The impact of obesity on outcomes following pancreatectomy for malignancy

Body mass index and pancreatic adenocarcinoma: A nationwide registry-based cohort study

BACKGROUND AND OBJECTIVE

An association between body mass index (BMI) and pancreatic cancer is suggested in observational studies. However, further studies are required to substantiate available evidence. The aim of this study was to explore the association between BMI and pancreatic ductal adenocarcinoma (PDAC) risk, treatment, and mortality.

METHODS

A registry-based cohort study was performed by combining data from four registries in Norway. Baseline data were collected between 1963 and 1975 with follow-up data collected until 2018. Kaplan-Meier curves and multivariable Cox regressions were estimated. Chi-square tests were used to analyze differences between groups.

RESULTS

The study cohort consisted of 1,723,692 individuals. A total of 8973 PDAC cases were identified during 55,744,749 person-years of follow-up. A 5 kg/m² increase in BMI was associated with an increased risk of PDAC if high BMI at young age (16-29 years) (hazard ratio (HR): 1.21, 95% confidence interval (CI): 1.13-1.31), both for men (HR: 1.30, 95% CI: 1.15-1.46) and women (HR: 1.16, 95% CI: 1.05-1.28). In men, there was a 52% increase in risk of early-onset PDAC (<age 50) (HR: 1.52, 95% CI: 1.13-2.03) with 5 kg/m² increase in BMI. A total of 2645 individuals were diagnosed with stage 1-3 disease, of whom 1131 underwent curative surgery. In all, 49% of normal weight, 38% overweight, and 30% obese individuals with stage 1-3 PDAC underwent surgery with curative intent (p < 0.001). Cancer survival was lower in overweight and obese individuals for both sexes. Analysis adjusted for sex, age, and period of diagnosis confirmed increased risk of cancer death in obese individuals.

CONCLUSION

This study suggests that increased BMI in young adults may increase the risk of PDAC, and higher BMI in men is associated with an increased risk of early onset PDAC (<age 50). Overweight and obese individuals were less likely to undergo curative surgery and obese individuals had a higher risk of cancer-related death.

Obesity affects outcomes of pancreatoduodenectomy

BACKGROUND

Obesity is a major global health problem, and it has reached epidemic proportions worldwide. Therefore, surgeons will confront an increasingly larger proportion of obese candidates for pancreatoduodenectomy (PD) in the future. Several small retrospective studies have been conducted to evaluate the role of Body Mass Index (BMI) in postoperative surgical complications after PD, with conflicting results. The aim of this study was to use a large multi-institutional database to clarify the impact of different levels of obesity after PD.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was queried for patients who underwent PD from 2014 to 2016. Patients were categorized in the following six BMI groups: <18.5 (Underweight), 18.5-24.9 (Normal Weight), 25-29.9 (Overweight), 30-34.9 (Class I obesity), 35-39.9 (Class II Obesity) and >40 (Class III Obesity). The primary outcomes of interest were 30-day mortality and morbidity after PD among the six BMI groups.

RESULTS

The final population consists of 10,316 patients. Class III is associated with higher risk of 30-day mortality (OR 2.56, 95% CI 1.25-5.25, p = 0.011), major complications (OR 2.23, 95% CI 1.54-3.22, p < 0.001), clinically relevant postoperative pancreatic fistula (OR 2.48, 95% CI 1.89-3.24, p < 0.001), surgical site infections (OR 2.06, 95% CI 1.61-2.65, p < 0.001) and wound dehiscence (OR 3.47, 95% CI 1.7-7.1, p < 0.001) in multivariable analysis.

CONCLUSIONS

In conclusion, our study shows that obesity is significantly associated with higher risk of postoperative complications in patients undergoing PD and patients with BMI≥40 have increased risk of mortality after PD.

The impact of obesity and severe obesity on postoperative outcomes after pancreatoduodenectomy

BACKGROUND

The impact of obesity on postoperative outcomes after pancreatoduodenectomy remains insufficiently studied.

METHODS

All pancreatoduodenectomy patients were abstracted from the 2014 to 2018 American College of Surgeons National Surgical Quality Improvement Program data sets and were stratified into the following 3 body mass index categories: non-obese (body mass index 18.5-29.9), class 1/2 obesity (body mass index 30-39.9), and class 3 severe obesity (body mass index ≥ 40). Analyses tested associations between patient factors and four 30-day postoperative outcomes: mortality, composite morbidity, delayed gastric emptying, and postoperative pancreatic fistula. Multivariable logistic regression models tested independent associations between patient factors and these 4 outcome measures.

RESULTS

A total of 16,823 patients were included in the study: 12,234 (72.7%) non-obese, 4,030 (24%) obese, and 559 (3.3%) with severe obesity. Bivariable analyses demonstrated significant associations between obesity, severe obesity, and greater proportions of numerous preoperative comorbidities as well as a greater likelihood of postoperative complications, including postoperative pancreatic fistula, delayed gastric emptying, composite morbidity, and mortality (all P ≤ .001). After adjusting for significant covariates, obesity was independently associated with postoperative pancreatic fistula (odds ratio 1.49, 95% confidence interval: 1.33-1.67, P < .001), delayed gastric emptying (odds ratio 1.16, 95% confidence interval: 1.05-1.28, P = .004), composite morbidity (odds ratio 1.28, 95% confidence interval: 1.18-1.38, P < .001), and mortality (odds ratio 1.79, 95% confidence interval: 1.36-2.36, P < .001).

CONCLUSION

Obesity and severe obesity are significantly associated with worse short-term outcomes after pancreatoduodenectomy. Preoperative considerations, such as weight management strategies during individualized treatment planning, could improve outcomes in this population.

Obesity and Pancreatic Cancer: A Matched-Pair Survival Analysis

BACKGROUND

Morbid obesity is a risk factor for pancreatic ductal adenocarcinoma (PDAC). However, the impact of obesity on postoperative outcomes and overall survival in patients with PDAC remains a controversial topic.

METHODS

Patients who underwent pancreatic surgery for PDAC between 1997 and 2018 were included in this study. Matched pairs (1:1) were generated according to age, gender and American Society of Anesthesiologists status. Obesity was defined according to the WHO definition as BMI ≥ 30 kg/m². The primary endpoint was the difference in overall survival between patients with and without obesity.

RESULTS

Out of 553 patients, a total of 76 fully matched pairs were generated. Obese patients had a mean BMI-level of 33 compared to 25 kg/m² in patients without obesity (p = 0.001). The frequency of arterial hypertension (p = 0.002), intraoperative blood loss (p = 0.039), and perineural invasion (p = 0.033) were also higher in obese patients. Clinically relevant postoperative complications (p = 0.163) and overall survival rates (p = 0.885) were comparable in both study groups. Grade II and III obesity resulted in an impaired overall survival, although this was not statistically significant. Subgroup survival analyses revealed no significant differences for completion of adjuvant chemotherapy and curative-intent surgery.

CONCLUSIONS

Obesity did not affect overall survival and postoperative complications in these patients with PDAC. Therefore, pancreatic surgery should not be withheld from obese patients.

The Effect of Obesity on Response to Neoadjuvant Therapy in Locally Advanced Gastric Cancer

Introduction:

The effect of obesity on response to neoadjuvant chemotherapy (NACT) remains unknown. We aimed to investigate the effect of obesity on response to NACT and survival in locally-advanced gastric cancer (GC).

Methods:

From 2010 to 2019, 142 GC patients with clinical stage III disease who underwent curative surgery after NACT were enrolled. Patients were divided into 3 groups according to body mass index (BMI) as follows; BMI < 25 kg/m², BMI = 25-30 kg/m², and BMI > 30 kg/m². The Mandard tumor regression grading system was used for tumor regression grade (TRG).

Results:

Of the 142 GC patients, 45(31.7%) were female. The median age was 58 years. BMI was < 25 kg/m² in 60 (42.3%) patients, 25-30 kg/m2 in 44 (31%) patients, and > 30kg/m² in 38 (26.8%) patients. The numbers of patients with TRGI-II, TRGIII, and TRGIV-V were 35 (24.6%), 44 (31%), and 63 (44.4%), respectively. There was no statistically significant difference among BMI groups in terms of disease-free survival (DFS) and overall survival (OS) (p = 0.919 and p = 0.398, respectively). According to TRG groups; mDFS was 46 months in TRG I-II, 28 months in TRG III, and 18 months in TRG IV-V (p<0.001). In multivariate analysis, presence of perineural invasion and lymphovascular invasion were the factors affecting TRG.

Conclusion:

In our study, we found that pre-treatment obesity did not affect the TRG in clinical stage III GC patients. However, a better TRG status was associated with improved survival.

The role of older age and obesity in minimally invasive and open pancreatic surgery: A systematic review and meta-analysis

BACKGROUND/OBJECTIVES

The aim of this study was to assess the impact of older age (≥70 years) and obesity (BMI ≥30) on surgical outcomes of minimally invasive pancreatic resections (MIPR). Subsequently, open pancreatic resections or MIPR were compared for elderly and/or obese patients.

