Influence of visceral obesity for postoperative pulmonary complications after pancreaticoduodenectomy

A novel prediction model of pancreatic fistula after pancreaticoduodenectomy using only preoperative markers

BACKGROUND

Since clinically relevant postoperative pancreatic fistula (CR-POPF) can cause intra-abdominal hemorrhage and abscesses, leading to surgery-related deaths after pancreaticoduodenectomy (PD), its preoperative prediction is important to develop strategies for surgical procedures and perioperative management. This study aimed to establish a novel prediction model for CR-POPF using preoperative markers.

METHODS

On a training set of 180 patients who underwent PD at the Yamaguchi University Hospital, a combination of CR-POPF predictors were explored using the leave-one-out method with a unique discrete Bayes classifier. This predictive model was confirmed using a validation set of 366 patients who underwent PD at the Osaka University Hospital.

RESULTS

In the training set, CR-POPF occurred in 60 (33%)　of 180 patients and 130 (36%)　of 366 patients in the validation set using selected markers. In patients with pancreatic ductal adenocarcinoma (PDAC), the main pancreatic duct (MPD) index showed the highest prognostic performance and could differentiate CR-POPF with 87% sensitivity and 81% specificity among 84 patients in the training set. In the validation set, the sensitivity and specificity of the MPD index-based model for 130 PDAC samples were 93% and 87%, respectively. In patients with non-PDAC, the MPD index/body mass index (BMI) combination showed the highest prognostic performance and could differentiate CR-POPF with 84% sensitivity and 57% specificity among 96 patients in the training set. In the validation set, the sensitivity and specificity of the MPD index/BMI-based model for 236 non-PDAC samples were 85% and 53%, respectively.

CONCLUSION

We developed a novel prediction model for pancreatic fistulas after PD using only preoperative markers. The MPD index and MPD index/BMI combination will be useful for CR-POPF assessment in PDAC and non-PDAC samples, respectively.

Risk factors for postoperative cholangitis after pancreaticoduodenectomy and evaluation of internal stenting on hepaticojejunostomy: A single-center propensity score-based analysis

BACKGROUND/PURPOSE

This retrospective study aimed to investigate the risk factors for postoperative cholangitis (POC) after pancreaticoduodenectomy (PD) and the efficacy of stenting on hepaticojejunostomy (HJ).

METHODS

We investigated 162 patients. Postoperative cholangitis occurring before and after discharge was defined as early-onset POC (E-POC) and late-onset POC (L-POC), respectively. Risk factors for E-POC and L-POC were identified using univariate and multivariate logistic regression analyses. Propensity score matching (PSM) between the stenting group (group S) and the non-stenting group (group NS), and subgroup analysis in patients with risk factors were performed to evaluate the efficacy of stenting on HJ in preventing POC.

RESULTS

Body mass index (BMI) ≥ 25 kg/m2 and preoperative non-biliary drainage (BD) were risk factors for E-POC and L-POC, respectively. PSM analysis revealed that E-POC occurrence was significantly higher in group S than in group NS (P = .045). In the preoperative non-BD group (n = 69), E-POC occurrence was significantly higher in group S than in group NS (P = .025).

CONCLUSIONS

BMI ≥ 25 kg/m2 and preoperative non-BD status were risk factors for E-POC and L-POC, respectively. Stenting on HJ implants did not prevent POC after PD.

The visceral pancreatic neck anterior distance may be an effective parameter to predict post-pancreaticoduodenectomy clinically relevant postoperative pancreatic fistula

Background

The clinically relevant postoperative pancreatic fistula (CR-POPF) is significantly correlated with a high post-pancreaticoduodenectomy (PD) mortality rate. Several studies have reported an association between visceral obesity and CR-POPF. Nevertheless, there are many technical difficulties and controversies in the measurement of visceral fat. The aim of this research was to determine whether the visceral pancreatic neck anterior distance (V-PNAD) was a credible predictor for CR-POPF.

Methods

We retrospectively analyzed the data of 216 patients who underwent PD in our center between January 2016 and August 2021. The correlation of patients' demographic information, imaging variables, and intraoperative data with CR-POPF was assessed. Furthermore, areas under the receiver operating characteristic curves for six distances (abdominal thickness, visceral thickness, abdominal width, visceral width, abdominal PNAD, V-PNAD) were used to identify the best imaging distance to predict POPF.

Results

In the multivariate logistic analysis, V-PNAD (P < 0.01) was the most significant risk factor for CR-POPF after PD. Males with a V-PNAD >3.97 cm or females with a V-PNAD >3.66 cm were included into the high-risk group. The high-risk group had a higher prevalence of CR-POPF (6.5% vs. 45.1%, P < 0.001), intraperitoneal infection (1.9% vs. 23.9%, P < 0.001), pulmonary infection (3.7% vs. 14.1%, P = 0.012), pleural effusion (17.8% vs. 33.8%, P = 0.014), and ascites (22.4% vs. 40.8%, P = 0.009) than the low-risk group.

Conclusion

Of all imaging distances, V-PNAD may be the most effective predictor of CR-POPF. Moreover, high-risk patients (males, V-PNAD >3.97 cm; females, V-PNAD >3.66 cm) have a high incidence of CR-POPF and poor short-term post-PD prognosis. Therefore, surgeons should perform PD carefully and take adequate preventive measures to reduce the incidence of pancreatic fistula when the patient has a high V-PNAD.

High visceral to subcutaneous fat area ratio predicts early postoperative small bowel obstruction after surgery for colorectal cancer

PURPOSE

Risks for postoperative small bowel obstruction have been demonstrated in several reports, most of which indicated male sex was a risk factor, but with the reason remaining unknown. We tested the hypothesis that it could be because males have more visceral fat than females. This prospective observational study aims to examine risks of early postoperative small bowel obstruction (EPSBO) after colorectal cancer surgery and the association between visceral to subcutaneous fat area ratio (V/S ratio) and EPSBO.

METHODS

Four hundred and seventy-four patients who underwent colectomy for colorectal cancer in our hospital were enrolled in this study. The influence of several factors including V/S ratio on the development of EPSBO was analyzed.

RESULTS

Thirty-one of the 474 patients (6.5%) developed EPSBO. EPSBO occurred more frequently in males (p = 0.03) and cases who developed postoperative anastomotic leakage (p < 0.001) or wound infection (p = 0.02). Higher V/S ratio was strongly related to male sex (p < 0.001). Multivariate analysis revealed higher V/S ratio (OR 2.25; p = 0.049) and anastomotic leakage (OR 5.86; p < 0.001) were independent risk factors for EPSBO.

CONCLUSION

Higher V/S ratio was significantly related to EPSBO, suggesting that one of the reasons EPSBO was more likely to occur in males because they have more visceral fat than females. Preoperative identification of this risk factor could help us watch out for this potential complication.

