and peak value of the glucose level were also significantly lower in patients fed LC/HM than the control (25.7 vs. 880 mg・h/dL and 153 vs. 272 mg/dL, respectively). Reactive hypoglycemia (AUC <70 mg/dL) was also significantly lower (0.63 vs. 16.7 mg・h/dL) and the minimum value of the glucose level higher (78.4 vs. 61.8 mg/dL) in patients fed LC/HM than the control. Conclusion The LC/HM formula is considered to markedly inhibit glycemic spikes and prevent rebound hypoglycemia in patients who receive enteral feeding after jejunostomy.

Influence of Hyperglycemia on Treatment Outcomes of Oral Cavity Squamous Cell Carcinoma

PURPOSE

The present study investigated the association between perioperative hyperglycemia and the treatment and survival outcomes of patients with oral cavity squamous cell carcinoma (OSCC).

PATIENTS AND METHODS

From 2004 to 2016, 385 patients with OSCC were enrolled and stratified into normoglycemic (<180 mg/dL) and hyperglycemic (≥180 mg/dL) groups. The clinicopathologic characteristics and treatment outcomes of OSCC were subsequently analyzed.

RESULTS

Of the 385 patients, 61 (15.8%) were in the hyperglycemic group. Hyperglycemia was significantly associated with pT stage, pN stage, overall pathologic stage, extranodal extension, albumin level, and tumor depth (P = .004, P = .042, P = .008, P = .001, P = .004, and P = .011, respectively). Patients with hyperglycemia also required a longer hospital stay (P = .003). The 5-year overall survival and disease-specific survival were poorer in the hyperglycemic group than in the normoglycemic group (P = .001 and P = .002, respectively). Multivariate analysis revealed that hyperglycemia is a significant adverse prognostic indicator for OSCC (hazard ratio, 1.709; 95% confidence interval, 1.003 to 2.912; P = .049).

CONCLUSIONS

Hyperglycemia is associated with more advanced disease and poorer survival rates in patients with OSCC. It correlates with adverse clinicopathologic characteristics and longer hospital stay. Screening for hyperglycemia and maintenance of normal glycemic status during the treatment course is imperative in the treatment of OSCC.

Hyperglycemia promotes Snail-induced epithelial-mesenchymal transition of gastric cancer via activating ENO1 expression

Background

Gastric cancer (GC) is one of the most common gastrointestinal malignancies worldwide. Emerging evidence indicates that hyperglycemia promotes tumor progression, especially the processes of migration, invasion and epithelial-mesenchymal transition (EMT). However, the underlying mechanisms of GC remain unclear.

Method

Data from the Gene Expression Omnibus (GEO) and The Cancer Genome Atlas (TCGA) databases were used to detect the expression of glycolysis-related enzymes and EMT-related transcription factors. Small interfering RNA (siRNA) transfection was performed to decrease ENO1 expression. Immunohistochemistry (IHC), Western blot and qRT-PCR analyses were used to measure gene expression at the protein or mRNA level. CCK-8, wound-healing and Transwell assays were used to assess cell proliferation, migration and invasion.

Results

Among the glycolysis-related genes, ENO1 was the most significantly upregulated in GC, and its overexpression was correlated with poor prognosis. Hyperglycemia enhanced GC cell proliferation, migration and invasion. ENO1 expression was also upregulated with increasing glucose concentrations. Moreover, decreased ENO1 expression partially reversed the effect of high glucose on the GC malignant phenotype. Snail-induced EMT was promoted by hyperglycemia, and suppressed by ENO1 silencing. Moreover, ENO1 knockdown inhibited the activation of transforming growth factor β (TGF-β) signaling pathway in GC.

Conclusions

Our results indicated that hyperglycemia induced ENO1 expression to trigger Snail-induced EMT via the TGF-β/Smad signaling pathway in GC.

