British Journal of Anaesthesia 115 (2): 194202 (2015)

doi: 10.1093/bja/aev199
Advance Access Publication Date 23 June 2015
Review Article

Impact of metabolic syndrome in surgical patients:

should we bother?
P. Tzimas1,*, A. Petrou1, E. Laou1, H. Milionis2, D. P. Mikhailidis3
and G. Papadopoulos1
1
Department of Anaesthesia and Postoperative Intensive Care, School of Medicine, University of Ioannina, Ioannina
University Campus, Stavros Niarchos Ave., Ioannina 45110, Greece, 2Department of Internal Medicine, School of
Medicine, University of Ioannina, Ioannina University Campus, Stavros Niarchos Ave., Ioannina 45110, Greece,
and 3Department of Clinical Biochemistry (Vascular Disease Prevention Clinics), Royal Free Hospital Campus,
University College London Medical School, University College London (UCL), Pond Street, London NW3 2QG, UK
*Corresponding author. E-mail: [email protected]; [email protected]

Abstract
Clinicians inevitably encounter patients who meet the diagnostic criteria for the metabolic syndrome (MetS); these criteria
include central obesity, hypertension, atherogenic dyslipidaemia, and hyperglycaemia. Regardless of the variations in its
denition, MetS may be associated with adverse outcomes in patients undergoing both cardiac and non-cardiac surgery. There
is a paucity of data concerning the anaesthetic management of patients with MetS, and only a few observational (mainly
retrospective) studies have investigated the association of MetS with perioperative outcomes. In this narrative review, we
consider the impact of MetS on the occurrence of perioperative adverse events after cardiac and non-cardiac surgery. Metabolic
syndrome has been associated with higher rates of cardiovascular, pulmonary, and renal perioperative events and wound
infections compared with patients with a non-MetS prole. Metabolic syndrome has also been related to increased health
service costs, prolonged hospital stay, and a greater need for posthospitalization care. Therefore, physicians should be able to
recognize the MetS in the perioperative period in order to formulate management strategies that may modify any
perianaesthetic and surgical risk. However, further research is needed in this eld.

Key words: anaesthesia; metabolic syndrome; postoperative outcome; surgical procedures

Editors key points (high triglyceride and low high-density lipoproteincholesterol

concentrations), high fasting glucose concentration, and central
In this narrative review, the authors describe the metabolic
obesity.1 Metabolic syndrome is associated with an increased
syndrome, outlining its impact and its recognition.
risk for cardiovascular disease and type 2 diabetes mellitus. 2
They outline management strategies and call for further
Moreover, MetS has been associated with an increased risk of
research in this area.
non-cardiac vascular diseases, including stroke, carotid artery
disease, peripheral artery disease, chronic kidney disease,
atherosclerotic renal artery stenosis, and abdominal aortic
aneurysms.2
Metabolic syndrome (MetS) comprises a group of risk factors The denition of MetS relies on clinical and laboratory criteria
that include high blood pressure, atherogenic dyslipidaemia and has been the subject of controversy.3 The rst attempt to

The Author 2015. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved.
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194
 Metabolic syndrome and surgical patients | 195