METHODS

A systematic review was conducted as part of the 2019 Miami International Evidence-Based Guidelines on MIPR (IG-MIPR). Study quality assessment was according to The Scottish Intercollegiate Guidelines Network (SIGN). A meta-analysis was performed to assess the impact of MIPR or open pancreatic resections in elderly patients.

RESULTS

After screening 682 studies, 13 observational studies with 4629 patients were included. Elderly patients undergoing laparoscopic distal pancreatectomy (LDP) had less blood loss (117 mL, p < 0.001) and a shorter hospital stay (3.5 days p < 0.001) than elderly patients undergoing open distal pancreatectomy (ODP). Postoperative pancreatic fistula (POPF) B/C, major complication and reoperation rate were not significantly different in elderly patients undergoing either laparoscopic or open pancreatoduodenectomy (OPD). One study compared robot PD with OPD in obese patients, indicating that patients with robotic surgery had less blood loss (mean 250 ml vs 500 ml, p = 0.001), shorter operative time (mean 381 min vs 428 min, p = 0.003), and lower rate of POPF B/C (13% vs 28%, p = 0.039).

CONCLUSION

The current available limited evidence does not suggest that MIPR is contraindicated in elderly or obese patients. Additionally, outcomes in MIPR are equal or more beneficial compared to the open approach when applied in these patient groups.

Relationship between Cancer Diagnosis and Complications Following Pancreatoduodenectomy for Duodenal Adenoma

BACKGROUND

Pancreatoduodenectomy (PD) for duodenal adenoma (DA) resection may be associated with excessive surgical risk for patients with potentially benign lesions, given the absence of pancreatic duct obstruction. We examined factors associated with final malignant pathology and evaluated the postoperative course of patients with DA versus pancreatic ductal adenocarcinoma (PDAC).

METHODS

We retrospectively analyzed patients with DA who underwent PD from 2008 to 2018 and assessed the accuracy rate of preoperative biopsy and factors associated with final malignant pathology. Complications for DA patients were compared with those of matched PDAC patients.

RESULTS

Forty-five consecutive patients who underwent PD for DA were identified, and the preoperative biopsy false negative rate was 29. Factors associated with final malignant pathology included age over 70 years, preoperative biliary obstruction, and common bile duct diameter > 8 mm (p < 0.05). Compared with patients with PDAC (n = 302), DA patients experienced more major complications (31% vs. 15%, p < 0.01), more grade C postoperative pancreatic fistulas (9% vs. 1%, p < 0.01), and greater mortality (7% vs. 2%, p < 0.05). Propensity score matched patients with DA had more major complications following PD (32% vs. 12%, p < 0.05).

CONCLUSIONS

Preoperative biopsy of duodenal adenomas is associated with a high false-negative rate for malignancy, and PD for DA is associated with higher complication rates than PD for PDAC. These results aid discussion among patients and surgeons who are considering observation versus PD for DA, especially in younger patients without biliary obstruction, who are less likely to harbor malignancy.

Higher body mass index deteriorates postoperative outcomes of pancreaticoduodenectomy

BACKGROUND

Previous studies presented controversies in impact of body mass index (BMI) on perioperative complications in pancreatectomy, and mainly focused on Western population. This study aimed to explore the impact of BMI on perioperative outcomes in Chinese patients undergoing pancreaticoduodenectomy.

METHODS

Seven hundred and seven adult patients undergoing open pancreaticoduodenectomy between January 2005 and December 2016 at Ruijin Hospital were studied retrospectively and categorized as obese (BMI ≥25 kg/m²), overweight (BMI ≥23 kg/m² and <25 kg/m²), or normal weight (BMI ≥18.5 kg/m² and <23 kg/m²). Associations of these BMI groups with perioperative outcomes were evaluated.

RESULTS

The overweight and obese groups experienced higher risk of clinically related postoperative pancreatic fistula (CR-POPF) (7.6% vs. 9.9% vs. 17.6%, P = 0.002) and re-operation (1.1% vs. 2.5%  vs. 5.1%, P = 0.017), and longer systemic inflammation response syndrome (SIRS) duration [2 (1-9) d vs. 2 (1-7) d vs. 3 (1-10) d, P = 0.003] and postoperative hospital stay [19 (2-84) d vs. 19 (7-158) d vs. 23 (8-121) d, P = 0.023] than the normal weight group did. The multiple logistic regression models showed obese as an independent risk factor for CR-POPF (P = 0.013). The multiple linear regression analysis confirmed BMI as a predictor for prolonged postoperative hospital stay (P = 0.005).

CONCLUSIONS

Higher BMI results in higher morbidity of Chinese patients undergoing open pancreaticoduodenectomy. Pancreaticoduodenectomy is still a safe surgery procedure for overweight and obese patients, with intensive perioperative management.

The Impact of Sarcopenia on Postoperative Course following Pancreatoduodenectomy: Single-Center Experience of 110 Consecutive Cases

BACKGROUND

Despite that mortality following pancreatoduodenectomy (PD) has gradually dropped during the past few decades, the incidence of postoperative complications remains high, ranging from 30-60%. Many studies have been focused on identification of perioperative risk factors for morbidity, and in recent years, sarcopenia has been pointed out as a valid predictor of postoperative complication.

MATERIALS AND METHODS

Perioperative data from 110 consecutive patients who underwent PD were retrieved, and the presence of sarcopenia was assessed by the measurement of Hounsfield unit average calculation on preoperative CT scans. Postoperative complications were graded according to Clavien-Dindo classification, and the morbidity burden was assessed by comprehensive complication index (CCI) calculation.

RESULTS

Sarcopenia was associated with advanced age (72 vs. 66 years; p = 0.014) and lower preoperative albumin levels (3.5 vs. 3.7 g/dL; p = 0.010); it represented an independent risk factor for clinically relevant complications (relative risk: 1.71; p = 0.015) and was related to a higher rate of Grade C postoperative pancreatic fistula (50.0 vs. 11.4%; p = 0.005) and a higher CCI (47.6 vs. 29.6; p = 0.001).

CONCLUSIONS

Sarcopenia represents a valid indicator of increased morbidity risk and may play a central role in preoperative risk stratification, allowing the selection of patients who may benefit from prehabilitation programs.

Pancreatectomy and body mass index: an international evaluation of cumulative postoperative complications using the comprehensive complications index

BACKGROUND

Overweight and obese patients undergoing pancreatectomy are at increased risk for postoperative complications and readmission. We examined the association between body mass index (BMI) and postoperative complications following major pancreatectomy using the novel Comprehensive Complications Index (CCI), which analyzes the impact of multiple surgical complications rather than just the most severe.

METHODS

We performed a retrospective dual institutional international review of 500 consecutive patients who underwent pancreatic resection and assessed the association of BMI with postoperative complications using the CCI and Clavien-Dindo Classification (CDC) with uni- and multivariable analyses.

RESULTS

Overweight and obese patients undergoing pancreatic resection demonstrated a higher incidence and severity of CCI-measured complications (29.3 vs. 21.1, P < 0.001), more pancreatic fistulae (15.4 vs. 8.8%, 95% CI 1.005 -1.902), and an increased 30-day readmission rate (21.1 vs. 12.1%, 95% CI 1.067 -1.852) (all p < 0.05) than normal-BMI patients. The CCI was a more sensitive marker of post-pancreatectomy complications relative to the CDC, with a higher multicomplication rate in overweight/obese patients (54.8% vs. 44.5%).

CONCLUSION

Patients with overweight and obese body mass index undergoing major pancreatectomy demonstrated higher rates of postoperative complications, pancreatic fistulae, and readmissions. The CCI is a more robust and sensitive tool to assess post-pancreatectomy complications than the CDC.

Obesity and surgical complications of pancreaticoduodenectomy: An observation study utilizing ACS NSQIP

BACKGROUND

An estimated 38% of US adults are obese. Obesity is associated with socioeconomic disparities and increased rates of comorbidities, and is a known risk factor for development of pancreatic cancer. As a fourth leading cause of death in the United States, pancreatic cancer is commonly treated with a pancreatico-duodenectomy (PD), or Whipple procedure. Data regarding the effects of obesity on post-operative complication rate primarily comes from specialized centers, however the results are mixed. Our aim is to elucidate the effects that obesity has on outcomes after PD for pancreatic head cancer using a national prospectively maintained clinical database.

METHOD

The 2010-2015 American College of Surgeons National Surgical Quality Improvement Project (ACS NSQIP) Participant Use Files (PUF) were used as the data source. We identified cases in which PD was performed (CPT code 48150) in the setting of a postoperative diagnosis of pancreatic cancer (ICD9 code 157.0). We excluded cases that had emergency admissions, BMI ≤18.5 kg/m², intraoperative wound classification of III or IV, and disseminated cancer. Cases with missing BMI, preoperative albumin, operative time, LOS data were also excluded. Multiple imputation for missing sex, race, functional status, and ASA classification using chained equations was performed.¹⁶ Patients that had BMI ≥30 kg/m² were considered obese, and patients with BMI <30 kg/m² were used as control.

