The impact of obesity on 30-day complications in pediatric surgery

Effects of Obesity on Urogynecologic Prolapse Surgery Outcomes: A Systematic Review and Meta-analysis

OBJECTIVE

To systematically review the literature on outcomes of pelvic organ prolapse (POP) surgery in patients from various body mass index (BMI) categories to determine the association between obesity and surgical outcomes.

DATA SOURCES

PubMed, EMBASE, and Cochrane databases were searched from inception to April 12, 2022; ClinicalTrials.gov was searched in September 2022 (PROSPERO 2022 CRD42022326255). Randomized and nonrandomized studies of urogynecologic POP surgery outcomes were accepted in which categories of BMI or obesity were compared.

METHODS OF STUDY SELECTION

In total, 9,037 abstracts were screened; 759 abstracts were identified for full-text screening, and 31 articles were accepted for inclusion and data were extracted.

TABULATION, INTEGRATION, AND RESULTS

Studies were extracted for participant information, intervention, comparator, and outcomes, including subjective outcomes, objective outcomes, and complications. Outcomes were compared among obesity categories (eg, BMI 30-34.9, 35-40, higher than 40), and meta-analysis was performed among different surgical approaches. Individual studies reported varying results as to whether obesity affects surgical outcomes. By meta-analysis, obesity (BMI 30 or higher) is associated with an increased odds of objective prolapse recurrence after vaginal prolapse repair (odds ratio [OR] 1.38, 95% CI, 1.14-1.67) and after prolapse repair from any surgical approach (OR 1.31, 95% CI, 1.12-1.53) and with complications such as mesh exposure after both vaginal and laparoscopic POP repair (OR 2.10, 95% CI, 1.01-4.39).

CONCLUSION

Obesity is associated with increased likelihood of prolapse recurrence and mesh complications after POP repair.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022326255.

Effect of Obesity on Surgical Outcomes and Complication Rates in Pediatric Patients: A Comprehensive Systematic Review and Meta-Analysis

Obesity is one of the primary public health problems faced by children. The increased incidence of obesity in the pediatric population poses significant challenges during and after surgical procedures. This systematic review and meta-analysis aimed to understand to what extent obesity is to surgical complications in pediatric patients. A systematic database search of PubMed, Web of Science, Scopus, and Science Direct was performed in June 2023. According to the inclusion and exclusion criteria, two evaluators independently conducted literature screening, data extraction, and quality evaluation of the retrieved literature. The Newcastle-Ottawa Scale score was used for quality evaluation, and a meta-analysis was performed using Review Manager software 5.4.1. A total of 1,170 relevant articles were initially identified, and 20 articles were finally included for data extraction and meta-analysis. The results of the meta-analysis showed that compared with normal-weight individuals, obese pediatric patients had a higher risk of developing surgical site infection (SSI) (relative risk (RR) = 1.63; 95% confidence interval (CI) = 1.33-2.00), wound dehiscence (RR = 2.01; 95% CI = 1.24-3.23), and underwent procedures that were 11.32 minutes longer (95% CI = 5.36-17.29). There were no differences in bleeding requiring transfusion, deep venous thromboembolism, postoperative abscess rate, and length of stay. Obese pediatric patients have a higher risk of SSI and dehiscence, along with a longer operative time. The established risks in obese adults undergoing surgery suggest a similar risk for obese pediatric patients. The findings of this study hold significant implications for clinical practice, suggesting the potential for additional measures to prevent surgical complications in children.

Racial Inequity in Pediatric Anesthesia

Purpose of Review

Minority health disparities have received renewed attention in the USA following several highly publicized racial injustices in 2020. Though the focus has been largely on adults, children are not immune to these inequities. By reviewing racial disparities in pediatric perioperative care, we aim to engage the anesthesia community in the fight against systemic racism.

Recent Findings

Minority children have higher rates of anesthetic and surgical morbidity compared to White children, including respiratory events, length of stay, hospital costs, and even death. These inequities occur across surgical specialties and environments.

Summary

Racial disparities in the perioperative health and management of children are ubiquitous. Herein, we will summarize recent pediatric health disparity literature, discuss some important contributors to persistent inequities, and propose avenues for anesthesiologists to impact the pursuit of equitable healthcare outcomes.

Obesity as a Risk Factor for Postoperative Adverse Events in Skull Base Surgery

OBJECTIVE

To determine the implications of obesity on postoperative adverse events following skull base surgery.