Body composition in relation to postoperative anastomotic leakage and overall survival in patients with esophageal cancer

BACKGROUND

Body composition was reported to be related to the prognosis of patients with cancer. This study aimed to investigate the influence of preoperative body composition on anastomotic leakage and overall survival in patients with esophageal cancer.

METHODS

In this retrospective study, 93 patients with esophageal cancers were evaluated. Skeletal muscle area, intermuscular adipose tissue, visceral adipose tissue (VAT), and subcutaneous adipose tissue were measured on computed tomography images at the level of the third lumbar vertebra. Subsequently, each body composition index was also calculated by dividing the body composition by the square of the height. The cut-off values of body compositions were defined using X-tile software (version 3.6.1; Yale University, New Haven, CTA). Univariate and multivariate analyses were performed to evaluate the risk factors of anastomotic leakage. Kaplan-Meier method and Cox regression analysis were used to evaluate the risk factors of overall survival.

RESULTS

VAT and visceral fat index (VFI) were higher in patients with anastomotic fistula than in those without anastomotic fistula, but none of them were independent risk factors. Patients with higher body mass index (BMI), higher VFI, and higher subcutaneous fat index (SFI) had better overall survival. By multivariate analysis, SFI >27.6 cm²/m² was still significantly associated with overall survival.

CONCLUSION

Patients with higher VAT and VFI were prone to have an anastomotic leakage. Lower BMI, VFI, and SFI were associated with a reduction in overall survival.

The Relationship Between Visceral Obesity and Post-operative Complications: A Meta-analysis

BACKGROUND

Body composition can have important influence on surgical outcome. There is substantial literature examining sarcopenia, however much less in known about the impact of fat. Visceral fat area (VFA) is a reliable measures of fat distribution that can be quantified with CT scan. The aim of this study is to determine the impact of VFA to predict complications and mortality after emergent or elective surgery.

MATERIALS AND METHODS

A systematic review and meta-analysis was performed in accordance with the Preferred.

Influence of Body Mass Index on Perioperative Outcomes Following Pancreaticoduodenectomy

Background: Overweight and obesity are increasing year by year all over the world, and there is a correlation between overweight and obesity and the risk of pancreatic cancer. However, the relationship between overweight and obesity and perioperative outcomes of pancreaticoduodenectomy (PD) was controversial. The purpose of this study was to investigate the effect of body mass index (BMI) on the perioperative outcome of PD. Methods: This study retrospectively evaluated 227 patients who underwent PD from 2015 to 2019. The patients were divided into three groups: underweight group (BMI <18.5 kg/m²), normal weight group (18.5 ≤ BMI <25 kg kg/m²), and overweight group (BMII ≥25 kg/m²). The association between different BMI groups and different perioperative results was discussed. Finally, the independent risk factors of clinically relevant-postoperative pancreatic fistula (CR-POPF) were analyzed by multivariate logistic regression. Results: The level of preoperative albumin was higher in patients of overweight group (P = .03). The incidence of hypertension increased gradually in the three BMI groups (P = . 039). The preoperative median CA19-9 level was significantly higher in the underweight group than that in the control groups (P = .001). The median operation time in the high BMI group was significantly longer than that in the other two groups. High BMI was an independent risk factor influencing CR-POPF after PD (P = .022, odds ratio 2.253, 95% confidence interval 1.123-4.518). Conclusions: Operation time of PD was increased in patients with high BMI. High BMI was an independent risk factor for the incidence of CR-POPF after PD. However, PD surgery is safe and feasible for patients with different BMI, and overweight and obese patients should not refuse PD surgery because of their BMI.

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 weight change on intra-abdominal and hernia volumes

BACKGROUND

Weight loss is often encouraged or required before open ventral hernia repair. This study evaluates the impact of weight change on total, intra-abdominal, subcutaneous, and hernia volume.

METHODS

Patients who underwent open ventral hernia repair from 2007 to 2018 with two preoperative computed tomography scans were identified. Scans were reviewed using 3D volumetric software. Demographics, operative characteristics, and outcomes were evaluated. The impact of weight change on intra-abdominal, subcutaneous, and hernia volume was assessed using Spearman's correlation coefficients and linear regression models.

RESULTS

A total of 250 patients met the criteria with a mean defect area of 155.6 ± 155.4 cm², subcutaneous volume of 6,800.0 ± 3,868.8 cm³, hernia volume of 915.7 ± 1,234.5 cm³, intra-abdominal volume equaling 4,250.2 ± 2,118.1 cm³, and time between computed tomography scans 13.9 ± 11.0 months. Weight change was associated with change in hernia, intra-abdominal, total, and subcutaneous volume (Spearman's correlation coefficients 0.17, 0.48, 0.51, 0.45, respectively, P ≤ 0.03 all values) and not associated in hernia length, width, or area (P ≥ 0.18 all values). A Δ5 kg was significantly associated with Δintra-abdominal volume (164.1 ± 30.0 cm³/Δ5 kg,P < .0001), Δtotal volume (209.9 ± 33.0 cm³/Δ5 kg, P < .0001), and Δsubcutaneous volume (234.4 ± 50.8 cm³/Δ5 kg, P < .0001). Per Δ5 kg, male patients had more than double the Δintra-abdominal, Δtotal, and Δsubcutaneous volume than did female patients. A weight change of 5 kg to10 kg was associated with approximately double the change in computed tomography parameters/Δ5 kg than any weight change after 10 kg. Regardless of weight change, all measured hernia parameters increased over time, with mean hernia volume of +40.6 ± 94.9 cm³/mo and area of +7.8 ± 13.3 cm²/mo (Spearman's correlation coefficient -0.03 to 0.07, P value 0.37-0.96).

CONCLUSION

Weight change is linearly correlated with intra-abdominal and subcutaneous fat gain or loss. Males show greater abdominal-related response to weight gain or loss. Hernia dimensions increase over time regardless of weight change.

Preoperative fecal elastase-1 (FE-1) adds value in predicting post-operative pancreatic fistula: not all soft pancreas share the same risk - A prospective analysis on 105 patients

BACKGROUND

Scores predicting postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) mainly use intraoperative predictors. The aim of this study is to investigate the role of pancreatic exocrine function expressed by fecal elastase (FE-1) as preoperative predictor of POPF.

METHODS

Patients scheduled for PD at the Department of General and Pancreatic Surgery, University of Verona Hospital, from April 2017 to July 2018 were prospectively enrolled. FE-1 was measured in a preoperative stool sample through an ELISA test.

RESULTS

The study population consisted of 105 patients. The POPF rate was 17.1%. Patients developing POPF showed high values of FE-1 (454 vs 155 mcg/g; p < 0.01), and FE-1 was an independent predictor of POPF (OR 1.008, CI 95% 1.003-1.014; p < 0.01), even considering only patients with a "soft" texture. A cut-off value of 260 mcg/g presented 100% sensitivity and 64.3% specificity (AUC 0.83) in predicting POPF. Approximately 30% of patients with a "soft" pancreatic texture presented with FE-1 < 260 mcg/g and did not develop POPF.