RESULTS

3484 patients underwent pancreaticoduodenectomy for pancreatic cancer. 860 patients were identified as obese. Propensity score analysis was performed matching age, sex, race, functional status, presence of dyspnea, diabetes, hypertension, acute renal failure, dialysis dependence, ascites, steroid use, bleeding disorders, history of chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), weight loss, American Society of Anesthesiologists (ASA) classification, and preoperative albumin levels. After matching, obese patients had higher risk of 30-day postoperative complications compared to control, including organ space wound infections (OR 1.38, 95% CI 1.07-1.79, p = 0.0128), returning to the operating room (OR 1.39, 95% CI 1.01-1.91, p = 0.0461), failure to extubate for greater than 48 h (OR 1.60, 95% CI 1.09-2.34, p = 0.0153), death (OR 1.68, 95% CI 1.01-2.78, p = 0.0453), septic shock (OR 2.22, 95% CI 1.46-3.38, p = 0.0002), pulmonary embolism (OR 2.42, 95% CI 1.07-5.45, p = 0.0332), renal insufficiency (OR 2.67, 95% CI 1.33-5.38, p = 0.0058). Sensitivity analysis yielded similar results with the exception of risk for return to the operating room, death, and pulmonary embolism, P > .05.

CONCLUSION

In this large observational study using a national clinical database, obese patients undergoing PD for head of pancreas cancer had increased risk of postoperative complications and mortality in comparison to controls.

Visceral fat area, not body mass index, predicts postoperative 30-day morbidity in patients undergoing colon resection for cancer

PURPOSE

Colectomy for cancer in obese patients is technically challenging and may be associated with worse outcomes. Whether visceral obesity, as measured on computed tomography, is a better predictor of complication than body mass index (BMI) or determines long-term oncologic outcomes has not been well characterized. This study examines the association between derived anthropometrics and postoperative complication and long-term oncologic outcomes.

METHODS

Retrospective review of patients undergoing elective colectomy for cancer at a single tertiary-care center from 2010 to 2016. Adipose tissue distribution measurements, including visceral fat area (VFA), were determined from preoperative imaging. The primary outcome was 30-day postoperative complication; secondary outcomes included overall and disease-free survival. Multivariable logistic regression was performed to determine association between obesity metrics and outcome.

RESULTS

Two hundred and sixty-four patients underwent 266 primary resections of colon cancer. Twenty-eight patients (10.5%) developed major morbidity (Clavien-Dindo grade ≥ III). VFA but not BMI was significantly associated with morbidity in multivariate analysis (p = 0.004, odds ratio 1.99, 95% confidence interval 1.25-3.19). No other imaging-derived anthropometric was associated with increased morbidity. In receiver operating characteristic analysis, VFA was predictive of major morbidity (area under curve 0.660). A cutoff value of VFA ≥ 191 cm² was associated with 50% sensitivity and 76% specificity for predicting major morbidity. Patients with VFA ≥ 191cm² had 19.4% risk of morbidity, whereas those with < 191 cm² had 7.2% risk (relative risk ratio 2.69, unadjusted p = 0.004). Neither VFA nor BMI was associated with overall or disease-free survival.

CONCLUSION

VFA but not BMI predicts morbidity following elective surgery for colon cancer.

Obesity as a surgical risk factor

In recent years, both the actual number of overweight/obese individuals and their proportion of the population have steadily been rising worldwide and obesity-related diseases have become major health concerns. In addition, as obesity is associated with an increased incidence of gastroenterological cancer, the number of obese patients has also been increasing in the field of gastroenterological surgery. While the influence of obesity on gastroenterological surgery has been widely studied, very few reports have focused on individual organs or surgical procedures, using a cross-sectional study design. In the present review, we aimed to summarize the impacts of obesity on surgeries for the esophagus, stomach, colorectum, liver and pancreas. In general, obesity prolongs operative time. As to short-term postoperative outcomes, obesity might be a risk for certain complications, depending on the procedure carried out. In contrast, it is possible that obesity doesn't adversely impact long-term surgical outcomes. The influences of obesity on surgery are made even more complex by various categories of operative outcomes, surgical procedures, and differences in obesity among races. Therefore, it is important to appropriately evaluate perioperative risk factors, including obesity.

Impact of obesity on short and long term results following a pancreatico-duodenectomy

BACKGROUND

The impact of obesity on short and long term outcomes following a pancreatico-duodenectomy (PD) is still unclear and needs further clarification.

METHODS

Demographic, operative and outcomes data in 524 patients undergoing PD were analysed.

RESULTS

Ninety-seven patients (18.5%) had BMI greater than or equal to 30 kg/m² (group A) and 427 patients (81.5%) had BMI less than 30 kg/m² (group B). Group A had a significantly greater operative duration, (375 vs 360 min, p = 0.024) and a higher intra-operative blood loss, (660 vs 500 ml, p = 0.005). Post-operative pancreatic fistula (POPF) were more common in Group A (28.9% vs 16.2%, p = 0.006), this difference was also observed when considering only major POPF (Grade B and C) (16.5% vs 8.0%, p = 0.020). Intra-abdominal collections were higher in Group A, 28.9% compared to 19.0% in Group B (p = 0.037). On multivariate analysis BMI (OR 2.006; 95% CI 1.147-4.985, p = 0.040), small pancreatic duct (OR 2.755; 95% CI 1.589-2.968, p = 0.026) and soft pancreas (OR 2.289; 95% CI 1.126-3.665, p = 0.040) were found to be independent factors for POPF. The median survival for adenocarcinomas was 20 months in Group A and 22 months in Group B, (p = 0.109).

CONCLUSION

Patients with BMI ≥ 30 are at an increased risk of developing pancreatic fistula following PD. Obesity does not appear to have an impact on long term outcomes in patients undergoing a PD for adenocarcinomas.

Robotic approach mitigates perioperative morbidity in obese patients following pancreaticoduodenectomy

INTRODUCTION

The aim was to evaluate the impact of obesity on perioperative outcomes in patients undergoing robotic pancreaticoduodenectomy (RPD) compared to open pancreaticoduodenectomy (OPD).

METHODS

A retrospective review of all pancreaticoduodenectomies from 9/2011 to 4/2015 was performed. Obesity was defined as body mass index (BMI) > 30 kg/m².

RESULTS

Of 474 pancreaticoduodenectomies performed: RPD = 213 (45%) and OPD = 261 (55%). A total of 145 (31%) patients were obese (70 RPD, 75 OPD). Obese patients had increased EBL (p = 0.03), pancreatic fistula (B&C; p = 0.077), and wound infection (p = 0.068) compared to the non-obese. For obese patients, RPD had decreased OR time (p = 0.0003), EBL (p < 0.001), and wound infection (p = 0.001) with no difference in Clavien ≥3 complications, margins, LOS or 30-day mortality compared with OPD. In multivariate analysis, obesity was the strongest predictor of Clavien ≥3 (OR 1.6; p = 0.041) and wound infection if BMI > 35 (OR 2.6; p = 0.03). The robotic approach was protective of Clavien ≥3 (OR 0.6; p = 0.03) on univariate analysis and wound infection (OR 0.3; p < 0.001) and grade B/C pancreatic fistula (OR 0.34; p < 0.001) on multivariate analysis.

CONCLUSIONS

Obese patients are at risk for increased postoperative complications regardless of approach. However, the robotic approach mitigates some of the increased complication rate, while preserving other perioperative outcomes.

Impact of obesity on surgical outcomes of laparoscopic distal pancreatectomy: A Norwegian single-center study

BACKGROUND

Obesity is known as a risk factor for intra- and postoperative complications in pancreatic operation. However, the operative outcomes in obese patients undergoing laparoscopic distal pancreatectomy remain unclear.

METHODS

A total number of 423 patients underwent laparoscopic distal pancreatectomy at Oslo University Hospital-Rikshospitalet from April 1997 to December 2015. Patients were categorized into 3 groups based on the body mass index: normal weight (18.5-24.9 kg/m²), overweight (25-29.9 kg/m²), and obese (≥30 kg/m²). After excluding underweight patients, 402 patients were enrolled in this study.

RESULTS

Obese patients had significantly longer operative time and increased blood loss compared with overweight and normal weight patients (190 [61-480] minutes vs 158 [56-520] minutes vs 153 [29-374] minutes, P = .009 and 200 [0-2,800] mL vs 50 [0-6250] mL vs 90 [0-2,000] mL, P = .01, respectively). A multiple linear regression analysis identified obesity as predictive of prolonged operative time and increased blood loss during laparoscopic distal pancreatectomy. The rates of clinically relevant pancreatic fistula and severe complications (≥grade III by Accordion classification) were comparable in the 3 groups (P = .23 and P = .37, respectively). A multivariate logistic regression model did not demonstrate an association between obesity and postoperative morbidity (P = .09). The duration of hospital stay was comparable in the 3 groups (P = .13).

CONCLUSION

In spite of longer operative time and greater blood loss, laparoscopic distal pancreatectomy in obese patients is associated with satisfactory postoperative outcomes, similar to those in normal weight and overweight patients. Hence, laparoscopic distal pancreatectomy should be equally considered both in obese and nonobese patients.

