Does obesity affect the outcomes of pulmonary resections for lung cancer? A National Surgical Quality Improvement Program analysis

Assessment of the Functioning Profile of Patients with Lung Cancer Undergoing Lobectomy in Relation to the ICF Rehabilitation Core Set

Lung cancer often presents with pain and breathlessness, frequently necessitating surgical procedures, such as lung lobectomy. A pivotal component of postoperative care is rehabilitation, aimed not only at improving the clinical condition but also at influencing the patient's functional profile. In a study conducted at the Clinic of Thoracic Surgery and Respiratory Rehabilitation in the Regional Multispecialist Center for Oncology and Traumatology of the Nicolaus Copernicus Memorial Hospital in Lodz, the effectiveness of rehabilitation intervention was assessed in 50 patients (n = 27 M, n = 23 F) postlobectomy due to early stage nonsmall cell lung cancer (NSCLC). The International Classification of Functioning, Disability, and Health-ICF Rehabilitation Core Set was used to evaluate the functional profile, the modified Laitinen scale for pain assessment, and the modified Borg scale for breathlessness evaluation. Additionally, lung-expansion time was monitored. The significance level of the statistical tests in this analysis was set at α = 0.05. The study employed an analysis of the normality of the distributions of the numerical variables, reporting of variable distributions, estimation of differences between groups, estimation of differences within groups, estimation of the independence of categorical variables, and regression analysis. The research confirmed that rehabilitation partially improves the functional profile of patients and reduces the sensation of breathlessness postsurgery. The study highlighted the need for future research with a larger number of participants and an extended observation period to gain a deeper understanding of the impact of rehabilitation on patients after lung lobectomy procedures.

Moving beyond frailty: Obesity paradox persists in lung resection

BACKGROUND

The apparent protective effect of high body mass index on postoperative outcomes, termed the "obesity paradox," has been postulated to reflect the relative frailty of patients without obesity. We wanted to examine the independent association between body mass index and outcomes after anatomic lung resection.

METHODS

All adults undergoing elective lung resection for cancer were identified in the 2012-2020 National Surgical Quality Improvement Program. The modified Frailty Index quantified degree of patient frailty. Malnutrition was defined as a preoperative serum albumin <3.5g/dL. Multivariable regressions were used to examine the independent association of body mass index and major adverse events, analyzed as a composite of 30-day mortality, postoperative complications, and unplanned reoperation.

RESULTS

Of an estimated 20,099 patients meeting study criteria, 6,424 (32.0%) had obesity. Relative to others, patients with obesity were significantly younger (49.3 vs 50.3 years), more commonly White (78.1 vs 74.9%), and more frequently frail (modified Frailty Index >1: 35.7 vs 22.5%, all P < .001). There was no significant difference in malnutrition rates (7.6 vs 8.4%, P = .05) or extent of resection between groups. After adjustment, obesity was associated with decreased odds of major adverse events (adjusted odds ratio 0.86, 95% confidence interval 0.78-0.94).

CONCLUSION

The present findings uphold the canonical obesity paradox in anatomic lung resection, despite adjustment for frailty and malnutrition. Further studies are warranted to characterize the nature of this association; however, our results may inform efforts to optimize risk stratification and patient selection for surgical intervention.

The Influence of Preoperative Nutritional and Systemic Inflammatory Status on Perioperative Outcomes following Da Vinci Robot-Assisted Thoracic Lung Cancer Surgery

Background: Nutrition is an important factor in the outcome of any disease process. We evaluated the relationship of nutritional status and inflammatory status of non-small cell lung cancer (NSCLC) patients undergoing robotic-assisted thoracic surgery (RATS) with postoperative complications. Methods: This prospective cohort study included 107 NSCLC patients undergoing surgical treatment, between 2019 and 2021. Nutritional status and inflammatory status were assessed before pulmonary resection using anthropometric assessment, blood tests, and body mass index (BMI). Results: The BMI was 27.5 ± 4.4. Based on BMI, 29% (n = 31) were classified as normal weight, 43% (n = 46) as overweight, and 28% (n = 30) as obese. The mean neutrophil/lymphocyte ratio (NLR) was 2.16 ± 0.85, the platelet/lymphocyte ratio (PLR) was 121.59 ± 44.21, and the lymphocyte/monocyte ratio (LMR) was 3.52 ± 1.17. There was no increase in the number of intraoperative complications or bleeding (p = 0.696), postoperative complications (p = 0.569), mean hospital stay (p = 0.258) or duration of chest drain (p = 0.369). Higher inflammatory status, with an NLR > 1.84, was associated with more overall postoperative complications (p = 0.028), only in univariate analysis, but this significance was not maintained on multivariate analysis. Conclusions: BMI was not a predictor of increased postoperative risk in this cohort; therefore, weight should not deter surgeons from using RATS for pulmonary resection.

