Postoperative Hypoglycemia Research Articles

The frequency of postoperative hypoglycemia after pheochromocytoma surgery is decreasing.

Hypoglycemia after pheochromocytoma resection is one of the most common postoperative complications, with a reported incidence of 12%-43%. In recent years, we have rarely experienced postoperative hypoglycemia after pheochromocytoma surgery at our institution. We reviewed our own experience and examined factors associated with postoperative hypoglycemia in pheochromocytoma patients. We collected and retrospectively reviewed medical information from 53 patients with pheochromocytoma who underwent initial surgery in our department between 1996 and 2022, who did not receive steroids in the perioperative period and received the same alpha-blocker preoperatively. Subjects were divided into two groups by the midpoint of the study period: Group 1 (G1), 1996-2009; and Group 2 (G2), 2010-2022. The two groups were compared. Hypoglycemia occurred significantly less often in G2 (0 patients, 0%) than in G1 (7 patients, 28%; p=0.003). Preoperative diabetes was significantly less frequent in G2 (2 patient, 7.1%) than in G1 (8 patients, 32%; p=0.03). Preoperative alpha-blocker dosage was significantly higher in G2 than in G1 (p=0.04). Multivariate logistic regression analysis showed that only alpha-blockers dosage was significantly associated with the occurrence of postoperative hypoglycemia (p=0.004). The current study suggest that the alpha-blocker dosage might be related to the lower incidence of postoperative hypoglycemia in Pheochromocytoma patients.

12394 "Sugar And Tumors: A Case Report On New-onset Diabetes In Metastatic Pheochromocytoma With Elevated Dopamine Levels"

Abstract Disclosure: B. Agrawal: None. V. mehta: None. R. naseem: None. M. Renzu: None. R. rashid: None. Introduction: Metastatic pheochromocytoma is a rare neuroendocrine tumor with potential complication of new-onset diabetes mellitus (DM). We present a case highlighting the challenges in managing a patient with metastatic pheochromocytoma and concurrent DM. Case presentation: A 66-year-old male with a history of hypertension and gout initially presented in 2010 with an adrenal mass, later identified as pheochromocytoma and resected. In 2018, he presented with bilateral leg pain, revealing metastatic disease-causing spinal cord compression along with metastatic lung nodules and metastasis in adrenalectomy bed. Despite interventions including T6,7,8 laminectomy in 2020 and radiation therapy, metastases persisted. In 2024, he presented with polyuria, polydipsia, and hyperglycemia (blood glucose >500 mg/dL). Laboratory findings showed elevated a1c of 15 in addition to elevated normetanephrines, metanephrines, and dopamine with levels of 3880, 48 and 488 respectively. He was diagnosed with new-onset DM and started on insulin therapy in addition to metformin and jardiance. Discussion: Secondary diabetes mellitus (DM) in secretory pheochromocytoma occurs in approximately 50% of cases, manifesting from mild insulin resistance to severe presentation like DKA. Epinephrine-secreting tumors contribute to glucose intolerance by activating beta receptors, thereby stimulating gluconeogenesis. Patients with higher levels of epinephrine and preoperative glucose intolerance were more prone to developing postoperative hypoglycemia, requiring close monitoring during the postoperative period. Additionally, research by DiSalvo et al. Epinephrine-secreting tumors have a more significant impact on hyperglycemia by impairing insulin secretion and stimulation GLP-1. Tumor resection has been found to be more effective effective in restoring normal glucose homeostasis in these patients. Dopamine-secreting pheochromocytomas are rare neoplasms characterized by the presence of immature catecholamine vesicles that inhibit dopamine conversio owing to localized dopamine beta hydroxylase. Typically presenting around the age of 48, these tumors often lack excess catecholamines, leading to atypical symptoms such as local discomfort or pain from tumor compression. These neoplasms are less detectable on metaiodobenzylguanidine (MIBG) scans, necessitating positron emission tomography (PET) for accurate diagnosis. Surgical resection is the treatment, with preoperative management involving metyrosine instead of alpha blockers. These tumors are frequently diagnosed late, often in a malignant stage, contributing to poor prognosis Conclusion: Overall, understanding the complex interplay between catecholamines and glucose metabolism is crucial for the comprehensive management of patients with pheochromocytoma and secondary DM. Presentation: 6/1/2024

