of the blood sugar. Even if the diabetic patient maintains his blood sugar at a normal level with diet or other means such as insulin, the disease of diabetes mellitus may still progress, affecting different organs in your body. It is in the latter context that the diabetic patient becomes of concern to the surgeon. Diabetes affects the small blood vessels, narrowing them and decreasing the blood supply to the hands and feet or the vessels in the heart and may lead to tissue damage in these areas, necessitating bypass surgeries (see Vascular Surgery). If very severe and not well managed, amputations of the toes or even a leg may be necessary. Because of the injury to microscopic vessels in the skin, the diabetic may have poor healing of skin wounds and surgical incisions may heal more slowly, with greater chance of infection and wound separation. Somehow the effect on the skin also involves the sensory nerves, and diabetic patients may develop abnormal nerve function and numbness, called neuropathies, in the toes and feet. If the diabetes affects the eyes, a condition called diabetic retinopathy can occur and lead to poor vision or blindness.
Diabetes mellitus is a strange and wide-affecting disease. What are the surgical considerations, and why do I give a whole chapter to the subject? First, the surgeon and anesthesiologist must carefully monitor the blood sugar during the stress of surgery; surgery is a stress both emotionally and physiologically! If the blood sugar gets too low, (hypoglycemia), then not enough sugar is getting to the brain cells and seizures or brain damage can occur. If the blood sugar gets too high, (hyperglycemia), then a serious condition called diabetic ketoacidosis can occur with severe tissue consequences and even death.
The surgeon knows that, because of the diabetic effect on tissue, there is poorer blood supply to tissue and skin and thereby a greater chance for wound infections (see Wound Healing chapter), slower healing, and more complications. Whereas, we usually take out skin sutures after seven to ten days, in the diabetic I may wait twice as long! Sores and ulcers that heal rapidly in the nondiabetic may become a complex lingering problem in the diabetic patient, and even skin grafting will have poorer results.
Patients who have blood vessel problems from hardening of the arteries or arteriosclerosis, or secondary to smoking will have even more problems if they are diabetic. In the diabetic patient with vascular disease, if they don't stop smoking, the outlook for saving a foot or leg is very poor! The diabetic needs to take exquisite care of his skin, and whenever there are even minor cuts or bruises he should seek out medical attention immediately.
New research with pancreas transplants may offer some wonderful treatment options in the future but this work is still embryonic in the transplantation field.
If you have diabetes mellitus, you probably know much about what I have spoken, and it is important that you continue to educate yourselves in all the new treatment possibilities on the market. Sometimes, a general physician may not have the time to be up-to-date on these types of advances and, as a second opinion, you may want to consult an endocrinologist, a physician who specializes in endocrine disease, of which diabetes mellitus is one!
Chapter 21
WOUND HEALING
I wish we'd find a magic way,
For scars and deformity to go away.
Unfortunately, though, the process of healing,
Leaves scars and deformities and some bad feeling!
Healing a wound is like building construction,
It starts with site cleanup and tissue destruction.
Certain cells, the WBC's, remove all the dead and poor tissue,
And then bring equipment to rebuild the issue.
And like any construction, it takes time for achievement,
And depends on the needed equipment receivement.
The roads for supply in the body are arteries.
If you have ‘em in plenty, the work soon gets starteried.
But also you need all the building materials.
Which you get in your body with all the right cereals,
With proteins and lipids and good carbohydrates.
And vitamins, minerals, and adequate heart rates.
And all this assumes you're in top peak condition,
Without Diabetes or heart aches or malnutrition,
Or aged, or fat, or have cancer or infection,
Or jaundice or trauma or lost an election.
In other words, the ideal state is just what it says,
Since most are not perfect in so many ways,
So I have to advise you, and it's not all my fault,
Take this information with a small grain of salt!
The healing process is a very sensible and orderly one, much like building a home. After an injury, which may be traumatic or surgical, the wound, like your building site, has to be cleansed of debris, and the body sends in white blood cells (WBC's) to do this function. The WBC's come in by small arteries (arterioles) and, much like in construction, the body has to build new roads to bring in the heavy building materials. In the body this is called angiogenesis (angio=vessel, genesis=creating), and this allows the entire “repair” team to get into the area for repair.
Most texts describe wound healing in stages, but in actuality many of these processes are happening at the same time. First comes hemostasis and coagulation, stopping the bleeding and sealing off the area from further bleeding. Then comes inflammation, which is a somewhat misunderstood word, because many of us equate inflammation with infection. Not so. Inflammation is actually the process of bringing white blood cells or leukocytes into the area of a wound. They have many roles, but mainly to clean up debris and bring in raw materials for healing. The next stage is the growth of fibroblasts, called fibroplasias, that will go on to form the building block of a strong wound, collagen. During this time another process called epithelialization is occurring in the skin, which means the growth of skin or epithelial or epidermal cells.
Now, how does the body know what to do and how to do it? Recent studies have shown that substances called cytokines appear in the blood stream after an injury or surgery, and these somehow act as messengers to organize this redevelopment process.
A lot of factors will affect your ability to heal properly, as mentioned in the poem, and I will repeat them here for you. If you have any of these factors, you will heal more slowly, and you should understand that the healing process in each individual is different. With a procedure as simple as an appendectomy, some individuals will be ready to go back to normal activity in a few days, whereas others may be incapacitated for a month or more.
The factors are age; general health; whether you have local wound problems such as hematoma or seroma; anemia; presence of malignancy; obesity; trauma; vitamin deficiencies; medications you are on, such as steroids, which markedly inhibit normal healing, diabetes mellitus; chemotherapy; and chronic liver disease, to name a few. Also, if your surgeon treats the tissue badly, it won't heal well. It's also important to keep the wound clean and probably best not to go bungee jumping or play football for a two to four-week period.
In conclusion, I should emphasize that, as of yet, there is no way to make an incision and not end up with a
