Impact of Glycemic Control on Intraoperative Difficulty in Diabetic Patients Undergoing Cholecystectomy: A Comparative Cross-Sectional Study

Abstract

Introduction: Gallstone disease is a common surgical condition, and cholecystectomy is the standard treatment for symptomatic gallbladder disease. In diabetic patients, chronic hyperglycemia may impair gallbladder motility and promote inflammation, fibrosis, and adhesions, thereby increasing operative difficulty.

Aim & Objective: To evaluate the impact of glycemic control on intraoperative difficulty in diabetic patients undergoing cholecystectomy and to assess the association of fasting blood sugar (FBS) and glycated hemoglobin (HbA1c) with the Nassar intraoperative difficulty grade, operative duration, and conversion to open surgery.

Materials & Methods: This comparative cross-sectional subgroup analysis was conducted from June 2024 to November 2025 at the Department of Surgery, Hamdard Institute of Medical Sciences and Research and Hakeem Abdul Hameed Centenary Hospital, New Delhi. A total of 186 diabetic patients undergoing cholecystectomy were enrolled. Glycemic status was assessed using FBS and HbA1c, and intraoperative difficulty was graded according to the Nassar classification. Associations were analyzed using the Chi-square test or Fisher’s exact test.

Results: Of the 186 patients, 59.7% had FBS ≥126 mg/dL and 39.8% had HbA1c ≥8%. Laparoscopic cholecystectomy was completed in 91.4% of cases, while 8.6% required conversion to open surgery. High intraoperative difficulty occurred in 27.5% of patients. HbA1c ≥8% was significantly associated with increased operative difficulty (33.8% vs 23.2%; p=0.048), whereas FBS and duration of diabetes were not. Difficult surgery was strongly associated with operative time >60 minutes, conversion to open surgery, and xanthogranulomatous cholecystitis (all p<0.001).

Conclusion: Poor long-term glycemic control, reflected by HbA1c ≥8%, was significantly associated with increased intraoperative difficulty in diabetic patients undergoing cholecystectomy.