ThP5.4 - Which Resection for Distal Cholangiocarcinoma?: Retrospective Study

Abstract Introduction The treatment of distal cholangiocarcinoma (DCC) is contingent upon the patient's condition and the local and lymphatic extent of the disease. Surgery remains the sole radical treatment, albeit infrequently feasible and often followed by biliary drainage. The surgical procedure involves resecting the bile duct with healthy distal and proximal margins, accompanied by lymphadenectomy. Cephalic pancreatectomy (DPC) is deemed the optimal oncological treatment for DCC. Method This retrospective study encompasses cancers of the main bile duct. Various factors influencing treatment were analyzed, focusing on the type of resection (biliary and pancreatic). Results From January 2014 to December 2021, 119 patients were treated for distal cholangiocarcinoma (88 men, 31 women, average age: 61 years). Twenty-one patients underwent endoscopic drainage, 17 transhepatic drainage, and 55 surgical interventions. Among them, 9 underwent preoperative drainage, 28 radical resection, 10 DPC, 18 biliary resections, and one total pancreatectomy. In 27 patients, radical surgery was impossible; 20 underwent drainage, and 7 did not. Three early surgical revisions in the biliary resection group, with incidents of digestive hemorrhage and hemoperitoneum. Two moderate pancreatic fistulas and immediate postoperative hypoglycemia were recorded. Two deaths in the biliary resection group and 7 in-hospital deaths in the biliary drainage group. All patients with external drainage died before 12 months, while 8 patients from the endoscopic drainage group survived after 12 months. Patients with radical surgery and adjuvant treatment exhibited longer survivals (36 months vs. 45 months). Conclusion Improving the prognosis of DCC requires early diagnosis and radical surgery combined with adjuvant treatment.

Association of Postoperative Hypoglycemia With Mortality After Elective Craniotomy.

Hypoglycemia is a known risk of intensive postoperative glucose control in neurosurgical patients. However, the impact of postoperative hypoglycemia after craniotomy remains unexplored. This study aimed to determine the association between postoperative hypoglycemia and mortality in patients undergoing elective craniotomy. This study involved adult patients who underwent elective craniotomy at the West China Hospital, Sichuan University, between January 2011 and March 2021. We defined moderate hypoglycemia as blood glucose levels below 3.9 mmol/L (70 mg/dL) and severe hypoglycemia as blood glucose levels below 2.2 mmol/L (40 mg/dL). The primary outcome was postoperative 90-day mortality. This study involved 15 040 patients undergoing an elective craniotomy. Overall, 504 (3.4%) patients experienced moderate hypoglycemia, whereas 125 (0.8%) patients experienced severe hypoglycemia. Multivariable analysis revealed that both moderate hypoglycemia (adjusted odds ratio [aOR] 1.86, 95% CI 1.24-2.78) and severe (aOR 2.94, 95% CI 1.46-5.92) hypoglycemia were associated with increased 90-day mortality compared with patients without hypoglycemia. Moreover, patients with moderate (aOR 2.78, 95% CI 2.28-3.39) or severe (aOR 16.70, 95% CI 10.63-26.23) hypoglycemia demonstrated a significantly higher OR for major morbidity after adjustment, compared with those without hypoglycemia. Patients experiencing moderate (aOR 3.20, 95% CI 2.65-3.88) or severe (aOR 14.03, 95% CI 8.78-22.43) hypoglycemia had significantly longer hospital stays than those without hypoglycemia. The risk of mortality and morbidity showed a tendency to increase with the number of hypoglycemia episodes in patients undergoing elective craniotomy (P for trend = .01, <.001). Among patients undergoing an elective craniotomy, moderate hypoglycemia and severe hypoglycemia are associated with increased mortality, major morbidity, and prolonged hospital stays. In addition, the risk of mortality and major morbidity increases with the number of hypoglycemia episodes.

Prolonged hypoglycemia after the resection of pheochromocytoma in a hemodialysis patient.

