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Lagazzi E, Nzenwa IC, Rafaqat W, Panossian VS, Hoekman AH, Arnold S, Ghaddar KA, Parks JJ, Paranjape CN, Velmahos GC, Kaafarani HMA, Hwabejire JO. Debunking the "Obesity Paradox": Obesity is Associated With Adverse Outcomes in Emergency General Surgery. J Surg Res 2024; 301:95-102. [PMID: 38917579 DOI: 10.1016/j.jss.2024.05.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 05/10/2024] [Accepted: 05/18/2024] [Indexed: 06/27/2024]
Abstract
INTRODUCTION Obesity is increasingly prevalent both nationwide and in the emergency general surgery (EGS) population. While previous studies have shown that obesity may be protective against mortality following EGS procedures, the association between body mass index (BMI) and postoperative outcomes, as well as intraoperative decision-making, remains understudied. METHODS The National Surgical Quality Improvement Program 2015-2019 database was used to identify all adult patients undergoing an open abdominal or abdominal wall procedure for EGS conditions. Our outcomes included 30-d postoperative mortality, composite 30-d morbidity, delayed fascial closure, reoperation, operative time, and hospital length of stay (LOS). Multivariable logistic regression models were used to explore the association between BMI and each outcome of interest while adjusting for patient demographics, comorbidities, laboratory tests, preoperative and intraoperative variables. RESULTS We identified 78,578 patients, of which 3121 (4%) were categorized as underweight, 23,661 (30.1%) as normal weight, 22,072 (28.1%) as overweight, 14,287 (18.2%) with class I obesity, 7370 (9.4%) with class II obesity, and 8067 (10.3%) with class III obesity. Class III obesity was identified as a risk factor for 30-d postoperative morbidity (adjusted odds ratio 1.14, 95% CI, 1.03-1.26, P < 0.01). An increase in obesity class was also associated with a stepwise increase in the risk of undergoing delayed fascial closure, experiencing a prolonged operative time, and having an extended LOS. CONCLUSIONS Obesity class was associated with an increase in delayed fascial closure, longer operative time, higher reoperation rates, and extended hospital LOS. Further studies are needed to explore how a patient's BMI impacts intraoperative factors, influences surgical decision-making, and contributes to hospital costs.
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Affiliation(s)
- Emanuele Lagazzi
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Ikemsinachi C Nzenwa
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Wardah Rafaqat
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Vahe S Panossian
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Anne H Hoekman
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Suzanne Arnold
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Karen A Ghaddar
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Jonathan J Parks
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Charudutt N Paranjape
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - George C Velmahos
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - John O Hwabejire
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts.
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Shpata V, Lilaj K, Kodra N. Surgical Outcomes in Different Age Cohorts Undergoing Abdominal Surgery: A Retrospective Study. J Perianesth Nurs 2024; 39:403-408. [PMID: 37999690 DOI: 10.1016/j.jopan.2023.08.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 08/17/2023] [Accepted: 08/25/2023] [Indexed: 11/25/2023]
Abstract
PURPOSE This study aimed to investigate and compare the surgical outcomes of younger and older patients after abdominal surgery and explore risk factors related to postoperative complications and in-hospital mortality in patients ≥65 years old. DESIGN A retrospective study on 540 adult patients who underwent abdominal surgery and stayed more than 48 hours in the hospital. METHODS The two groups of patients: younger than 65 years and ≥65 years old were compared related to postoperative complications, length of hospital stay, and mortality rates. The cohort of patients aged ≥65 years was selected to analyze risk factors for complications occurrence and in-hospital mortality. FINDINGS Patients ≥65 years old had poorer outcomes after abdominal surgery than younger patients. Pre-existence of comorbidities, American Society of Anesthesiologists physical status classification greater than two, emergency admission, and low preoperative serum albumin levels were risk factors for postoperative complications and mortality in elderly patients. Other risk factors for in-hospital mortality were the age ≥75 years, obesity, postoperative serum albumin level less than 30 g/L, presence of anemia before and after surgery, and occurrence of postoperative complications. Logistic regression revealed as independent risk factors for the postoperative complications the American Society of Anesthesiologists' physical status classification greater than two (odds ratio [OR]: 3.05, 95% confidence interval [CI]: 1.63-5.67, P = .0004) and preoperative serum albumin levels lower than 30 g/L (OR: 2.12, 95% CI: 1.08-4.17, P = .02), while for in-hospital postoperative mortality, independent risk factors were postoperative anemia (OR: 4.13; 95% CI: 1.22-13.97, P = .02) and obesity (OR: 7.65, 95% CI: 2.59-22.57, P = .0002). CONCLUSIONS Optimizing the preoperative conditions of older patients will improve their postoperative outcomes, especially for patients ≥75 years old, with obesity, comorbidities, anemia, severe nutritional risk, and emergency admission.
