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A quandary. A conundrum. A medical riddle. A dilemma.
We had one recently, and (spoiler alert) all came out well. But, as is often the case, by the very success we experienced, more questions were raised.
A study of one is not all that scientific in it's conclusion, but this 'one' may possibly lead to a lowered threshold to take a patient to surgery that otherwise may not get there all that soon, or maybe ever.
Enough delay - Here's the deal...
A 29 y/o BMI 40 patient with quite poorly controlled T2DM (most recent A1C over 11), on Lantus 42 units and mealtime bolus Humalog 25 units at each meal, and Metformin 1000 BID. She was scheduled for surgery, Gastric Bypass, but unable to be cleared by her PCP due to poor control of her Diabetes, as essentially a standard reasonable precaution for any elective surgery.
Many studies have been done in the General Surgery, as well as other surgical disciplines, demonstrating a notable increased perioperative risk, mostly due to infections. Since there really isn't anything that can be characterized as an 'emergency' (non-elective) Bariatric surgery, the decision was to wait until better control was achieved through diet, lifestyle, and improved medical management. It was generally agreed that we didn't need a "Normal" A1C (6.5 or less), but heading in the right direction, closer to 8%, with a few weeks to months of better control as the plan. Hopefully...
Enter Mr. Gall Bladder. Either from weight loss from our preoperative diet, or retrospectively just because of divine 'timing', she developed RUQ abdominal pain and N/V and when we worked her up we found a normal GB U/S - that is no stones, sludge, wall thickening, or pericholecystic fluid. However, with persistent symptoms consistent with biliary colic, we did get a PIPIDA which showed positive for significantly decreased EF.
We subsequently had hoped things would quiet down on their own as we headed toward the intended weight loss surgery, but no...
And, add to that, an altered diet (anorexia) from N/V, abdominal pain, especially post prandially. To make matters worse, BG's were now even higher due to her difficulty knowing 'when' (and 'IF') to take her insulin, and if so how much depending on what she could eat, and what she would keep down. It was getting messy.
So, it was crystallizing to this. Do the Laparoscopic Gall Bladder quickly and get out, and then come back another day for the Bypass. Or, take the Gall Bladder, and add the extra 90 minutes or so and do the metabolic surgery (the Gastric Bypass) at the same time as we had originally planned, just that now it would be in a more acute setting, and with not the best antecedent BG control.
*The Benefits of doing both: Get the Gall Bladder out, and get started on a big DM2 benefit and get her started with better glucose control with greatly reduced meds. One time exposure to anesthesia. Reduced risk of 'losing' her to continued poor DM control and perhaps not having the Bypass and therefore not getting the metabolic benefit from surgery, maybe not ever (it has happened before).
**The Risks: The standard reasons why we usually do not do it this way, that is performing an elective surgery in the face of poorly controlled blood sugars / Diabetes - Infection. Electrolyte issues. Intravascular volume contraction from glycosuria. Metabolic issues from a relatively insulinopenic state.
We did get PCP clearance with this unusual instance clarified for this specific case, and then cardiology clearance just to be sure (history of Mom with sudden ?cardiac death in her 40s).
She came in at 289 to the day surgery area on the AM of surgery, mainly owing to a reported low BG issue at 10 PM the night before, and did not take any of her Lantus- I guess it could have been worse - at least she didn't eat after midnight. We scaled her with Novolog in the preop holding area, and got her to high 100's low 200's before, and kept her there during surgery.
Not great, but actually way better than where she had been living the preceding few months when was with us (high 200's / low 300's).
So, surgery went well, both cases done in just over 2 hours. Blood sugars rapidly regulated, after some short acting insulin (Novolog) in the PACU, and followed every 2 hours. She actually needed very little additional insulin, and we were able to follow a moderate QID scale and she got about 8 additional units total during her two day stay, keeping her BGs in the low to mid 100's.
No Lantus needed. No infections. No cardiac issues or tachycardia. No surgical complications.
Huge Win-Win.
Just seen at her 1 week followup, she remains well, no further nausea or abdominal pain as she had with her Gall Bladder, and her BGs are in the 100-130 range as she advances her diet and is just on Metformin 1000 mg BID.
Surgery truly is powerful medicine.
And while we don't have this dilemma all that often, when we did, we have always leaned toward delaying surgery until it was 'safer' by standard best practices, that is with near optimal BG control before surgery.
With our experience here, maybe our threshold to do a weight loss / metabolic surgery will be lowered, taking into account the potentially rapid benefit of glucose regulation that lifestyle and medicines had been unable to deliver up until that point.