The Effect of Body Mass Index on Surgical Outcomes in Patients Undergoing Pancreatic Resection: A Systematic Review and Meta-Analysis

OBJECTIVES

Previous studies that investigated the association between body mass index (BMI) and pancreatectomy outcomes have produced conflicting conclusions. We conducted this meta-analysis to assess the association between them.

METHODS

We searched PubMed, EMBASE, and Cochrane Library databases up to December 28, 2014. Patients were divided into high-BMI group (BMI ≥ 25 kg/m) and normal-BMI group (BMI < 25 kg/m). Postoperative and intraoperative outcomes were evaluated. Meta-regression and subgroup analysis were performed to evaluate any factors accountable for the heterogeneity. Meta-analysis was performed using a random-effect model.

RESULTS

We included 22 studies involving 8994 patients. Patients in the high-BMI group had significantly increased postoperative pancreatic fistula rate (odds ratio [OR],1.96; 95% confidence interval [CI], 1.43-2.67), delayed gastric emptying rate (OR, 1.62; 95% CI, 1.15-2.29), wound infection rate (OR, 1.43; 95% CI, 1.07-1.93), operation time (mean difference [MD],15; 95% CI, 13.40-16.60), blood loss (MD, 270.71; 95% CI, 248.93-292.49), and length of hospital stay (MD, 2.87; 95% CI, 1.51-4.24). For modest heterogeneity in postoperative pancreatic fistula, regional distribution tended to be the contributor.

CONCLUSIONS

High BMI not only increased the surgical difficulty but also decreased the surgical safety for pancreatectomy.

Impact of Obesity on Robot-Assisted Distal Pancreatectomy

BACKGROUND

Obesity has been steadily increasing in the United States. The effect of body mass index (BMI) on surgical outcomes in pancreatic surgery is still controversial. Currently, there is no report related to obesity and robotic pancreatic surgery. The purpose of this study was to evaluate the impact of BMI on the surgical outcomes of both nonobese and obese patients undergoing robot-assisted distal pancreatectomy (RADP).

METHODS

A prospectively collected database for RADP was retrieved for analysis. Patients were categorized as obese (BMI ≥30 kg/m(2)) and nonobese (BMI <30 kg/m(2)). Demographics, perioperative data, American Society of Anesthesiologists score, diagnosis, conversion rate, morbidity, surgical mortality, pancreatic fistula rate, and length of stay were compared.

RESULTS

A total for 85 RADP were included, with 57 (67%) in the nonobese group and 28 (33%) in the obese group. No differences were found between nonobese and obese patients regarding demographic, preoperative risk, and perioperative parameters and mortality. There was a trend in the obese group associated with a higher rate of postoperative complications, but it was statistically insignificant. Clinically significant pancreatic fistula (grade B) occurred in 28.5% of obese patients and in 7% of nonobese patients, but without statistical significance (P = .064).

CONCLUSIONS

Obesity does not have a significant impact on the perioperative outcomes and surgical risks for patients undergoing RADP, but high BMI may be a predictor for pancreatic fistula after RADP.

Effect of Body Mass Index on Overall Survival of Pancreatic Cancer: A Meta-Analysis

Although obesity has been identified as a risk factor for pancreatic cancer, the important question of whether obesity influences the prognosis of pancreatic cancer has not been explicated thoroughly. We therefore performed a meta-analysis to investigate the association between body mass index (BMI) and survival outcomes of patients with pancreatic cancer.Studies that described the relationship between BMI and overall survival (OS) of pancreatic cancer were searched in PubMed, Embase, Ovid, and Cochrane Library Databases from the earliest available date to May 12, 2015. Hazard ratios (HRs) for OS in each BMI category from individual studies were extracted and pooled by a random-effect model. Dose-response meta-analysis was also performed to estimate summary HR and 95% confidence interval (CI) for every 5-unit increment. Publication bias was evaluated by Begg funnel plot and Egger linear regression test.Ten relevant studies involving 6801 patients were finally included in the meta-analysis. Results showed that obesity in adulthood significantly shortened OS of pancreatic cancer patients (HR: 1.29, 95% CI: 1.17-1.41), whereas obesity at diagnosis was not associated with any increased risk of death (HR: 1.10, 95% CI: 0.78-1.42). For every 5-kg/m increment in adult BMI, the summary HR was 1.11 (95% CI: 1.05-1.18) for death risk of pancreatic cancer. However, no dose-response relationship was found in the BMI at diagnosis. Egger regression test and Begg funnel plot both revealed no obvious risk of publication bias.In conclusion, increased adult BMI is associated with increased risk of death for pancreatic cancer patients, which suggested that obesity in adulthood may be an important prognostic factor that indicates an abbreviated survival from pancreatic cancer. More studies are needed to validate this finding, and the mechanism behind the observation should be evaluated in further studies.

Impact of body mass index on postoperative complications and long-term survival in patients with esophageal squamous cell cancer

Undernutrition and cachexia have been suggested to be risk factors for postoperative complications and survival in cancer patients. The aim of this study was to investigate whether body mass index (BMI) is related to the short-term and long-term outcomes in patients who undergo an esophagectomy for the resection of esophageal squamous cell cancer (ESCC). Three hundred forty patients who underwent an esophagectomy for the resection of ESCC between 2003 and 2008 were retrospectively reviewed. The patients were divided into two groups: an L-BMI group characterized by a BMI < 18.5 kg/m(2) and an N-BMI group characterized by a BMI ≥ 18.5 kg/m(2). Clinical and pathological outcome were compared between groups. The study included 40 patients in the L-BMI group and 300 patients in the N-BMI group. A clinicopathological assessment showed that nodal involvement was seen more frequently in the L-BMI group (P = 0.016). Pulmonary complications seemed to occur more frequently in the L-BMI group (P = 0.006). The 5-year overall survival rate was higher in the N-BMI group (63.6%) than in the L-BMI group (32.3%) (P < 0.001). The 5-year disease-free survival rate was also higher in the N-BMI group (58.0%) than in the L-BMI group (33.6%) (P = 0.001). In multivariate analysis, the BMI (hazard ratio, 2.154; 95% CI, 1.349-3.440, P = 0.001) was found to be an independent prognostic factor for overall survival. Our data suggested that a lower BMI not only increased pulmonary complications but also impaired overall and disease-free survival after an esophagectomy for the resection of ESCC.

Adipocytes enhance murine pancreatic cancer growth via a hepatocyte growth factor (HGF)-mediated mechanism

INTRODUCTION

Obesity accelerates the development and progression of pancreatic cancer, though the mechanisms underlying this association are unclear. Adipocytes are biologically active, producing factors such as hepatocyte growth factor (HGF) that may influence tumor progression. We therefore sought to test the hypothesis that adipocyte-secreted factors including HGF accelerate pancreatic cancer cell proliferation.

MATERIAL AND METHODS

Murine pancreatic cancer cells (Pan02 and TGP-47) were grown in a) conditioned medium (CM) from murine F442A preadipocytes, b) HGF-knockdown preadipocyte CM, c) recombinant murine HGF at increasing doses, and d) CM plus HGF-receptor (c-met) inhibitor. Cell proliferation was measured using the MTT assay. ANOVA and t-test were applied; p < 0.05 considered significant.

RESULTS

Wild-type preadipocyte CM accelerated Pan02 and TGP-47 cell proliferation relative to control (59 ± 12% and 34 ± 12%, p < 0.01, respectively). Knockdown of preadipocyte HGF resulted in attenuated proliferation vs. wild type CM in Pan02 cells (35 ± 5% vs. 68 ± 14% greater than control; p < 0.05), but proliferation in TGP-47 cells remained unchanged. Recombinant HGF dose-dependently increased Pan02, but not TGP-47, proliferation (p < 0.05). Inhibition of HGF receptor, c-met, resulted in attenuated proliferation versus control in Pan02 cells, but not TGP-47 cells.

CONCLUSIONS

These experiments demonstrate that adipocyte-derived factors accelerate murine pancreatic cancer proliferation. In the case of Pan02 cells, HGF is responsible, in part, for this proliferation.

Hysterectomy in very obese and morbidly obese patients: a systematic review with cumulative analysis of comparative studies

PURPOSE

Some studies suggest that also regarding the patient with a body mass index (BMI) ≥35 kg/m(2) the minimally invasive approach to hysterectomy is superior. However, current practice and research on the preference of gynaecologists still show that the rate of abdominal hysterectomy (AH) increases as the BMI increases. A systematic review with cumulative analysis of comparative studies was performed to evaluate the outcomes of AH, laparoscopic hysterectomy (LH) and vaginal hysterectomy (VH) in very obese and morbidly obese patients (BMI ≥35 kg/m(2)).

METHODS

PubMed and EMBASE were searched for records on AH, LH and VH for benign indications or (early stage) malignancy through October 2014. Included studies were graded on level of evidence. Studies with a comparative design were pooled in a cumulative analysis.