Hypoglycemia occasionally develops after the resection of pheochromocytoma due to decreased catecholamine secretion. The unique glucose metabolism in dialysis patients may potentially affect postoperative hypoglycemia, although few reports have focused on this issue. A 47-year-old woman who had chronic renal failure under hemodialysis was diagnosed with right pheochromocytoma and underwent an adrenalectomy. Three hours after surgery, she experienced symptomatic hypoglycemia, which was repeated until postoperative day 3. Continuous glucose infusion was required until postoperative day 8 and asymptomatic hypoglycemia was repeated until postoperative day 11. In hemodialysis patients, more careful management of hypoglycemia may be required after the resection of pheochromocytoma compared with non-hemodialysis patients.

Association Between the Blood Glucose Value at PACU Discharge and Postoperative Hypoglycemia in Nondiabetic Patients With Hyperglycemia After Hysteroscopic Surgery: A Retrospective Cohort Study

PurposeThe target glycemic control for nondiabetic patients in the postanesthesia care unit (PACU) after hysteroscopic surgery remains unclear. Our goal is to determine the optimal level of glycemic control by finding the relationship between blood glucose level (BGL) leaving the PACU and postoperative hypoglycemia in nondiabetic patients. DesignThis retrospective cohort study was conducted at a comprehensive tertiary hospital in Chongqing, China between June 2018 and December 2020. MethodsThe target independent and dependent variables were BGL leaving the PACU and postoperative hypoglycemia, respectively. The primary outcome was the incidence of hypoglycemia. Logistic regression was used to explore the association between discharge BGL and hypoglycemia. The optimal glycemic control range was determined by using the receiver operating characteristic (ROC) curve. FindingsPrior to insulin use, BGL in the insulin-using subgroup might be as high as 20 mmol/L. Hypoglycemia was related to the BGL while leaving the PACU (odds ratio (OR) 0.37 [95% confidence interval (CI) 0.22 to 0.65]). The best cut-off value (12.95 mmol/L) was determined by fitting the ROC curve. ConclusionsIf severe hyperglycemia develops during hysteroscopic surgery in individuals with 5% glucose as the mediator of uterine distention, the recommendation is to maintain blood glucose above 12.95 mmol/L when treated with insulin.

Risks of peri- and postoperative complications with glucagon-like peptide-1 receptor agonists.

To assess whether adults with diabetes on oral hypoglycaemic agents undergoing general endotracheal anaesthesia during nine common surgical procedures who are glucagon-like peptide-1 receptor agonist (GLP1-RA) users, compared with non-users, are at increased risk of six peri- and post-procedure complications. A retrospective observational cohort analysis of over 130 million deidentified US adults with diabetes (defined as being on oral hypoglycaemic agents) from a nationally representative electronic health dataset between 1 January 2015 and 1 April 2023 was analysed. Cohorts were matched by high-dimensionality propensity scoring. We compared the odds of six peri- and postoperative complications in GLP1-RA users and non-users. A sensitivity analysis compared these odds in GLP1-RA users to non-users with diabetes and obesity. We measured the odds of (a) a composite outcome of postoperative decelerated gastric emptying, including antiemetic use, ileus within 7 days post-procedure, gastroparesis diagnosis, gastric emptying study; (b) postoperative aspiration or pneumonitis; (c) severe respiratory failure; (d) postoperative hypoglycaemia; (e) inpatient mortality; and (f) 30-day mortality. Among 13 361 adults with diabetes, 16.5% were treated with a GLP1-RA. In the high-dimensionality propensity score-matched cohort, GLP1-RA users had a lower risk of peri- and postoperative complications for decelerated gastric emptying and antiemetic use compared with non-users. The risk of ileus within 7 days, aspiration/pneumonitis, hypoglycaemia and 30-day mortality were not different. A sensitivity analysis showed similar findings in patients with diabetes and obesity. No increased risk of peri- and postoperative complications in GLP1-RA users undergoing surgery with general endotracheal anaesthesia was identified.

