Impact of Metabolic Syndrome in Surgical Patients
Impact of Metabolic Syndrome in Surgical Patients
Metabolic syndrome may have a negative impact on outcomes after non-cardiac procedures and increases the risk of adverse peri- and postoperative events.
Based on available data, MetS significantly affects mortality and morbidity rates in general surgery patients. A retrospective study evaluated 3973 patients included in the National Surgical Quality Improvement Program database who underwent liver resection. This study assessed the impact of MetS on the complication rate and 30 day mortality. The presence of MetS was associated with an increased risk of postoperative death [odds ratio (OR) 2.7, 95% confidence interval (CI) 1.5–4.8; P=0.001)]. The cumulative incidence of death was 6.9 deaths per 1000 person-days among patients with MetS compared with 2.6 deaths per 1000 person-days among those without MetS. Metabolic syndrome is also related to an increased risk of postoperative complications. Specifically, patients with MetS were at greater risk for infectious, pulmonary, and cardiac complications (OR 1.4, 95% CI 1.02–1.8; P=0.04). Furthermore, in elective surgery under general anaesthesia the frequency of hypotension, hypoxaemia, hypertension, bleeding, pain, and postoperative nausea and vomiting is increased (OR 3.31; 95% CI 1.7–6.4; P<0.05) in patients with MetS (case–control study, 150 MetS patients, 150 control subjects, P<0.0001).
The MetS group (n=42, 36.8%) of 114 patients who underwent elective resection of colorectal cancer experienced a higher rate of postoperative complications and a longer length of hospital stay than the non-MetS group (40.5 vs 11.1%, P<0.001; 11.2 vs 8.1 days, P<0.006, respectively). It is important to mention that MetS as an entity significantly predicted poor surgical outcomes; this was not true for any of its individual components.
According to the largest retrospective study based on data from 310 208 patients from the American College of Surgeons National Surgical Quality Improvement Program database, patients with MetS (defined as the coexistence of obesity, hypertension, and DM) undergoing non-cardiac surgery are at increased risk for mortality, cardiac adverse events, pulmonary complications, acute kidney injury, stroke and coma, wound complications, and postoperative sepsis. In that study, patients underwent general, vascular, or orthopaedic surgery between 2005 and 2007. Specifically, patients with the modified MetS experienced nearly two- to three-fold higher risk of cardiac adverse events, a 1.5- to 2.5-fold higher risk of pulmonary complications, a two-fold higher risk of neurological complications, and a three- to seven-fold higher risk of acute kidney injury compared with patients of normal weight.
Vascular interventions are of specific interest and should be considered as high-risk procedures according to the European Society of Anaesthesiology and Cardiology guidelines. The prevalence of MetS is considerable in patients with vascular disease (>30% in patients with carotid artery disease; >50% in those with peripheral arterial disease) and seems to affect mortality and adverse event rates depending on the type of vascular surgery. A retrospective study described the effect of MetS on the outcomes in 921 patients who underwent carotid endarterectomy or carotid stenting. Patients with MetS were more likely to experience a complication than non-MetS patients (23 vs 14%, P=0.001). There was no difference between MetS and non-MetS patients with respect to patency, restenosis, re-intervention, or survival, but a difference existed for freedom from stroke, myocardial infarction, and major adverse events as evaluated by Kaplan–Meier analysis. Of note, the presence of DM was associated with higher rates of major adverse events and myocardial infarction in MetS patients compared with the non-MetS group. Smolock and colleagues studied 738 patients undergoing superficial femoral artery interventions for symptomatic lower extremity arterial disease. They found that the overall mortality was higher in the MetS group, with patient survival rates of 71 (sd 2) and 53 (sd 3)% at 5 yr in the non-MetS and MetS groups, respectively. Thirty day major adverse cardiac events were equivalent, but the incidence of 30 day major adverse limb events was higher in the MetS group compared with the non-MetS group.
Metabolic syndrome may predict adverse outcomes in major orthopaedic surgery. Common perioperative complications after total joint arthroplasties (TJA) include pulmonary embolism (PE), deep vein thrombosis, wound infection, and cardiovascular events. An increased risk for PE has been recognized in patients who fulfilled modified MetS criteria and underwent total hip and knee replacement. In one study, patients with MetS had a significantly higher incidence of PE (2.7%, 95% CI 1.8–4.0%) than patients without MetS (1.3%, 95% CI 1.0–1.6%, P=0.001), and after adjusting for all other significant risk factors, patients with MetS still had 1.6 times (95% CI 1.01–2.56; P=0.043) greater odds for developing PE than those without MetS. Notably, the increasing number of MetS components significantly augmented the incidence of PE by 23% for each additional component of MetS. The most important MetS component was obesity, based on BMI (because waist circumference values were lacking).