dene MetS came in 1998 from the World Health Organization.1 MetS, while the percentage in Southeast Asia is less than one-
Insulin resistance was suggested to be the major underlying fth, and this can be attributed in part to differences in the
risk factor and a prerequisite for the diagnosis.1 Nowadays, a gen- median age of Asian and European populations.9 In China, the
erally accepted denition is the one that came from the American prevalence is relatively low in the general population, and in
Heart Association/National Heart, Lung, and Blood Institute Japan, it varies considerably according to each study.9
Scientic Statement.4 It involves the following ve diagnostic Metabolic syndrome is considered a constellation of patho-
criteria, any three of which constitute the diagnosis of MetS: in- physiological processes. Currently, it is primarily thought to be
creased waist circumference, elevated triglycerides, reduced caused by adipose tissue dysfunction and insulin resistance,
high-density lipoproteincholesterol,5 elevated blood pressure, which is associated with abnormalities in insulin secretion, re-
and elevated fasting glucose (Table 1). Some individuals or ethnic ceptor signalling, and impaired glucose disposal. Visceral or
groups (e.g. Asians, especially South Asians) appear to be suscep- intra-abdominal fat is also known to secrete free fatty acids and
tible to development of MetS at waist circumferences below those potentially harmful concentrations of cytokines, such as tumour
presented in Table 1, which mostly refers to populations in in- necrosis factor, leptin, resistin, and plasminogen activator inhibi-
dustrialized countries.6 Although the International Diabetes Fed- tor, which in turn promote insulin resistance.10 11 They might
eration denition initially considered central (abdominal) also initiate a prothrombotic12 and pro-inammatory13 state
obesity as a sine qua non risk factor for establishing the diagno- that has been reported in patients with MetS.14 High blood pres-
sis of MetS, both the International Diabetes Federation and the sure and dyslipidaemia are well documented and modiable risk
American Heart Association/National Heart, Lung, and Blood In- factors for atherosclerotic vascular disease. It is unclear whether
stitute nally agreed that abdominal obesity should not be a pre- environmental factors, genetic predisposition, or both are also
requisite feature but rather one of the ve equally balanced involved. One key feature of MetS is that each diagnostic compo-
diagnostic criteria of MetS.6 nent may not stand out on its own because it is not markedly
Metabolic syndrome has a high prevalence worldwide that abnormal. However, when these relatively minor abnormalities
may vary according to the set of diagnostic criteria used (current occur together, there is a substantially increased risk of vascular
or older).7 It is more prominent in countries with Western life- events. The presence of MetS has been associated with a high risk
styles, affecting around 3439% of the adult population in the of vascular and metabolic complications (e.g. future develop-
USA with roughly equal prevalence in men and women.8 In Eur- ment of diabetes mellitus) independently of its individual diag-
ope, approximately one-quarter of the adult population has nostic features. Therefore, the identication of subjects with
MetS warrants a holistic management of coexisting risk factors,
which is considered the preferable strategy rather than targeting
any single characteristic of the syndrome independently. While
Table 1 Criteria for clinical diagnosis of metabolic syndrome
the pathophysiology of MetS is not yet fully understood, there
(at least three are required).6 *Waist circumference is measured
with a tape in a horizontal plane around the abdomen at the are concerns of an increased perioperative risk because of the
superior point of the iliac crest as dened by the National co-morbidities associated with this syndrome, which represent
Cholesterol Education Programs Adult Treatment Panel III a challenge for the anaesthetist.
guidelines The aim of this narrative review is to provide an overview of
the literature regarding the impact of MetS on perioperative out-
Clinical measure Categorical cut-off points comes in patients undergoing cardiac and non-cardiac surgery.
Waist circumference* 102 cm in men
(European, Caucasian, 88 cm in women
USA, Canada) Search methods
Triglycerides 150 mg dl1 (1.7 mmol l1) We searched MEDLINE up to October 1, 2014 for relevant publica-
or tions using combinations of the keywords, such as metabolic
On drug treatment for
syndrome, outcome, perioperative complications, surgery, mor-
elevated triglycerides
tality, morbidity, colon cancer, rectal cancer, liver surgery, ortho-
High-density lipoprotein <40 mg dl1 (1.0 mmol l1) in men
paedic surgery, total joint arthroplasty, risk factors, and spinal
cholesterol <50 mg dl1 (1.3 mmol l1) in
surgery. We also examined the reference list of the articles iden-
women
tied and selected those we judged relevant. These were included
or
On drug treatment for low
in this narrative review.
high-density lipoprotein-
cholesterol
Metabolic syndrome and cardiac surgery
Blood pressure 130 mm Hg systolic blood
pressure Incidence of metabolic syndrome in cardiac
or surgery patients
85 mm Hg diastolic blood
pressure The estimated prevalence of MetS in cardiac surgery patients is
or fairly high (nearly 46%).15 16 This incidence is almost double
On antihypertensive drug that found in the general population (2328%).17 18 Hypertension
treatment in a patient with a is commonly a diagnostic feature of MetS in cardiac surgery
history of hypertension patients (up to 85%).15 Not all cardiac surgery patients diagnosed
Fasting glucose 100 mg dl1 (5.6 mmol l1) with the MetS are obese, but the majority appear to be at least
or overweight and have increased waist circumference.6 In a retro-
On drug treatment for spective study15 of 5304 patients, only 46.5% of those who met
elevated glucose the criteria for MetS had a BMI >30 kg m2, while 12.9% were nor-
mal weight (18.5<BMI<24.9); the rest (40.4%) were overweight.15
196 | Tzimas et al.