Postoperative hyperglycemia affects survival after gastrectomy for cancer: A single-center analysis using propensity score matching

BACKGROUND

No data are present currently on the potential correlation between postoperative hyperglycemia and long-term outcomes after gastric surgery for cancer. The aim of this study was to investigate the effects of postoperative hyperglycemia on survival after curative gastrectomy for cancer.

METHODS

All patients who underwent gastric surgery for cancer with curative intent were reviewed retrospectively. Diabetic patients and patients who needed pancreatic resection were excluded. In all patients, a prepared intravenous infusion of NaCl and carbohydrates (Isolyte Baxter 2,000 mL/day; glucose 50.0 g/L;Ringers lactate 1,000 mL/day) was used, and the patients were kept nil by mouth until the fourth postoperative day. The glucose levels were monitored during the first 72 hours. The study population was divided into normoglycemic and hyperglycemic patients according to the blood glucose level (<140 mg/dL and ≥140 mg/dL, respectively). The 2 groups were matched for age, sex, type of operative procedure, TNM status, and lymph node status.

RESULTS

After matching, 104 patients were included for the analysis. Perioperative morbidity accounted for 18.3% with a greater rate for hyperglycemic patients (12% vs 31%; P = .018). When compared with normoglycemic patients, hyperglycemic patients had worse overall survival (45% vs 57%; P = .05) and worse disease-free survival (46% vs 68%; P = .02). On the multivariate analysis, hyperglycemia was an independent risk factor for a worse overall and disease-free survival.

CONCLUSION

Postoperative hyperglycemia owing to surgical stress conditions can affect postoperative outcomes. Additionally, hyperglycemia may be a factor that promotes gastric cancer progression.

Risk Factors for Doxorubicin-Induced Serious Hyperglycaemia-Related Adverse Drug Reactions

INTRODUCTION

Mortality rates from various cancer types are higher in patients with hyperglycaemia-associated pathologies. Among antineoplastics for treating pancreatic carcinoma, doxorubicin was found to be top of the list for inducing hyperglycaemia-related adverse drug reactions.

METHODS

Individual case safety reports of doxorubicin-induced hyperglycaemia-related adverse drug reactions (HG-ADRs) submitted during the period 2000-2017 were extracted from VigiBase^®. Factors influencing outcome seriousness in these cases were analyzed using bivariate correlation and logistical regression. Age was stratified into five groups.

RESULTS

Among the 558 cases with high blood glucose included in this study, with an average patient age of 55.9 ± 14.3 years, 71.1% had serious outcomes and 10.9% died. Three factors-died, age, and gender-were all found to be significantly correlated with outcome seriousness (P < 0.01), while five factors-year reported, ADR duration, latency, treatment duration, and dosage-showed no correlation with outcome seriousness (P > 0.05). Identical conclusions were reached upon analyzing only the cases that did not involve corticosteroid use.

CONCLUSION

Age and gender are risk factors for doxorubicin-induced serious HG-ADRs; males and older patients are more likely to suffer a serious outcome following such a reaction.

The risk trajectory between preoperative fasting glucose and common digestive tract cancer-specific mortality in the FIESTA cohort involving 6865 Chinese patients

Backgrounds: High blood glucose or hyperglycemia is an established risk factor for the development and progression of cancer at many sites, whereas data on the relevance between low blood glucose or hypoglycemia and cancer survival are lacking.

Aims: We aimed to assess the shape of risk trajectory between preoperative fasting glucose and postoperative digestive cancer-specific mortality in Chinese.

Methods: In total, 6865 patients who underwent radical surgery for esophageal cancer (n=2535), gastric cancer (n=3012) and colorectal cancer (n=1318) during 2000-2010 were followed up as of December 2015. All patients received neither chemotherapy nor radiotherapy before and after the surgery. Optimal cutoff points were determined using survival tree analysis.