RESULTS

Two randomized controlled trials, seven prospective studies and 14 retrospective studies were included (2232 patients; 1058 AHs, 959 LHs, and 215 VHs). The cumulative analysis identified that, compared to LH, AH was associated with more wound dehiscence [risk ratio (RR) 2.58, 95 % confidence interval (CI) 1.71-3.90; P = 0.000], more wound infection (RR 4.36, 95 % CI 2.79-6.80; P = 0.000), and longer hospital admission (mean difference 2.9 days, 95 % CI 1.96-3.74; P = 0.000). The pooled conversion rate was 10.6 %. Compared to AH, VH was associated with similar advantages as LH.

CONCLUSIONS

Compared to AH, both LH and VH are associated with fewer postoperative complications and shorter length of hospital stay. Therefore, the feasibility of LH and VH should be considered prior the abdominal approach to hysterectomy in very obese and morbidly obese patients.

Impact of body mass index on complications following pancreatectomy: Ten-year experience at National Cancer Center in China

AIM: To examine the impact of body mass index (BMI) on outcomes following pancreatic resection in the Chinese population.

METHODS: A retrospective cohort study using prospectively collected data was conducted at the Cancer Hospital of the Chinese Academy of Medical Sciences, China National Cancer Center. Individuals who underwent pancreatic resection between January 2004 and December 2013 were identified and included in the study. Persons were classified as having a normal weight if their BMI was < 24 kg/m² and overweight/obese if their BMI was ≥ 24 kg/m² as defined by the International Life Sciences Institute Focal Point in China. A χ² test (for categorical variables) or a t test (for continuous variables) was used to examine the differences in patients’ characteristics between normal weight and overweight/obese groups. Multiple logistic regression models were used to assess the associations of postoperative complications, operative difficulty, length of hospital stay, and cost with BMI, adjusting for age, sex, and type of surgery procedures.

RESULTS: A total of 362 consecutive patients with data available for BMI calculation underwent pancreatic resection for benign or malignant disease from January 1, 2004 to December 31, 2013. Of the 362 patients, 156 were overweight or obese and 206 were of normal weight. One or more postoperative complications occurred in 35.4% of the patients following pancreatic resection. Among patients who were overweight or obese, 42.9% experienced one or more complications, significantly higher than normal weight (29.6%) individuals (P = 0.0086). Compared with individuals who had normal weight, those with a BMI ≥ 24.0 kg/m² had higher delayed gastric emptying (19.9% vs 5.8%, P < 0.0001) and bile leak (7.7% vs 1.9%, P = 0.0068). There were no significant differences seen in pancreatic fistula, gastrointestinal hemorrhage, reoperation, readmission, or other complications. BMI did not show a significant association with intraoperative blood loss, operative time, length of hospital stay, or cost.

CONCLUSION: Higher BMI increases the risk for postoperative complications after pancreatectomy in the Chinese population. The findings require replication in future studies with larger sample sizes.

Sarcopenia, obesity and sarcopenic obesity: effects on liver function and volume in patients scheduled for major liver resection

BACKGROUND

Sarcopenia, obesity and sarcopenic obesity have been linked to impaired outcome after liver surgery. Preoperative liver function of sarcopenic, obese and sarcopenic-obese patients might be reduced, possibly leading to more post-operative morbidity. The aim of this study was to explore whether liver function and volume were influenced by body composition in patients undergoing liver resection.

METHODS

In 2011 and 2012, all consecutive patients undergoing the methacetin breath liver function test were included. Liver volumetry and muscle mass analysis were performed using preoperative CT scans and Osirix(®) software. Muscle mass and body-fat% were calculated. Predefined cut-off values for sarcopenia and the top two body-fat% quintiles were used to identify sarcopenia and obesity, respectively. Histologic assessment of the resected liver gave insight in background liver disease.

RESULTS

A total number of 80 patients were included. Liver function and volume were comparable in sarcopenic(-obese) and non-sarcopenic(-obese) patients. Obese patients showed significantly reduced liver function [295 (95-508) vs. 358 (96-684) µg/kg/h, P = 0.018] and a trend towards larger liver size [1694 (1116-2685) vs. 1533 (869-2852) mL, P = 0.079] compared with non-obese patients. Weight (r = -0.40), body surface area (r = -0.32), estimated body-fat% (r = -0.43) and body mass index (r = -0.47) showed a weak but significant negative (all P < 0.05) correlation with liver function. Moreover, body-fat% was identified as an independent factor negatively affecting the liver function.

CONCLUSION

Sarcopenia and sarcopenic obesity did not seem to influence liver size and function negatively. However, obese patients had larger, although less functional, livers, indicating dissociation of liver function and volume in these patients.

Body Surface Area: A new predictive factor of mortality and pancreatic fistula after pancreaticoduodenectomy: A cohort-study

INTRODUCTION

To assess the role of Body Surface Area (BSA) in predicting pancreatic fistula and mortality after pancreaticoduodenectomy.

METHODS

The data of patients who underwent pancreaticoduodenectomy between January 1992 to December 2012 at the University Hospital of Caen were collected prospectively and analyzed retrospectively. Pancreatic fistula was determined according to the ISPGF (International Study Group for Pancreatic Fistula) criteria. The Clavien and Dindo classification was used for grading post-operative complications and BSA was calculated according to the Boyd formula. Patients were classified as "large" and "non-large" using a BSA value ≥1.82 to define the large group and the non-large group. The primary end points were post-operative mortality rate, and the rate and grade of post-operative pancreatic fistula.

RESULTS

411 patients underwent pancreaticoduodenectomy with a mean age of 61.2 (±12.1) year. Six patients (1.45%) died post-operatively. Patients with a BSA ≥1.82 had a significantly higher risk of post-operative death: OR 3.55 [1.43-8.80] (p < 0.0005). Eighty-five patients (20.7%) developed a post-operative pancreatic fistulas. The grade A pancreatic fistula rate was 87.1%. Patients with a BSA ≥1.82 had a significantly higher risk of developing overall post-operative pancreatic fistula (p < 0.038). Multivariate analysis showed that "large" patients (1.86, 95%CI[1.09-3.92], p = 0.0229), soft pancreas (6.5, 95%CI[2.39-9.31], p = 0.0155) and a BMI ≥ 25 (1.09, 95%CI[1.031-1.163], p = 0.0407) were independent risk factors of pancreatic fistula.

CONCLUSION

Body Surface Area is a useful factor after pancreaticoduodenectomy to predict mortality and post-operative fistula.

The impact of body mass index dynamics on survival of patients with advanced pancreatic cancer receiving chemotherapy

CONTEXT

High body mass index (BMI) is linked to an increased risk of developing pancreatic cancer (PC). However, in patients with advanced PC (APC), especially those receiving palliative chemotherapy, the impact of BMI on survival has not been investigated fully.

OBJECTIVES

To assess changes in BMI during the course of APC and their impact on patient survival, specifically for those receiving palliative chemotherapy.

METHODS

Consecutive patients with APC, all of whom were treated with palliative chemotherapy, were enrolled during 2003-2010. Clinical characteristics and prognoses were analyzed.

RESULTS

A total of 425 patients participated (median age, 60.1 years). At diagnosis of APC, patients' BMI distribution of patients was as follow: <18.5 (45, 10.6%); 18.5-19.9 (67, 15.8%); 20.0-22.4 (156, 36.7%); 22.5-24.9 (107, 25.2%); 25.0-29.9 (49, 11.5%); and ≥ 30.0 (1, 0.2%). Median overall survival (OS) was 8.1 months (95% confidence interval 7.2, 9.1). Precancer BMI and baseline BMI (at diagnosis) had no impact on OS. Weight loss at diagnosis (precancer weight minus weight at diagnosis) and weight loss during first-line chemotherapy (both stipulated as BMI change ≥ 1) were associated with shortened OS (hazard ratio, 1.300; P = 0.012 and hazard ratio, 1.367; P = 0.010, respectively).

CONCLUSION

In patients with APC undergoing palliative chemotherapy, decreases in BMI at APC diagnosis and during chemotherapy are more hazardous for OS than precancer BMI or baseline BMI (at diagnosis) as absolute values. Further studies are needed to validate this finding and investigate strategies to maintain BMI during chemotherapy in this setting.

Effect of donor body mass index on the outcome of donation after cardiac death kidneys: how big is too big?

INTRODUCTION

Morbid obesity (MO) has become an epidemic in the United Sates and is associated with adverse effects on health. The purpose of this study was to examine the effects of MO on the short-term outcomes of kidneys transplanted from donation after cardiac death (DCD) donors.

PATIENTS AND METHODS

Using a prospectively collected database, we reviewed 467 kidney transplantations performed at a single center between January 2008 and June 2011 to identify 67 recipients who received transplants from 40 DCD donors. The outcomes of 14 MO DCD donor kidneys were compared with 53 non-MO DCD grafts. MO was defined as a body mass index ≥ 35. Mean patient follow-up was 16 months.

