Surgical aspects of dm

SURGICAL ASPECTS
OF
DIABETES MELLITUS
Dr.Prashanth.S
Junior Resident
Dept. of General Surgery

• Perioperative management of diabetes
• Diabetic foot
• Surgical infections

• Between 2 - 2.5 per cent of the population are known to
be diabetic and there may be an equal number of
undiagnosed diabetic individuals.
• Diabetes affects about one in six patients over the age of
65 years, and one in four over the age of 85 years.
• The perioperative mortality of diabetic patients varies
between 4 -13%.
• Management of the diabetic patient does not only depend
on the careful assessment of the state of glycaemia, but
requires attention to the other sites of end-organ disease.

• Cardiovascular system:
• 1. Hypertension - seen in 30 and 60 per cent, and may
be part of the so-called syndrome X.
• Many of these hypertensive patients will have an
associated autonomic neuropathy; they are at increased
risk of gastroparesis and consequent aspiration, as well
as sudden cardiorespiratory arrest.
• During anaesthesia, the diabetic patient with hypertension
may be prone to hypotension, especially if the blood
pressure was poorly controlled before the operation.

• The combination of preoperative hypertension and
intraoperative hypotension is associated with an
increased incidence of postoperative renal and
cardiovascular complications.
• 2. Coronary arterial disease - most common cause of
death in elderly diabetic patients.
• Because of the functional denervation of the cardiac
sympathetic afferent fibres, many cases of infarction are
‘silent'.

• 3. Cardiorespiratory autonomic neuropathy - occurs in
over 50 per cent of patients.
• Apart from silent ischaemia, the neuropathy may lead to
orthostatic hypotension and cardiovascular instability
during anaesthesia.
• Deficiency of catecholamine release associated with the
induction of anaesthesia and during tracheal intubation;
this may result in significant hypotension and bradycardia,
especially in the presence of large doses of opioid drugs
such as fentanyl.

• Another aspect of the cardiac neuropathy is
prolongation of the QT interval, and
associated QT dispersion
has been suggested as a useful, non-invasive marker for
estimating the perioperative risk of cardiac arrhythmias and
sudden cardiac death.

• Respiratory system:
• Most diabetic patients will also have a mild pulmonary
restrictive defect due to reduced elastic recoil and a
reduced carbon monoxide pulmonary diffusing capacity.
• The residual effects of general anaesthesia combined
with the effects of major abdominal surgery can result in
major postoperative respiratory complications.

• Renal system:
• During anaesthesia, metabolic decompensation leads to
hyperglycaemia, an osmotic diuresis, and marked
reduction in the intravascular volume.
• As a result, renal perfusion falls and this may lead to
acute perioperative renal failure, especially if the
alternating combination of hypotension and hypertension
is present.
• Hypoproteinaemia (as a sequel to the microalbuminuria);
this will lead to increased free-drug concentrations (and
hence the propensity to adverse effects).

• Gastrointestinal system
• Delayed gastric emptying occurs in 20 to 30 per cent of all
diabetic patients,( autonomic neuropathy.)
• Prescription of metoclopramide preoperatively is
indicated.
• Stiff joint syndrome – 30%
• It arises from the glycosylation of tissue proteins
secondary to chronic hyperglycaemia and may affect
many joints of the body.(limited mobility of the
temperomandibular and atlanto-occipital joints.)

• Metabolic response to surgery
• Surgery produces a glycaemic stress response, the
magnitude of which is dependent on the site and duration
of surgery; the severity of the underlying pathology; and
the type of diabetes.
• The main catabolic effects - adrenaline (epinephrine),
noradrenaline (norepinephrine), glucagon, and cortisol.
• The diabetic patient is very unlikely to develop
intraoperative hypoglycaemia unless treated with large
doses of insulin.

• Acute hyperglycaemia during surgery may result in a
number of undesirable sequelae
(a) altered host defence mechanisms
(b) extracellular dehydration and electrolyte imbalance,
(c) intracellular dehydration and
(d) impaired wound healing.