Of note, almost one-third to one-half of those diagnosed with the incidence of postoperative AF.25 Another study26 showed that
MetS and who undergo coronary artery bypass grafting (CABG) the relative risk for aortic valve calcication was 1.49 for women
surgery are also diabetic.15 16 A prospective study19 including and 1.70 for men with MetS compared with those without MetS.
100 patients demonstrated a similar incidence of obesity (57.5% Investigating the progression of aortic bioprosthetic valve
with BMI >30 kg m2) and diabetes mellitus (DM; 45%) among stenosis retrospectively,23 one study found that patients with
patients with MetS. MetS presented a more rapid increase of transprosthetic gradient
compared with those without MetS (4 [ 5] vs 2 [ 2] mm Hg
yr1, P<0.001, respectively when evaluated 3 yr after surgery),
Metabolic syndrome and mortality in cardiac surgery
a more frequent worsening of prosthetic aortic insufciency
patients
(25 vs 12%, respectively) and worse valve haemodynamics
Metabolic syndrome seems to be an independent predisposing fac- (41 vs 25%, P=0.02, respectively).23
tor for mortality after CABG surgery.20 21 In the retrospective ana- A small retrospective study demonstrated that at 4.5 yr after
lysis of 5304 cardiac surgery patients,15 those with MetS had a mitral bioprosthetic valve implantation, patients with MetS had
2.4% mortality rate compared with 0.9% for those without MetS. increased transprosthetic valve gradients (6.8 vs 4.7 mm Hg,
In multivariate analysis, patients with MetS had a three-fold in- P=0.007, respectively) compared with those without MetS.24
creased probability of death.15 This increased mortality occurred
irrespective of gender and the presence (2.71 vs 0.21%, P<0.0001) Metabolic syndrome and stroke
or absence of DM (2.04 vs 1%, P=0.014), and in this study, DM was One study,27 which investigated risk factors for postoperative
not shown to increase overall mortality in the absence of MetS. stroke after cardiac surgery, conrmed that among others, two
An observational report studied long-term mortality among 1183 risk factors of MetS (diabetes and hypertension) were independ-
CABG patients and found that MetS increases all-cause and cardiac ent risk factors for stroke.27 Echahidi and colleagues15 reported a
mortality only in non-diabetic patients (hazard ratio 1.34, P=0.028 signicantly increased rate of stroke (2.3 vs 1.4%) and renal failure
and 2.31, P=0.002, respectively).16 Conversely, the survival of dia- (12.4 vs 6.8%) in patients with MetS undergoing CABG compared
betic patients was not affected by the presence of MetS.16 This with those without MetS.
study used a BMI >25 kg m2 instead of waist circumference for In summary, patients undergoing cardiac surgery are more
assigning patients to the MetS group, and it is unclear whether likely to have MetS, with or without obesity and DM. Cardiac sur-
this modication affected the results. In both retrospective studies, gery patients with MetS have higher morbidity and mortality
causes of death were also not different between those with and than those without MetS, and they are more likely to develop
without MetS.15 16 A small prospective study failed to detect any peri- and postoperative complications. However, larger prospect-
difference in mortality between those with and without MetS.19 ive studies are needed in order to form a denitive opinion.