Noniatrogenic hypoglycemia: A universal marker for poor outcomes

ObjectivePrevious retrospective studies have established a relationship between postoperative hypoglycemia and adverse outcomes after cardiac surgery, but none have accounted for the cause of hypoglycemia. MethodsA retrospective review was performed of patients who underwent cardiac surgery at a single institution between 2016 and 2021. Patients were categorized as hypoglycemic if they had 1 or more postoperative blood glucose measurement less than 70 mg/dL and normoglycemic otherwise. Hypoglycemia was subcategorized as noniatrogenic (underlying liver failure, adrenal insufficiency, sepsis, or shock) or iatrogenic (insulin infusion continued while nil per os or infusion protocol violated) via manual chart review. Baseline characteristics were compared between groups using Pearson χ2, analysis of variance, and Kruskal-Wallis testing, and outcomes were compared using multivariable logistic regression. ResultsIn total, 5373 patients and 183,346 glucose measurements were included. Hypoglycemia occurred in 5% (267) of patients, of whom 63% (169) were iatrogenic and 37% (98) were noniatrogenic. In a multivariate analysis adjusting for age, sex, case urgency, pre-existing diabetes, and bypass time, both iatrogenic and noniatrogenic hypoglycemia were associated with greater odds of renal failure, prolonged ventilation, and prolonged intensive care unit length of stay relative to normoglycemia, but the magnitude was substantially lower in iatrogenic hypoglycemia. Patients with noniatrogenic hypoglycemia had 68.6 times greater odds of mortality relative to patients who were normoglycemic (odds ratio, 68.6; confidence interval, 39.5-119), but patients with iatrogenic hypoglycemia had no increased odds of mortality (odds ratio, 1.45; confidence interval, 0.77-2.73). ConclusionsWhen excluding patients with conditions known to cause hypoglycemia from the analysis, the morbidity and mortality of iatrogenic hypoglycemia from tight postoperative glycemic control is dramatically attenuated.

Differences in glycemic trends due to reconstruction methods after proximal gastrectomy from the perspective of continuous glucose-monitoring.

In recent years, clinicians have focused on the importance of preventing hypoglycemia. We evaluated the impact of different reconstruction procedures after proximal gastrectomy on glycemic variability in non-diabetic patients with gastric cancer. This prospective observational study was conducted between April 2020 and March 2023. Flash continuous glucose-monitoring, a novel method for assessing glycemic control, was used to evaluate the glycemic profiles after gastrectomy. A flash continuous glucose-monitoring sensor was placed subcutaneously at the time of discharge, and glucose trends were evaluated for 2weeks. The anastomotic methods for proximal gastrectomy were esophagogastrostomy in 10 patients and double-tract reconstruction in 10 patients. The time below this range (glucose levels < 70mg/dL) was significantly higher in the double-tract reconstruction group than in the esophagogastrostomy group (p = 0.049). A higher nocturnal time below this range was significantly correlated with an older age and double-tract reconstruction (p = 0.025 and p = 0.025, respectively). These findings provide new insights into reconstruction methods after proximal gastrectomy by assessing postoperative hypoglycemia in non-diabetic patients with gastric cancer.

Hypoglycemia after Mitral Valve Repair in Dogs.

Hypoglycemia has not been previously reported as a postoperative complication of mitral valve repair (MVR) in dogs; however, the authors have encountered cases of hypoglycemia after MVR. This study aimed to determine the incidence of hypoglycemia in dogs after MVR and investigate its causes. Blood glucose levels were measured at multiple timepoints in dogs undergoing MVR. Simultaneously, insulin and glucagon blood concentrations in dogs with hypoglycemia preoperatively and postoperatively were compared to verify the physiological responses to hypoglycemia. Furthermore, risk factors for hypoglycemia, using variables selected based on the characteristics of MVR and dogs undergoing MVR, were examined prospectively. The incidence of hypoglycemia after MVR was 14.2%, and plasma glucagon concentrations increased in these dogs (mean: 260 pg/mL and 644 pg/mL pre- and postoperatively, p < 0.001), whereas serum insulin concentrations decreased (median: 0.50 ng/mL and 0.29 ng/mL pre- and postoperatively, p = 0.002). Therefore, hyperinsulinemia or hypoglucagonemia is unlikely to be the cause of postoperative hypoglycemia. The identified risk factors for hypoglycemia included low body weight and asymptomatic myxomatous mitral valve disease. Monitoring blood glucose levels after MVR should be included in the standard hospitalization plan to prevent hypoglycemic emergencies in dogs.