• Elective surgery in the type-II diabetic patient
• The acceptable upper limit for the fasting blood glucose is
7.8 mmol/l.
• In all patients, the oral hypoglycaemic agents should be
discontinued on the morning of surgery and
recommenced whenever possible the next day.
• The exceptions are those patients receiving
chlorpropamide or metformin, where the longer half-lives
of the drugs make it sensible for them to be discontinued
on the day before surgery.

• Most type-II diabetics have sufficient endogenous insulin
secretion to carry them through minor surgery, so avoid
the need for transient insulin therapy.
• For major surgery, exogenous insulin will usually be
necessary to maintain glucose homeostasis.
• A threshold blood glucose of 11 mmol/l has been
proposed as a suitable trigger for insulin therapy.

• Elective surgery in the type-I diabetic patient
1. a ‘split-normal-dose' regimen where the patient
receives 1/4 to 1/2 the usual morning dose of insulin plus 5
per cent dextrose solution at a rate between 100 and 200
ml/h;
2. the intensive Glucose–Insulin–Potassium regimen as
described by Alberti and colleagues;

• 3. the regular intravenous administration of boluses of
insulin or an infusion of insulin with the simultaneous
infusion of 5 per cent dextrose (with constant infusion of
100 ml/h of 5 per cent glucose, and adjustment of the rate
of infusion of the insulin based on frequent blood glucose
estimations).
• With all these methods of diabetic control, frequent blood
glucose determinations are mandatory.

• Fluid replacement should be given as normal saline.
• A higher blood glucose (and therefore higher insulin
requirements) are found in patients receiving either 5 per
cent dextrose or Hartmann's solution (Ringer's lactate),
the latter being an important gluconeogenic precursor,
especially in the starved or catabolic patient.
• The same regimen should be used for postoperative
diabetic control.
• If a regimen of no insulin until the patient commences oral
feeding is adopted, there is a high risk of them developing
ketosis.

• For patients undergoing surgery whilst receiving local
anaesthesia alone (i.e., without sedation)
• For type I diabetes, most patients cope well if they receive
between 50 to 60 per cent of their normal intermediate or
long-acting insulin, if the blood glucose concentration
exceeds 300 mg/dl (16.7 mmol/l).
• For type II patients, the best policy is to omit their oral
medication before surgery, and then give it on return to
the ward before they receive their normal diet.

Diabetic foot
‘Diabetics should treat their Feet like they do their Face’

Introduction
• Foot infections - among the most frequent and serious
consequences of diabetes mellitus
• Responsible for more hospital days than any other
complication of diabetes
• Dealing with this problem will require
– Greater understanding of the pathophysiology of these infections
– Better systems for implementing proven effective measures
Lipsky BA, Berendt AR. Diabetes Metab Res Rev 2004; 20(Suppl 1): S56–S64.

Definition
International Consensus on Diagnosing and Treating the
Infected Diabetic Foot (2003)
Berendt T. Diabetic foot infection: what remains to be discovered?. FDA Anti-Infective Drugs Advisory Committee, October 2003.
http://www.fda.gov/OHRMS/DOCKETS/ac/03/slides/3997S1_01_Berendt.ppt. Accessed on 24-7-06.
Any infection involving the foot in a person with
diabetes originating in a chronic or acute injury to
the soft tissues of the foot, with evidence of pre-
existing neuropathy and/or ischemia

Typical Indian with diabetic foot
• First time presentation
– Male with an average age of 56 yrs
– Type 2 diabetes with average duration of 12 yrs
– Most have some degree of neuropathy and few have peripheral
Vascular Disease
– Common precipitating factors
 Lack of footwear
 Irregular foot care
 Burns
Morbach S, Viswanathan . Diabet Med. 2004 Jan;21(1):91-5.

Typical Indian with diabetic foot
• Patients requiring surgery
– Majority of the patients had grade II and III ulcers (50% and
26.5%, respectively)
– Grade IV was seen in another 21.9%
• After surgery
– The median healing time was 44 days
– Recurrence of infection occurred in 53%
 More common in patients with neuropathy and peripheral vascular
disease (PVD)
Vijay V, Narasimham DV. Diabet Med. 2000 Mar;17(3):215-8

Pathogenesis of Diabetic foot
• Multi-factorial, Complex and still poorly understood
– Neuropathy
– Vasculopathy
– Immune dysfunction
– Infection
• Prolonged Hyperglycemia contributes to all the above
factors through different mechanisms
Lipsky BA. Clin Infect Dis. 2004 Aug 1;39 Suppl 2:S104-14.