CONCLUSION

FE-1 is a promising tool to preoperatively assess the risk of POPF after PD. Further studies with larger populations are needed to potentially incorporate FE-1 into risk scores for PD with better stratification.

Efficacy of Peak Hounsfield Units of the Visceral Fat Area in Predicting Postoperative Complications after Pancreaticoduodenectomy

BACKGROUND

Morbidity following pancreaticoduodenectomy (PD) has been reported to remain high. This study sought to measure the peak Hounsfield units (HUs) of visceral attenuation in patients undergoing PD and to assess the quality of adipocytes by comparing these measurements with perioperative factors.

METHODS

Patients undergoing PD were retrospectively identified (n = 108). Abdominal perimeter, subcutaneous fat area (SFA), visceral fat area (VFA), and peak HU of the VFA were measured. Logistic regression analysis was used to identify independent predictors of postoperative pancreatic fistula (POPF) or complications. Histopathological examination was performed for qualitative diagnosis of the stromal tissue.

RESULTS

The overall rate of POPF was 16%, and severe complications occurred in 23% of the cases. A criterion for peak HU of the VFA only independently predicted POPF (p = 0.007) in the multivariate analysis. A criterion for peak HU of the VFA (p = 0.015) was associated with an increased rate of postoperative severe complications in the univariate analysis. The peak HU of the VFA was significantly correlated with abdominal perimeter (p < 0.001) and VFA (p < 0.001). The peak HU of the VFA was significantly correlated with adipocyte diameter (p < 0.001) and the ratio of stromal connective tissue area around the adipocytes (p < 0.001).

CONCLUSION

The peak HU of the VFA was an independent factor contributing to severe complications, including POPF after PD. It reflects the amount of stromal connective tissue around the adipocytes.

Sarcopenia and visceral obesity assessed by computed tomography are associated with adverse outcomes in patients with Crohn's disease

BACKGROUND

Altered body composition may impact on the clinical course of Crohn's disease (CD) but is not detected by the simple body mass index (BMI) assessment.

AIM

To assess the prevalence of sarcopenia and visceral obesity by a single computed tomography (CT) slice, and its association with adverse events in an adult hospitalized CD cohort.

METHODS

88 CD patients who had abdominal CT scans during hospitalization were retrospectively enrolled. The skeletal muscle index (SMI) at the third lumbar vertebra level was used to assess sarcopenia. Sarcopenia was defined as a SMI <38.5 cm²/m² in women, <52.4 cm²/m² in men and visceral obesity as a visceral fat area ≥130 cm². Clinical malnutrition was defined by a BMI <18.5 kg/m². Univariate analysis was performed, and predictors for surgery in the follow-up were entered in a stepwise logistic regression model for multivariate analysis.

RESULTS

The prevalence of sarcopenia was 58%, malnutrition 21.6%, and visceral obesity 19.3%. Among sarcopenic patients, 49% had a normal BMI, 13.7% were overweight, and 1(2%) was obese. Sarcopenic CD patients had significantly more abscesses (51% vs 16.7%, p = 0.001), hospitalizations (61.2% vs 36.1%, p = 0.022) and digestive surgery (63.3% vs 27.8%, p = 0.001) than non-sarcopenic patients during the follow-up, whereas usual malnutrition assessment was not correlated with disease outcomes. In multivariate analysis, both sarcopenia and visceral obesity were associated with further occurrence of digestive surgery.

CONCLUSION

Both sarcopenia and visceral obesity were associated with adverse outcomes in severe CD patients whereas usual nutritional assessment was not.

Evaluation of the Severity of Hyperlipidemia Pancreatitis Using CT-measured Visceral Adipose Tissue

BACKGROUND

Computed tomography-measured visceral adipose tissue (VAT) and the distribution of VAT are highly correlated with the severity and prognosis of acute pancreatitis (AP). To date, all available data are from the overall AP patient population; no subgroup analysis has been conducted to evaluate patients with moderately severe AP or patients with hyperlipidemia acute pancreatitis (HLAP) as independent populations. Currently, studies on the relationship between VAT and HLAP are lacking.

MATERIALS AND METHODS

A total of 235 patients with moderately severe AP or severe acute pancreatitis were divided into 2 groups according to whether hyperlipidemia was present: the HLAP group and the non-HLAP group. The general inpatient information was collected, and computed tomography was used to measure VAT, subcutaneous adipose tissue (SAT), total adipose tissue, and VAT/SAT (V/S). The data were subjected to t test, χ test, matrix scatter plot, logistic regression, and receiver operating characteristic analyses to evaluate the relationship between VAT and HLAP severity.

RESULTS

Significant differences were observed in VAT, SAT, total adipose tissue, and triglycerides (TGs) between the HLAP group and the non-HLAP group (P<0.001). Significant correlations were observed between VAT and body mass index (r=0.425, P=0.017) and between VAT and TG (r=0.367, P=0.042). In the HLAP group, VAT, V/S, TG, and local complications may have significant effects on disease severity. The receiver operating characteristic curves showed that VAT and V/S were more reliable than TGs in evaluating disease severity [area under the curve (AUC) of VAT: 0.819, P<0.001; AUC of V/S: 0.855, P<0.001; AUC of TG: 0.671, P=0.04]. Disease severity was reliably evaluated at 139 cm, the cut-off value of VAT. The cut-off value of V/S was 1.145; high V/S was associated with extended intensive care unit stay. VAT and its distribution had no significant effects on mortality.

CONCLUSIONS

For patients with moderately severe to severe HLAP, VAT was correlated with body mass index and TG. VAT and V/S were valuable factors for evaluating disease severity and prognosis. However, VAT had no effect on mortality, and VAT could not be used to evaluate patients with moderately severe to severe non-HLAP.

Three-dimensional hernia analysis: the impact of size on surgical outcomes

INTRODUCTION

BMI and hernia defect size are strongly associated with outcomes after open ventral hernia repair (OVHR). The impact of abdominal subcutaneous fat (SQV), intra-abdominal volume (IAV), hernia volume (HV), and ratio of HV to intra-abdominal volume (HV:IAV, representing visceral eventration) is less clearly elucidated. This study examines the interaction of multiple markers of adiposity and hernia size in OVHR.

METHODS

OVHR with preoperative CT scans were identified. 3D volumetric software measured HV, SQV, IAV, and HV:IAV was calculated. A principal component analysis was performed to create new component variables for collinear variables. Hernia PC was composed primarily of hernia dimensions, EAV (extra-abdominal volume PC) included SQV and BMI, and IAV PC included IAV.