Obesity Does Not Increase Perioperative Outcomes in Older Patients Undergoing Thoracoscopic Anatomic Lung Cancer Surgery

Objectives

To investigate the relationship between obesity status and perioperative outcomes in elderly patients undergoing thoracoscopic anatomic lung cancer surgery.

Methods

From January 2016 to December 2018, we performed a monocentric retrospective cohort study among 4164 consecutive patients aged 65 years or older who underwent thoracoscopic anatomic lung cancer surgery at Shanghai Chest Hospital. Two groups were stratified by body mass index (BMI): nonobese (BMI<28kg/m²) and obese status (BMI≥28kg/m²). Using a 1:1 propensity score matching (PSM) analysis to compare perioperative outcomes between two groups.

Results

4035 older patients were eventually enrolled, with a mean age of 69.8 years (range: 65-87), and 305 patients were eligible for obese status, with a mean BMI of 29.8 ± 1.7kg/m². Compared with nonobese patients, obese patients were more likely to have higher rates of intraoperative hypoxemia (1.2% vs 3.9%, P=0.001) and new-onset arrhythmia (2.3% vs 4.3%, P=0.034). The difference in intraoperative transfusion and conversion rates and postoperative outcomes regarding pulmonary complications, new-onset arrhythmia, transfusion, length of hospital stay, 30-day readmission and hospitalization costs between two groups were not significant (P>0.05). After a 1:1 PSM analysis, the difference in both intraoperative and postoperative complications among two groups were not significant (P>0.05). In subgroup analysis, patients with BMI≥30kg/m² had a similar incidence of perioperative complications compared to patients with BMI between 28 and 30 kg/m² (P>0.05).

Conclusions

Our research data support evidence for “obesity paradox” and also contribute the growing body of evidence that obesity in older patients should not exclude candidates for thoracoscopic anatomic lung cancer surgery.

"Obesity paradox" has not an impact on minimally invasive anatomical lung resection

INTRODUCTION

The paradoxical benefit of obesity, the 'obesity paradox', has been analyzed in lung surgical populations with contradictory results. Our goal was assessing the relationship of body mass index (BMI) to acute outcomes after minimally invasive major pulmonary resections.

METHODS

Retrospective review of consecutive patients who underwent pulmonary anatomical resection through a minimally invasive approach for the period 2014-2019. Patients were grouped as underweight, normal, overweight and obese type I, II and III. Adjusted odds ratios regarding postoperative complications (overall, respiratory, cardiovascular and surgical morbidity) were produced with their exact 95% confidence intervals. All tests were considered statistically significant at p<0.05.

RESULTS

Among 722 patients included in the study, 37.7% had a normal BMI and 61.8% were overweight or obese patients. When compared with that of normal BMI patients, adjusted pulmonary complications were significantly higher in obese type I patients (2.6% vs 10.6%, OR: 4.53 [95%CI: 1.86-12.11]) and obese type II-III (2.6% vs 10%, OR: 6.09 [95%CI: 1.38-26.89]). No significant differences were found regarding overall, cardiovascular or surgical complications among groups.

CONCLUSIONS

Obesity has not favourable effects on early outcomes in patients undergoing minimally invasive anatomical lung resections, since the risk of respiratory complications in patients with BMI≥30kg/m² and BMI≥35kg/m² is 4.5 and 6 times higher than that of patients with normal BMI.

Effects of Smoking, Obesity, and Pulmonary Function on Home Oxygen Use after Curative Lung Cancer Surgery

RATIONALE

Lung cancer surgical morbidity has been decreasing, increasing attention to quality-of-life measures. A chronic sequela of lung cancer surgery is use of postoperative oxygen at home after discharge. Prospective studies are needed to identify risk predictors for home oxygen(HO2) use after curative lung cancer surgery.

OBJECTIVES

To prospectively assess risk factors for postoperative oxygen use and post-surgical morbidity in patients undergoing curative lung cancer surgery. We hypothesized that obesity, poor pre-operative pulmonary function, and smoking status would contribute to the risk of postoperative oxygen use.

METHODS

Patients undergoing surgery for first primary non-small cell lung cancer at Mount Sinai, from 2016 to 2020. Univariate, multivariable logistic regression analyses and adjusted odds ratio and 95% confidence intervals were assessed.