Metabolic syndrome and morbidity in cardiac Metabolic syndrome and non-cardiac

surgery patients surgical procedures
Regarding complications rate, it appears that patients with MetS
Metabolic syndrome may have a negative impact on outcomes
are more prone to develop renal failure or infection ( pneumonia,
after non-cardiac procedures and increases the risk of adverse
mediastinitis, or wound infection), compared with those without
peri- and postoperative events.
MetS.15 19 In one study, patients with MetS had a higher incidence
of perioperative stroke (2.3 vs 1.4%, P=0.014) and similar rates
of perioperative myocardial infarction (based on elevations of Metabolic syndrome and general surgery
creatine kinase-MB or troponin I concentrations) compared Based on available data, MetS signicantly affects mortality and
with patients without MetS.15 It also seems that patients with morbidity rates in general surgery patients. A retrospective
MetS have a higher risk for either pre- or postoperative atrial b- study28 evaluated 3973 patients included in the National Surgical
rillation (AF) and present increased perioperative resistance to in- Quality Improvement Program database who underwent liver
sulin and postoperative cognitive dysfunction compared with resection. This study assessed the impact of MetS on the compli-
patients without MetS (see the section entitled Specic anaes- cation rate and 30 day mortality. The presence of MetS was asso-
thetic considerations in the management of surgical patients ciated with an increased risk of postoperative death [odds ratio
with metabolic syndrome). (OR) 2.7, 95% condence interval (CI) 1.54.8; P=0.001)]. The cumu-
lative incidence of death was 6.9 deaths per 1000 person-days
Metabolic syndrome and valvular decay among patients with MetS compared with 2.6 deaths per 1000
One important aspect of MetS is a tendency to accelerated devel- person-days among those without MetS.28 Metabolic syndrome
opment of a pressure gradient in both native and bioprosthetic is also related to an increased risk of postoperative complica-
valves.2224 When studying the progression of aortic stenosis in tions. Specically, patients with MetS were at greater risk for
patients with MetS (using a BMI >30 kg m2 instead of waist cir- infectious, pulmonary, and cardiac complications (OR 1.4, 95%
cumference), it was reported that stenosis advanced more quickly CI 1.021.8; P=0.04).28 Furthermore, in elective surgery under gen-
(0.14 vs 0.08 cm2 yr1, P=0.008, respectively) than in those with- eral anaesthesia the frequency of hypotension, hypoxaemia,
out MetS.22 Metabolic syndrome was an independent predictor of hypertension, bleeding, pain, and postoperative nausea and
rapid progression of aortic stenosis in terms of aortic valve area vomiting is increased (OR 3.31; 95% CI 1.76.4; P<0.05) in patients
and peak gradient, and the relative risk of this adverse outcome with MetS (casecontrol study, 150 MetS patients, 150 control
was 3.85 in patients with MetS compared with those without subjects, P<0.0001).29
MetS. Other investigators reported that although MetS does not The MetS group (n=42, 36.8%) of 114 patients who underwent
change the severity of the aortic stenosis (in terms of mean gra- elective resection of colorectal cancer experienced a higher rate
dient and aortic valve area), it signicantly affects the preopera- of postoperative complications and a longer length of hospital
tive left ventricular remodelling in these patients and increases stay than the non-MetS group (40.5 vs 11.1%, P<0.001; 11.2 vs
 Metabolic syndrome and surgical patients | 197

