Hysterectomy Complications Relative to HbA1c Levels: Identifying a Threshold for Surgical Planning

Abstract

Study Objective: To evaluate whether diabetes diagnosis and level of diabetes control as reflected by higher preoperative glycosylated hemoglobin (HbA1c) levels are associated with increased complication rates after hysterectomy and to identify a threshold of preoperative HbA1c level past which we should consider delaying surgery owing to increased risk of complications. Design: Retrospective cohort study. Setting: Hospitals in the Michigan Surgical Quality Collaborative between June 4, 2012, and October 17, 2017. Patients: Women with and without a diabetes diagnosis. Interventions: Hysterectomy. Measurements and Main Results: Data on demographics, preoperative HbA1c values, surgical approach, composite postoperative complications, readmissions, emergency department visits, and reoperations were abstracted. The risk of a postoperative complication when diabetes was stratified by preoperative HbA1c level was evaluated in a sensitivity analysis, and independent associations were identified in a mixed, multivariate logistic regression model. We identified 41 286 hysterectomies performed at 70 hospitals to be included for analysis. The sensitivity analysis identified 4 groups of risk for postoperative complications: group 1: no diabetes diagnosis and no HbA1c value; group 2: no diabetes diagnosis, with HbA1c levels between 4% and 6.5%; group 3: diabetes diagnosis and no HbA1c value or HbA1c levels <9%; and group 4: diabetes diagnosis with HbA1c levels ≥9%. In the adjusted model, there were significant 32% and 34% increased odds of postoperative complications for groups 2 and 3, respectively, compared with group 1. There were more than 2-fold increased odds of complications for women with diabetes and a preoperative HbA1c level ≥9% (group 4) compared with the women in group 1. Diabetes diagnosis with preoperative HbA1c levels ≥9% had increased odds of complications compared with diabetes diagnosis with preoperative HbA1c levels <9%. Patients with well-controlled diabetes seemed to have increased odds of complications with laparoscopic surgery. Conclusion: Diabetes diagnosis and measurement of preoperative HbA1c levels provide risk stratification for postoperative complications after hysterectomy, with the highest observed effect among patients with diabetes with a preoperative HbA1c level ≥9%.