RESULTS

Of the 433 patients diagnosed with pathologic stage I non-small cell lung cancer, 63 (14.5%) were discharged with HO2. Using multivariable analyses, body mass index (OR for BMI25-30=4.0, 95% CI:1.6-11.2, p = 0.005 and OR for BMI≥ 30=6.1, 95% CI:2.4-17.5, p<0.001)and pre-operative diffusing capacity for carbon monoxide(DLCO) (OR for DLCO<40=24.9, 95% CI:3.6-234.1, p=0.002 and OR for DLCO 40-59=3.1, 95% CI:1.3-7.2, p=0.008) were significant independent risk factors associated with risk of home oxygen after controlling for other covariates. Although current smoking significantly increased the risk in the univariate analysis, it was no longer significant in the multivariable model.

CONCLUSIONS

Obesity and diffusing capacity for carbon monoxide were significant as risk factors for oxygen use at home after discharge. These findings allow for identification of patients at risk of being discharged with home oxygen after lung resection surgery.

"Obesity paradox" has not an impact on minimally invasive anatomical lung resection

INTRODUCTION

The paradoxical benefit of obesity, the 'obesity paradox', has been analyzed in lung surgical populations with contradictory results. Our goal was assessing the relationship of body mass index (BMI) to acute outcomes after minimally invasive major pulmonary resections.

METHODS

Retrospective review of consecutive patients who underwent pulmonary anatomical resection through a minimally invasive approach for the period 2014-2019. Patients were grouped as underweight, normal, overweight and obese type I, II and III. Adjusted odds ratios regarding postoperative complications (overall, respiratory, cardiovascular and surgical morbidity) were produced with their exact 95% confidence intervals. All tests were considered statistically significant at p<0.05.

RESULTS

Among 722 patients included in the study, 37.7% had a normal BMI and 61.8% were overweight or obese patients. When compared with that of normal BMI patients, adjusted pulmonary complications were significantly higher in obese type I patients (2.6% vs 10.6%, OR: 4.53 [95%CI: 1.86-12.11]) and obese type II-III (2.6% vs 10%, OR: 6.09 [95%CI: 1.38-26.89]). No significant differences were found regarding overall, cardiovascular or surgical complications among groups.

CONCLUSIONS

Obesity has not favourable effects on early outcomes in patients undergoing minimally invasive anatomical lung resections, since the risk of respiratory complications in patients with BMI≥30kg/m2 and BMI≥35kg/m2 is 4.5 and 6 times higher than that of patients with normal BMI.

Recommendations from the Italian intersociety consensus on Perioperative Anesthesia Care in Thoracic surgery (PACTS) part 1: preadmission and preoperative care

INTRODUCTION

Anesthetic care in patients undergoing thoracic surgery presents specific challenges that necessitate standardized, multidisciplionary, and continuously updated guidelines for perioperative care.

METHODS

A multidisciplinary expert group, the Perioperative Anesthesia in Thoracic Surgery (PACTS) group, comprising 24 members from 19 Italian centers, was established to develop recommendations for anesthesia practice in patients undergoing thoracic surgery (specifically lung resection for cancer). The project focused on preoperative patient assessment and preparation, intraoperative management (surgical and anesthesiologic care), and postoperative care and discharge. A series of clinical questions was developed, and PubMed and Embase literature searches were performed to inform discussions around these areas, leading to the development of 69 recommendations. The quality of evidence and strength of recommendations were graded using the United States Preventative Services Task Force criteria.

RESULTS

Recommendations for preoperative care focus on risk assessment, patient preparation (prehabilitation), and the choice of procedure (open thoracotomy vs. video-assisted thoracic surgery).

CONCLUSIONS

These recommendations should help pulmonologists to improve preoperative management in thoracic surgery patients. Further refinement of the recommendations can be anticipated as the literature continues to evolve.

Underweight patients are at just as much risk as super morbidly obese patients when undergoing anterior cervical spine surgery

BACKGROUND CONTEXT

Past studies have focused on the association of high body mass index (BMI) on spine surgery outcomes. These investigations have reported mixed conclusions, possible due to insufficient power, poor controlling of confounding variables, and inconsistent definitions of BMI categories (e.g. underweight, overweight, and obese). Few studies have considered outcomes of patients with low BMI.

PURPOSE

To analyze how anterior cervical spine surgery outcomes track with World Health Organization categories of BMI to better assess where along the BMI spectrum patients are at risk for adverse perioperative outcomes.

DESIGN/SETTING

Retrospective cohort study.

PATIENT SAMPLE

Patients undergoing elective anterior cervical spine surgery were abstracted from the 2005 to 2016 American College of Surgeons National Surgical Quality Improvement Program database.

OUTCOME MEASURES

Thirty-day adverse events, hospital readmissions, postoperative infections, and mortality.