RESULTS

A total of 1178 OVHR patients had a preoperative CT scan. Their demographics included a mean age of 58.5 ± 12.4 years, BMI of 34.2 ± 7.7 kg/m², and 57.8% were female. The mean defect area was 150.8 ± 136.7 cm², and 66.0% were recurrent, Patients had mean SQV of 6719.4 ± 3563.9 cm³, HV of 966.9 ± 1303.5 cm³, IAV of 4250.2 ± 2118.1 cm³, and a HV:IAV of 0.29 ± 0.46. In multivariate analysis, Hernia PC was associated with panniculectomy (OR 1.52, CI 1.37-1.69) and component separation (OR 1.34, CI 1.21-1.49) and was negatively associated with fascial closure (OR 0.78, CI 0.69-0.88). Hernia PC was also associated with reoperation, readmission, and development of wound complications (OR 1.18, CI 1.08-1.30; OR 1.15, CI 1.04-1.27; OR 1.28, CI 1.16-1.41, respectively). EAV PC was associated with performance of a panniculectomy (OR 1.33, CI 1.20-1.48), readmission (OR 1.18, CI 1.06-1.32), and wound complications (OR 1.41, CI 1.27-1.57). IAV PC was not associated with adverse outcomes.

CONCLUSION

Values of hernia area, volume, IAV, HV:IAV, BMI, and SQV are collinear markers of patient obesity and hernia proportions. They are distinct enough to be represented by three principal component variables, indicating more nuanced discrete influences on variability of surgical outcomes other than BMI.

Variation in pancreatoduodenectomy as delivered in two national audits

Background

Nationwide audits facilitate quality and outcome assessment of pancreatoduodenectomy. Differences may exist between countries but studies comparing nationwide outcomes of pancreatoduodenectomy based on audits are lacking. This study aimed to compare the German and Dutch audits for external data validation.

Methods

Anonymized data from patients undergoing pancreatoduodenectomy between 2014 and 2016 were extracted from the German Society for General and Visceral Surgery StuDoQ|Pancreas and Dutch Pancreatic Cancer Audit, and compared using descriptive statistics. Univariable and multivariable risk analyses were undertaken.

Results

Overall, 4495 patients were included, 2489 in Germany and 2006 in the Netherlands. Adenocarcinoma was a more frequent indication for pancreatoduodenectomy in the Netherlands. German patients had worse ASA fitness grades, but Dutch patients had more pulmonary co-morbidity. Dutch patients underwent more minimally invasive surgery and venous resections, but fewer multivisceral resections. No difference was found in rates of grade B/C postoperative pancreatic fistula, grade C postpancreatectomy haemorrhage and in-hospital mortality. There was more centralization in the Netherlands (1·3 versus 13·3 per cent of pancreatoduodenectomies in very low-volume centres; P &lt; 0·001). In multivariable analysis, both hospital stay (difference 2·49 (95 per cent c.i. 1·18 to 3·80) days) and risk of reoperation (odds ratio (OR) 1·55, 95 per cent c.i. 1·22 to 1·97) were higher in the German audit, whereas risk of postoperative pneumonia (OR 0·57, 0·37 to 0·88) and readmission (OR 0·38, 0·30 to 0·49) were lower. Several baseline and surgical characteristics, including hospital volume, but not country, predicted mortality.

Conclusion

This comparison of the German and Dutch audits showed variation in case mix, surgical technique and centralization for pancreatoduodenectomy, but no difference in mortality and pancreas-specific complications.

Preoperative Evaluation: Estimation of Pulmonary Risk Including Obstructive Sleep Apnea Impact

One in 4 deaths occurring within a week of surgery are related to pulmonary complications, making it the second most common serious morbidity after cardiovascular events. The most significant predictors of the postoperative pulmonary complications (PPCs) are American Society of Anesthesiologists physical status, advanced age, dependent functional status, surgical site, and duration of surgery. The overall risk of PPCs can be predicted using scores that incorporate readily available clinical data.

Impact of preoperative sarcopenia on postoperative outcomes following pancreatic resection: A systematic review and meta-analysis

BACKGROUND

Morphometric analysis of sarcopenia has garnered interest due to its putative role in predicting outcomes following surgery for a variety of pathologies, including resection for pancreatic disease. However, there are no standard recommendations on whether sarcopenia is a clinically relevant predictor of outcomes in this setting. The aim of this study was to review the prognostic impact of preoperatively diagnosed sarcopenia on postoperative outcomes following pancreatic resection.

METHODS

A systematic review of published literature was performed using PRISMA guidelines, and included a search of PubMed, MEDLINE and SCOPUS databases until May 2018.

RESULTS

Thirteen studies, including 3608 patients, were included. There was a significant increase in the mean duration of post-operative hospital stay (mean difference of 0.73 days, CI: 0.06-1.40, P = 0.033), there was no difference in the postoperative outcomes, including: clinically relevant postoperative pancreatic fistula, delayed gastric emptying, post-operative bile leak, surgical site infection, significant morbidity and overall morbidity.

CONCLUSION

Preoperative sarcopenia is associated with prolonged hospital stay after pancreatic surgery. However, sarcopenia does not appear to be a significant negative predictive factor in postoperative morbidity although study heterogeneity and risk of bias limit the strength of these conclusions.

Visceral Adiposity Predicts Severity of Acute Pancreatitis

OBJECTIVES

The aim of this study was to determine the association of visceral adiposity with severe outcomes in acute pancreatitis (AP).

METHODS

This retrospective study included consecutive patients with AP admitted to a tertiary care hospital between January 2010 and January 2015 who underwent a computed tomography scan. The visceral adipose tissue (VAT) volume was estimated using the method of Linder and colleagues. Multivariable logistic regression analysis was conducted to assess VAT as a predictor of severe AP compared with other validated predictors of severity.

RESULTS

Five hundred and seventy four patients were admitted during the study period, of which 252 had a computed tomography scan available. Patients with severe AP had a larger VAT area compared with those with mild or moderate AP (mean: 184.9 cm vs 79.9 cm, P = 0.006). Patients who developed multisystem organ failure or had acute necrotic collections had a larger VAT area than those who did not (150.6 cm vs 91.0 cm, P = 0.004 and 174.0 cm vs 91.9 cm, P = 0.003, respectively). Visceral adipose tissue area demonstrated superior discrimination of severe AP compared with other severity predictors.

CONCLUSIONS

Increased VAT area is a strong predictor of severe pancreatitis, necrosis, and multisystem organ failure.