Retrospective studies observed an increased incidence of in-hospital major complications and significantly higher median hospital charges in MetS compared with non-MetS patients. Surprisingly, the mortality was lower in the MetS group in one of these studies, while the other study did not comment on mortality. Likewise, a higher rate of perioperative cardiovascular complications (AF, pulmonary oedema, arrhythmias, bradycardia, and cardiac arrest) were observed in patients with MetS after TJA compared with those without MetS. A multivariate logistic regression model adjusting for age, sex, race, surgery type, and the presence of risk factors (coronary artery disease, congestive heart failure, cerebrovascular disease, and thromboembolic disease) revealed that the risk of cardiovascular complications after TJA was significantly higher in patients with MetS (P=0.017, OR 1.64, 95% CI 1.09–2.46). It has also been reported that patients with uncontrolled diabetes, hypertension, or dyslipidaemia (as components of MetS together with a BMI >30 kg m) have increased risk of perioperative complications and increased length of hospital stay after TJA. The rate of postoperative complications was significantly greater in the uncontrolled MetS group (48.6%) than in the well-controlled MetS group (7.9%, P<0.0001). Patients with uncontrolled MetS required a mean hospital stay of 7.2 days (95% CI 5.2–9.0) compared with 4.0 days (95% CI 3.6–4.3) for patients with controlled MetS (P<0.0001).
In patients who underwent primary posterior lumbar spine fusion surgery, the MetS was identified as a risk factor for perioperative life-threatening complications, increased cost, longer in-hospital stay, and non-routine discharge. Specifically, patients with MetS experienced myocardial infarction, cardiac complications, pneumonia, and pulmonary complications more frequently when compared with non-MetS patients. Patients with MetS were more often discharged to another health-care facility than to their home. Median hospital charges were also higher for MetS vs non-MetS patients for posterior lumbar spine fusion.
Bariatric surgery is an acceptable and effective method to manage obesity-related co-morbidities in morbidly obese patients. According to the current guidelines, bariatric surgery should be considered in subjects with a BMI ≥35 kg m in the presence of metabolic disease including type 2 diabetes mellitus and MetS. Nearly four in five patients undergoing bariatric surgery present with MetS. Co-morbidities (cardiac, pulmonary, metabolic, and hepatic) and complications of morbid obesity in individuals undergoing bariatric surgery may vary and include multiple systems, thus posing particular challenges to the anaesthetist. Hypertension, dyslipidaemia, and hyperglycaemia (i.e. the key components of MetS) respond to bariatric surgery. A recent retrospective study on the largest cohort to date of bariatric surgery patients did not reveal increased rates of perioperative complications in obese patients with MetS compared with those without MetS.
Metabolic Syndrome and Non-cardiac Surgical Procedures
Metabolic syndrome may have a negative impact on outcomes after non-cardiac procedures and increases the risk of adverse peri- and postoperative events.
Metabolic Syndrome and General Surgery
Based on available data, MetS significantly affects mortality and morbidity rates in general surgery patients. A retrospective study evaluated 3973 patients included in the National Surgical Quality Improvement Program database who underwent liver resection. This study assessed the impact of MetS on the complication rate and 30 day mortality. The presence of MetS was associated with an increased risk of postoperative death [odds ratio (OR) 2.7, 95% confidence interval (CI) 1.5–4.8; P=0.001)]. The cumulative incidence of death was 6.9 deaths per 1000 person-days among patients with MetS compared with 2.6 deaths per 1000 person-days among those without MetS. Metabolic syndrome is also related to an increased risk of postoperative complications. Specifically, patients with MetS were at greater risk for infectious, pulmonary, and cardiac complications (OR 1.4, 95% CI 1.02–1.8; P=0.04). Furthermore, in elective surgery under general anaesthesia the frequency of hypotension, hypoxaemia, hypertension, bleeding, pain, and postoperative nausea and vomiting is increased (OR 3.31; 95% CI 1.7–6.4; P<0.05) in patients with MetS (case–control study, 150 MetS patients, 150 control subjects, P<0.0001).
The MetS group (n=42, 36.8%) of 114 patients who underwent elective resection of colorectal cancer experienced a higher rate of postoperative complications and a longer length of hospital stay than the non-MetS group (40.5 vs 11.1%, P<0.001; 11.2 vs 8.1 days, P<0.006, respectively). It is important to mention that MetS as an entity significantly predicted poor surgical outcomes; this was not true for any of its individual components.
According to the largest retrospective study based on data from 310 208 patients from the American College of Surgeons National Surgical Quality Improvement Program database, patients with MetS (defined as the coexistence of obesity, hypertension, and DM) undergoing non-cardiac surgery are at increased risk for mortality, cardiac adverse events, pulmonary complications, acute kidney injury, stroke and coma, wound complications, and postoperative sepsis. In that study, patients underwent general, vascular, or orthopaedic surgery between 2005 and 2007. Specifically, patients with the modified MetS experienced nearly two- to three-fold higher risk of cardiac adverse events, a 1.5- to 2.5-fold higher risk of pulmonary complications, a two-fold higher risk of neurological complications, and a three- to seven-fold higher risk of acute kidney injury compared with patients of normal weight.