Results: The median follow-up time was 44.9 months (range: 0.5-188.9 months), with 1065 deaths from esophageal cancer, 1331 from gastric cancer and 412 from colorectal cancer. Using fasting glucose (4.36, 6.09] mmol/L as the reference group, hazard ratios for fasting glucose ≤4.36, (6.09, 8.95], (8.95, 11.5] and >11.5 mmol/L were 1.35 (95% confidence interval: 1.19, 1.54), 2.82 (2.57, 3.11), 3.56 (3.10, 4.08) and 4.27 (3.67, 4.97), respectively (p<0.001).

Conclusions: Our findings indicate a U-shaped risk trajectory between preoperative fasting glucose and digestive tract cancer-specific mortality in Chinese. Further external validation is warranted.

Diabetes: Oral Health Related Quality of Life and Oral Alterations

Background and Objectives

About 5% of the world's population is affected by diabetes; these patients must be further treated during medical and surgical treatments. These patients, due to the glycemic conditions, realize during their life multiorgan changes, in different body districts. Moreover, this condition obliges them to undertake hypoglycemic therapies. Diabetes is a risk factor for many diseases, including those concerning the oral district with immunological implications.

Materials and Methods

A comprehensive review of the literature was conducted according to PRISMA guidelines accessing the NCBI PubMed database. Authors conducted the search of articles in English language. The results of the last 10 years have been considered, which present useful information regarding the oral conditions. A total of 17 relevant studies were included in the review. The study evaluated only papers with specific inclusion criteria regarding oral health. The works initially taken into consideration were 782; subsequently applying the inclusion and exclusion criteria, there were 42 works. After a careful analysis of the work obtained by two academics who have worked separately, there have been 17 studies. All data from the studies were compared and many of these confirmed alteration in the oral district.

Results

The studies taken into consideration evaluated different factors, such as OHRQoL, QoL, and oral alterations, involving soft tissue, dental structures, and postrehabilitative complications, as well as immunological alterations.

Conclusions

We can affirm, in conclusion, that this study has brought to light those that are complications due to diabetic pathology, from different points of view. The psychological and psychosocial alterations, certainly present in these patients, are probably due to local and systemic alterations; this is confirmed by the correlation between oral health and quality of life reported by the patients.

Outcomes associated with hyperglycemia after abdominal aortic aneurysm repair

OBJECTIVE

We evaluated the association between postoperative hyperglycemia and outcomes after abdominal aortic aneurysm (AAA) repair.

METHODS

We used diagnosis and procedure codes (International Classification of Diseases, Ninth Revision, Clinical Modification) to identify patients who underwent open or endovascular repair of a nonruptured AAA from September 2008 to March 2014 from the Cerner Health Facts database (Cerner Corporation, North Kansas City, Mo). We evaluated the association between postoperative hyperglycemia (glucose concentration >180 mg/dL) and infections, in-hospital mortality, readmission, patients' characteristics, length of hospital stay, and medications. Multivariable logistic models examined the association of postoperative hyperglycemia with in-hospital infection and mortality.

RESULTS

Of 2478 patients, 2071 (83.5%) had good postoperative glucose control (80-180 mg/dL), and 407 (16.5%) had suboptimal control (hyperglycemia). Patients who had postoperative hyperglycemia experienced longer hospital stays (9.5 vs 4.7 days; P < .0001), higher infection rates (18% vs 8%; P < .0001), higher in-hospital mortality (8.4 vs 1.2%; P <.0001), and more acute complications (ie, acute renal failure, fluid and electrolyte disorders, respiratory complications). After adjusting for patients' characteristics and medications, multivariable logistic regression models demonstrated that patients receiving postoperative insulin had nearly 1.6 times the odds of having an infectious complication (odds ratio [OR], 1.6; 95% confidence interval [CI], 1.12-2.2; P = .007) than those who did not. Hyperglycemic patients had 3.5 times the odds of in-hospital mortality (OR, 3.48; 95% CI, 1.78-6.80 [P = .0003]; 2.3% vs 1.2%; P < .001). When stratified by procedure type, patients with hyperglycemia who underwent endovascular repair had nearly 2 times the odds of an infectious complication (OR, 1.85; 95% CI, 0.98-3.51; P = .05) and 7.5 times the odds of in-hospital mortality (OR, 7.54; 95% CI, 1.95-29.1; P = .003). Patients who underwent an open AAA repair and who had hyperglycemia had three times the odds of dying in the hospital (OR, 3.05; 95% CI, 1.29-7.21; P = .01).