Impact of visceral obesity and metabolic syndrome on the postoperative immune, inflammatory, and endocrine response following surgery for esophageal adenocarcinoma

Visceral obesity and metabolic syndrome (MetSyn) represent a constellation of inflammation, insulin resistance, and hyperglycemia and are established risk factors for gastrointestinal cancer. However, their impact on the immune and inflammatory response after major upper gastrointestinal oncologic surgery is unknown. In 125 consecutive patients who underwent esophagectomy, C-reactive protein (CRP) and CRP:albumin levels were recorded preoperatively and on days 1, 3, 7, and 14 postoperatively. In a subset of 30 patients, circulating levels of IL-6, IL-8, IL-10, IL-12p70, IFN-γ, TNF-α, TGF-β, and cortisol were measured. Incidences of postoperative complications were prospectively recorded. In the study cohort, 51% of patients were viscerally obese, 40.7% had MetSyn, and 33.6% were hyperglycemic. Viscerally obese and MetSyn-positive patients demonstrated greater postoperative CRP levels and CRP:albumin levels on day 7 and day 14 compared with nonobese and MetSyn-negative patients (P < 0.05). Higher postoperative circulating levels of cortisol were observed in the viscerally obese and hyperglycemic patients compared to nonobese and normoglycemic patients. No association was observed between visceral obesity, MetSyn or hyperglycemia, and postoperative cytokine profile. Viscerally obese patients had an increased overall incidence of postoperative complications compared to nonobese patients (67.2% vs. 47.5%, P = 0.031) on univariate but not multivariate analysis (P = 0.078) and visceral obesity was not associated with an increased incidence of specific complications. Visceral obesity, MetSyn, and hyperglycemia are prevalent in patients undergoing major upper gastrointestinal resection and are associated with an exaggerated acute-phase inflammatory response postoperatively. Further research is warranted to determine whether this association is directly causal.

Low skeletal muscle radiation attenuation and visceral adiposity are associated with overall survival and surgical site infections in patients with pancreatic cancer

BACKGROUND

Cancer cachexia and skeletal muscle wasting are related to poor survival. In this study, quantitative body composition measurements using computed tomography (CT) were investigated in relation to survival, post-operative complications, and surgical site infections in surgical patients with cancer of the head of the pancreas.

METHODS

A prospective cohort of 199 patients with cancer of the head of the pancreas was analysed by CT imaging at the L3 level to determine (i) muscle radiation attenuation (average Hounsfield units of total L3 skeletal muscle); (ii) visceral adipose tissue area; (iii) subcutaneous adipose tissue area; (iv) intermuscular adipose tissue area; and (v) skeletal muscle area. Sex-specific cut-offs were determined at the lower tertile for muscle radiation attenuation and skeletal muscle area and the higher tertile for adipose tissues. These variables of body composition were related to overall survival, severe post-operative complications (Dindo-Clavien ≥ 3), and surgical site infections (wounds inspected daily by an independent trial nurse) using Cox-regression analysis and multivariable logistic regression analysis, respectively.

RESULTS

Low muscle radiation attenuation was associated with shorter survival in comparison with moderate and high muscle radiation attenuation [median survival 10.8 (95% CI: 8.8-12.8) vs. 17.4 (95% CI: 14.7-20.1), and 18.5 (95% CI: 9.2-27.8) months, respectively; P < 0.008]. Patient subgroups with high muscle radiation attenuation combined with either low visceral adipose tissue or age <70 years had longer survival than other subgroups (P = 0.011 and P = 0.001, respectively). Muscle radiation attenuation was inversely correlated with intermuscular adipose tissue (r_p  = -0.697, P < 0.001). High visceral adipose tissue was associated with an increased surgical site infection rate, OR: 2.4 (95% CI: 1.1-5.3; P = 0.027).

CONCLUSIONS

Low muscle radiation attenuation was associated with reduced survival, and high visceral adiposity was associated with an increase in surgical site infections. The strong correlation between muscle radiation attenuation and intermuscular adipose tissue suggests the presence of ectopic fat in muscle, warranting further investigation. CT image analysis could be implemented in pre-operative risk assessment to assist in treatment decision-making.

A high visceral adipose tissue-to-skeletal muscle ratio as a determinant of major complications after pancreatoduodenectomy for cancer

OBJECTIVE

Complication rates after pancreatic resections remain high despite improvement in perioperative management. The effects of body composition and the relationship among different body compartments on surgical morbidity are not comprehensively investigated. The aim of this study was to assess whether the evaluation of different body compartments and their relationship was associated with the development of major postoperative complications after pancreatoduodenectomy (PD) for cancer.

METHODS

We retrospectively analyzed 124 patients who underwent PD and had a staging computed tomography (CT) scan at our center. CT scan was used to measure abdominal skeletal muscle area and volume, as well as visceral fat area (VFA) and volume. The total abdominal muscle area (TAMA) was then normalized for height. The severity of complications was assessed. Univariate and multivariate analyses were performed to investigate correlations between the above variables and postoperative complications. The receiver operating characteristic curve methodology was used to investigate the predictive ability of each parameter.

RESULTS

Major complications occurred in 42 patients (33.9%). The prevalence of sarcopenia was 24.2%. Regression analyses revealed no correlation between abdominal muscular and adipose tissue areas. Univariate analysis showed that the depletion of muscle area normalized for height was not per se predictive of complications (P = 0.318). Multivariate logistic regression showed that the VFA/TAMA was the only determinant of major complications (odds ratio, 3.20; 95% confidence interval, 1.35-7.60; P = 0.008). The model predictive performance was 0.735 (area under the curve) with a sensitivity of 64.3% and a specificity of 74.4%.

CONCLUSION

Sarcopenic obesity is a strong predictor of major complications after PD for cancer.

Computed Tomography Morphometrics and Pulmonary Intolerance in Endometrial Cancer Robotic Surgery

STUDY OBJECTIVES

To identify morphometric characteristics of obese patients that best predict pulmonary intolerance to robotic pelvic surgery using a novel method for quantifying adipose distribution.

DESIGN

Retrospective study (Canadian Task Force classification II-2).

SETTING

University hospital.

PATIENTS

Fifty-nine patients with endometrial cancer who underwent robotic hysterectomy and lymphadenectomy between April 2008 and May 2014 and also underwent perioperative computed tomography (CT) imaging within 1 year.

INTERVENTION

Visceral fat volume (VFV) and subcutaneous fat volume (SFV) were quantified through waist circumference measurements along with average volume estimation of slices taken at 3 levels: mid-waist, L2-L3, and L4-L5. Mean and maximum values were obtained for intraoperative physiological data.

MEASUREMENTS AND MAIN RESULTS

The patients' mean body mass index (BMI) was 34 (range, 20-59). Along with waist circumference, VFV and SFV quantified by CT at the mid-waist, L2-L3, and L4-L5 levels were all significant independent predictors for peak airway pressure (PAP; average and maximum) and plateau airway pressure (Pplat; average and maximum) on multivariate regression analysis after adjustment for age, ethnicity, diabetes, hypertension, pulmonary disease, smoking, obstructive sleep apnea, American Society of Anesthesiologists classification, and duration of anesthesia. Compared with the other CT parameters, L2-L3 VFV was the best predictor of average PAP (β = 0.398; p = .002), maximum PAP (β = 0.493; p < .001), average Pplat (β = 0.536; p < .001), and maximum Pplat (β = 0.573; p < .001).