Metabolic Syndrome and Vascular Interventions
Vascular interventions are of specific interest and should be considered as high-risk procedures according to the European Society of Anaesthesiology and Cardiology guidelines. The prevalence of MetS is considerable in patients with vascular disease (>30% in patients with carotid artery disease; >50% in those with peripheral arterial disease) and seems to affect mortality and adverse event rates depending on the type of vascular surgery. A retrospective study described the effect of MetS on the outcomes in 921 patients who underwent carotid endarterectomy or carotid stenting. Patients with MetS were more likely to experience a complication than non-MetS patients (23 vs 14%, P=0.001). There was no difference between MetS and non-MetS patients with respect to patency, restenosis, re-intervention, or survival, but a difference existed for freedom from stroke, myocardial infarction, and major adverse events as evaluated by Kaplan–Meier analysis. Of note, the presence of DM was associated with higher rates of major adverse events and myocardial infarction in MetS patients compared with the non-MetS group. Smolock and colleagues studied 738 patients undergoing superficial femoral artery interventions for symptomatic lower extremity arterial disease. They found that the overall mortality was higher in the MetS group, with patient survival rates of 71 (sd 2) and 53 (sd 3)% at 5 yr in the non-MetS and MetS groups, respectively. Thirty day major adverse cardiac events were equivalent, but the incidence of 30 day major adverse limb events was higher in the MetS group compared with the non-MetS group.
Metabolic Syndrome and Orthopaedic Surgery
Metabolic syndrome may predict adverse outcomes in major orthopaedic surgery. Common perioperative complications after total joint arthroplasties (TJA) include pulmonary embolism (PE), deep vein thrombosis, wound infection, and cardiovascular events. An increased risk for PE has been recognized in patients who fulfilled modified MetS criteria and underwent total hip and knee replacement. In one study, patients with MetS had a significantly higher incidence of PE (2.7%, 95% CI 1.8–4.0%) than patients without MetS (1.3%, 95% CI 1.0–1.6%, P=0.001), and after adjusting for all other significant risk factors, patients with MetS still had 1.6 times (95% CI 1.01–2.56; P=0.043) greater odds for developing PE than those without MetS. Notably, the increasing number of MetS components significantly augmented the incidence of PE by 23% for each additional component of MetS. The most important MetS component was obesity, based on BMI (because waist circumference values were lacking).
Retrospective studies observed an increased incidence of in-hospital major complications and significantly higher median hospital charges in MetS compared with non-MetS patients. Surprisingly, the mortality was lower in the MetS group in one of these studies, while the other study did not comment on mortality. Likewise, a higher rate of perioperative cardiovascular complications (AF, pulmonary oedema, arrhythmias, bradycardia, and cardiac arrest) were observed in patients with MetS after TJA compared with those without MetS. A multivariate logistic regression model adjusting for age, sex, race, surgery type, and the presence of risk factors (coronary artery disease, congestive heart failure, cerebrovascular disease, and thromboembolic disease) revealed that the risk of cardiovascular complications after TJA was significantly higher in patients with MetS (P=0.017, OR 1.64, 95% CI 1.09–2.46). It has also been reported that patients with uncontrolled diabetes, hypertension, or dyslipidaemia (as components of MetS together with a BMI >30 kg m) have increased risk of perioperative complications and increased length of hospital stay after TJA. The rate of postoperative complications was significantly greater in the uncontrolled MetS group (48.6%) than in the well-controlled MetS group (7.9%, P<0.0001). Patients with uncontrolled MetS required a mean hospital stay of 7.2 days (95% CI 5.2–9.0) compared with 4.0 days (95% CI 3.6–4.3) for patients with controlled MetS (P<0.0001).
In patients who underwent primary posterior lumbar spine fusion surgery, the MetS was identified as a risk factor for perioperative life-threatening complications, increased cost, longer in-hospital stay, and non-routine discharge. Specifically, patients with MetS experienced myocardial infarction, cardiac complications, pneumonia, and pulmonary complications more frequently when compared with non-MetS patients. Patients with MetS were more often discharged to another health-care facility than to their home. Median hospital charges were also higher for MetS vs non-MetS patients for posterior lumbar spine fusion.
Metabolic Syndrome and Bariatric Surgery
Bariatric surgery is an acceptable and effective method to manage obesity-related co-morbidities in morbidly obese patients. According to the current guidelines, bariatric surgery should be considered in subjects with a BMI ≥35 kg m in the presence of metabolic disease including type 2 diabetes mellitus and MetS. Nearly four in five patients undergoing bariatric surgery present with MetS. Co-morbidities (cardiac, pulmonary, metabolic, and hepatic) and complications of morbid obesity in individuals undergoing bariatric surgery may vary and include multiple systems, thus posing particular challenges to the anaesthetist. Hypertension, dyslipidaemia, and hyperglycaemia (i.e. the key components of MetS) respond to bariatric surgery. A recent retrospective study on the largest cohort to date of bariatric surgery patients did not reveal increased rates of perioperative complications in obese patients with MetS compared with those without MetS.
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