Closed-Loop Insulin Delivery May Help Prevent Metabolic Complications During Bariatric Surgery in Patients with Type 1 Diabetes: A Case Report.

Introduction: Obesity in patients with type 1 diabetes (T1D) may worsen their prognosis. Bariatric surgery in these patients can be associated with complications such as diabetic ketoacidosis and severe hypoglycemic episodes. Closed-loop insulin delivery could be a solution to avoid them. Case Report: A 45-year-old woman with T1D and obesity (body mass index of 38.4 kg/m2) was included in our preoperative course of bariatric surgery. Three months before surgery, a closed-loop insulin delivery was instituted due to one prior severe hypoglycemia. Patient did not have immediate or late postoperative hypoglycemia despite consuming a weak amount of carbohydrate. Three months after surgery glycemic control was on target with 86% of time in range 70-180 mg/dL and no time below 70 mg/dL. Conclusion: This case report shows that the use of a closed-loop insulin delivery made it possible to perform bariatric surgery in complete safety for our patient.

Identification of Risk Factors and Development of a Predictive Model for Postoperative Hypoglycemia among Diabetic Patients during the Perioperative Period.

To explore the incidence and influencing factors of postoperative hypoglycemia in diabetic patients during the perioperative period and to construct a risk prediction model for postoperative hypoglycemia. Patients with T2DM admitted to the nonendocrinology department of Nanjing Drum Tower Hospital from December 2019 to January 2022 were included as research subjects. Basic information, hospital blood glucose management methods, laboratory indicators, and surgery-related indicators were collected. A risk prediction model and scoring table for postoperative hypoglycemia in patients with perioperative diabetes mellitus were established. A total of 440 patients were included, of which 109 had hypoglycemia, resulting in an incidence of postoperative hypoglycemia of 24.78%. The results show that preoperative C-peptide and operation duration were risk factors for postoperative hypoglycemia, while BMI and preoperative fasting blood glucose were protective factors. The model constructed in this study is a good method for evaluating the risk of postoperative hypoglycemia. The scoring table intuitively quantifies the risk of risk factors for outcome variables and has strong clinical practicability.

Attenuation of right gastrocaval extrahepatic shunt with cellophane band in a dog: Case report

Congenital extrahepatic portosystemic shunt is a vascular anomaly that consists in the communication between the portal and systemic circulation, causing substances normally metabolized and excreted by the liver to be diverted directly to the systemic circulation and triggering changes in neurological, gastrointestinal and urinary systems. Diagnosis is through imaging tests, such as ultrasound and computed tomography. For patient stabilization, initial clinical treatment is highly indicated, especially for those who manifest signs of hepatic encephalopathy, and the definitive treatment is gradual surgical attenuation. Currently, the most indicated techniques for shunt occlusion are the ameroid constrictor ring and the cellophane band, which have good long-term results. The prognosis of patients undergoing the surgical procedure varies according to the general condition of the patient at the time of diagnosis and the complications that may occur in the trans and postoperative periods, such as portal hypertension, seizures, hypoglycemia and failure to close the shunt. This report aims to describe a case of surgical attenuation of a right extrahepatic gastrocaval shunt using the cellophane band technique. The canine patient, pug, aged eight months, was treated at the Veterinary Hospital of the Federal University of Paraná, presenting neurological clinical signs and a previous diagnosis of portosystemic shunt. To determine the origin of the anomalous vessel and optimize surgical planning, computed angiotomography was indicated. Clinical treatment was instituted and, after 15 days, surgical attenuation of the shunt was performed using the cellophane band fixed with titanium clips. The patient showed signs of portal hypertension, ascites and postoperative hypoglycemia, which were treated during hospitalization. After 15 days of hospital discharge, the patient returned to the Veterinary Hospital with good general condition, absence of ascites and neurological signs and no significant changes were observed in laboratory tests, demonstrating the effectiveness of the chosen surgical technique.