CONCLUSIONS

Among patients undergoing elective AAA repair, approximately one in six had postoperative hyperglycemia. After AAA repair in patients with and without diabetes, postoperative hyperglycemia was associated with adverse events, including in-hospital mortality and infections. Compared with those who had open surgery, patients undergoing endovascular repair who had postoperative hyperglycemia had greater risk of infection and death. After controlling for insulin administration and postoperative hyperglycemia, a diabetes diagnosis was associated with lower odds of both infection and in-hospital mortality. Our study suggests that hyperglycemia may be used as a clinical marker as it was found to be significantly associated with inferior outcomes after elective AAA repair. This retrospective study, however, cannot imply causation; further study using prospective methods is needed to elucidate the relationship between postoperative hyperglycemia and patient outcomes.

The association of postoperative glycemic control and lower extremity procedure outcomes

OBJECTIVE

The effect of postoperative hyperglycemia in patients undergoing open and endovascular procedures on the lower extremities has not been fully characterized with regard to associated admission diagnoses, hospital complications, mortality, and 30-day readmission. This study evaluated the relationship of postoperative hyperglycemia on outcomes after lower extremity vascular procedures for peripheral artery disease.

METHODS

Patients with peripheral artery disease admitted for elective lower extremity procedures between September 2008 and March 2014 were selected from the Cerner Health Facts (Cerner Corporation, Kansas City, Mo) database using International Classification of Diseases, Ninth Edition, Clinical Modification diagnosis and procedure codes. Using χ² analysis, we evaluated the relationship of postoperative hyperglycemia (>180 mg/dL) with sociodemographic characteristics, acute and chronic diagnoses, infections, hospital length of stay (LOS), and 30-day readmission. An adjusted multivariable logistic model was used to examine the association of postoperative hyperglycemia with infection and LOS.

RESULTS

Of 3586 patients in the study, 2812 (78%) had optimal postoperative glucose control, and 774 (22%) had suboptimal glucose control (hyperglycemia). On average, patients with postoperative hyperglycemia experienced longer hospital stays (6.9 vs 5.1 days; P < .0001), higher Charlson Comorbidity Index scores (3.4 vs 2.5, P < .0001), higher rates of infection (23% vs 14%, P < .0001), more acute complications (ie, fluid and electrolyte disorders, acute renal failure, postoperative respiratory complications), and chronic problems (ie, anemia, chronic heart disease, chronic kidney disease, and diabetes) than patients with optimal glucose control. Overall 30-day readmission was 10.9% and was similar between the groups (10.9% for both; P = .93). Major amputations did not differ between groups (P = .21). After adjusting for other risk factors using multivariable logistic regression, patients with hyperglycemia have 1.3-times the odds to have an infectious complication compared with those with optimal glucose control (odds ratio [OR], 1.34; 95% confidence interval [CI], 1.06-1.69) and 1.7-times the odds to have a hospital LOS >10 days (OR, 1.69; 95% CI, 1.32-2.15). As well, patients with postoperative hyperglycemia have 8.4-times the odds of dying in the hospital (OR, 8.40; 95% CI, 3.95-17.9).

CONCLUSIONS

One in five patients undergoing vascular procedures had postoperative hyperglycemia. Postoperative hyperglycemia was associated with adverse events after lower extremity vascular procedures in patients with and without diabetes, including infection, increased hospital utilization, and mortality. No difference was found with respect to hospital readmission. Postprocedure glucose management may represent an important quality marker for improving outcomes after lower extremity vascular procedures.