Motor
Neuropathy
Sensory
Neuropathy
Autonomic
Neuropathy
Vasculopathy
Immune
dysfunction
Complex interplay of factors
Ulbrecht JS, Cavanagh PR. Clin Infect Dis. 2004 Aug 1;39 Suppl 2:S73-82.

Neuropathy
• Sensory
– Loss of protective sensation
– Loss of position sense
• Motor
– Muscle weakness
– Foot deformity
• Autonomic
– Poor blood flow regulation
– Dry, stiff skin
Unaware of minor cuts/bruises
Poor weight
distribution
Cracked skin allows easy
entry of bacteria
Clawed toes
Prominent metatarsals

Forefoot ulcer due to Neuropathy
Inappropriately
high pressure
distribution

• Accelerated atherosclerosis
– Diabetes
– Hypertension
– Obesity
– Age
– Dyslipidemia
Decreased
local blood flow
Poor
wound
healing
Poor
antibiotic
penetration
Heel ulcer is typical of poor blood
circulation due to vasculopathy
Vasculopathy
Watkins PJ. BMJ. 2003 May 3;326(7396):977-9.

Immune dysfunction
• Impaired defenses against infection
1.  Polymorphonuclear leukocyte migration
2.  Phagocytosis
3.  Intracellular killing
4.  Chemotaxis
Geerlings SE, Hoepelman AI. FEMS Immunol Med Microbiol. 1999 Dec; 26(3-4):259-65
1
2
3
4

Infection
– Foot infections in diabetic patients usually begin in a skin ulceration
– Most infections remain superficial, but 25% will spread contiguously from
the skin to deeper subcutaneous tissues and/or bone.
– An infected foot ulcer precedes 60% of amputations, making infection
perhaps the most important proximate cause of this tragic outcome.
– Because all skin wounds contain microorganisms, infection must be
diagnosed clinically, that is, by the presence of systemic signs (e.g.,
fever, chills, and leukocytosis), purulent secretions (pus), or 2 local
classical signs or symptoms of inflammation (warmth, redness, pain or
tenderness, and induration).
– In chronic wounds, additional signs suggesting infection may include
delayed healing, abnormal coloration, friability, or foul odor.

• Infection profile (n=775)
– Polymicrobial
 Average of 3.07 organisms isolated per case
 71.09% aerobic
 28.91% anaerobic
– Related to severity of disease
 Staphylococcus and Streptococcus 50% in the first two Wagner
grades and were reduced to less than one-fourth of the total
organisms in the last two grades
 Significant increase in the Gram-negative organisms and anaerobes
in the last two grades
Pathare NA, Bal A. Indian J Pathol Microbiol. 1998 Oct;41(4):437-41.
Microbiology of Diabetic foot: India

Classification
• Wagner’s Classification of diabetic ulcer
• Grade 0 — No ulcer in a high risk foot.
• Grade 1 — Superficial ulcer involving the full skin thickness but not
underlying tissues
• Grade 2 — Deep ulcer, penetrating down to ligaments and muscle,
but no bone involvement or abscess formation
• Grade 3 — Deep ulcer with cellulitis or abscess formation, often with
osteomyelitis
• Grade 4 — Localized gangrene.
• Grade 5 — Extensive gangrene involving the whole foot.
Calhoun JH, Cantrell J. Foot Ankle. 1988 Dec;9(3):101-6.

Examples of different grades
Hall J, Preventive foot care for diabetes patients in primary care. Pfizer. Data on file.