Effect of early hypoglycaemia on hospitalization outcomes in patients undergoing coronary artery bypass grafting

ObjectiveTo investigate the effect of early postoperative hypoglycaemia on hospitalization outcomes including major cardiovascular complications and in-hospital mortality among patients undergoing coronary artery bypass grafting (CABG). MethodsData from an observational study of 9583 patients in the intensive care unit (ICU) who underwent CABG were analyzed. Hypoglycaemia was defined as a nadir blood glucose level <70 mg/dL (3.9 mmol/L). One-to-one propensity score matching (PSM) was used to identify 251-balanced pairs of patients to compare outcomes. ResultsA total of 306 (3.2%) patients experienced hypoglycaemia, of whom, 133 had diabetes, 173 hadn’t diabetes. Patients who were hypoglycaemia had higher incidences of compositeoutcomes than those without hypoglycaemia (12.1% versus 6.0%, P < 0.0001). Postoperative length of ICU stay was longer in patients with hypoglycaemia [2.8 (0.8–21.0) versus 2.0 (0.25–36.0) days, P < 0.0001]. After PSM, the compositeoutcomes and length of ICU stay remained significantly increased for the patients with hypoglycaemia [compositeoutcomes: odd ratio (OR) 2.78, 95% CI, 1.30–5.88, P = 0.01; length of ICU stay: OR 1.60, 95% CI, 1.14–2.26, P = 0.007]. ConclusionPostoperative hypoglycaemia was an independent associated factor of adverse composite outcomes and a lengthened ICU stay after CABG. Hypoglycaemia should be avoided for both postoperative patients with and without diabetes.

Comparison of preoperative to postoperative blood glucose in puppies undergoing elective surgical neutering

The objective of this study was to determine if overnight fasting is associated with hypoglycemia in puppies undergoing elective surgical neutering. One hundred seventy-one apparently healthy puppies between the age of 2 and 6 months presented for elective surgical neutering. Owners were instructed to withhold food from puppies after midnight the night before surgery; water was to be freely available. Blood samples were collected pre- and postoperatively to determine blood glucose, packed cell volume (PCV), and serum total protein (TP). Pre- and postoperative data were compared with a paired Wilcoxon test (paired samples). Hypoglycemia was defined as glucose < 4.2 mmol/L (76 mg/dL) for pediatric puppies ≤ 16 weeks of age (n = 116), and < 3.6 mmol/L (65 mg/dL) for juvenile puppies > 16 weeks of age (n = 55).Blood glucose significantly increased after surgery from median 8.8 mmol/L (interquartile range [IQR], 1.7 mmol/L; range, 4.9–12.3 mmol/L) to a median 9.7 mmol/L (IQR, 1.8 mmol/L; range, 5.4–14.7 mmol/L; P < 0.0001). Preoperative median PCV was 35% (IQR, 6.5%; range, 26–53%) and TP was 58 g/L (IQR, 6 g/L; range, 44–82 g/L). Preoperative values were significantly higher than postoperative values for PCV (median, 31%; IQR, 4%; range, 24–43%) and TP (median, 55 g/L; IQR, 7 g/L; range, 40–76 g/L; P < 0.0001). No puppy developed hypoglycemia and no adverse events were observed or reported. Overnight fasting did not result in pre- or postoperative hypoglycemia in studied puppies undergoing elective neutering.

Intraoperative dextrose rate during exploratory laparotomies in neonates and the incidence of postoperative hyperglycemia: A retrospective observational study.

