Adipose tissue composition determines its computed tomography radiodensity

OBJECTIVES

Adipose tissue radiodensity in computed tomography (CT) performed before surgeries can predict surgical difficulty. Despite its clinical importance, little is known about what influences radiodensity. This study combines desorption electrospray ionization mass spectrometry imaging (DESI-MSI) and electrospray ionization (ESI) with machine learning to unveil how chemical composition of adipose tissue determines its radiodensity.

METHODS

Patients in the study underwent abdominal surgeries. Before surgery, CT radiodensity of fat near operated sites was measured. Fifty-three fat samples were collected and analyzed by DESI-MSI, ESI, and histology, and then sorted by radiodensity, demographic parameters, and adipocyte size. A non-negative matrix factorization (NMF) algorithm was developed to differentiate between high and low radiodensities.

RESULTS

No associations between radiodensity and patient age, gender, weight, height, or fat origin were found. Body mass index showed negative correlation with radiodensity. A substantial difference in chemical composition between adipose tissues of high and low radiodensities was observed. More radiodense tissues exhibited greater abundance of high molecular weight species, such as phospholipids of various types, ceramides, cholesterol esters and diglycerides, and about 70% smaller adipocyte size. Less radiodense tissue showed high abundance of short acyl-tail fatty acids.

CONCLUSIONS

This study unveils the connection between abdominal adipose tissue radiodensity and its chemical composition. Because the radiodensity of the fat around the surgical site is associated with surgical difficulty, it is important to understand how adipose tissue composition affects this parameter. We conclude that fat tissue with a higher content of various phospholipids and waxy lipids is more CT radiodense.

CLINICAL RELEVANCE STATEMENT

This study establishes the connection between the CT radiodensity of adipose tissue and its chemical composition. Clinicians may use this information for preoperative planning of surgical procedures, potentially modifying their surgical approach (for example, performing partial nephrectomy openly rather than laparoscopically).

KEY POINTS

• Adipose tissue radiodensity values in computed tomography images taken prior to the surgery can potentially predict surgery difficulty. • Fifty-three human specimens were analyzed by advanced mass spectrometry, molecular imaging, and machine learning to establish the key features that determine Hounsfield units' values of adipose tissue. • The findings of this research will enable clinicians to better prepare for surgical procedures and select operative strategies.

Port Site Obstructed Hernia in a Morbidly Obese Patient: A Case Report

Indications for laparoscopic surgeries are increasing in the current era in view of the advantages they offer in terms of less perioperative morbidities, early mobilization, and better cosmesis. These benefits are perceived even more in obese women. However, there are special challenges in this population, associated with their body habitus, poor visibility, and perioperative anesthesia risks. Difficulty in port closure is one such problem encountered in these women causing inadequate rectus suturing and leading to port site hernia. We report a case of a 59-year-old morbidly obese lady who underwent a total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymph node dissection for carcinoma endometrium. The intraoperative course was uneventful. In the postoperative period, she developed acute obstruction due to port site herniation of the small bowel, which was not suspected till postoperative day five. This was due to an inaccurate assessment of her abdomen because of her body habitus. A CT scan was done in view of the non-resolving obstruction, which revealed herniation of a small bowel loop through the umbilical port. Immediate correction was resorted to under local anesthesia. Rectus sheath closure was done in the same sitting. The patient had a quick recovery after that and was discharged three days later. Rectus sheath closure should be done for all ports 10 mm or greater in diameter. There should be a low threshold to get cross-sectional imaging in postoperative obese women with non-resolving gastrointestinal symptoms.

A Practical Approach to Total Laparoscopic Hysterectomy in a Morbidly Obese Patient: A Case Report and Literature Review

Morbid obesity, traditionally considered to be a contraindication to total laparoscopic hysterectomy, is now evolving into an indication. Innovations and advancements in minimally invasive surgical techniques have significantly improved patient morbidity and mortality rates, reduced operational costs, and provided patients with an overall safer surgical experience. Although the laparoscopic approach is associated with several physiologic and technical challenges in the morbidly obese, it is plausible that these patients stand to benefit the most from minimally invasive surgery. This report highlights the methods of preoperative optimization, intraoperative considerations, and postoperative management strategies employed to achieve a successful total laparoscopic hysterectomy, bilateral salpingo-oophorectomy and pelvic lymph node dissection in a patient with a BMI of 45kg/m², diagnosed with grade 1 endometrial adenocarcinoma and several obesity-related comorbidities.

