Impact of obesity on short-term outcomes of laparoscopic colorectal surgery for Japanese patients with colorectal cancer: A multicenter study

Preoperative Weight Loss Program for Hepatocellular Carcinoma Patients with High Body Mass Index in Hepatectomy

BACKGROUND

This study aimed to investigate the usefulness of a weight-loss program (WLP) in patients with a high body mass index (BMI) prior to liver resection (Hx) for hepatocellular carcinoma (HCC).

METHODS

Among 445 patients with HCC who underwent initial Hx between 2000 and 2020, 19 with a high BMI (≥25.0) were enrolled in our WLP since 2014. For calorie restriction, the amount of energy consumed was calculated as the standard body weight (SBW) kg × 20-25 kcal/day. Protein mass was calculated as SBW kg × 1.0-1.2 g/day to maintain skeletal muscle mass. Patients also performed both aerobic and resistance exercises. The before-and-after changes were compared, and the effect of WLP on the short- and long-term results was investigated.

RESULTS

The average length of WLP was 21 days, and weight loss was successfully achieved in all patients. Body fat mass was reduced during the program, while skeletal muscle mass was maintained. WLP led to improvements in liver function and fibrotic markers, without tumor progression. There were no postoperative complications (≥Clavien-Dindo [CD] III). A retrospective comparison between with and without WLP using propensity score-matching analysis revealed that WLP group showed better NLR value, however, there were no significant differences in both short and long-term outcomes after Hx based on participation in the WLP.

CONCLUSIONS

WLP with multidisciplinary intervention improved immune-nutrition status and liver function of obese patients. WLP had not affected both short and long-term outcomes after Hx.

Effect of obesity on perioperative outcomes following gastrointestinal surgery: meta-analysis

BACKGROUND

Obesity can pose perioperative challenges related to obesity-associated co-morbidities and technical factors. However, the true impact of obesity on postoperative outcomes is not well established and reports are conflicting. The aim was to perform a systematic review and meta-analysis to explore the effect of obesity on perioperative outcomes for general surgery procedures in distinct obesity subtypes.

METHODS

A systematic review was performed for studies reporting postoperative outcomes in relation to BMI in upper gastrointestinal, hepatobiliary and colorectal based on an electronic search using the Cochrane Library, Science Direct, PubMed and Embase up to January 2022. The primary outcome was the incidence of 30-day postoperative mortality among patients with obesity undergoing general surgical procedures in comparison to patients with normal range BMI.

RESULTS

Sixty-two studies, including 1 886 326 patients, were eligible for inclusion. Overall, patients with obesity (including class I/II/II) had lower 30-day mortality rates in comparison to patients with a normal BMI (odds ratio (OR) 0.75, 95 per cent c.i. 0.66 to 0.86, P < 0.0001, I2 = 71 per cent); this was also observed specifically in emergency general surgery (OR 0.83, 95 per cent c.i. 0.79 to 0.87, P < 0.0000001, I2 = 7 per cent). Compared with normal BMI, obesity was positively associated with an increased risk of 30-day postoperative morbidity (OR 1.11, 95 per cent c.i. 1.04 to 1.19, P = 0.002, I2 = 85 per cent). However, there was no significant difference in postoperative morbidity rates between the cohorts of patients with a normal BMI and class I/II obesity (OR 0.98, 95 per cent c.i. 0.92 to 1.04, P = 0.542, I2 = 92 per cent). Overall, the cohort with obesity had a higher rate of postoperative wound infections compared with the non-obese group (OR 1.40, 95 per cent c.i. 1.24 to 1.59, P < 0.0001, I2 = 82 per cent).

CONCLUSION

These data suggest a possible 'obesity paradox' and challenge the assumption that patients with obesity have higher postoperative mortality compared with patients with normal range BMI. Increased BMI alone is not associated with increased perioperative mortality in general surgery, highlighting the importance of more accurate body composition assessment, such as computed tomography anthropometrics, to support perioperative risk stratification and decision-making.

REGISTRATION NUMBER

CRD42022337442 (PROSPERO https://www.crd.york.ac.uk/prospero/).

Relationship between body mass index and short-term postoperative prognosis in patients undergoing colorectal cancer surgery

BACKGROUND

Obesity is a state in which excess heat is converted into excess fat, which accumulates in the body and may cause damage to multiple organs of the circulatory, endocrine, and digestive systems. Studies have shown that the accumulation of abdominal fat and mesenteric fat hypertrophy in patients with obesity makes laparoscopic surgery highly difficult, which is not conducive to operation and affects patient prognosis. However, there is still controversy regarding these conclusions.