CONCLUSION

These novel CT morphometric measurements represent valid predictors of pulmonary intolerance to robotic surgery in obese patients. Of the measures analyzed, VFV at L2-L3 best predicts pulmonary tolerance in obese 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.

Visceral obesity, muscle mass and outcome in rectal cancer surgery after neo-adjuvant chemo-radiation

BACKGROUND

Preoperative chemoradiation has become a routine modality in the treatment of rectal carcinoma that may impair a patients general condition. In these patients, it is important to identify factors that influence postoperative recovery. Visceral obesity(VO) as a metabolic risk factor was studied in rectal cancer patients receiving preoperative chemoradiation.

AIM

The impact of VO on post-operative outcome in rectal carcinoma surgery after preoperative chemoradiation was studied. In addition, the effect of chemoradiation on body composition was studied.

METHOD

The visceral fat area(VFA), total fat area(TFA) and skeletal muscle area(SMA) were measured on cross-sectional CT-slides in 74 patients who underwent rectal cancer surgery after chemoradiation. CT-scans taken before and after chemoradiation were analysed. Associations between VFA, per- and postoperative complications were studied. A VFA of 100 cm(2) and 130 cm(2) was used to differentiate between non-VO and VO.

RESULTS

Using a VO cut-off point of a VFA of 100 cm(2), the VO patients had more per-operative blood loss(471 mL vs 271 mL p = 0.020), a higher complication rate(10% vs 49% p = 0.001), more ileus(2% vs 28% p = 0.027) and a longer length of stay(9.7days vs 13days p = 0.027). When a VFA of 130 cm(2) was used, VO patients showed more complications(17% vs 55%, p = 0.001) and ileus(10% vs 32% p = 0.017). During chemoradiation the SMA increased(Mean difference: 2.2 cm(2) p = 0.024), while the VFA showed no change.

CONCLUSION

It appears that VO is associated with co-morbidity and poor outcome in rectal cancer patients. Using different cutoff values for VO different associations with outcome were found. SMA increased during chemoradiation, a phenomenon that remains to be explained.

Is pancreaticoduodenectomy a safe procedure in the cirrhotic patient?

INTRODUCTION

Pancreaticoduodenectomy (PD) is usually contraindicated in chronic liver disease. The objective of the present study was to analyze PD results in cirrhotic patients, and compare them with non-cirrhotic ones.

METHODS

Between 1994 and 2014 we prospectively collected all patients with a PD for periampullar neoplasms in Hospital Universitari de Bellvitge. We registered preoperative, intraoperative and postoperative variables. We defined patients undergoing PD with liver cirrhosis as the study group (CH group), and those without liver cirrhosis as the control group (NCH group). A case/control study was performed (1/2).

RESULTS

We registered 15 patients in the CH group, all with good liver function (Child A), and included 30 patients in NCH group. The causes of hepatopathy were HCV (60%) and alcoholism (40%). For the 3 moments studied, the CH group had a lower blood platelet count and a higher prothrombin ratio, compared with NCH group. Postoperative morbidity was 60% and mean postoperative stay was 25±19 days, with no differences in terms of complications between CH group and NCG group (73% vs. 53%, P=.1). Presence of ascites was higher in the CH group compared with NCH group (28 vs. 0%, P<.001). There were no differences in terms of hemorrhage or pancreatic fístula. Four patients of the CH group and 2 patients of the NCH group were reoperated on (26.7 vs. 6.7%, P=.1). There was no postoperative mortality.

CONCLUSIONS

PD is a safe procedure in cirrhotic patients with good liver function although it presents high morbidity.

Association between high visceral fat area and postoperative complications in patients with Crohn's disease following primary surgery

AIM

The aim of this study was to determine the association between visceral fat area (VFA) on CT and postoperative complications after primary surgery in patients with Crohn's disease (CD).

METHOD

Inclusion criteria were patients with a confirmed diagnosis of CD who had preoperative abdominal CT scan. The areas of total fat, subcutaneous fat and visceral fat were measured using an established image-analysis method at the lumbar 3 (L3) level on CT cross-sectional images. Visceral obesity was defined as a visceral fat area (VFA) of ≥ 130 cm(2) . Clinical variables, intra-operative outcomes and postoperative courses within 30 days were analysed.

RESULTS

A total of 164 patients met the inclusion criteria. Sixty-three (38.4%) patients had postoperative complications. The mean age of the patients with complications (the study group) was 40.4 ± 15.4 years and of those without complications (the control group) was 35.8 ± 12.9 years (P = 0.049). There were no differences in disease location and behaviour between patients with or without complications (P > 0.05). In multivariable analysis, VFA [odds ratio (OR) = 2.69; 95% confidence interval (CI): 1.09-6.62; P = 0.032] and corticosteroid use (OR = 2.86; 95% CI: 1.32-6.21; P = 0.008) were found to be associated with postoperative complications. Patients with visceral obesity had a significantly longer operative time (P = 0.012), more blood loss (P = 0.019), longer bowel resection length (P = 0.003), postoperative ileus (P = 0.039) and a greater number of complications overall (P < 0.001).

CONCLUSION

High VFA was found to be associated with an increased risk for 30-day postoperative complications in patients with CD undergoing primary surgery.

Effect of sarcopenia and visceral obesity on mortality and pancreatic fistula following pancreatic cancer surgery

BACKGROUND

Analytical morphometric assessment has recently been proposed to improve preoperative risk stratification. However, the relationship between body composition and outcomes following pancreaticoduodenectomy is still unclear. The aim of this study was to assess the impact of body composition on outcomes in patients undergoing pancreaticoduodenectomy for cancer.

METHODS

Body composition parameters including total abdominal muscle area (TAMA) and visceral fat area (VFA) were assessed by preoperative staging CT in patients undergoing pancreaticoduodenectomy for cancer. Perioperative variables and postoperative outcomes (mortality or postoperative pancreatic fistula) were collected prospectively in the institutional pancreatic surgery database. Optimal stratification was used to determine the best cut-off values for anthropometric measures. Multivariable analysis was performed to identify independent predictors of 60-day mortality and pancreatic fistula.

RESULTS

Of 202 included patients, 132 (65·3 per cent) were classified as sarcopenic. There were 12 postoperative deaths (5·9 per cent), major complications developed in 40 patients (19·8 per cent) and pancreatic fistula in 48 (23·8 per cent). In multivariable analysis, a VFA/TAMA ratio exceeding 3·2 and American Society of Anesthesiologists grade III were the strongest predictors of mortality (odds ratio (OR) 6·76 and 6·10 respectively; both P < 0·001). Among patients who developed major complications, survivors had a significantly lower VFA/TAMA ratio than non-survivors (P = 0·017). VFA was an independent predictor of pancreatic fistula (optimal cut-off 167 cm(2) : OR 4·05; P < 0·001).