RESULTS

The MO and non-MO DCD donor groups were similar with respect to donor and recipient age, gender, race, cause of death and renal disease, time from withdrawal of life support to organ perfusion, mean human leukocyte antigen (HLA) mismatch, and overall recipient survival. Organs from MO DCD donors also had comparable rates of delayed graft function (21.4% vs 20.0%; P = not significant [NS]). At 1 year post-transplantation, a small but statistically insignificant difference was observed in the graft survival rates of MO and non-MO donors (87% vs. 96%; P = NS). One MO kidney had primary nonfunction.

CONCLUSIONS

These data demonstrate that kidneys procured from MO DCD donors have equivalent short-term outcomes compared with non-MO grafts and should continue to be used. Further investigation is needed to examine the effect of MO on long-term renal allograft survival.

Impact of obesity on surgical outcomes post-pancreaticoduodenectomy: a case-control study

BACKGROUND

Obesity is a growing worldwide epidemic. There is association between obesity and pancreatic cancer risk. However, the impact of obesity on the outcome of pancreatoduodenectomy (PD) is controversial. The aim of this study was to elucidate effect of obesity on surgical outcomes of PD.

STUDY DESIGN

A case-control study.

PATIENT AND METHODS

We retrospectively studied all patients who underwent PD in our center between January 2000 and June 2012. Patients were divided into two groups; Group A (patients with BMI <25) and Group B (patients with BMI > 25). Preoperative demographic data, intraoperative data, and postoperative details were collected.

RESULTS

Only 112/471 patients (25.9%) had BMI > 25. The median intraoperative blood loss was more in overweight patients (P = 0.06). The median surgical time in group B was significantly longer than that in group A (P = 0.003). The overall incidence of complications was higher in the overweight group (P = 0.001). The severity of complications was also higher in the overweight group (P = 0.0001). Postoperative pancreatic fistula (POPF) (P = 0.0001) and hospital mortality (P = 0.001) were significantly higher in overweight patients. Oral intake was significantly delayed in overweight patients in comparison to normal weight group (P = 0.02). Postoperative stay was significantly longer in overweight patients (P = 0.0001).

CONCLUSION

PD is associated with an increased risk of postoperative morbidity in overweight patient. Overweight patients must not be precluded from undergoing PD. However, operative techniques and pharmacological prophylaxis to decrease POPF should be considered in overweight patients.

Impact of body mass index for patients undergoing pancreaticoduodenectomy

AIM: To evaluate the impact of body mass index (BMI) on short and long term results after pancreaticoduodenectomies (PD).

METHODS: A consecutive series of PDs performed at the Karolinska University Hospital from 2004 till 2010 were retrieved from our prospective database. The patients were divided by BMI into overweight/obese (O; BMI ≥ 25 kg/m²) and controls (C; BMI < 25 kg/m²). Demographics, peri-operative data, morbidity, mortality, pancreatic fistula (PF) rate, length of stay (LOS), hospital costs, histology, and survival were analyzed. An additional sub analysis of survival was performed in patients with a diagnosis of pancreatic ductal adenocarcinoma (PDAC) and divided in underweight, normal-weight, overweight and obese.

RESULTS: A total of 367 PDs were included (O = 141/C = 226). No differences were found between O and C regarding demographics, peri-operative data, costs, morbidity or mortality. O was associated with higher intra-operative blood loss (1392 ± 115 mL vs 1121 ± 83 mL; P = 0.01), rate of PF (20% vs 9.5%; P = 0.006) and marginally longer LOS (18 ± 0.9 d vs 15 ± 1.1 d; P = 0.05). An increasing risk for PF was observed with increasing BMI. The 1, 3 and 5 years survival rate was similar in O and C in PDAC (68.7%, 26.4% and 8.8% vs 66.1%, 30.9% and 17.9% respectively; P = 0.9). When the survival was analyzed using 4 different categories of BMI (underweight, normal, overweight and obese), a trend was seen toward a difference in survival, with a worse prognosis for the underweight and obese patients compared to normal weight and overweight patients.

CONCLUSION: Overweight increases the risk for intra-operative bleeding and PF, but do not otherwise alter short or long term outcome after PD for pancreatic cancer.

Effect of metabolic syndrome on perioperative outcomes after liver surgery: A National Surgical Quality Improvement Program (NSQIP) analysis

BACKGROUND

The problem of obesity has risen to epidemic levels in the United States. A subset of patients with obesity will have metabolic syndrome. We sought to examine the impact of metabolic syndrome on the risk of morbidity and mortality among a large cohort of patients who underwent hepatic resection.

METHODS

Patients included in the National Surgical Quality Improvement Program (NSQIP) dataset who underwent hepatic resection between January 2005 and December 2008 were identified. Data on clinical characteristics, comorbidities, operative details, as well as postoperative complications and mortality were collected and analyzed. Patients with BMI >30 kg/m(2) who also had hypertension and diabetes were defined as having metabolic syndrome.

RESULTS

A total of 3,973 patients who underwent a liver resection were identified. Overall mean body mass index was 28 kg/m(2); 31.7% patients were obese (>30 kg/m(2)). Of the patients who were obese, 256 (20%) had metabolic syndrome. Patients with metabolic syndrome were less likely to have had a major hepatectomy (≥hemi-hepatectomy, 36% vs 43%; P = .01) but had a greater mean number of red blood cell transfusions (1.6 vs 1; P = .02). The incidence of postoperative complications after hepatectomy was 23%. Patients with metabolic syndrome had a greater risk for reintubation (odds ratio [OR] 1.9; P = .02), >48 hours ventilator dependence (OR 2.0; P = .003), myocardial infarction (OR 5.5; P = .01) and superficial surgical-site infections (OR 1.7; P = .02) compared with nonmetabolic patients. Overall postoperative mortality was 3%. Metabolic syndrome was associated with an increased risk of postoperative death (OR 2.7; P = .001).

CONCLUSION

The presence of metabolic syndrome was associated with a greater risk of perioperative complications. In addition, patients with metabolic syndrome had greater than a 2-fold increased risk of death after hepatic resection.

Obesity and survival in population-based patients with pancreatic cancer in the San Francisco Bay Area

BACKGROUND

Obesity has been consistently associated with increased risk of pancreatic cancer incidence and mortality. However, studies of obesity and overall survival in patients with pancreatic cancer are notably lacking, especially in population-based studies.

METHODS

Active and passive follow-up were used to determine vital status and survival for 510 pancreatic cancer patients diagnosed from 1995 to 1999 in a large population-based case-control study in the San Francisco Bay Area. Survival rates were computed using Kaplan-Meier methods. Hazard ratios (HR) and 95 % confidence intervals (CI) were estimated in multivariable Cox proportional hazards models as measures of the association between pre-diagnostic obesity and pancreatic cancer survival.

RESULTS

An elevated hazard ratio of 1.3 (95 % CI, 0.91-1.81) was observed for obese [body mass index (BMI) ≥ 30] compared with normal range BMI (<25) patients. Associations between BMI and overall survival did not statistically significantly vary by known prognostic and risk factors (all p-interaction ≥0.18), yet elevated HRs consistently were observed for obese compared with normal BMI patients [localized disease at diagnosis (HR, 3.1), surgical resection (HR, 1.6), ever smokers (HR, 1.6), diabetics (HR, 3.3)]. Poor survival was observed among men, older patients, more recent and current smokers, whereas improved survival was observed for Asian/Pacific Islanders.

CONCLUSIONS

Our results in general provide limited support for an association between pre-diagnostic obesity and decreased survival in patients with pancreatic cancer. Patterns of reduced survival associated with obesity in some patient subgroups could be due to chance and require assessment in larger pooled studies.

Impact of obesity on perioperative complications and long-term survival of patients with gastric cancer

BACKGROUND

The prevalence of obesity is increasing in the United States. Obesity has been associated with worse surgical outcomes, but its impact on long-term outcomes in gastric cancer is unclear. The aim of this study was to evaluate the effects of being overweight on surgical and long-term outcomes for patients with gastric cancer.

METHODS

Patients who underwent curative intent resection for gastric carcinoma from 1985 to 2007 were identified from a prospectively collected gastric cancer database. Overweight was defined as a body mass index (BMI) of 25 kg/m(2) or higher. Clinical outcomes of overweight and nonoverweight patients were compared.

RESULTS

From the total population of 1,853 patients, 1,125 (60.7%) were overweight. Overweight patients tended to have more proximal tumors and a lower T stage. Accurate complication data were available on a subset of patients from 2000 to 2007. A BMI of ≥25 was associated with increased postoperative complications (47.9 vs. 35.8%, p < 0.001). This was mainly due to an increase in the rate of wound infections (8.9 vs. 4.7%, p = 0.02) and anastomotic leaks (11.8 vs. 5.4%, p = 0.002). Multivariate logistic regression analysis showed that higher BMI, total gastrectomy, and use of neoadjuvant chemotherapy were associated with increased wound infection and anastomotic leak. Overweight patients were less likely to have adequate lymph node staging (73.3 vs. 79.2%, p = 0.047). There was no difference in overall survival or disease-specific survival between the two groups.

CONCLUSIONS

Increased BMI is a predictor of increased postoperative complications, including anastomotic leak, but it is not a predictor of survival in gastric cancer.