AIM

To explore the relationship between body mass index (BMI) and short-term prognosis after surgery for colorectal cancer.

METHODS

PubMed, Embase, Ovid, Web of Science, CNKI, and China Biology Medicine Disc databases were searched to obtain relevant articles on this topic. After the articles were screened according to the inclusion and exclusion criteria and the risk of literature bias was assessed using the Newcastle-Ottawa Scale, the prognostic indicators were combined and analyzed.

RESULTS

A total of 16 articles were included for quantitative analysis, and 15588 patients undergoing colorectal cancer surgery were included in the study, including 3775 patients with obesity and 11813 patients without obesity. Among them, 12 articles used BMI ≥ 30 kg/m² and 4 articles used BMI ≥ 25 kg/m² for the definition of obesity. Four patients underwent robotic colorectal surgery, whereas 12 underwent conventional laparoscopic colorectal resection. The quality of the literature was good. Meta-combined analysis showed that the overall complication rate of patients with obesity after surgery was higher than that of patients without obesity [OR = 1.35, 95%CI: 1.23-1.48, Z = 6.25, P < 0.0001]. The incidence of anastomotic leak after surgery in patients with obesity was not significantly different from that in patients without obesity [OR = 0.99, 95%CI: 0.70-1.41), Z = -0.06, P = 0.956]. The incidence of surgical site infection (SSI) after surgery in patients with obesity was higher than that in patients without obesity [OR = 1.43, 95%CI: 1.16-1.78, Z = 3.31, P < 0.001]. The incidence of reoperation in patients with obesity after surgery was higher than that in patients without obesity; however, the difference was not statistically significant [OR = 1.15, 95%CI: 0.92-1.45, Z = 1.23, P = 0.23]; Patients with obesity had lower mortality after surgery than patients without obesity; however, the difference was not statistically significant [OR = 0.61, 95%CI: 0.35-1.06, Z = -1.75, P = 0.08]. Subgroup analysis revealed that the geographical location of the institute was one of the sources of heterogeneity. Robot-assisted surgery was not significantly different from traditional laparoscopic resection in terms of the incidence of complications.

CONCLUSION

Obesity increases the overall complication and SSI rates of patients undergoing colorectal cancer surgery but has no influence on the incidence of anastomotic leak, reoperation rate, and short-term mortality rate.

A meta-analysis of the effect of different body mass index on surgical wound infection after colorectal surgery

We conducted a meta-analysis to assess the effect of different body mass index on surgical wound infection after colorectal surgery. A systematic literature search up to November 2022 was performed and 2349 related studies were evaluated. The chosen studies comprised 15 595 colorectal surgery subjects participated in the selected studies' baseline trials; 4390 of them were obese according to the selected body mass index cut-off used to measure obesity in the selected studies, while 11 205 were nonobese. Odds ratio (OR) with 95% confidence intervals (CIs) were calculated to assess the effect of different body mass index on wound infection after colorectal surgery by the dichotomous methods with a random or fixed effect model. The body mass index ≥30 kg/m² resulted in significantly higher surgical wound infection after colorectal surgery (OR, 1.76; 95% CI, 1.46-2.11, P < .001) compared with the body mass index <30 kg/m² . The body mass index ≥25 kg/m² resulted in significantly higher surgical wound infection after colorectal surgery (OR, 1.64; 95% CI, 1.40-1.92, P < .001) compared with the body mass index <25 kg/m² . The subjects with higher body mass index had a significantly higher surgical wound infection after colorectal surgery compared with the subjects with normal body mass index.

Advantage of laparoscopic surgery in patients with generalized obesity operated for colorectal malignancy: A retrospective cohort study

Background

Because of the progression of minimally invasive surgery skills and obesity in colorectal surgery, we aimed to evaluate the short-term outcomes of colorectal cancer resections in patients with generalized obesity at a single teaching hospital with mature surgical techniques and training programs.

Methods

A total of 537 patients were diagnosed with CRC and had a body mass index ≥30 kg/m² between January 2009 and December 2019 at a single institution. 265 patients underwent open surgery and 272 patients underwent laparoscopic surgery. Data were analysed to explore the independent risk factors for postoperative complications.