CONCLUSION

Sarcopenia is common among patients undergoing pancreaticoduodenectomy. The combination of visceral obesity and sarcopenia was the best predictor of postoperative death, whereas VFA was an independent predictor of pancreatic fistula.

Preoperative Computed Tomography to Predict and Stratify the Risk of Severe Pancreatic Fistula After Pancreatoduodenectomy

The aim of this article is to assess whether measures of abdominal fat distribution, visceral density, and antropometric parameters obtained from computed tomography (CT) may predict postoperative pancreatic fistula (POPF) occurrence.We analyzed 117 patients who underwent pancreatoduodenectomy (PD) and had a preoperative CT scan as staging in our center. CT images were processed to obtain measures of total fat volume (TFV), visceral fat volume (VFV), density of spleen, and pancreas, and diameter of pancreatic duct. The predictive ability of each parameter was investigated by receiver-operating characteristic (ROC) curves methodology and assessing optimal cutoff thresholds. A stepwise selection method was used to determine the best predictive model.Clinically relevant (grades B and C) POPF occurred in 24 patients (20.5%). Areas under ROC-curves showed that none of the parameters was per se significantly predictive. The multivariate analysis revealed that a VFV >2334 cm, TFV >4408 cm, pancreas/spleen density ratio <0.707, and pancreatic duct diameter <5 mm were predictive of POPF. The risk of POPF progressively increased with the number of factors involved and age.It is possible to deduce objective information on the risk of POPF from a simple and routine preoperative radiologic workup.

Visceral obesity determined by CT scan and outcomes after colorectal surgery; a systematic review and meta-analysis

BACKGROUND

Visceral obesity may affect outcome after colorectal surgery. The visceral fat area as determined by CT scanning is considered the standard in the detection of visceral obesity.

METHOD

A systematic review was performed of trials investigating the effect of visceral obesity on outcomes of patients with colorectal cancer with no radiotherapy or chemotherapy and measured by CT scanning. The main endpoints were primary hospital stay, morbidity, operative time and blood loss. Quality assessment and data extraction were performed independently by two observers.

RESULTS

Seven studies were eligible for analysis, including 1230 patients. Primary hospital stay (weighted mean difference 1.16 days, 95% CI 0.0.05 to 2.28 days, p = 0.04), morbidity rates (RR 0.15, 95% CI 0.10 to 0.21, p < 0.00001) and operative time (weighted mean difference 20.47 min, 95% CI 12.76 to 28.17 min, p < 0.00001) were significantly higher for visceral obese patients. No difference was found in blood loss.

CONCLUSION

Visceral obesity leads to a longer hospital stay, higher morbidity and longer operative time after elective colon surgery. These findings show that the preoperative CT scan for detecting disseminated disease can be used to assess visceral obesity and helps in risk profiling patients undergoing elective colon surgery.

Computed tomographic measurements predict component separation in ventral hernia repair

BACKGROUND

Preoperative imaging with computed tomography (CT) scans can be useful in preoperative planning. We hypothesized that CT measurements of ventral hernia defect size and abdominal wall thickness (AWT) would correlate with postoperative complications and need for complex abdominal wall reconstruction (AWR).

MATERIALS AND METHODS

Patients who underwent open ventral hernia repair and had preoperative abdominal CT imagining were identified from an institutional hernia-specific surgery outcomes database at our tertiary referral hernia center. Grade III and IV hernias and biologic mesh cases were excluded. CT measures of defect size and AWT were analyzed and correlated to complications and the need for AWR techniques using univariate, multivariate, and principal component (PC) analyses. PC1 and PC2 used five AWT measures, hernia defect width, and body mass index to create a new component variable.

RESULTS

There were 151 open ventral hernia repairs included in the study. Preoperative findings included 37.7% male; age 55.3 ± 12.5 years; body mass index (BMI) 33.3 ± 7.8 kg/m(2); 60.3% were recurrent hernias with average defect width 8.5 ± 5.0 cm and area 178.3 ± 214 cm(2); AWT at umbilicus 3.5 ± 1.8 cm; and AWT at pubis 7.0 ± 3.2. Component separation was performed in 24.0% of patients and panniculectomy in 34.4%. Wound complications occurred in 13.3% patients, and 2.7% had hernia recurrence. Increasing defect width, length, and area as well as select AWT measurements were associated with increased need for component separation, concomitant panniculectomy, and higher rates of wound and total complications (all P < 0.05). Using multivariate regression, PC1 was associated with wound complications (odds ratio [OR], 1.08; 95% confidence interval [CI], 1.01-1.16); PC2 (hernia defect width) was associated with the need for component separation (OR, 1.16; 95% CI, 1.03-1.30). Hernia recurrence was not predicted by AWT or defect size (OR, 1.00; 95%CI, 0.87-1.15).

CONCLUSIONS

Preoperative CT measurements of hernia defects and AWT predict wound complications and the need for complex AWR techniques. Obtaining preoperative CT imaging should be a consideration in preoperative planning and may help with patient counseling.

A comparison of two invagination techniques for pancreatojejunostomy after pancreatoduodenectomy

Background. The aim of the study was to compare two invagination techniques for pancreatojejunostomy after pancreatoduodenectomy. Methods. For effective prevention of the development of pancreatic leakage, we modified invagination technique that we term the "serous touch." We analysed the diameter of the main pancreatic duct, the texture of the remnant pancreas, the method of the reconstruction, pancreatic external drainage, anastomotic procedure time, histopathological examination, and postoperative complications. Results. Fifty-two patients underwent pancreatoduodenectomy with pancreatojejunostomy using "serous touch" technique (ST group) and 52 classic pancreatojejunostomy (C group). In the ST group one patient (1.9%) was diagnosed as grade B pancreatic fistula, and no patient experienced fistula grade A or C. In the C group 6 patients (11.5%) were diagnosed as fistula grade A, 1 (1.9%) patient as fistula grade B, and 1 (1.9%) patient as fistula grade C. There was a significant statistical difference in incidents of pancreatic fistula (P < 0.05) and no statistical difference in other postoperative complications or mortality in comparison group. Anastomosis time was statistically shorter in the ST group. Conclusions. "Serous touch" technique appeared to be easy, safe, associated with fewer incidences of pancreatic fistulas, and less time consuming in comparison with classical pancreatojejunostomy.

Early discharge after pancreatoduodenectomy: what helps and what prevents?

OBJECTIVES

Shorter hospital stay after pancreatoduodenectomy (PD) is a desired goal. Implementation of enhanced recovery after surgery (ERAS) protocols can possibly help in achieving this target. We aimed to determine the factors influencing the successful implementation of ERAS protocols by analyzing their relation to the surrogate marker of enhanced recovery, namely, duration of hospital stay.