METHODS

The 2005-2017 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for adverse events in skull base surgery cases. Patients were stratified by body mass index (BMI) into normal weight (18.5 ≤ BMI < 25), overweight (25 ≤ BMI < 30), and obese (BMI ≥ 30) cohorts. Logistic regression was used to assess the association of overweight or obese BMI with various 30-day postoperative adverse events.

RESULTS

A total of 2305 patients were included for analysis, of which 732 (31.8%) and 935 (40.6%) were overweight or obese, respectively. The mean age was 53.8 ± 15.3 years and 1214 (52.7%) patients were female. Obese patients were younger (P = .033) and possessed higher frailty (P < .001) and ASA scores (P < .001). Operation times and lengths of hospitalization were not significantly different across patient cohorts (all P > .05). On propensity score-adjusted multivariable analysis, only bleeding (OR = 0.42, P < .001) and deep vein thrombosis (OR = 6.46, P = .015) were significantly associated with obesity. There were no significant differences in rates of readmission, reoperation, or mortality between normal weight and obese patients (all P > .05).

CONCLUSIONS

Obesity was associated with decreased postoperative bleeding and increased deep vein thromboses. Obese patients were otherwise at no higher risk for medical or surgical complications. Elevated BMI did not confer an increased risk for readmission, reoperation, or death. Thus, patient obesity should not be a major determinant in offering skull base surgery in individuals who would otherwise benefit from treatment.

Obesity Increases the Risk of Hospital Readmission Following Intestinal Surgery for Children With Crohn Disease

OBJECTIVES

Obese habitus can lead to adverse outcomes for colorectal surgeries due to technical challenges and pro-inflammatory immune mediators associated with excess adipose tissue. Surgical planning, pre-operative risk stratification, and patient counseling of pediatric Crohn disease (CD) patients are limited by the scarcity of data on this topic. We sought to determine the association between obesity and hospital readmission in children with CD undergoing intestinal resection.

METHODS

We used the National Surgical Quality Improvement Program-Pediatric (NSQIP-P) database to identify pediatric CD patients undergoing intestinal resection between 2012 and 2018. We calculated age- and sex-adjusted body mass index (BMI) z scores using CDC population statistics. We used logistic regression to evaluate the association between obesity and readmission compared to average-BMI patients adjusting for age, race, sex, steroid exposure, disease activity, and surgery type.

RESULTS

We evaluated 1258 pediatric CD intestinal resections occurring between 2012 and 2018. Patients were predominantly adolescent (91%), white (84%), and male (56%). Those with average BMI comprised 50% of the cohort, 31% were underweight, 11% overweight, and 8% obese. The overall 30-day hospital readmission rate was 8.8%. Compared to those with average BMI, obese children had a 2-fold (adjusted odds ratio 1.9, 95% confidence interval 1.0-3.8) increase in risk of hospital readmission.

CONCLUSIONS

Obese patients undergoing intestinal resection face a higher risk of 30-day hospital readmission compared to average-BMI patients. These results can inform pre-surgical risk counseling and underscore the need for long-term weight management strategies to aid in risk reduction for obese children with CD at risk of future surgery.

Hot Topics in Safety for Pediatric Anesthesia

Anesthesiology is one of the leading medical specialties in patient safety. Pediatric anesthesiology is inherently higher risk than adult anesthesia due to differences in the physiology in children. In this review, we aimed to describe the highest yield safety topics for pediatric anesthesia and efforts to ameliorate risk. Conclusions: Pediatric anesthesiology has made great strides in patient perioperative safety with initiatives including the creation of a specialty society, quality and safety committees, large multi-institutional research efforts, and quality improvement initiatives. Common pediatric peri-operative events are now monitored with multi-institution and organization collaborative efforts, such as Wake Up Safe.

Does obesity affect the short-term outcomes after cardiothoracic surgery in adolescents with congenital heart disease?

BACKGROUND

Obesity is a modifiable, independent risk factor for mortality and morbidity after cardiovascular surgery in adults. Our objective was to evaluate the impact of obesity on short-term outcomes in adolescents undergoing surgery for congenital heart disease (CHD).

METHODS

This retrospective chart review included patients 10-18 years of age who underwent CHD surgery. Our exclusion criteria were patients with a known genetic syndrome, heart transplantation, and patients with incomplete medical records. The clinical data collected included baseline demographics and multiple perioperative variables. Charting the body mass index in the Centers for Disease Control and Prevention growth curves, the entire cohort was divided into three categories: obese (>95th percentile), overweight (85th-95th percentile), and normal weight (<85th percentile). The composite outcome included survival, arrhythmias, surgical wound infection, acute neurologic injury, and acute kidney injury.