Relaparoscopy in the management of post-operative complications after minimally invasive gastrectomy for gastric cancer

Laparoscopy has already been validated for treatment of early gastric cancer. Despite that, no data have been published about the possibility of a minimally invasive approach to surgical complications after primary laparoscopic surgery. In this multicentre study, we describe our experience in the management of complications following laparoscopic gastrectomy for gastric cancer. A chart review has been performed over data from 781 patients who underwent elective gastrectomy for gastric cancer between January 1996 and July 2020 in two high referral department of gastric surgery. A fully descriptive analysis was performed, considering all the demographic characteristics of patients, the type of primary procedure and the type of complication which required reoperation. Moreover, a logistic regression was designed to investigate if either the patients or the primary surgery characteristics could affect conversion rate during relaparoscopy. Fifty-one patients underwent reintervention after elective laparoscopic gastric surgery. Among patients who received a laparoscopic reintervention, 11 patients (34.3%) required a conversion to open surgery. Recovery outcomes were significantly better in patients who completed the reoperation through laparoscopy. Relaparoscopy is safe and effective for management of complications following laparoscopic gastric surgery and represent a useful tool both for re-exploration and treatment, in expert and skilled hands.

The impact of obesity on minimally invasive colorectal surgery: A report from the Surgical Care Outcomes Assessment Program collaborative

BACKGROUND

Operating on obese patients can increase case complexity and result in worse outcomes. We described the incremental impact of BMI on morbidity and outcomes of colorectal operations and whether laparoscopic and robotic(MIS) approaches mitigate this morbidity differently.

METHODS

A retrospective cohort of patients undergoing elective colorectal operations in SCOAP was created to examine the association of increasing BMI on surgical outcomes. Additionally, multivariable logistic regression models were constructed.

RESULTS

From 2011 to 2019, 22,863 elective colorectal operations (mean age 62, 55% female) were performed at 42 hospitals. Patients had BMI≥30 in 7576(33%) and BMI≥40 in 1180(5%) of operations. After risk adjustment, BMI≥40 was associated with increased conversions(OR1.57,95%CI1.26-1.96), increased combined adverse events(CAE)(OR1.32,95%CI1.15-1.52), and death(OR2.24, 95%CI1.41-3.55)(all p < 0.01). MIS approaches were each associated with lower CAE(lap OR0.49,95%CI0.46-0.53; robot OR0.42,95%CI0.37-0.47), and death(lap OR0.24,95%CI0.18-0.33; robot OR0.18,95%CI0.10-0.35)(all p < 0.01).

CONCLUSIONS

Severe obesity is associated with increased conversion rates and worse short-term outcomes after colorectal surgery, though this trend is partially mitigated with a minimally invasive approach. These findings support the broad application of MIS for colorectal operations in obese patients.

Randomized control trial on effectiveness and safety of direct trocar versus Veress needle entry techniques in obese women during diagnostic laparoscopy

PURPOSE

To determine the benefits and safety of direct trocar insertion versus Veress needle technique in obese women undertaking diagnostic laparoscopy procedures.

METHODS

Randomized-controlled trial on 135 obese women undergoing diagnostic laparoscopy and dye test for infertility was conducted. Women were randomly assigned to either direct trocar access (n = 68) or Veress needle access (n = 67) before achieving pneumoperitoneum. The same surgeon executed the laparoscopic techniques with a single-puncture technique. The primary outcome measures included total length of the procedure and incidence of any complications, while the mean laparoscopic entry time, volume of CO₂ required, and total of tries needed to attain successful entry were secondary outcomes. Intention-to-treat principle was applied to analysis.