Compared with the older pediatric population, neonates have greater perioperative morbidity and mortality. Difficulty with glucose regulation may be a contributing modifiable risk factor during perioperative anesthetic management. To mitigate the risk of hyperglycemia in neonates, some providers empirically halve the preoperative rate of dextrose-containing infusions during surgery. To assess the association between halving the preoperative maintenance dextrose rate and postoperative euglycemia in neonatal intensive care unit patients undergoing exploratory laparotomies. Neonatal intensive care unit patients who underwent exploratory laparotomy under general anesthesia from 1/1/2014 to 11/21/2019 were included in this analysis. Hyperglycemia and hypoglycemia were defined as >150mg/dL and <46mg/dL. A calculated dextrose ratio was utilized to categorize patients into full and half intraoperative dextrose rate cohorts. Univariate analyses were performed with Fisher's exact test, the Wilcoxon rank sum test, or Spearman's correlation. Multivariable analyses with regression models were conducted after graphical evaluation of a predetermined set of independent variables. 107 patients were included in the full dextrose rate cohort and 96 patients in the half dextrose rate cohort with postoperative hyperglycemia occurring in 47 and 28 patients, respectively. On univariate analysis, halving the preoperative dextrose rate was associated with decreased postoperative hyperglycemia (odds ratio: 0.53; 95% CI: 0.28-0.98, P= 0.041). This association continued in the regression model (adjusted odds ratio: 0.49; 95% CI: 0.25-0.80, P= 0.008) after controlling for preoperative dextrose rate, preoperative serum glucose, preoperative pH, surgical duration, postmenstrual age at surgery, and the presence of necrotizing enterocolitis. Only one patient was hypoglycemic postoperatively, and they were in the full dextrose cohort. Halving of preoperative dextrose rates intraoperatively during exploratory laparotomy in neonatal intensive care unit patients was associated with a decreased risk of postoperative hyperglycemia without substantially increasing the occurrence of postoperative hypoglycemia. The practice of halving preoperative dextrose rates may be an effective empirical approach for intraoperative glucose management in the high-risk neonatal population when blood glucose monitoring is challenging.

Glucose Intolerance on Phaeochromocytoma and Paraganglioma-The Current Understanding and Clinical Perspectives.

Half of the patients with phaeochromocytoma have glucose intolerance which could be life-threatening as well as causing postoperative hypoglycemia. Glucose intolerance is due to impaired insulin secretion and/or increased insulin resistance. Impaired insulin secretion is caused by stimulating adrenergic α2 receptors of pancreatic β-cells and increased insulin resistance is caused by stimulating adrenergic α1 and β3 receptors in adipocytes, α1 and β2 receptors of pancreatic α-cells and skeletal muscle. Furthermore, different affinities to respective adrenergic receptors exist between epinephrine and norepinephrine. Clinical studies revealed patients with phaeochromocytoma had impaired insulin secretion as well as increased insulin resistance. Furthermore, excess of epinephrine could affect glucose intolerance mainly by impaired insulin secretion and excess of norepinephrine could affect glucose intolerance mainly by increased insulin resistance. Glucose intolerance on paraganglioma could be caused by increased insulin resistance mainly considering paraganglioma produces more norepinephrine than epinephrine. To conclude, the difference of actions between excess of epinephrine and norepinephrine could lead to improve understanding and management of glucose intolerance on phaeochromocytoma.

Minimally invasive partial versus total adrenalectomy for unilateral primary hyperaldosteronism-a retrospective, multicenter matched-pair analysis using the new international consensus on outcome measures

