North Carolina-based Marc S. Stevens, MD, FACS, is one of the top orthopedic surgeons in the country. Previously, while practicing in Little Rock, he was named Arkansas Physician of the Year. In addition to his orthopedic expertise, Dr. Stevens has developed a reputation as an expert in nutrition, especially as it relates to wound healing, bone and joint health, and healthy weight. To learn more about Dr. Marc S. Stevens go to www.DRSHealthInc.com
When Dr. Stevens spoke recently with Diabetes Health Publisher and Editor-in-Chief Nadia Al-Samarrie, he provided a surgeon’s point of view about surgery for people with diabetes.
Nadia: Your focus on nutrition is wonderful-and unusual. Why are you so interested in nutrition?
Dr. Stevens: You have to go back to the 1980s, when proponents started to claim that good nutrition could do anything: “It will grow your hair back, it will make you taller, it will make you stronger, it will make you 18 again.” Instead of getting involved and trying to redirect those outlandish claims in a more scientific direction, medicine kind of stepped back and said, “Well, we’re not going to have anything to do with nutrition anymore. We’re just going to go what’s called the allopathic route and focus on what we do best.”
As a result, we lost a chance to connect with an important aspect of health. Most doctors still grasp that nutrition is vital. The reason we call certain things “vitamins” is because they are vital minerals, essential to good health. We all check for them, and we treat deficiencies when we find them lacking. But when it comes to prevention and how nutrition can support wound recovery or preparation for surgery, we just don’t typically think that way.
Because I have paid close attention to nutrition, I’ve been very excited over the past five years to see the infection rate and returns to surgery in my practice reduced to almost zero. That’s because whenever I see people who are even close to having a problem, I put them on high-dose supplements and they get better. This concept benefits the patient so much that I’ve started using the phrase in lectures that “we’re trying to bridge the gap between medicine and nutrition.”
Nadia: What are the concerns for a person with diabetes before they undergo surgery? As a surgeon, what do you consider before you operate?
Dr. Stevens: The biggest concern we see among diabetes patients is “Will I heal?” Everybody has this concept that diabetics don’t heal. I’ve actually had many diabetic patients tell me. “Well, you know I can’t have surgery because I’m a diabetic.” And that’s just a complete misunderstanding. It takes the truth that sometimes there is an increased risk of slower healing way too far.
That isn’t to say that fears about healing don’t have a reasonable basis. Diabetes is a disease of the small blood vessels. It affects even the tiniest blood vessels, which are necessary for tissue repair after surgery. Those small vessels maintain the nerves, so when they’re constricted and aren’t working right, it affects the rate of healing and slows the process.
It can also cause more pain because the nerves are basically working in a oxygen-deprived environment. It’s like if I take you down to a place where there’s very little oxygen-you’re going to be breathing heavier and working harder. And when the nerves get like that, they become more irritated and sensitive.
So, a diabetic often will heal well, but it just may take longer. Our main concern with slow healing is that it prolongs the time when a patient is vulnerable to infection. If I operate on you and your wound heals in two, three, or seven days, once the skin is closed your risk of infection is basically gone. But if you’re going to have a slightly open wound for two weeks or maybe longer, that’s just giving bacteria more time and opportunity to get into a wound and cause an infection.
So a surgeon worries about whether you might get an infection after surgery. In the case of extremities, such as the feet and hands, if a patient doesn’t have good blood flow, that increases the risks of getting what we call wound breakdown. So it’s critical that we do anything we can to help a diabetic be ready for surgery or any procedure, and then get them healed as fast as possible.
Nadia: Can you expand on what occurs in the body during an infection?
Dr. Stevens: In a regular infection, bacteria or viruses get into the body through our noses or gastrointestinal tracts. But what we’re talking about here is when there has been an incision or wound in the skin that God designed to be a perfect barrier against almost anything. As long as the skin is intact, you have the best possible barrier there is against infection. When it’s breached, the bacteria that are already on your skin or in the environment suddenly have an avenue right into your body.