REFERENCES

1. Gutt C, Schläfer S, Lammert F. The treatment of gallstone disease. Dtsch Arztebl Int. 2020;117(9):148-158.
2. National Institutes of Health Consensus Development Conference Statement. Gallstones and laparoscopic cholecystectomy. Bethesda (MD): National Institutes of Health, Office of Medical Applications of Research; 1992:14-16. https://doi.org/10.1089/lps.1993.3.77
3. Jadon AS, Kaushik MP, Anitha K, Bhatt S, Bhadauriya P, Sharma M. Types of diabetes mellitus, mechanism of insulin resistance and associated complications. In: Biochemical Immunology of Diabetes and Associated Complications. Elsevier; 2024:1-18. https://doi.org/10.1016/b978-0-443-13195-0.00001-6
4. World Health Organization. Diagnostic criteria and classification of hyperglycaemia first detected in pregnancy. Geneva: World Health Organization; 2013:1-63. https://doi.org/10.1016/j.diabres.2013.10.012
5. Kalyani DV, Sheela P, Kumar PS, Nagalingam S. Gall bladder ejection fraction as a marker of autonomic neuropathy in type 2 diabetes mellitus. Int J Res Med Sci. 2019;7(7):2669-2672. https://doi.org/10.18203/2320-6012.ijrms20192898
6. Rahmani B, Gandhi J, Joshi G, Smith NL, Reid I, Khan SA. The role of diabetes mellitus in diseases of the gallbladder and biliary tract. Curr Diabetes Rev. 2020;16(9):931-948.https://doi.org/10.2174/1573399816666200305094727
7. Rodbard D. Clinical interpretation of indices of quality of glycemic control and glycemic variability. Postgrad Med. 2011;123(4):107-118. https://doi.org/10.3810/pgm.2011.07.2310
8. Mosca A, Lapolla A, Gillery P. Glycemic control in the clinical management of diabetic patients. Clin Chem Lab Med. 2013;51(4):753-766. https://doi.org/10.1515/cclm-2012-0594
9. Wong JK, Ke Y, Ong YJ, Li H, Wong TH, Abdullah HR. The impact of preoperative glycated hemoglobin (HbA1c) on postoperative complications after elective major abdominal surgery: a meta-analysis. Korean J Anesthesiol. 2022;75(1):47-60. https://doi.org/10.4097/kja.21295
10. Rollins KE, Varadhan KK, Dhatariya K, Lobo DN. Systematic review of the impact of HbA1c on outcomes following surgery in patients with diabetes mellitus. Clin Nutr. 2016;35(2):308-316. https://doi.org/10.1016/j.clnu.2015.03.007
11. Seshadri A, Peitzman AB. The difficult cholecystectomy: what you need to know. J Trauma Acute Care Surg. 2024;97(3):325-336. https://doi.org/10.1097/ta.0000000000004337
12. Radkowski P, Kędziora B, Eliszewska L, Jackowska K, Mandziuk-Radkowska O, Dawidowska-Fidrych J. Perioperative management of patients with diabetes. Med Stud. 2023;39(3):272-280. https://doi.org/10.5114/ms.2023.131683
13. Levy N, Dhatariya K. Pre-operative optimisation of the surgical patient with diagnosed and undiagnosed diabetes: a practical review. Anaesthesia. 2019;74(1):58-66. https://doi.org/10.1111/anae.14510
14. Shirol VV, Motimath PS. Occurrence of gallbladder stones and its association with HbA1c among participants with type 2 diabetes mellitus: one-year cross-sectional study. APIK J Intern Med. 2020;8(3):128-131. https://doi.org/10.4103/ajim.ajim_35_19
15. Almobarak AO, Jervase A, Fadl AA, Garelnabi NIA, Al Hakem S, Hussein TM, et al. The prevalence of diabetes and metabolic syndrome and associated risk factors in Sudanese individuals with gallstones: a cross-sectional survey. Transl Gastroenterol Hepatol. 2020;5:1-14. https://doi.org/10.21037/tgh.2019.10.09
16. Nassar AH, Khan KS, Ng HJ, Sallam M. Operative difficulty, morbidity and mortality are unrelated to obesity in elective or emergency laparoscopic cholecystectomy and bile duct exploration. J Gastrointest Surg. 2022;26(9):1863-1872. https://doi.org/10.1007/s11605-022-05344-7
17. Luthra A, Behura A, Behera CR, Mishra A, Mohanty S, Panda B, et al. Intraoperative findings of elective laparoscopic cholecystectomy in diabetics versus nondiabetics: a comparative study. Cureus. 2022;14(1):1-7. https://doi.org/10.7759/cureus.20886
18. Malik M, Bhimani Z, Singh S, Shah N, Eswar P. Observational study to compare surgical outcome in diabetics and non-diabetics patients undergoing laparoscopic cholecystectomy. Int J Hepatol Res. 2025;7(1):1-4. https://doi.org/10.33545/26646595.2024.v7.i1a.28
19. Bedirli A, Sözüer EM, Yüksel O, Yilmaz Z. Laparoscopic cholecystectomy for symptomatic gallstones in diabetic patients. J Laparoendosc Adv Surg Tech A. 2001;11(5):281-284. https://doi.org/10.1089/109264201317054564
20. Agarwal S, Shrimali L, Mehta R, Joshi CP. Study of gall bladder disease in diabetic and non diabetic patients. J Evid Based Med Healthc. 2015;2(42):7484-7491. https://doi.org/10.18410/jebmh/2015/1011
21. Giudicelli X, Rode A, Bancel B, Nguyen AT, Mabrut JY. Xanthogranulomatous cholecystitis: diagnosis and management. J Visc Surg. 2021;158(4):326-336. https://doi.org/10.1016/j.jviscsurg.2021.02.004