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Glycemic control in perioperative period
Glycemic control pre-, intra-, and postoperatively has been proven essential for reducing complications
in elective surgery, particularly infection [35-37] . Hyperglycemia has been shown to have numerous adverse
effects at the cellular level including altered chemotaxis, phagocytosis, pseudopod formation, and oxidative
[38]

burst, all of which prevent neutrophils from functioning optimally . In diabetic patients or those with
suspected hyperglycemia, glycemic control should be measured with hemoglobin A1c (HbA1c), which gives
an indication of glycemic control over the previous 2-3 months. While a goal HbA1c of 6.5% is ideal, the
[35]
risk of infection rises significantly at values > 7.5% . Those patients with difficulty in achieving a HbA1c
below 7.5% warrant additional education and assistance from an endocrinologist, diabetic nutritionist, and/
or diabetes nurse educator.

In the early 2000s, a large randomized controlled trial (RCT) demonstrated that tight glucose control (80-
110 mg/dL) resulted in a decrease in ICU and surgical patient mortality giving rise to the popularity of
[39]
strict glucose regulation . In the years after this study, the risks of hypoglycemia and its complications
[40]
were found to outweigh the benefits of meticulous glucose protocol (80-110 mg/dL) . Currently,
perioperative blood sugar control in both diabetic and non-diabetic patients should aim for 120-160 mg/dL
to minimize complication risks [40-42] . Postoperative hyperglycemia remains a significant risk factor for the
development of surgical site occurrences; it has been reported that even one episode of serum glucose of >
200 mg/dL increases the risk of wound dehiscence [37,43] . Strict protocols for preventing hyperglycemia and
glycemic interventions have effectively reduced rates of hyperglycemia and improved outcomes [43,44] .

Sarcopenia
[45]
Sarcopenia refers to a combination of muscle atrophy and replacement by fibrosis or adipose . This
degenerative loss of muscle mass is most strongly associated with aging and is commonly a component
of underlying pathologic processes such as cancer or liver disease. It may also occur in relatively healthy
individuals if they are obese and inactive. Compared to sarcopenia in non-obese patients, sarcopenia
[46]
in obesity is associated with a decrease in overall survival . Sarcopenia is quantified using computed
2
2
tomography by measuring a cross-sectional muscle area (cm /m ) of the paraspinous muscles at the L3 level
and comparing the values to sex-specific cutoffs [45,47] . The presence of sarcopenia in surgical and critical
care patients has been shown to be a predictor of poor outcomes such as surgical site occurrence, length
of stay (LOS), and need for rehabilitation [48-53] . Increased ventilator dependence and overall mortality were
[49]
seen in elderly trauma patients found to be sarcopenic . Some retrospective data with VHR patients
[54]
show an association of sarcopenia with increased postoperative complications and hernia recurrences ,
[55]
whereas other preliminary reviews of prospective data fail to show a significant correlation . The true role
of sarcopenia in AWR and VHR requires further investigation, but methods to preserve and improve lean
[56]
body mass would likely have a positive impact on patient outcomes .
Conditioning and prehabilitation
It has been widely accepted that poor physical fitness is associated with poor surgical outcomes. While surgical
risk calculators use biometric variables and laboratory data from the NSQIP database to estimate 30-day
[58]
[57]
perioperative risks, quantifying functional status might be a better predictive tool . Reddy et al. found
that time to complete a stair climb in a preoperative setting was strongly associated with complication
rates after abdominal surgery. The stress of this exercise likely simulates the physiologic demand induced
in surgery and may help triage patients for fitness optimization. This concept, known as preconditioning
or prehabilitation, serves to improve functional status leading up to an elective operation utilizing a
multidisciplinary approach that includes psychological, physical, and nutritional interventions. Numerous
studies have been completed over the past decade to investigate the utility of prehabilitation and
[59]
demonstrate improved preoperative functional capacity , rate of return to preoperative function after
[60]
[61]
abdominal surgery , and reduction of complication rates in elective abdominal aortic aneurysm repair .