Multi-institutional analysis of pancreatic adenocarcinoma demonstrating the effect of diabetes status on survival after resection

BACKGROUND

The effect of diabetes on survival after resection pancreatic ductal carcinoma (PDAC) is unclear. The present study was undertaken to determine whether pre-operative diabetes has any predictive value for survival.

METHODS

A retrospective review from seven centres was performed. Metabolic factors, tumour characteristics and outcomes of patients undergoing resection for PDAC were collected. Univariate and multivariable analyses were performed to determine factors associated with disease-free (DFS) and overall survival (OS).

RESULTS

Of the 509 patients in the present study, 31.2% had diabetes. Scoring systems were devised to predict OS and DFS based on a training set (n= 245) and were subsequently tested on an independent set (n= 264). Pre-operative diabetes (P < 0.001), tumour size >2 cm (P= 0.001), metastatic nodal ratio >0.1 (P < 0.001) and R1 margin (P < 0.001) all correlated with DFS and OS on univariate analysis. Scoring systems were devised based on multivariable analysis of the above factors. Diabetes and the metastatic nodal ratio were the most important factors in each system, earning two points for OS and four points for DFS. These scoring systems significantly correlated with both DFS (P < 0.001) and OS (P < 0.001).

CONCLUSION

Pre-operative diabetes status provides useful information that can help to stratify patients in terms of predicted post-operative OS and DFS.

Impact of obesity and body fat distribution on survival after pancreaticoduodenectomy for pancreatic adenocarcinoma

BACKGROUND

Epidemiologic studies have reported a positive correlation between body mass index (BMI) and pancreatic cancer risk, but clinical relevance of obesity and/or body fat distribution on tumor characteristics and cancer-related outcome remain controversial. We sought to assess the influence of obesity and body fat distribution on pathologic characteristics and survival after pancreaticoduodenectomy for pancreatic adenocarcinoma.

METHODS

Demographic and biometric data were collected on 328 patients undergoing pancreaticoduodenectomy for pancreatic ductal adenocarcinoma. In a subset of patients, pancreatic fatty infiltration and fibrosis were assessed pathologically, and visceral fat area (VFA) was evaluated. Influence of BMI and body fat distribution on tumor characteristics and survival were evaluated.

RESULTS

A significant positive correlation between BMI and VFA was observed, with a wide range of VFA value within each BMI class. According to BMI or VFA distribution, there were no significant differences in patient characteristics, intraoperative or perioperative outcome, or pathologic characteristics, with the exception of significantly higher blood loss in patients with an increased body weight or VFA. Unadjusted overall and disease-free survival between BMI class and VFA quartile were not significantly different.

CONCLUSIONS

In this study, obesity and body fat distribution were not correlated with specific tumor characteristics or cancer-related outcome.

Obesity and pancreatic cancer: overview of epidemiologic evidence and biologic mechanisms

In the United States, pancreatic cancer is characterized by a low 5-yr survival rate of approximately 6%, fewer than 10% of patients diagnosed with localized disease and thus candidates for "curative" surgical resection, increasing incidence and few established risk factors. Similar statistics are observed for other industrialized nations. With new evidence to suggest that pancreatic cancer develops over a number of years, markers that can better identify high risk patients and are applicable to earlier diagnosis hold promise for improving these dire statistics. Obesity is one of the few modifiable risk factors that has been associated with increased risk of pancreatic cancer and also is related to increased risk of diabetes, a condition that in turn has been associated with pancreatic cancer development. Given recent data that nearly 70% of United States adults are overweight or obese, a clarification of the complex association between obesity and pancreatic cancer may disclose targets for prevention and intervention to decrease incidence and improve prognosis of this highly fatal disease. An overview of the current epidemiology and hypothesized biological mechanisms involved in the obesity-pancreatic cancer association are presented.

Body mass index and outcomes from pancreatic resection: a review and meta-analysis

INTRODUCTION

There are 1.6 billion adults worldwide who are overweight, with body mass indices (BMI) between 25 and 30, while more than 400 million are obese (BMI >30). Obesity predicts the incidence of and poor outcomes from pancreatic cancer. Obesity has also been linked to surgical complications in pancreatectomy, including increased length of hospital stay, surgical infections, blood loss, and decreased survival. However, BMI's impact on many complications following pancreatectomy remains controversial.

METHODS

We performed a MEDLINE search of all combinations of "BMI" with "pancreatectomy," "pancreatoduodenectomy," or "pancreaticoduodenectomy." From included studies, we created pooled and weighted estimates for quantitative and qualitative outcomes. We used the PRISMA criteria to ensure this project's validity.

RESULTS

Our primary cohort included 2,736 patients with BMI <30, 1,682 with BMI >25, and 546 with BMI between 25 and 30. Most outcomes showed no definitive differences across BMIs. Pancreatic fistula (PF) rates ranged from 4.7% to 31.0%, and four studies found multivariate association between BMI and PF (range odds ratio 1.6-4.2). Pooled analyses of PF by BMI showed significant association (p < 0.05).

CONCLUSION

BMI increases the operative complexity of pancreatectomy. However, with aggressive peri- and post-operative care, increases in BMI-associated morbidity and mortality may be mitigated.

Influence of obesity and other risk factors on survival outcomes in patients undergoing pancreaticoduodenectomy for pancreatic cancer

OBJECTIVES

Established risk factors for the development of pancreatic cancer include tobacco use, family history of pancreatic cancer, personal history of diabetes, and obesity. The impact of risk factors on prognosis in patients with pancreatic cancer, particularly obesity, has recently become controversial.

METHODS

We conducted a retrospective analysis of patients with pancreatic adenocarcinoma who underwent pancreaticoduodenectomy between 1995 and 2009. Patients were categorized by body mass index (BMI) as normal (18.5-24.9 kg/m), overweight (25-29.9 kg/m), or obese (≥30 kg/m). Univariate analysis was performed to evaluate the association of obesity and other risk factors on overall survival.

RESULTS

Of the 355 patients evaluated, 149 (42.0%) had normal BMI, 131 (36.9%) were overweight, and 75 (21.1%) were obese. Overall survival for normal, overweight, and obese groups was 17.3 months (95% confidence interval [CI], 14.2-20.8 months), 20.0 months (95% CI, 16.6-23.6 months), and 22.1 months (95% CI, 16.5-36.4 months), respectively (P = 0.58). Hazard ratios for tobacco use, family history of pancreatic cancer, and history of diabetes were 1.07, 1.38, and 0.87, respectively.

CONCLUSIONS

Obesity and other risk factors have no impact on overall survival in patients with adenocarcinoma after pancreaticoduodenectomy. Further studies investigating the relationship between risk factors and their prognostic significance in patients with pancreatic cancer are warranted.

Safety and feasibility of pancreaticoduodenectomy in the elderly: a matched study

OBJECTIVES

To compare the clinical outcomes after pancreaticoduodenectomy (PD) in patients older than 70 years old against a matched cohort of patients younger than 70.

METHODS

A search of the department database revealed that 285 consecutive patients underwent PD from 1996 to 2009. Forty-one patients (14%) were identified to be older than 70 years (group 1), and they were matched with 41 patients younger than 70 (group 2) according to sex, body mass index, American Society of Anesthesiologists score and tumor staging. Medical comorbidities, preoperative CA19-9 and hemoglobin levels, operative and histopathologic data, postoperative course, and survival outcomes were compared between the 2 groups of patients.

RESULTS

Statistical analyses revealed no significant difference between the 2 groups, except for preoperative CA19-9 and hemoglobin levels, operating time, duration of hospitalization, and the number of lymph nodes removed. These parameters, however, did not have an impact on morbidity, mortality, and overall survival.

CONCLUSIONS

Based on our study, perioperative morbidity, mortality, and overall survival are not poorer in patients older than 70. Thus, PD should not be contraindicated solely on the basis of chronological age. Moreover, PD can be rationally proposed to patients meeting the "fit elderly" definition.

Obesity adversely affects survival in pancreatic cancer patients

BACKGROUND

Higher body-mass index (BMI) has been implicated as a risk factor for developing pancreatic cancer, but its effect on survival has not been thoroughly investigated. The authors assessed the association of BMI with survival in a sample of pancreatic cancer patients and used epidemiologic and clinical information to understand the contribution of diabetes and hyperglycemia.

METHODS

A survival analysis using Cox proportional hazards by usual adult BMI was performed on 1861 unselected patients with pancreatic adenocarcinoma; analyses were adjusted for covariates that included clinical stage, age, and sex. Secondary analyses incorporated self-reported diabetes and fasting blood glucose in the survival model.

RESULTS

BMI as a continuous variable was inversely associated with survival from pancreatic adenocarcinoma (hazard ratio [HR], 1.019 for each increased unit of BMI [kg/m2], P<.001) after adjustment for age, stage, and sex. In analysis by National Institutes of Health BMI category, BMIs of 30 to 34.99 kg/m2 (HR, 1.14; 95% confidence interval [CI], 0.98-1.33), 35 to 39.99 kg/m2 (HR 1.32, 95% CI 1.08-1.62), and ≥40 (HR 1.60, 95% CI 1.26-2.04) were associated with decreased survival compared with normal BMI of 18.5 to 24.99 kg/m2 (overall trend test P<.001). Fasting blood glucose and diabetes did not affect the results.