BackgroundPrimary hyperaldosteronism is a recognized risk factor for myocardial infarction, stroke, and atrial fibrillation. Minimally invasive adrenalectomy is the first-line treatment for localized primary hyperaldosteronism. Whether minimally invasive adrenalectomy should be performed using a cortex-sparing technique (partial minimally invasive adrenalectomy) or not (total minimally invasive adrenalectomy) remains a subject of debate. The aim of our study was to evaluate the clinical and biochemical efficacy of both procedures and to examine the morbidity associated with partial minimally invasive adrenalectomy versus total minimally invasive adrenalectomy in a multicenter study. MethodsUsing a retrospective study design, we determined the efficacy, morbidity, and mortality of partial minimally invasive adrenalectomy and total minimally invasive adrenalectomy. The Primary Aldosteronism Surgical Outcome Study classification was used to explore clinical and biochemical success. Matched-pair analysis was used in order to address possible bias. ResultsWe evaluated 234 matched patients with unilateral primary hyperaldosteronism: 78 (33.3%) underwent partial minimally invasive adrenalectomy, and 156 (66.7%) were treated with total minimally invasive adrenalectomy. Complete clinical success was achieved in 40.6%, and partial clinical success in an additional 52.6% of patients in the entire cohort. Complete biochemical success was seen in 94.0% of patients. Success rates and the incidence of perioperative complications were comparable between groups. Both postoperative hypocortisolism (11.5% vs 25.0% after partial minimally invasive adrenalectomy and total minimally invasive adrenalectomy, respectively; P < .001) and postoperative hypoglycemia (2.6% vs 7.1% after partial minimally invasive adrenalectomy and total minimally invasive adrenalectomy; P = .039) occurred more frequently after total minimally invasive adrenalectomy. ConclusionOur study provides evidence that patients with unilateral primary hyperaldosteronism are good surgical candidates for partial minimally invasive adrenalectomy. Not only is the surgical outcome comparable to that of total minimally invasive adrenalectomy, but also postsurgical morbidity, particularly in terms of hypocortisolism and hypoglycemia, may be reduced.

Outcome after surgical management of canine insulinoma in 49 cases.

Canine insulinoma has historically been associated with a poor prognosis; however, prolonged survival times have recently been reported. Prognostic indicators that are available preoperatively are of limited predictive accuracy, and consensus on post-operative treatment recommendations is lacking. The objectives of this study were to describe outcomes in dogs with insulinoma treated surgically, and to assess whether selected potential risk factors are strongly associated with outcomes after surgery. Medical records of two institutions were searched for dogs with insulinoma that were treated surgically. Forty-nine dogs were included. Thirty-nine dogs (80%) had immediate resolution of hypoglycaemia and 10 (20%) remained persistently hypoglycaemic postoperatively. The median survival time (MST) for all dogs was 561 days. The MST for dogs that had resolution of hypoglycaemia was 746 days. The median of the overall euglycaemic time (times from surgery to first detection of hypoglycaemia at any time point after surgery) for all dogs was 424 days. Forty-four percent of those that had resolution of hypoglycaemia experienced recurrence of hypoglycaemia by 2 years postoperatively. Pathological stage was a predictor of persistent post-operative hypoglycaemia which, in turn, was a predictor of survival time. These results show that dogs with insulinoma can have prolonged survival, and that pathological stage is a predictor of outcome.

Standardized Glycemic Management versus Conventional Glycemic Management and Postoperative Outcomes in Type 2 Diabetes Patients Undergoing Elective Surgery.

PurposeOptimized postoperative blood glucose control can minimize postoperative complications. Conventional perioperative glycemic control protocol (CG), which has been routinely used in our institution, lacks detailed perioperative glycemic management. A new standardized glycemic control protocol (SG) was designed which employs frequent postoperative monitoring of blood glucose, more tightly targeted blood glucose control, and adjustment of insulin dosage prior to surgery. This study compared the efficacy of postoperative glycemic control and complications with the two protocols, CG and SG.Patients and MethodsThree hundred and eighty type 2 diabetes patients who underwent elective surgeries were included in the study. Of those, 182 patients with CG were identified retrospectively as a historical control cohort. Additional 198 patients with SG were prospectively enrolled. Covariate imbalance was controlled using propensity score matching. Outcomes were evaluated using regression analysis clustered by type of surgery.ResultsThe SG group had lower mean levels of postoperative 24-hr blood glucose than the CG group (β =−8.6 mg/dL; 95% CI (−16.5 to −7.9), p=0.042). In SG group, the incidence of ICU admission and of acute kidney injury after surgery was lower than in the CG group (OR 0.36; 95% CI (0.18–0.74), p=0.005 and OR=0.59; 95% CI (0.41–0.85), p=0.005, respectively). There was no significant difference in postoperative hypoglycemia, infection, cardiovascular complications, stroke, or mortality rate between the two groups.ConclusionFor type 2 diabetes patients undergoing elective surgery, the SG protocol is more effective in controlling blood glucose. The protocol can also reduce the incidence of some postoperative complications compared to CG with no increased risk of hypoglycemia.