METHODS

Patients undergoing anterior cervical spine procedures (anterior cervical discectomy and fusion, anterior cervical corpectomy, cervical arthroplasty) were identified in the 2005 to 2016 National Surgical Quality Improvement Program database. Patients were then aggregated into modified World Health Organization categories of BMI. Odds ratios of adverse outcomes, normalized to average risk of normal weight subjects (BMI 18.5-24.9 kg/m²), were calculated. Multivariate analyses were then performed on aggregated adverse outcome categories controlling for demographics (age, sex, functional status) and overall health as measured by the American Society of Anesthesiologists classification.

RESULTS

In total, 51,149 anterior cervical surgery patients met inclusion criteria. Multivariate analyses revealed the odds of any adverse event to be significantly elevated for underweight and super morbidly obese patients (Odds Ratios [OR] of 1.62 and 1.55, respectively). Additionally, underweight patients had elevated odds of serious adverse events (OR=1.74) and postoperative infections (OR=1.75) and super morbidly obese patients had elevated odds of minor adverse events (OR=1.72). Relative to normal BMI patients, there was no significant elevation for any adverse outcomes for any of the other overweight/obese categories, in fact some had reduced odds of various adverse outcomes.

CONCLUSIONS

Underweight and super morbidly obese patients have the greatest odds of adverse outcomes after anterior cervical spine surgery. The current study identifies underweight patients as an at-risk population that has previously not received significant focus. Physicians and healthcare systems should give additional consideration to this population, as they often already do for those at the other end of the BMI spectrum.

Influence of obesity on in-hospital and postoperative outcomes of hepatic resection for malignancy: a 10-year retrospective analysis from the US National Inpatient Sample

OBJECTIVES

The influence of obesity on the outcomes of curative liver resection for malignancies remains controversial. We aimed to compare the in-hospital outcomes of liver resection for malignancy between obese and non-obese patients.

DESIGN

This was a population-based, retrospective, observational study using data from the Nationwide Inpatient Sample (NIS), the largest all-payer US inpatient care database.

SETTING

Hospitalisations of adults ≥18 years old with diagnoses of primary hepatobiliary malignancy or secondary malignant neoplasms of liver in the USA were identified from the NIS database between 2005 and 2014.

PARTICIPANTS

Data of 18 398 patients ≥18 years old and underwent liver resection without pancreatic resection in the NIS were extracted. All included subjects had primary hepatobiliary malignancy or secondary malignant neoplasms of the liver. Patients were divided into obese and non-obese groups. These groups were compared with respect to postoperative complications, length of hospital stay and hospital cost according to surgical extent and approach.

INTERVENTIONS

Patients were undergoing lobectomy of liver or partial hepatectomy.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary endpoints of this study were postoperative complications, length of hospital stay and hospital cost.

RESULTS

After adjustment, obese patients were significantly more likely to experience postoperative complications than were non-obese patients (adjusted OR 1.25, 95% CI 1.10 to 1.42), regardless of whether lobectomy or partial hepatectomy was performed. Furthermore, obesity was significantly associated with increased risk of postoperative complications in patients who underwent open liver resection, but not laparoscopic resection. No significant difference was observed in length of hospital stay or total hospital costs between obese and non-obese patients.

CONCLUSIONS

After adjustment for preoperative comorbidities and other potential confounders, obesity is significantly associated with greater risk of complications in patients undergoing open liver resection for malignancy, but not laparoscopic resection.

Thoracic Surgery Considerations in Obese Patients

The obesity epidemic in the United States has increased greatly over the past several decades, and thoracic surgeons are likely to see obese patients routinely in their practices. Obesity has direct deleterious health effects such as metabolic disorder and cardiovascular disease, and is associated with many cancers. Obese patients who need thoracic surgery pose practical challenges to many of the routine elements in perioperative management. Preoperative assessment of obesity-related comorbid conditions and risk stratification for surgery, thorough intraoperative planning for anesthesia and surgery, and postoperative strategies to optimize pulmonary hygiene and mobility minimize the risk of adverse outcomes.

Association of body mass index and outcomes following lobectomy for non-small-cell lung cancer

Background

Obesity and overweight have become increasingly prevalent, but no consensus has been reached regarding the effect of body mass index (BMI) on surgical outcomes. In this study, we sought to examine the influence of BMI on perioperative outcomes in a large cohort of patients with non-small-cell lung cancer (NSCLC) who underwent lobectomy.

Methods

A retrospective study was conducted in 1198 patients who underwent lobectomy for primary NSCLC at Shandong Provincial Hospital between November 2006 and January 2017. BMI was calculated using measured height and weight on admission and categorized as obese (≥ 30 kg/m²), overweight (25 to 29.9 kg/m²), normal (18.5 to 24.9 kg/m²), or underweight (< 18.5 kg/m²). Patients’ baseline characteristics and outcomes were abstracted from medical records following institutional review board approval. Endpoints included operative mortality, perioperative complications, and length of stay (LOS). Complications were divided into four groups as respiratory, cardiovascular, other, and overall. Logistic regression models were constructed to assess the association between BMI and adverse outcomes.