Differentiation of Ischaemic and
Neuropathic Ulcer
Ischaemic ulcer Neuropathic ulcer
Symptoms Claudication
Rest pain
Usually painless
Or painful neuropathy
Inspection Dependent rubor
Trophic changes
Gangrenous digits
High arch + clawing of
toes
No trophic changes
Surrounded by callus
Palpation Cold
Pulseless
Warm
palpable pulses
Ulceration Painful
At the distal and over
bony prominences
Painless
Sites of pressures
(metatarsal heads,
heels)

Ischaemic ulcer Neuropathic ulcer

Principles of Management
• Multidisciplinary approach
– Medical
– Surgical
– Orthopedics
• Evaluation of the patient
– Look for danger signs needing urgent intervention
• Good Blood glucose control
• Long term care after wound healing is complete
– Education and preventive foot care

Evaluation of the patient
Check
posterior tibial pulse
Check
Dorsalis pedis pulse Sensory
examination
X-ray of
the foot
Select patients
•Doppler study
•Angiography

Danger signs for urgent action
• Redness and swelling of a foot that even when
neuropathic causes some discomfort and pain; this often
indicates a developing abscess, and urgent surgery may
be needed to save the leg
• Cellulitis, discoloration, and crepitus (gas in soft tissues)
• Pink, painful, pulseless foot even without gangrene
indicates critical ischaemia that needs urgent arterial
investigation followed by surgical intervention whenever
possible

Cornerstones of treatment
• Surgical debridement
– Drain pus and abscess cavities and to remove all necrotic and infected tissue
including devitalised and infected bone resulting from osteomyelitis
• Eradication of infection
– Antibiotic choices should optimally be based on results of culture
 If empirical therapy is necessary, it should cover S. aureus and anaerobes
 Broader coverage should be considered based on the history & clinical judgment
• Adjuvant therapies
– Utility remains controversial
• Reduction of weight bearing forces
– Bed rest with foot raised
Lipsky BA, Berendt AR. Diab Metabol Res Rev 2004; 20: S56-S64. Ulbrecht JS, Cavanagh PR. Clin Infect Dis. 2004 Aug 1;39 Suppl 2:S73-82.

Osteomyelitis in
diabetic foot infections
• Dealing with osteomyelitis is perhaps the most difficult aspect in the
management of diabetic foot infections
• Presence of osteomyelitis
– Increases the likelihood of surgical intervention, including amputation
– Impairs healing of the overlying wound
– Acts as a focus for recurrent infection
– Increases the required duration of antibiotic therapy
• ESR of >40 mm/h was associated with almost a 12-fold increased
likelihood of osteomyelitis
• Larger ( ulcer area > 2 cm) and deeper (depth > 3 mm) increases the
likelihood of osteomyelitis
Lipsky BA, Berendt AB. Clinical Infectious Diseases 2004; 39:885–910 Lipsky BA. Clinical Infectious Diseases 1997;25:1318–

Duration of antibiotic therapy
• The optimal duration of antibiotic therapy for diabetic foot infections is
unknown.
• On the basis of available studies,
– Mild to moderate infections, 1 to 2 weeks is usually effective
– Serious infections, 2 to 4 weeks is usually sufficient
• Longer duration may be needed for
– Immunocompromised patients, poorly perfused, deep, large or necrotic wounds,
osteomyelitis, patients who cannot (or will not) undergo surgical resection, or who
have an implanted foreign body at the infection site
• Adequate debridement, resection, or amputation of infected tissue can
shorten the necessary duration of therapy.
• Antibiotic therapy can generally be discontinued when signs and symptoms of
infection have resolved, even if the wound has not completely healed.
Lipsky BA, Berendt AR. Diabetes Metab Res Rev 2004; 20(Suppl 1): S56–S64.