RESULTS

Women in both groups had similar socio-demographic and clinical characteristics and none were lost to follow-up. The overall length of the procedure was significantly lesser in the direct trocar group compared to the Veress needle group (9.9 ± 6.0 vs 16.7 ± 4.7 min; p < 0.001). No significant differences occurred in other outcomes including mean entry time, volume of CO₂ used, number of attempts for successful entry, and major/minor complications (p > 0.05).

CONCLUSIONS

Direct trocar technique may be an effective alternative to Veress needle for pneumoperitoneum in obese women for diagnostic laparoscopy. It has a comparable rapid laparoscopic entry time but a significantly lower duration of the procedure and shorter exposure to anesthesia. Both methods are equally effective as there was no significant difference in the complications recorded. A greater sample trial may be essential for more corroborative substantiation.

CLINICAL TRIAL REGISTRATION

PACTR201510000999192.

Multifactorial impact on the outcome of interval debulking surgery in patients with advanced epithelial ovarian or peritoneal cancers

OBJECTIVE

To evaluate the impact of multiple clinical features upon the outcome of interval cytoreductive surgery and thus upon the survival in patients with advanced ovarian cancer and primary peritoneal carcinoma.

METHODS

A retrospective analysis of patients receiving NACT followed by IDS between 2009 and 2017. Patients were analyzed according to the pre-NACT CA125, pre-IDS CA125, pre-IDS CA125 decline, patients' pre-IDS BMI, multisite bowel involvement and different working years of surgeons, for their influence upon the IDS outcome (e.g. optimal vs suboptimal) and the survival.

RESULTS

After interval debulking surgery following 1-6 cycles of NACT, all patients analyzed were identified as optimal (n = 113) and suboptimal (n = 47) based on patients' record. The PFS/OS were 21/68 months and 9/26 months in optimal and suboptimal groups, respectively (p = .000, p = .000). Although differential levels of pre-IDS CA125, pre-IDS CA125 decline, bowel involvement and surgeons' working years were found to be significantly different between the two groups, surgeons' working years and multisite bowel invasion were the independent factors for IDS outcome, and the latter one was also highly related to survival.

CONCLUSIONS

Following NACT, the rate of optimal IDS might be improved for patients without multisite bowel involvement. For those with bowel involvement, management strategy made by well-experienced surgeons might be a key factor for the outcome of IDS.

Influences of Total Laparoscopic Hysterectomy According to Body Mass Index (Underweight, Normal Weight, Overweight, or Obese)

Study Objective:

The aim of this study is to evaluate the effect of body mass index (BMI) on laparoscopic hysterectomy outcomes.

Design:

This was retrospective study.

Setting:

Minoh City Hospital, Japan.

Materials and Methods:

Between January 1, 2014, and June 30, 2017, 183 patients underwent total laparoscopic hysterectomy (TLH) at our institution.

Intervention:

Patients who underwent TLH were grouped according to BMI, as follows: underweight group (BMI <18.5 kg/m²), normal-weight group (18.5 ≤BMI <25 kg/m²), overweight group (25 ≤BMI <30 kg/m²), and obese group (BMI ≥30 kg/m²).

Measurements and Main Results:

Information on patients’ clinical characteristics and surgical results were collected retrospectively by medical record review. The severity of complications was graded according to the Clavien–Dindo classification. We assessed clinical characteristics, surgical results, and the perioperative complications in each BMI group. Surgical results included operation time, nonsurgical operating room time estimated blood loss, uterine weight, and postoperative hospital stay. Compared with the normal-weight group, the obese group had significantly more complications (P = 0.012) and longer operation time (P = 0.04). The underweight and overweight groups did not have significantly different surgical results than the normal-weight group.

Conclusion:

Underweight and overweight patients had no significant differences in surgical results, compared with patients of normal weight. Obese patients had significantly longer operation times and more perioperative complications than patients with normal weight. Laparoscopic hysterectomy has burdens and risks for obese patients. Our results suggest that appropriate weight control may decrease the risk of surgery for obese patients.