Results

When compared with normal BMI, obesity and overweight did not increase the risk of complications in any category, operative mortality, or prolonged LOS. In fact, the incidence of operative mortality and respiratory complications tended to be lower in overweight patients than in normal weight patients (P = 0.047 and P = 0.041, respectively). Conversely, underweight patients experienced significantly more operative mortality, respiratory complications, and prolonged LOS (P = 0.004, P = 0.011, and P = 0.003, respectively).

Conclusions

Obesity and overweight did not confer adverse surgical outcomes. Underweight patients presented increased risk of respiratory complications, perioperative death, and prolonged LOS. Thus, overweight and obesity should not be a relative contraindication for lobectomy. Meanwhile, nurses and surgeons should focus on perioperative management of underweight patients.

Preoperative nutritional status assessment predicts postoperative outcomes in patients with surgically resected non-small cell lung cancer

BACKGROUND

As nutritional status plays an important role in outcomes after surgery, this study evaluated the association between preoperative nutritional status (NS) and postoperative outcomes after major resection for lung cancer.

METHODS

We identified 219 patients with a diagnosis of cancer who underwent pulmonary resection from 2010 to 2012. Preoperative NS was assessed by anthropometric and biological parameters, body mass index (BMI), and the Nutritional Risk Index (NRI). We stratified this population into 4 BMI groups: underweight, normal weight, overweight and obese and 4 NRI groups: well-nourished; mildly malnourished; moderately malnourished and severely malnourished. The outcomes measured were postoperative complications; 30-day postoperative mortality; hospital length of stay (LOS), overall survival (OS) and disease-free survival (DFS). We performed both unadjusted analysis and adjusted multivariable analysis, controlling for statistically significant variables.

RESULTS

Mean BMI and NRI were, respectively, 26.5 ± 4.3 and 112.4 ± 3.3. There were no significant differences between BMI categories and resection type, pathological stage, or overall postoperative complications. By contrast, significant differences (p < 0.05) in postoperative complications were observed among the NRI groups. LOS was longer in underweight and/or malnourished patients. In terms of OS, we found no significant differences according to NRI and BMI; however, patients with underweight had significantly shorter DFS compared with patients with overweight and obesity (log-rank p-value = 0.001).

CONCLUSION

NS as measured by the NRI is an independent predictor of the risk of postsurgical complications, regardless of clinicopathologic characteristics. NRI might therefore be an useful tool for identifying early-stage lung cancer patients at risk for postoperative complications.

Systematic review of prognostic roles of body mass index for patients undergoing lung cancer surgery: does the 'obesity paradox' really exist?

Summary

The paradoxical benefit of obesity, the 'obesity paradox', has been recently identified in surgical populations. Our goal was to evaluate by a systematic review with meta-analysis the prognostic role of body mass index (BMI) and to identify whether the 'obesity paradox' exists in lung cancer surgery. Comprehensive literature retrieval was conducted in PubMed to identify the eligible articles. The odds ratios (OR) and hazard ratios (HR) with the corresponding 95% confidence intervals (CI) were used to synthesize in-hospital and long-term survival outcomes, respectively. The heterogeneity level and publication bias between studies were also estimated. Finally, 25 observational studies with 78 143 patients were included in this review. The pooled analyses showed a significantly better long-term survival rate in patients with higher BMI, but no significant benefit of increased BMI was found for in-hospital morbidity. The pooled analyses also showed that overall morbidity (OR: 0.84; 95% CI: 0.73-0.98; P  =   0.025) and in-hospital mortality (OR: 0.78; 95% CI: 0.63-0.98; P  =   0.031) were significantly decreased in obese patients. Obesity could be a strong predictor of the favourable long-term prognosis of lung cancer patients (HR: 0.69; 95% CI: 0.56-0.86; P  =   0.001). The robustness of these pooled estimates was strong. No publication bias was detected. In summary, obesity has favourable effects on in-hospital outcomes and long-term survival of surgical patients with lung cancer. The 'obesity paradox' does have the potential to exist in lung cancer surgery.

Gender differences in the correlation between prognosis and postoperative weight loss in patients with non-small cell lung cancer

OBJECTIVES

The aim of this study was to investigate gender differences in the relationship between preoperative body mass index (BMI), postoperative body weight change and prognosis in patients with non-small cell lung cancer (NSCLC).

METHODS

Two hundred and sixty-three patients with NSCLC were enrolled in this study. Preoperative BMI was categorized based on WHO definition as follows: underweight (BMI <18.5): 21 patients (8.0%), normal (18.5 ≦ BMI <25): 179 patients (68%), overweight and obese (BMI ≧25): 63 patients (24%). Several factors such as age, sex, cancer stage, body weight change and BMI were recorded and correlated to the postoperative overall survival (OS).