8.1 days, P<0.006, respectively). It is important to mention that obesity, based on BMI (because waist circumference values
MetS as an entity signicantly predicted poor surgical outcomes; were lacking).41
this was not true for any of its individual components.30 Retrospective studies42 43 observed an increased incidence of
According to the largest retrospective study31 based on data in-hospital major complications and signicantly higher median
from 310 208 patients from the American College of Surgeons hospital charges43 in MetS compared with non-MetS patients.
National Surgical Quality Improvement Program database, patients Surprisingly, the mortality was lower in the MetS group in one
with MetS (dened as the coexistence of obesity, hypertension, and of these studies,43 while the other study did not comment on
DM) undergoing non-cardiac surgery are at increased risk for mor- mortality.42 Likewise, a higher rate of perioperative cardiovascu-
tality, cardiac adverse events, pulmonary complications, acute lar complications (AF, pulmonary oedema, arrhythmias, brady-
kidney injury, stroke and coma, wound complications, and post- cardia, and cardiac arrest) were observed in patients with MetS
operative sepsis. In that study, patients underwent general, vascu- after TJA compared with those without MetS.42 A multivariate
lar, or orthopaedic surgery between 2005 and 2007. Specically, logistic regression model adjusting for age, sex, race, surgery
patients with the modied MetS experienced nearly two- to type, and the presence of risk factors (coronary artery disease,
three-fold higher risk of cardiac adverse events, a 1.5- to 2.5-fold congestive heart failure, cerebrovascular disease, and thrombo-
higher risk of pulmonary complications, a two-fold higher risk of embolic disease) revealed that the risk of cardiovascular compli-
neurological complications, and a three- to seven-fold higher risk cations after TJA was signicantly higher in patients with MetS
of acute kidney injury compared with patients of normal weight.31 (P=0.017, OR 1.64, 95% CI 1.092.46).42 It has also been reported
that patients with uncontrolled diabetes, hypertension, or dysli-
pidaemia (as components of MetS together with a BMI >30 kg
Metabolic syndrome and vascular interventions
m2) have increased risk of perioperative complications and in-
Vascular interventions are of specic interest and should be con- creased length of hospital stay after TJA. The rate of postoperative
sidered as high-risk procedures according to the European Soci- complications was signicantly greater in the uncontrolled MetS
ety of Anaesthesiology and Cardiology guidelines.3234 The group (48.6%) than in the well-controlled MetS group (7.9%,
prevalence of MetS is considerable in patients with vascular dis- P<0.0001). Patients with uncontrolled MetS required a mean hos-
ease (>30% in patients with carotid artery disease;35 >50% in pital stay of 7.2 days (95% CI 5.29.0) compared with 4.0 days (95%
those with peripheral arterial disease)36 and seems to affect mor- CI 3.64.3) for patients with controlled MetS (P<0.0001).40
tality and adverse event rates depending on the type of vascular In patients who underwent primary posterior lumbar spine
surgery. A retrospective study described the effect of MetS on the fusion surgery, the MetS was identied as a risk factor for peri-
outcomes in 921 patients who underwent carotid endarterec- operative life-threatening complications, increased cost, longer
tomy or carotid stenting.35 Patients with MetS were more likely in-hospital stay, and non-routine discharge. Specically, patients
to experience a complication than non-MetS patients (23 vs with MetS experienced myocardial infarction, cardiac complica-
14%, P=0.001). There was no difference between MetS and non- tions, pneumonia, and pulmonary complications more frequently
MetS patients with respect to patency, restenosis, re-interven- when compared with non-MetS patients. Patients with MetS
tion, or survival, but a difference existed for freedom from stroke, were more often discharged to another health-care facility than
myocardial infarction, and major adverse events as evaluated by to their home. Median hospital charges were also higher for
KaplanMeier analysis. Of note, the presence of DM was asso- MetS vs non-MetS patients for posterior lumbar spine fusion.44
ciated with higher rates of major adverse events and myocardial
infarction in MetS patients compared with the non-MetS group.35
Metabolic syndrome and bariatric surgery
Smolock and colleagues37 studied 738 patients undergoing
supercial femoral artery interventions for symptomatic lower Bariatric surgery is an acceptable and effective method to man-
extremity arterial disease. They found that the overall mortality age obesity-related co-morbidities in morbidly obese patients.45 46
was higher in the MetS group, with patient survival rates of 71 According to the current guidelines, bariatric surgery should be
( 2) and 53 ( 3)% at 5 yr in the non-MetS and MetS groups, re- considered in subjects with a BMI 35 kg m2 in the presence of
spectively. Thirty day major adverse cardiac events were equiva- metabolic disease including type 2 diabetes mellitus and MetS.47
lent, but the incidence of 30 day major adverse limb events was Nearly four in ve patients undergoing bariatric surgery present
higher in the MetS group compared with the non-MetS group.37 with MetS.48 Co-morbidities (cardiac, pulmonary, metabolic, and
hepatic) and complications of morbid obesity in individuals
undergoing bariatric surgery may vary and include multiple sys-
Metabolic syndrome and orthopaedic surgery tems,49 thus posing particular challenges to the anaesthetist.50
Metabolic syndrome may predict adverse outcomes in major Hypertension, dyslipidaemia, and hyperglycaemia (i.e. the key
orthopaedic surgery. Common perioperative complications components of MetS) respond to bariatric surgery.47 A recent
after total joint arthroplasties (TJA) include pulmonary embolism retrospective study on the largest cohort to date of bariatric sur-
(PE), deep vein thrombosis, wound infection, and cardiovascular gery patients did not reveal increased rates of perioperative com-
events.3840 An increased risk for PE has been recognized in plications in obese patients with MetS compared with those
patients who fullled modied MetS criteria and underwent without MetS.48
total hip and knee replacement. In one study, patients with
MetS had a signicantly higher incidence of PE (2.7%, 95% CI
1.84.0%) than patients without MetS (1.3%, 95% CI 1.01.6%, Specic anaesthetic considerations in
P=0.001), and after adjusting for all other signicant risk factors, the management of surgical patients
patients with MetS still had 1.6 times (95% CI 1.012.56; P=0.043) with metabolic syndrome
greater odds for developing PE than those without MetS. Notably,
Metabolic syndrome and atrial brillation
the increasing number of MetS components signicantly
augmented the incidence of PE by 23% for each additional com- Atrial brillation is common after cardiac surgery. It carries
ponent of MetS. The most important MetS component was almost double the morbidity and mortality rate of postoperative
198 | Tzimas et al.