CONCLUSIONS

Higher BMI is associated with decreased survival in pancreatic cancer. Although the mechanism of this association remains undetermined, diabetes and hyperglycemia do not appear to account for the observed association.

Intra-abdominal fat predicts survival in pancreatic cancer

BACKGROUND

Body mass index (BMI) has proven unreliable in predicting survival following pancreaticoduodenectomy for cancer. While measures of intra-abdominal fat correlate with medical and postoperative complications of obesity, the impact of intra-abdominal fat on pancreatic cancer survival is uncertain. We hypothesized that the quantity of intra-abdominal fat would predict survival following resection of pancreatic cancer.

METHODS

Preoperative CT imaging was used to measure intra-abdominal fat. Cox regression analyses were used to identify independent predictors of survival.

RESULTS

Sixty-one patients from 2000-2009 underwent pancreaticoduodenectomy for exocrine pancreatic adenocarcinoma. After adjusting for age and perineural invasion status, preoperative BMI did not predict overall survival (p < 0.827). Unlike BMI, quartile of intra-abdominal fat predicted survival. Relative to patients with the least intra-abdominal fat (lowest quartile), those with more intra-abdominal fat demonstrated worse overall survival, but in a non-linear fashion. Individuals in the second quartile showed a fourfold increase in likelihood of death (HR 4.018, 95% CI 1.099-14.687, p < 0.035) relative to the lowest quartile. Patients in the third (HR 2.124, 95% CI 0.278-16.222, p < 0.468) and fourth quartile (HR 1.354, 95% CI 0.296-6.190, p < 0.696) also showed greater risk of death.

CONCLUSIONS

Measuring intra-abdominal fat identifies a subset of patients with worse prognosis in pancreatic cancer.

Does body mass index/morbid obesity influence outcome in patients who undergo pancreatoduodenectomy for pancreatic adenocarcinoma?

INTRODUCTION

The obesity epidemic coupled with epidemiologic evidence of the link between pancreatic cancer and obesity has raised the interest in the impact of body mass index (BMI) on outcomes for resected pancreatic cancer.

METHODS

All patients who underwent pancreatoduodenectomy (PD) for pancreatic adenocarcinoma from 1981 to 2007 were categorized into four groups according to their BMI (<25, 25 to <30, 30 to <35, and ≥35). Associations of these BMI groups with perioperative (operating time, blood loss, complications, in-hospital mortality), pathologic (tumor diameter, tumor stage, differentiation, lymph node status, R0 status) features and long-term patient outcome were evaluated using Kruskal-Wallis and chi-square tests, logistic regression, and Cox proportional hazards regression. A second set of analyses were performed by dichotomizing patients into morbidly obese (BMI ≥ 35) in comparison to the rest.

RESULTS

Of the 586 consecutive patients studied, there were 232 (39.6%) with BMI <25, 232 (39.6%) with BMI 25 to <30, 89 (15.2%) with BMI 30 to <35, and 33 (5.6%) with BMI ≥ 35. Operating time (P = 0.003) and intraoperative blood loss (P < 0.001) increased with BMI, although none of the remaining perioperative features differed significantly among the BMI groups. Similarly, there were no significant associations between BMI group and the pathological features studied, particularly lymph node status (P= 0.98). BMI was not associated with lymph node status even after adjusting for tumor diameter. All analyses were repeated for the morbidly obese. Cox regression did not demonstrate an impact of BMI or morbid obesity on overall or disease-free survival.

CONCLUSIONS

BMI (and morbid obesity) does not appear to influence long-term outcomes for patients undergoing PD. Surgeons should be vigilant of the greater risk of perioperative blood loss with increasing BMI.

Body mass index and adverse perioperative outcomes following hepatic resection

BACKGROUND

The effect of obesity on perioperative outcomes following hepatic resection is not clearly defined. We sought to understand the implications of obesity on post-hepatectomy outcomes in a nationally represented cohort of patients.

METHODS

Using a retrospective cohort design, we studied the effect of obesity on complications and 30-day mortality using multivariable logistic regression using comprehensive clinical data from the American College of Surgeons National Surgical Quality Improvement Program (2005-2008).

RESULTS

During our study period, 3,960 patients underwent hepatic resection; 32.4% had a normal body mass index (BMI; 18.5-24.9 kg/m(2)), 2.5% were underweight (<18.5 kg/m(2)), 33.4% were overweight (25.0-29.9 kg/m(2)), and 31.7% were obese (>30.0 kg/m(2)). 23.3% had at least one post-operative complication and the overall mortality rate was 2.5%. Compared to normal patients, obese patients had significantly higher unadjusted odds of having a complication (26.5% vs. 21.3%, OR 1.34, 95% CI 1.12-1.61) and dying (3.0% vs. 1.7%, OR 1.79, 95% CI 1.05-3.05). The obese were also more likely to have multiple complications compared to normal BMI patients (6.1% vs. 3.7%, OR 1.70, 95% CI 1.17-2.46). After risk adjustment, obesity was associated with attenuated but significantly higher odds of having any perioperative complication (OR 1.24, 95% CI 1.01-1.55), but was not a significant predictor of mortality.

CONCLUSIONS

After adjusting for other clinical factors, the degree of obesity is independently associated with an increasing complication rate but not mortality. Risk adjustment may not capture the total clinical risk of patients at the extremes of BMI.

Influence of body mass index on complications and oncologic outcomes following hepatectomy for malignancy

BACKGROUND

Following hepatectomy for malignancy, the effect of body mass index (BMI) on hepatic and oncologic outcomes is unknown.

METHODS

Two hundred seventy-nine post-hepatectomy patients with malignancy from our center were included in the cohort (1996-2006). BMI was categorized using World Health Organization criteria. The effect of BMI was evaluated using risk-adjusted Cox models for time to recurrence and overall survival.

RESULTS

Seventy-nine patients (28.3%) had primary hepatobiliary cancers, 134 (48.0%) had colorectal metastases, and 66 (25.3%) had other metastases. Thirty-five percent of patients were obese (BMI > 30). Obese patients had more hepatic-specific perioperative complications (27.8% vs. 15.9%, p = 0.018), bile leaks (18.6% vs. 9.9%, p = 0.030), post-operative pneumonia (9.3% vs. 2.2%, p = 0.0074), intra-abdominal abscesses (7.2% vs. 1.7%, p = 0.017), acute renal failure (7.2% vs. 1.7%, p = 0.017), urinary tract infections (16.4% vs. 7.7%, p = 0.024), and longer lengths of stay (10.5 vs.8.6 days, p = 0.029). Obese and non-obese patients had similar perioperative mortality, time to recurrence, and overall survival on univariate analysis. However, after adjusting for demographic, tumor, and operative characteristics, and complications, increasing BMI displayed improved recurrence-free (HR 0.90, 95% CI 0.86-0.95) and overall survival (HR 0.96, 95% CI 0.92-0.99).

CONCLUSIONS

High BMI patients may have better oncologic outcomes despite higher perioperative morbidity and hepatic complications following hepatectomy. These findings have important clinical and biological implications.

Influence of body mass index on complications and oncologic outcomes following hepatectomy for malignancy

BACKGROUND

Following hepatectomy for malignancy, the effect of body mass index (BMI) on hepatic and oncologic outcomes is unknown.

METHODS

Two hundred seventy-nine post-hepatectomy patients with malignancy from our center were included in the cohort (1996-2006). BMI was categorized using World Health Organization criteria. The effect of BMI was evaluated using risk-adjusted Cox models for time to recurrence and overall survival.

RESULTS

Seventy-nine patients (28.3%) had primary hepatobiliary cancers, 134 (48.0%) had colorectal metastases, and 66 (25.3%) had other metastases. Thirty-five percent of patients were obese (BMI > 30). Obese patients had more hepatic-specific perioperative complications (27.8% vs. 15.9%, p = 0.018), bile leaks (18.6% vs. 9.9%, p = 0.030), post-operative pneumonia (9.3% vs. 2.2%, p = 0.0074), intra-abdominal abscesses (7.2% vs. 1.7%, p = 0.017), acute renal failure (7.2% vs. 1.7%, p = 0.017), urinary tract infections (16.4% vs. 7.7%, p = 0.024), and longer lengths of stay (10.5 vs.8.6 days, p = 0.029). Obese and non-obese patients had similar perioperative mortality, time to recurrence, and overall survival on univariate analysis. However, after adjusting for demographic, tumor, and operative characteristics, and complications, increasing BMI displayed improved recurrence-free (HR 0.90, 95% CI 0.86-0.95) and overall survival (HR 0.96, 95% CI 0.92-0.99).

CONCLUSIONS

High BMI patients may have better oncologic outcomes despite higher perioperative morbidity and hepatic complications following hepatectomy. These findings have important clinical and biological implications.