RESULTS

For male patients, those in the low-BMI group had the worst prognosis (P < 0.05) whereas female patients with low BMI did not. Male patients with low BMI had statistically significant poorer prognosis compared to corresponding female patients (P < 0.05). Male patients with more than 5% body weight loss within 1 year after operation when compared to preoperative body weight had poorer prognosis than those with less than 5% body weight loss (P < 0.001). Furthermore, these male patients had statistically significant worse prognosis than the corresponding female patients (P < 0.05). In multivariable analysis, gender, more than 5% of body weight loss compared to preoperative body weight, and pathological stage were independent prognostic factors in NSCLC.

CONCLUSIONS

This study illustrates significant gender differences in the relationship between prognosis and BMI or body weight change in patients with postoperative NSCLC.

Obesity Paradox in Lung Cancer Prognosis: Evolving Biological Insights and Clinical Implications

The survival rate of lung cancer remains low despite the progress of surgery and chemotherapy. With the increasing comorbidity of obesity in patients with lung cancer, new challenges are emerging in the management of this patient population. A key issue of interest is the prognostic effect of obesity on surgical and chemotherapeutic outcomes in patients with lung cancer, which is fueled by the growing observation of survival benefits in overweight or obese patients. This unexpected inverse relationship between obesity and lung cancer mortality, called the obesity paradox, remains poorly understood. The evolving insights into the heterogeneity of obesity phenotypes and associated biological connections with lung cancer progression in recent years may help explain some of the seemingly paradoxical relationship, and well-designed clinical studies looking at the causal role of obesity-associated molecules are expected. Here, we examine potential biological mechanisms behind the protective effects of obesity in lung cancer. We highlight the need to clarify the clinical implications of this relationship toward an updated intervention strategy in the clinical care of patients with lung cancer and obesity.

Associations between maternal size and health outcomes for women undergoing caesarean section: a multicentre prospective observational study (The MUM SIZE Study)

OBJECTIVES

To investigate associations between maternal body mass index (BMI) at delivery (using pregnancy-specific BMI cut-off values 5 kg/m² higher in each of the WHO groups) and clinical, theatre utilisation and health economic outcomes for women undergoing caesarean section (CS).

DESIGN

A prospective multicentre observational study.

SETTING

Seven secondary or tertiary referral obstetric hospitals.

PARTICIPANTS

One thousand and four hundred and fifty-seven women undergoing all categories of CS.

DATA COLLECTION

Height and weight were recorded at the initial antenatal visit and at delivery. We analysed the associations between delivery BMI (continuous and pregnancy-specific cut-off values) and total theatre time, surgical time, anaesthesia time, maternal and neonatal adverse outcomes, total hospital admission and theatre costs.

RESULTS

Mean participant characteristics were: age 32 years, gestation at delivery 38.4 weeks and delivery BMI 32.2 kg/m². Fifty-five per cent of participants were overweight, obese or super-obese using delivery pregnancy-specific BMI cut-off values. As BMI increased, total theatre time, surgical time and anaesthesia time increased. Super-obese participants had approximately 27% (17 min, p<0.001) longer total theatre time, 20% (9 min, p<0.001), longer surgical time and 40% (11 min, p<0.001) longer anaesthesia time when compared with normal BMI participants. Increased BMI at delivery was associated with increased risk of maternal intensive care unit admission (relative risk 1.07, p=0.045), but no increased risk of neonatal admission to higher acuity care. Total hospital admission costs were 15% higher in super-obese women compared with normal BMI women and theatre costs were 27% higher in super-obese women.

CONCLUSIONS

Increased maternal BMI was associated with increased total theatre time, surgical and anaesthesia time, increased total hospital admission costs and theatre costs. Clinicians and health administrators should consider these clinical risks, time implications and financial costs when managing pregnant women.

Smoking and timing of cessation on postoperative pulmonary complications after curative-intent lung cancer surgery

BACKGROUND

Smoking is a risk factor for postoperative pulmonary complications (PPC) following non-small cell lung cancer (NSCLC) surgery. The optimal timing for preoperative smoking cessation has not been identified. Our study aimed to observe the impact of preoperative smoking cessation on PPC incidence and other postoperative outcomes including long-term survival.

METHODS

A prospective study included consecutive patients following resection for NSCLC in a regional thoracic centre over a 4-year period (2010-2014). Patients were stratified according to self-reported preoperative smoking status. The primary endpoint was PPC incidence, which was assessed from postoperative day one onwards using the Melbourne Group Scale. Secondary endpoints included short-term outcomes (hospital length of stay [LOS], intensive therapy unit [ITU] admission, 30-day hospital readmission rate) and long-term survival.