cardiac patients without AF51 and has a signicant impact on those without MetS or no surgery, especially in recent verbal
hospitalization costs.52 Metabolic syndrome has been associated memory tests (P<0.02).64 Besides, cognitive functions appear
with increased incidence of AF in the general population.53 54 One also to be more profoundly affected in subjects with MetS com-
study53 reported 60 events per 10 000 person-yr in MetS patients pared with their healthier counterparts after non-cardiac
and 36 events in patients with no MetS during 15 yr follow-up. surgery.65
They calculated that if MetS could be eliminated with appropriate The results outlined above are documented in a rat model.
treatment, as many as 22% fewer AF events would have occurred. Using this model, MetS produced greater memory impairment
In cardiac surgery, AF affects approximately one-third of post- and persistent learning and memory decline after tibial fracture
operative cardiac patients (1140% after CABG and almost 50% surgery under isourane anaesthesia.66
after valve surgery).5557
The pathophysiological link between MetS and AF has not
Potential treatment options for patients with
been dened. It is speculated that electrical imbalance, which re-
presents the functional component of atrial remodelling, might
metabolic syndrome who will require surgery
be targeted by certain factors. In cardiac surgery patients, these Available evidence3 31 suggests that MetS provides a useful tool to
could include the increased free fatty acids generated during recognize surgical patients at increased risk of peri- and post-
the lipolytic process as a result of perioperative stress in addition operative complications. However, there is a paucity of data
to the inammatory processes linked to cardiopulmonary bypass showing that potential interventions could improve surgery out-
and the inammatory component of the MetS per se.52 58 59 come in patients with MetS.
Echahidi and colleagues,52 in a retrospective study (5085 car- Given that obesity and smoking are main causes of prevent-
diac patients), found that AF was slightly more common (29 vs able mortality,67 therapeutic lifestyle changes, incorporating in-
26%) in those with MetS according to National Cholesterol Educa- tense behavioural intervention to reduce weight and improve
tion Program-Third Adult Treatment Panel criteria than those tness level, are advisable in overweight or obese subjects.68 69
without MetS, and the incidence increased progressively in paral- These interventions could be implemented long before planned
lel with their BMI. Older patients (>50 yr old) presented a signi- surgery in patients with MetS, though their benet may not be
cantly higher incidence of postoperative AF (29 vs 8%) compared easily quantied. Preoperative nutrition therapy (including cal-
with the younger patient group (<50 yr old). In the older patient orie restriction and low-carbohydrate consumption) may be con-
group, obesity (BMI >30 kg m2) and not MetS was found to be sig- sidered in order to prepare patients metabolically for the surgical
nicantly associated with AF, whereas in younger patients the stress; however, the duration and specic measures regarding
presence of MetS doubled the rate of new-onset postoperative nutrition need further investigation.70 In orthopaedic surgery,
AF (from 6 to 12%, P=0.01). Other researchers found contrasting preoperative assessment of nutrition and optimization of nutri-
effects of DM and MetS on postoperative AF after cardiac sur- tional parameters, including tight glucose control and targeted
gery.60 Hurt and colleagues60 showed that MetS was not individu- weight loss, may reduce the risk of perioperative complications,
ally predictive of postoperative AF, but DM appeared to be the including infection.71
decisive factor contributing independently to increased post- Non-alcoholic fatty liver disease is associated with fat accu-
operative incidence of AF. mulation in the liver and insulin resistance and is considered
to be the hepatic manifestation of the MetS.72 73 In this regard,
preoperative low-energy diet appears to reduce liver size and
Metabolic syndrome and intraoperative hyperglycaemia
facilitate the surgical procedure when surgery must be per-
Glycaemic control is an important component of perioperative formed on morbidly obese patients.74 A short-term (4 weeks)
management. While the avoidance of signicant hypergly- low-carbohydrate diet has been proved to be an effective treat-
caemia may decrease perioperative morbidity and mortality, irre- ment strategy for patients with non-alcoholic fatty liver disease
spective of the existence of an established diagnosis of DM, undergoing mainly bariatric surgery or any foregut operations.75
concerns have been raised that strict glycaemic control might in- There is evidence that active smoking is associated with the
crease morbidity and mortality mainly as a result of perioperative development of MetS, whereas smoking cessation appears to
hypoglycaemia and stroke.61 A small prospective study in cardiac reduce the risk of the syndrome.76 Indeed, plasma concentrations
patients revealed that only those with MetS presented signi- of adiponectin, an adipocyte-derived plasma protein that is
cantly enhanced perioperative insulin resistance that was closely related to insulin sensitivity and MetS,77 increase after
accompanied by signicantly higher values of C-reactive pro- smoking cessation.78 Current smoking is also associated with
tein.62 The authors imply a parallel involvement of inammation an elevated risk of mortality in patients undergoing major
and the adverse metabolic state of MetS in the development of surgery,79 while discontinuation of smoking before surgery has
insulin resistance. Clinicians should be alert with regard to a favourable impact on perioperative outcome.80 Consequently,
potentially detrimental effects of immediate postoperative smoking cessation counselling and interventions should be im-
hypoglycaemia as a result of intense intraoperative insulin plemented before surgery for all smokers with metabolic distur-
treatment.63 bances, such as diabetes, obesity, or dyslipidaemia.81
Untreated hypertensive subjects have an increased risk for peri-
operative stroke, myocardial ischaemia, and renal failure.32 8284
Metabolic syndrome and cognitive dysfunction
While hypertension is not a strong independent predictor for
There is some evidence that postoperative cognitive function is perioperative cardiovascular events in the general population
adversely affected by the presence of MetS in cardiac surgery cohort, it is recommended that effective blood pressure control
patients. In a small prospective study of 56 cardiac surgery improves the perioperative risk prole by reducing the extent of
patients (28 with and 28 without MetS)64 and 28 coronary patients target organ damage (i.e. heart failure, stroke, and renal dysfunc-
who did not undergo surgery, verbal and non-verbal memory and tion).32 85 Lifestyle changes, including at least 30 min moderate
executive function were assessed. Patients with MetS had lower aerobic exercise (brisk walking, cycling etc.) 34 days per week
scores both before and 1 week after surgery compared with may improve blood pressure and glycaemic control.8688
 Metabolic syndrome and surgical patients | 199