Adjuvant therapies are
not universally accepted
• Several additional measures have been used to improve infection resolution,
wound healing, and host response.
• Recombinant granulocyte-colony stimulating factor
– Larger trials are needed to define whether, and for whom, these compounds can
be recommended.
• Hyperbaric oxygen
– Expensive and limited resource that should remain reserved for severe cases
• Revascularization
– An aggressive approach to revascularization in an ischemic infected foot can
result in 3-year limb-salvage rates of up to 98%
• Edema control
– Simple interventions, such as leg elevation and compression stockings, are likely
to be beneficial l

Suggested antibiotic regimens for
treatment of diabetic foot infections*
• Mild/moderate (oral for entire course)
– Clindamycin (300 mg t.i.d.) or Cephalexin (500 mg. q.i.d.) or Levofloxacin
(750 mg q.d.)
• Moderate/severe (iv until stable, then switch to oral equivalent)
– Clindamycin (450 mg q.i.d.) + ciprofloxacin (750 mg b.i.d.)
– Clindamycin (600 t.i.d.) + ceftazidime (2 g t.i.d.)
– Ampicillin/sulbactam (3.0 g q.i.d.)
• Life-threatening (prolonged iv)
– Clindamycin (900 mg t.i.d.) + tobramycin (5.1 mg/kg./d) + ampicillin (50
mg/kg. q.i.d.)
– Imipenem/cilastin (500 mg q.i.d.)
– Vancomycin (15 mg/kg b.i.d.) + aztreonam (2.0 g t.i.d.) + metronidazole (7.5
mg/kg q.i.d.)
*Based on theoretical considerations and available clinical trials.
A similar agent of the same class or generation may be substituted.

Prevention
• Regular foot exams and patient education can prevent
85% of amputations
• Four basic steps for preventive foot care
– Early identification of the high risk diabetic foot
– Early diagnosis of foot problems
– Early intervention to prevent further deterioration that may lead to
amputation
– Patient education for proper care of the the feet and footwear

• Offloading is a precaution in wound care that required
you to keep all weight off of the extremity that has the
ulcer.
most effective is contact casting.
specialized offloading shoe (not designed for walking.)
• prescribe you a walker, crutches or a wheelchair if patient
must be mobile.

Educate Patients on Proper Foot Care – The “DO’s”

Educate Patients on Proper Foot Care – The “DON’Ts”
DO NOT …
Cut your own corns or callouses
Treat your own in-growing toenails or slivers with a razor or scissors. See your
doctor or foot care specialist
Use over-the-counter medications to treat corns and warts
Apply heat with a hot water bottle or electric blanket – may cause burns unknowingly
Soak your feet
Take very hot baths
Use lotion between your toes
Walk barefoot inside or outside
Wear tight socks, garter or elastics or knee highs
Wear over-the-counter insoles – may cause blisters if not right for your feet
Sit for long periods of time
Smoke

Summary
• Foot ulceration, sepsis, and amputation are known and
feared by almost every person who has diabetes
• Potentially, they are the most preventable of all diabetic
complications by the simplest techniques of education
and care
• The majority can also be cured by immediate and
energetic treatment which includes appropriate antibiotic
selection
– Clindamycin (Dalacin C) is safe and effective as monotherapy or
in a combination regime and offers many advantages over
alternative agents e.g., in patients with osteomyelitis
Watkins PJ, BMJ. 2003 May 3;326(7396):977-9. Klainer AS. Clindamycin in the treatment of diabetic foot infections. In: Zambrano D ed. Clindamycin in the
treatment of human infections. Ch 11. Sec.11.1- 11.16.Diamantopoulos EJ ; Haritos D. Exp Clin Endocrinol Diabetes. 1998; 106(4):346-52

• Suboptimal response to infection in a person with
diabetes is caused by the presence of chronic
complications, such as vascular disease and
neuropathies, and by the presence of hyperglycemia and
altered neutrophil function.
• Hyperglycemia and glycosuria may influence the growth
of microorganisms and increase the severity of the
infection.

• Certain types of infections occur with increased frequency in people
with diabetes:
• Respiratory s.pneumoniae
influenza
H1N1
tuberculosis
• Urinary tract asympomatic bactiruria
fungal cystitis
emphysematous cystitis
bacterial pyelonephritis and perinephric abscess

• GIT H.pylori infection
oral and oesophageal candiasis
emphysematous cholecystitis
hepatitis C and B
enteroviruses
• Skin and soft tissue infections
carbuncle
necrotising fascitis and fournier’s gangrene

• Head and neck
invasive otitis externa
rhinocerebral mucormycosis

Surgical aspects of dm

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