RESULTS

Four hundred and sixty-two patients included 111 (24%) current smokers, 55 (12%) ex-smokers <6 weeks, 245 (53%) ex-smokers ≥6 weeks and 51 (11%) never smokers. PPC occurred in 60 (13%) patients in total. Compared to never smokers, current smokers had a higher frequency of PPC (22% vs. 2%, p = 0.004), higher frequency of ITU admission (14% vs. 0%; p = 0.001) and a longer median (IQR) hospital LOS (6 [5] vs. 5 [2]; p = 0.001). In the ex-smokers there was a trend for a lower frequency of PPC (<6 weeks, 10.9% vs. ≥6 weeks, 11.8%) and ITU admission (<6 weeks, 5.5% vs. ≥6 weeks, 4.5%), but there was no difference between the <6 weeks or ≥6 weeks ex-smoking groups prior to surgery. There was no significant difference in long-term survival found between the groups of differing smoking status (median follow-up 29.8 months, 95%CI 28.4-31.1).

CONCLUSION

Current smokers have higher postoperative morbidity; this risk reduces following smoking cessation but 6 weeks does not appear to identify a time-point where differences in outcomes are noted.

The Influence of Body Mass Index on Overall Survival Following Surgical Resection of Non-Small Cell Lung Cancer

BACKGROUND

Population studies suggest that high body mass index (BMI) correlates with a reduced risk for death from lung cancer. The aim of our study was to evaluate definitively the influence of BMI on long-term overall survival (OS) in surgical patients with NSCLC.

METHODS

The study population consisted of 1935 patients who underwent surgical resection for lung cancer at M. D. Anderson Cancer Center (2000-2014). Study variables included both patient- and treatment-related characteristics. Univariate and multivariate Cox regression analyses were performed to identify variables associated with OS.

RESULTS

On univariate analysis, significant predictors of improved survival were higher BMI, pathologic tumor stage (stage I versus stage II, III, or IV), type of surgical procedure (lobectomy/pneumonectomy versus wedge resection/segmentectomy), younger age, female sex, and adenocarcinoma histologic subtype (versus squamous) (all p < 0.05). Morbidly obese patients (BMI ≥ 35) demonstrated a trend toward better outcomes than those classified as obese (BMI ≥30 and <35 kg/m²) (p = 0.05), overweight (BMI ≥ 25 and <30 kg/m²) (p = 0.13), or healthy weight (BMI <25 kg/m²) (p = 0.37) (hazard ratio = 0.727, 0.848, 0.926, and 1, respectively). On multivariate analysis, BMI remained an independent predictor of survival (p = 0.02). Propensity matching analysis demonstrated significantly better OS (p = 0.003) in patients with a BMI of 30 kg/m² or higher as compared with a BMI of 25 kg/m².

CONCLUSIONS

In this large, retrospective, single-center series, after control for disease stage and other variables, higher BMI was associated with improved OS after surgical resection of NSCLC. Further studies are necessary to elucidate the precise relationship between BMI and treatment outcomes.

Associations among Metabolism, Circadian Rhythm and Age-Associated Diseases

Accumulating epidemiological studies have implicated a strong link between age associated metabolic diseases and cancer, though direct and irrefutable evidence is missing. In this review, we discuss the connection between Warburg effects and tumorigenesis, as well as adaptive responses to environment such as circadian rhythms on molecular pathways involved in metabolism. We also review the central role of the sirtuin family of proteins in physiological modulation of cellular processes and age-associated metabolic diseases. We also provide a macroscopic view of how the circadian rhythm affects metabolism and may be involved in cell metabolism reprogramming and cancer pathogenesis. The aberrations in metabolism and the circadian system may lead to age-associated diseases directly or through intermediates. These intermediates may be either mutated or reprogrammed, thus becoming responsible for chromatin modification and oncogene transcription. Integration of circadian rhythm and metabolic reprogramming in the holistic understanding of metabolic diseases and cancer may provide additional insights into human diseases.

Predictors of active cancer thromboembolic outcomes: validation of the Khorana score among patients with lung cancer

Essentials Venous thromboembolism (VTE) prevention strategies require effective risk assessment models. We sought to validate the Khorana Risk Score (KRS) in patients with lung cancer. A high KRS was not predictive of VTE but was independently associated with all-cause mortality. Our findings stress the need for a lung cancer-specific VTE risk assessment model.