METHODS

A retrospective analysis of a prospectively maintained ERAS database of 208 consecutive patients who underwent PD at a tertiary referral care center was done.

RESULTS

Two hundred eight patients underwent a classical PD with a median duration of hospital stay of 8 days (range, 4-52 days) with an overall morbidity rate of 34.5% and a mortality rate of 3.8%. The 30-day readmission rate was 4% (8 patients). An elevated body mass index (relative risk, 1.098; 95% confidence interval, 1.015-1.188; P = 0.02) and respiratory comorbidities (relative risk, 8.024; 95% confidence interval, 2.018-31.904; P = 0.003) were independent factors resulting in a longer (>8 days) hospital stay.

CONCLUSIONS

Being overweight or obese and respiratory comorbidities are independent predictors of prolonged hospital stay despite the implementation of ERAS protocol. Hypoalbuminemia does not have a direct effect on hospital stay but may predispose the patient to the development of complications.

Randomized clinical trial of isolated Roux-en-Y versus conventional reconstruction after pancreaticoduodenectomy

BACKGROUND

Pancreaticoduodenectomy (PD) is associated with a high incidence of postoperative complications including pancreatic fistula. This randomized clinical trial compared the incidence of pancreatic fistula between the isolated Roux-en-Y (IsoRY) and conventional reconstruction (CR) methods.

METHODS

Patients admitted for PD between June 2009 and September 2012 in a single centre were assigned randomly to CR or IsoRY. The primary endpoint was the incidence of pancreatic fistula (grade A-C) defined according to the International Study Group on Pancreatic Fistula. Secondary endpoints were complication rates, mortality and hospital stay. Multiple logistic regression analysis was performed to identify factors associated with pancreatic fistula.

RESULTS

Some 153 patients were randomized, 76 to CR and 77 to IsoRY; two patients from the IsoRY group were excluded after randomization. Pancreatic fistula occurred in 26 patients (34 per cent) in the CR group and 25 (33 per cent) in the IsoRY group (P = 0·909). The number of patients with a clinically relevant pancreatic fistula (grade B or C) was similar in the two groups (10 and 11 patients respectively; P = 0·789), as were complication rates (42 versus 40 per cent; P = 0·793) and mortality (none in either group; P = 0·999). Soft pancreas was the only independent risk factor for pancreatic fistula (odds ratio 4·42, 95 per cent confidence interval 1·85 to 10·53; P <0·001).

CONCLUSION

This study showed that IsoRY reconstruction does not reduce the incidence of pancreatic fistula compared with CR.

REGISTRATION NUMBER

NCT00915863 (http://www.clinicaltrials.gov/) and UMIN000001967 (http://www.umin.ac.jp/).

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.

Indicators for proper management of surgical drains following pancreaticoduodenectomy

BACKGROUND

The indicators for proper drain management following pancreaticoduodenectomy (PD) remain unclear. Our aim was to identify appropriate timing and proper indicators for safe drain management after PD.

METHODS

Prospectively collected data from 200 patients who underwent PD were evaluated. Postoperative clinical factors for clinically relevant pancreatic fistulas (CR-POPFs) and management of surgically placed drains were analyzed retrospectively.

RESULTS

CR-POPFs occurred in 8% of patients. By logistic regression analysis, one factor (non-serous fluid in the drain) on postoperative day (POD) 1 and two factors (non-serous fluid in the drain and serum CRP levels) on POD 3 and 4 were significantly associated with CR-POPFs. Receiver operating characteristic analysis demonstrated that combined predictive factors on POD 4 were the most accurate. Of 163 patients with serous fluid in the drain and CRP <15.6 mg/dl on POD 4, 1% had CR-POPFs, but no patient required POPF-related re-drainage. In contrast, among 37 patients with non-serous fluid in the drain or CRP levels ≥15.6 mg/dl, 35% had CR-POPFs, and 8% required POPF-related re-drainage.

CONCLUSIONS

A combination of CRP levels and the color of surgical drain fluid, not POD1 or 3, but on POD 4, may be the most accurate indicators for safe drain management following PD.

The cost of obesity for nonbariatric inpatient operative procedures in the United States: national cost estimates obese versus nonobese patients

OBJECTIVE

To evaluate the economic impact of obesity on hospital costs associated with the commonest nonbariatric, nonobstetrical surgical procedures.

BACKGROUND

Health care costs and obesity are both rising. Nonsurgical costs associated with obesity are well documented but surgical costs are not.

METHODS

National cost estimates were calculated from the Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS) database, 2005-2009, for the highest volume nonbariatric nonobstetric procedures. Obesity was identified from the HCUP-NIS severity data file comorbidity index. Costs for obese patients were compared with those for nonobese patients. To control for medical complexity, each obese patient was matched one-to-one with a nonobese patient using age, sex, race, and 28 comorbid defined elements.

RESULTS

Of 2,309,699 procedures, 439,8129 (19%) were successfully matched into 2 medically equal groups (obese vs nonobese). Adjusted total hospital costs incurred by obese patients were 3.7% higher with a significantly (P < 0.0001) higher per capita cost of $648 (95% confidence interval [CI]: $556-$736) compared with nonobese patients. Of the 2 major components of hospital costs, length of stay was significantly increased in obese patients (mean difference = 0.0253 days, 95% CI: 0.0225-0.0282) and resource utilization determined by costs per day were greater in obese patients due to an increased number of diagnostic and therapeutic procedures needed postoperatively (odds ratio [OR] = 0.94, 95% CI: 0.93-0.96). Postoperative complications were equivalent in both groups (OR = 0.97, 95% CI: 0.93-1.02).

CONCLUSIONS

Annual national hospital expenditures for the largest volume surgical procedures is an estimated $160 million higher in obese than in a comparative group of nonobese patients.

Predicting postoperative pulmonary complications in the general population

PURPOSE OF REVIEW

Postoperative pulmonary complications (PPCs) are common and lead to longer hospital stays and higher mortality. A wide range of patient, anaesthetic and surgical factors have been associated with risk for PPCs. This review discusses our present understanding of PPC risk factors that can be used to plan preoperative risk reduction strategies. The methodological and statistical basis for building risk scores is also described.

RECENT FINDINGS

Studies in specific surgical populations or large patient samples have identified a range of predictors of PPC risk. Factors such as age, types of comorbidity and surgical characteristics have been found to be relevant in most of these studies. Recently, researchers have begun to develop risk scoring systems for a PPC composite outcome or for specific PPCs, especially pneumonia and respiratory failure. Preoperative arterial oxyhaemoglobin saturation is an objective measure that is easy to record and discriminates level of risk for impaired cardiorespiratory function. Preoperative anaemia and recent respiratory infection are factors that have lately been found to confer risk for PPCs.

SUMMARY

PPC risk prediction scales based on large population studies are being developed. New studies to confirm the validity of these scales in different geographic areas will be needed before we can be sure of their generalizability.