Disorders of haemostasis have been documented in subjects and non-cardiac surgery. Metabolic syndrome probably contri-
with MetS.12 Indeed, coagulation is enhanced in MetS because of butes to even more perioperative events, with the most common
the increased plasma concentrations of brinogen, tissue factor being cardiac, pulmonary, renal, cerebrovascular, thrombo-
and factor VII, which are related to inammation and central embolic, sepsis, and wound infection. Metabolic syndrome has
obesity.12 8992 These abnormalities, combined with the de- been correlated with a prolonged length of hospital stay after
creased brinolytic activity, in patients with MetS contribute to major surgery and a higher need for posthospitalization care, re-
a greater risk of thrombotic events (arterial and venous).93 94 sulting in additional cost. Despite several denitions of MetS cur-
Diet and lifestyle changes can affect coagulation and brinoly- rently in use, the recognition of MetS as a group of risk factors for
sis.95 However, we need to establish whether commonly used perioperative adverse outcomes urges clinicians to recognize the
medications (e.g. antihypertensive agents and statins) inuence syndrome, to familiarize themselves with its characteristics, and
haemostasis in patients with MetS. Obesity and insulin resist- most importantly, to formulate management strategies that
ance enhance platelet activity in subjects with MetS.12 96 Finally, could possibly lead to a reduction of perianaesthetic and peri-
the surgical procedure per se is associated with platelet activa- operative risks. More research in this eld is required. Apart
tion.97 Discontinuation of antithrombotic drugs because of con- from specically designed studies, the use of registries could
cerns regarding perioperative bleeding in patients with MetS prove useful.
may carry an even greater thrombotic risk. This is of major im-
portance in patients with previous coronary stenting.98 There-
fore, it is advisable that antithrombotic treatment should be Authors contributions
tailored according to the estimated risk of surgical bleeding vs Study planning: P.T., H.M., G.P.
thrombotic complications. Manuscript preparation: P.T., A.P., E.L., H.M., D.P.M.
Statins are the principal lipid-lowering agents. Their protect- Analysis and interpretation of data: P.T., D.P.M., G.P.
ive role exceeds their ability to change blood lipid concentra- Data collection: A.P., E.L.
tions.99 These agents appear to have favourable pleiotropic Manuscript approval: all authors.
effects on vascular endothelial function, atherosclerotic plaque
stability, inammation, and thrombosis.100 101 There is no con-
clusive evidence or guidelines regarding the appropriate time to Declaration of interest
initiate statin therapy before an elective surgical procedure in
statin-naive patients with MetS. However, based on current evi- None declared.
dence for patients undergoing vascular surgery 102 we suggest
that statins should be started as soon as possible in statin-
naive patients with MetS (at least 2 weeks before elective high-
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