Once a bacterium gets inside the body, it finds a wonderful world. It has all the nutrients and sugar it needs to start replicating very quickly. All of a sudden, it begins to spread-an action we call infection. If it gets into the bloodstream, it can become septic. Bacteria can spread through the body so rapidly that they can simultaneously affect vital organs-the brain, kidneys, and so on.
After the skin, the body’s next line of defense is our white blood cells and immune system. After bacteria have entered the body, they’re ready to attack. One thing they do is release chemicals that begin to cause damage to tissues. Ironically, the body’s response to the attack also causes damage. That response, inflammation, is a very aggressive process. But in diabetics, when blood sugars go up, white blood cells actually lose some of their ability to track, hunt down, and kill bacteria. It’s kind of like a worker who’s intoxicated or hasn’t slept very well. They just don’t function as fast as they normally do.
So if you have somewhat disabled white blood cells in a high blood sugar environment, you have a perfect storm scenario for the bacteria. There’s little opposition and lots of fuel they love-sugar-that lets them come in and grow rapidly. That’s why we medical doctors are very aggressive about preventing infection in people with diabetes, and if we see any signs of it, quickly use antibiotics or surgical procedures to stop it-more so than we would with the normal population.
Nadia: Is there a correlation between a patient’s A1C and the chance of increased postoperative infection?
Dr. Stevens: Anybody with diabetes knows that the A1C is an average measurement of blood sugar levels over a certain time. If it’s elevated, that’s an indication that the white blood cells haven’t been functioning properly during that time. Several studies have shown that the higher blood sugar gets from that 150 mark, the more our immune system functions are impaired. Having a high A1C is a risk factor for infection, as well as for damage to your kidneys and eyes, and you’re certainly putting yourself at risk for developing ulcerations.
That’s why diabetics need to understand why it’s so important to deal with a foot ulcer and get it healed. Developing an ulcer puts them at high risk of needing an amputation at some point-something we always want to avoid. If you get an amputation, there’s a dramatic increase in the risk of a second amputation. If you have an amputation on one part of a leg, even if it’s a toe, your risk for an amputation on the other leg actually doubles.
Nadia: Is there an A1C above which you won’t operate?
Dr. Stevens: Well, as a trauma surgeon, there really isn’t a marker where I’d say, “I can’t operate on you because your blood sugars are high.” In a trauma situation, we’d treat the patient with insulin and bring his blood sugar down to a normal range, proceed with the surgery, and then do our best to keep him in a normal range post-op.
If you’re talking about an elective procedure, and you have a patient whose A1C has been up and down and all over the place on multiple checks by his primary care physician, then we would put off the surgery. To say yes, we’d need to see it demonstrated that you can control your sugars. If a patient is someone who has no regard for his diet, is breaking all the rules, and is not taking his medicine, his A1C is going to demonstrate that to us. And that would be a person you wouldn’t want to do any kind of elective surgery on.
Nadia: What advice do you have for people with diabetes who are facing surgery?
Dr. Stevens: The first thing that I look at as a surgeon is how the patient is overall. There are a lot of people who have diabetes who are extremely healthy. They’ve managed the disease wonderfully well with medications, diet, and exercise. If they are healthy diabetics, we congratulate them and proceed to surgery expecting an outcome no different than what we expect with nondiabetic patients. Even though a lot of people believe that “I’m a diabetic; therefore, surgery could go bad,” the truth of the matter is that if you’re a diabetic who has been doing the right things, when it comes to surgery, you’re OK. The risk level is not that much higher in a well-controlled diabetic than in a nondiabetic person.
Then there is the non-healthy diabetic, who very well can be somebody for whom control is hard no matter how much she works at it. If you’re a type 1 on insulin and you just can’t get your numbers under control, it’s very important that you work with your primary caregiver, doctor or endocrinologist, and surgeon all together on how to get your blood sugars under control before, during, and after the surgery. The most critical time after surgery is those initial six weeks. If a patient can be very focused and diligent and work closely with professionals, she can get through that critical period in good shape.
Nadia: Thank you, Dr. Stevens.