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Background: Despite the recognition of the important role that tight glycemic control plays in patients with diseased states, the risk of poor control in patients undergoing surgical closure has yet to be fully defined. As such, the decision to perform primary closure in patients with hyperglycemia or to wait until better control has been achieved can be difficult, especially in patients at high risk for complications. We therefore sought to determine the increased risk that poor glycemic control introduces to surgical closures in a high risk patient population.

Methods: We performed further analysis of a previous randomized study to assess the effect of glucose levels in high risk patients seen regularly at our wound center who underwent surgical closure of a variety of wounds. Blood glucose levels were taken regularly during their hospital stay and recorded for five days before and after surgical closure. Primary endpoints recorded included rates of healing, dehiscence, infection and reoperation. Univariate and multivariate analyses were performed.

Results: 81 patients who underwent primary closure of their wounds, the majority of which occurred in the lower extremity (89%), were included for analysis. Average follow up was 113 days. Preoperative and postoperative hyperglycemia (defined as any blood glucose measurement recorded above 200) were significantly associated with increased rates of dehiscence (Odds ratio 3.46, p=0.028 and Odds ratio 3.46 and p=0.028 respectively) and preoperative hyperglycemia trended toward significance with increased rates of reoperation (p=0.09). There was no association between preoperative or postoperative hyperglycemia and increased rates of infection (p=0.46 and p=0.46). Variability in preoperative glucose (as defined as a range of glucose measurements exceeding 200 points) was significantly associated with increased rates of reoperation (p=0.025).

	Dehiscence Rate	Re-operation Rate	Infection Rate
Preoperative BG <200mg/dl	18.2%	12.1%	6.2%
Preoperative BG >200mg/dl	43.5% P=.028 OR: 3.462 (1.2-9.9)	29.5% P=.096 OR: 3.04 (.89-10.40)	13.0% P=.457
Postoperative BG <200mg/dl	18.2%	15.1%	6%
Postoperative BG >200mg/dl	43.5% P=.028 OR: 3.462 (1.2-9.9)	27.3% P=.27	13% P=.457
Perioperative BG <200mg/dl	16%	12.0%	8.0%
Perioperative BG>200mg/dl	40.7% P=0.039 OR: 3.6 (1.08-11.97)	26.9% P=.24	11.1% P=1.0
Glucose Variability<200mg/dl	26.1%	11.6%	6.5%
Glucose Variability >200mg/dl	42.4% P=.150	35.3% P=.025 OR 4.14 (1.3-13.33)	15.2% P=.27

In multivariate analysis including glycemic control, patient demographics, postoperative dressing and preoperative co-morbidities, including a history of diabetes mellitus, only perioperative hyperglycemia was significantly associated with increased rates of dehiscence and trended toward increased rates of reoperation.

Conclusions: When considering primary closure of surgical wounds in high risk patients, the importance of tight glycemic control cannot be underestimated. Glucose levels above 200 and large swings in glucose levels are associated with increased rates of dehiscence and reoperation whether present in the preoperative or postoperative period. The reconstructive surgeon must therefore insist on tight glycemic control before and after surgical closure for better results. Further studies are needed to determine the best treatment algorithm for accomplishing this goal.