Results

The laparoscopic group had less blood loss (73 ± 128 vs. 148 ± 290 ml, p < 0.001) and a shorter postoperative hospital stay (10.8 ± 17.1 vs. 11.7 ± 6.8 days, p < 0.001) than the open group. The number of harvested lymph nodes did not significantly differ between the two groups (30.9 ± 18.3 vs. 30.2 ± 15.3, p = 0.981). Although anastomotic leakage was significantly higher in the laparoscopic group (1.5% vs. 4.8%, p = 0.030), there were also similar overall postoperative morbidity and mortality rates between the open and laparoscopic groups for CRC patients with generalized obesity who underwent surgery.

Conclusion

Laparoscopic surgery can reduce blood loss, decrease the length of hospital stay, obtain a similar number of harvested lymph nodes, and achieve an acceptable conversion rate for CRC patients with generalized obesity. We suggest that laparoscopic surgery could become a standard method for CRC treatment in patients with generalized obesity.

Effect of body mass index on surgical site wound infection, mortality, and postoperative hospital stay in subjects undergoing possibly curative surgery for colorectal cancer: A meta-analysis

We performed a meta-analysis to evaluate the effect of body mass index on surgical site wound infection, mortality, and postoperative hospital stay in subjects undergoing possibly curative surgery for colorectal cancer. A systematic literature search up to March 2022 was performed and 2247 subjects with possibly curative surgery for colorectal cancer at the baseline of the studies; 2889 of them were obese, and 9358 were non-obese. Odds ratio (OR) and mean difference (MD) with 95% confidence intervals (CIs) were calculated to assess the effect of body mass index on surgical site wound infection, mortality, and postoperative hospital stay in subjects undergoing possibly curative surgery for colorectal cancer using the dichotomous or contentious methods with a random or fixed-effect model. The obese subjects had a significantly higher surgical site wound infection after colorectal surgery (OR, 1.87; 95% CI, 1.62-2.15, P < .001), and higher mortality (OR, 1.58; 95% CI, 1.07-2.32, P = .02) in subjects with possibly curative surgery for colorectal cancer compared with non-obese. However, obese did not show any significant difference in postoperative hospital stay (MD, 0.81; 95% CI, -0.030 to 1.92, P = .15) compared with non-obese in subjects with possibly curative surgery for colorectal cancer. The obese subjects had a significantly higher surgical site wound infection after colorectal surgery, higher mortality, and no significant difference in postoperative hospital stay compared with non-obese in subjects with possibly curative surgery for colorectal cancer. The analysis of outcomes should be with caution because of the low number of studies in certain comparisons.

Risk factors for failure of ileal pouch-anal anastomosis in patients with refractory ulcerative colitis

BACKGROUND

Proctocolectomy with ileal pouch-anal anastomosis is the standard surgical procedure for ulcerative colitis refractory to medical treatment. In a few cases, ileal pouch-anal anastomosis cannot be completed due to intraoperative technical problems. The aim of this single-center study was to identify risk factors for a technically failed ileal pouch-anal anastomosis.

METHODS

In total, 391 patients with ulcerative colitis who received ileal pouch-anal anastomosis were identified. Clinical and perioperative data from patients with successful ileal pouch-anal anastomosis (IPAA+) were compared to data from failed ileal pouch-anal anastomosis (IPAA-). Definition of failed ileal pouch-anal anastomosis was intraoperative failure to perform ileal pouch-anal anastomosis. Risk factors for failed ileal pouch-anal anastomosis were assessed by logistic regression. Cut-off values were calculated on the basis of receiver operating characteristic curves and the Youden Index.

RESULTS

The rate of failed ileal pouch-anal anastomosis was 26 of 391 (6.6%). In 22 of 26 cases (84.6%), there was an insufficient length of the small intestinal mesentery. Patients with failed ileal pouch-anal anastomosis were more often male (80.8% vs 54.5%, P = .009), older (47.1 ± 14.1 vs 39.2 ± 12.8 years, P = .007), had a higher body mass index 27.2 ± 4.5 vs 23.7 ± 4.3 kg/m², P < .001), and had extraintestinal manifestations more frequently (65.4% vs 26.3%, P < .001). Further risk factors for failed ileal pouch-anal anastomosis were hypertension and Cushing's syndrome.

CONCLUSION

Technical failure of ileal pouch-anal anastomosis is elevated in patients with higher body mass index, with refractory ulcerative colitis, and/or extended immunosuppressive medication. Three-staged ileal pouch-anal anastomosis and optimizing preoperative conditions may help to elevate the rate of successful ileoanal pouch construction in these patients.