RESULTS

The study cohort (n = 149) had a mean standard deviation (SD), body mass index (BMI) of 22.6 ± 6.5 g/m2, and 65% were male. There were 27 obese (18.1%), 24 overweight (16.1%), and 98 normal weight (65.8%) patients. Twenty-seven (18%) patients had composite adverse outcomes. Overweight and obese patients had significantly higher adverse outcomes compared with normal weight patients (odds ratio (OR): 2.9; confidence interval (CI): 1-8.5, p = 0.04 and OR: 3; CI: 1-8.5, p = 0.03, respectively). In multivariate analysis, obesity was an independent predictor of adverse outcome in our cohort (p = 0.04).

CONCLUSIONS

Obesity is associated with short-term adverse outcome and increased health resource utilisation in adolescents following surgery for CHD. Further studies should evaluate if intervention in the preoperative period can improve outcomes in this population.

Trends in hospital length of stay and 30-day morbidity in pediatric patients undergoing laparoscopic ileocecal resection, 2012-2016

PURPOSE

To examine postoperative length of stay (LOS), hospital readmission, and 30-day complications in pediatric patients undergoing laparoscopic ileocecal resection in a contemporary cohort.

METHODS

Retrospective review of the American College of Surgeons National Surgery Quality Improvement Project, Pediatric (NSQIP-P) 2012-2016 participant user files for patients <19 years old who underwent laparoscopic ileocecal resection. Mean postoperative LOS, hospital readmission and both wound-specific and composite complications were calculated and compared by year of operation.

RESULTS

348 patients were identified (range, 46-96 per year); 55.2-69.8% of these were admitted the day of operation, with a nonsignificant increase in frequency over the study period. Postoperative LOS ranged from 5.4 ± 2.9 days to 7.3 ± 9.1 days (p = 0.24). In subset analysis of only those patients admitted on the day of operation, postoperative LOS remained relatively long, ranging from 5.0 ± 3.0 days to 5.7 ± 4.0 days (p = 0.89). 30-day hospital readmission proportions rose insignificantly, from 6.9% in 2012 to 15.5% in 2016 (p = 0.41). Wound complication rates (including superficial, deep, and deep organ space infections, as well as wound dehiscence) ranged from 0.0% to 8.6%, but did not vary in a statistically significant manner. Nonwound complication rates were vanishingly small.

CONCLUSIONS

Postoperative LOS in pediatric patients undergoing laparoscopic ileocecal resection in a select group of patients cared for in hospitals participating in NSQIP-P has not decreased in the past 5 years despite emerging evidence of the safety and relevance of enhanced recovery after surgery programs. Opportunities for shortening LOS without compromising patient safety may still exist.

LEVEL-OF-EVIDENCE

III Retrospective comparative study.

Predictors for hemorrhage following pediatric adenotonsillectomy

OBJECTIVE

To determine risk factors and trends for posttonsillectomy hemorrhage (PTH) following adenotonsillectomy (T&A) at a single children's tertiary referral hospital.

METHODS

Charts from all patients 2-12 years old undergoing T&A alone at a single children's hospital from January 1, 2010 through December 31, 2015 were reviewed. Data was collected on patient demographics, indication for procedure, time of year, academic affiliation of surgeon, surgical technique and method, post-operative pain medication prescribed,and readmission for PTH. Univariate chi-square analyses and logistic regression along with multivariable stepwise logistic regression were used to identify predictors of PTH. SPSS version 24 was used for statistical analyses with p < .05 indicating statistical significance.

RESULTS

There were 2565 children undergoing T&A during the study period. One hundred seventy-three (6.7%) patients were readmitted, of which 53 (30.6%) were due to PTH. Univariate analyses identified children at the highest age quartile of the study, 7.72-12.97 years old (odds ratio [OR] = 5.775, 95% confidence interval [CI] = 2.248-14.837, p < .001) and children with a BMI z-score of 2 or greater (OR = 3.391, 95% CI = 1.497-7.680, p = .003) were at increased risk for PTH. Multivariable analyses also identified both the highest age quartile and BMI z-score of 2 or greater to be a risk factor for PTH.

CONCLUSION

In children undergoing T&A, age greater than 7.72 years old and BMI z-score of 2 or greater are significant risk factors for PTH. Replication of these findings in a more highly powered trial is needed.