SUMMARY

Objectives Lung cancer is strongly associated with venous thromboembolism (VTE), but primary prevention against VTE is not a validated management strategy. Risk assessment models will be necessary for efficient implementation of preventative strategies. Materials and methods Utilizing a prospectively collected lung cancer database, we aimed to validate the Khorana Risk Score (KRS) in the prediction of VTE among patients with lung cancer. VTE events were retrospectively identified by reviewers unaware of the clinical prediction score calculation. The association between KRS and the risk of VTE was examined using cumulative incidence function with competing risk models. Mortality prediction was evaluated as a secondary outcome. Results We included 719 patients in our review. The patients were predominantly older men with non-small cell lung cancer and 40% had metastatic disease at inception. The median follow-up was 15.2 months. There were 83 VTEs (11.5%) and 568 (78.8%) patients died. A high KRS (cumulative incidence, 12.4%; 95% confidence interval [CI], 6.4-20.5%) was not associated with VTE compared with an intermediate score (cumulative incidence, 12.1%; 95% confidence interval, 9.5-15.0%) in both univariate and multivariable analyses. However, a high KRS was a predictor of mortality (hazard ratio, 1.7; 95% CI, 1.4-2.2). Conclusions Among patients with lung cancer, the KRS did not stratify the patients at the highest risk of VTE. Improved risk stratification methods are needed for this group of patients prior to implementing a primary prevention strategy.

Operative Risk for Major Lung Resection Increases at Extremes of Body Mass Index

BACKGROUND

Although body mass index (BMI) has been used in risk stratification for lung resection, many models only take obesity into account. Recent studies have demonstrated that underweight patients also experience increased postoperative complications. We explored the relationship of extremes of BMI to outcomes after lung resection for non-small cell cancer.

METHODS

Patients in the Society of Thoracic Surgeons General Thoracic Surgery Database (2009 to 2014) undergoing elective lung resection for cancer were evaluated. Multivariable logistic regression was used to adjust for potential confounders including functional status and spirometry.

RESULTS

We evaluated 41,446 patients (median 68 years of age; 53% female) grouped by BMI: underweight (<18.5 kg/m²; 3.0%), normal (18.5 to 24.9 kg/m²; 33.5%), overweight (25 to 29.9 kg/m²; 35.4%), obese I (30 to 34.9 kg/m²; 18.1%), obese II (35 to 39.9 kg/m²; 6.4%), and obese III (≥40 kg/m²; 3.6%). Pulmonary complication rates were higher in underweight and obese III patients compared to normal BMI patients (p < 0.001). On multivariable analysis, compared to patients with normal BMI, being underweight was associated with an increased risk of pulmonary complications (adjusted odds ratio [OR]: 1.41, 95% confidence interval [CI]: 1.16 to 1.70) and any postoperative event (adjusted OR: 1.44, 95% CI: 1.26 to 1.64). Obese III patients had an increased risk of any major postoperative complication (adjusted OR: 1.18, 95% CI: 1.02 to 1.36). Overweight and obese class I to II patients had a lower risk of pulmonary complications and any postoperative event.

CONCLUSIONS

BMI is associated with postoperative complications after lung resection for cancer. Being underweight or severely overweight is associated with an increased risk of complications, whereas being overweight or moderately obese appears to have a protective effect.

Influence of body mass index on outcomes after major resection for cancer

BACKGROUND

Evidence supporting worse outcomes among obese patients is inconsistent. This study examined associations between body mass index (BMI) and outcomes after major resection for cancer.

METHODS

Data from the 2005-2012 ACS-NSQIP were used to identify cancer patients (≥18 years) undergoing 1 of 6 major resections: lung surgery, esophagectomy, hepatectomy, gastrectomy, colectomy, or pancreatectomy. We used crude and multivariable regression to compare differences in 30-day mortality, serious and overall morbidity, duration of stay, and operative time among 3 BMI cohorts defined by the World Health Organization: normal versus underweight, overweight-obese I, and obese II-III. Propensity-scored secondary assessment and resection type-specific stratified analyses corroborated results.

RESULTS

A total of 529,955 patients met inclusion criteria; 32.06% had normal BMI, 3.45% were underweight, 32.52% overweight, and 17.76%, 7.51%, and 4.94% obese I-III, respectively. Risk-adjusted outcomes for underweight patients consistently were worse. Overweight-obese I fared similarly to patients with normal BMI but had greater odds of isolated complications. Obese II-III patients experienced only marginally increased odds of morbidity. Analyses among propensity-scored cohorts and stratified by cancer-resection type reported similar trends. Worse outcomes were observed among morbidly obese hepatectomy and pancreatectomy patients.

CONCLUSION

Evidence-based assessment of outcomes after major resection for cancer suggests that obese patients should be treated with the aim for optimal oncologic standards without being hindered by a misleading perception of prohibitively increased perioperative risk. Underweight and certain types of morbidly obese patients require targeted provision of appropriate care.