This study is the first to specifically investigate the effects of chronic and perioperative glycaemic control in high risk patients undergoing primary closure of wounds. Seventy-nine patients were included – 93% of closures were of the lower limb and only 6% in the trunk. Wound dehiscence, infection and reoperation rates were utilised as outcome measures. The authors demonstrated that pre and postoperative hyperglycaemia defined as any blood glucose measurement >200mg/dl and elevated HbA1c of 6.5% is associated with increased rates of dehiscence and reoperation, although it did not achieve statistical significance. Eighty-eight percent of patients who had an HbA1c >7% developed hyperglycaemia in the perioperative period. Overall, the authors utilised a good methodology in this retrospective study. Patient characteristics and co-morbidities were similar amongst those studied. In addition, the authors achieved freedom from infection and adequate debridement prior to primary surgical closure. There are a few confounding factors in the study; although negative cultures were observed, this does not completely prove the wounds to be clear of biofilm potentially leading to chronic infections. Also, the nutritional status of the patient population was an unknown variable, which may have impacted the study parameters. Wound characteristics such as wound type, location and size were not taken into account, partially sabotaging the conclusions, e.g. which of the chronic wounds amenable to primary closure were of ischaemic, venous or mixed aetiology. There was use of non-standardised timing of glucose sampling – this may jeopardise the conclusions. Of note, 64 out of 79 patients had HbA1c data and 36 out of 79 had complete five-day glucose data – this may have skewed the data. Despite this being a retrospective study and several confounding factors, this study found associations between glycaemic control and wound complications, mainly dehiscence. These associations are valuable as it provides the surgeon with information when counselling patients and helps define the risk of surgical complications. The authors have highlighted the issue of whether tight perioperative control in the presence of poor chronic control could lead to better outcomes. However, further investigation is needed with a larger prospective study specifically looking at this. 

The role of chronic and perioperative glucose management in high-risk surgical closures: A case for tighter glycaemic control.
Endara M, Masden D, Goldstein J, et al.
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Zeeshan Sheikh

NHS Lothian, UK

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