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Affiliation(s)
- Vjollca Shpata
- Faculty of Rehabilitation Sciences, University of Sports of Tirana, Tirana, Albania.
| | - Krenar Lilaj
- Faculty of Medicine, University of Medicine, Tirana, Albania; University Hospital Center of Tirana "Mother Theresa", Tirana, Albania
| | - Nertila Kodra
- University Hospital Center of Tirana "Mother Theresa", Tirana, Albania
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Dhanasekara CS, Shrestha K, Grossman H, Garcia LM, Maqbool B, Luppens C, Dumas RP, Taveras Morales LR, Brahmbhatt TS, Haqqani M, Lunevicius R, Nzenwa IC, Griffiths E, Almonib A, Bradley NL, Lerner EP, Mohseni S, Trivedi D, Joseph BA, Anand T, Plevin R, Nahmias JT, Lasso ET, Dissanaike S. A comparison of outcomes including bile duct injury of subtotal cholecystectomy versus open total cholecystectomy as bailout procedures for severe cholecystitis: A multicenter real-world study. Surgery 2024:S0039-6060(24)00226-5. [PMID: 38777659 DOI: 10.1016/j.surg.2024.03.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 02/27/2024] [Accepted: 03/27/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Dense inflammation obscuring the hepatocystic anatomy can hinder the ability to perform a safe standard laparoscopic cholecystectomy in severe cholecystitis, requiring use of a bailout procedure. We compared clinical outcomes of laparoscopic and open subtotal cholecystectomy against the traditional standard of open total cholecystectomy to identify the optimal bailout strategy for the difficult gallbladder. METHODS A multicenter, multinational retrospective cohort study of patients who underwent bailout procedures for severe cholecystitis. Procedures were compared using one-way analysis of variance/Kruskal-Wallis tests and χ2 tests with multiple pairwise comparisons, maintaining a family-wise error rate at 0.05. Multiple multivariate linear/logistical regression models were created. RESULTS In 11 centers, 727 bailout procedures were conducted: 317 laparoscopic subtotal cholecystectomies, 172 open subtotal cholecystectomies, and 238 open cholecystectomies. Baseline characteristics were similar among subgroups. Bile leak was common in laparoscopic and open fenestrating subtotal cholecystectomies, with increased intraoperative drain placements and postoperative endoscopic retrograde cholangiopancreatography(P < .05). In contrast, intraoperative bleeding (odds ratio = 3.71 [1.9, 7.22]), surgical site infection (odds ratio = 2.41 [1.09, 5.3]), intensive care unit admission (odds ratio = 2.65 [1.51, 4.63]), and length of stay (Δ = 2 days, P < .001) were higher in open procedures. Reoperation rates were higher for open reconstituting subtotal cholecystectomies (odds ratio = 3.43 [1.03, 11.44]) than other subtypes. The overall rate of bile duct injury was 1.1% and was not statistically different between groups. Laparoscopic subtotal cholecystectomy had a bile duct injury rate of 0.63%. CONCLUSION Laparoscopic subtotal cholecystectomy is a feasible surgical bailout procedure in cases of severe cholecystitis where standard laparoscopic cholecystectomy may carry undue risk of bile duct injury. Open cholecystectomy remains a reasonable option.
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Affiliation(s)
| | - Kripa Shrestha
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX
| | - Holly Grossman
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX
| | - Liza M Garcia
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX
| | - Baila Maqbool
- Department of Surgery, University of New Mexico, Albuquerque, NM
| | - Carolyn Luppens
- Department of Surgery, University of New Mexico, Albuquerque, NM
| | - Ryan P Dumas
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | | | | | - Maha Haqqani
- Department of Surgery, Boston Medical Center, Boston, MA
| | - Raimundas Lunevicius
- Department of General Surgery, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Ikemsinachi C Nzenwa
- Department of General Surgery, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK; Department of Surgery, Massachusetts General Hospital, MA
| | - Ewen Griffiths
- Queen Elizabeth Hospital, University Hospitals NHS Foundation Trust, Edgbaston, Birmingham, UK
| | - Ahmed Almonib
- Queen Elizabeth Hospital, University Hospitals NHS Foundation Trust, Edgbaston, Birmingham, UK
| | | | - E Paul Lerner
- Department of Surgery, University of Alberta, Canada
| | - Shahin Mohseni
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, Sheikh Shakhbout Medical City-Mayo Clinic, Abu Dhabi, UAE; School of Medical Sciences, Orebro University, Sweden
| | - Dhanisha Trivedi
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, Sheikh Shakhbout Medical City-Mayo Clinic, Abu Dhabi, UAE; School of Medical Sciences, Orebro University, Sweden
| | | | - Tanya Anand
- Department of Surgery, University of Arizona, Tucson, AZ
| | - Rebecca Plevin
- Department of Surgery, University of California San Francisco, CA
| | - Jeffry T Nahmias
- Department of Surgery, University of California, Irvine, Orange, CA
| | - Erika Tay Lasso
- Department of Surgery, University of California, Irvine, Orange, CA
| | - Sharmila Dissanaike
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX.
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Tian WM, Chang D, Pressley M, Muhammed M, Fong P, Webster W, Herbert G, Gallagher S, Watters CR, Yoo JS, Zani S, Agarwal S, Allen PJ, Seymour KA. Development of a prospective biliary dashboard to compare performance and surgical cost. Surg Endosc 2023; 37:8829-8840. [PMID: 37626234 DOI: 10.1007/s00464-023-10376-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 07/30/2023] [Indexed: 08/27/2023]
Abstract
BACKGROUND Transparency around surgeon level data may align healthcare delivery with quality care for patients. Biliary surgery includes numerous procedures performed by both general surgeons and subspecialists alike. Cholecystectomy is a common surgical procedure and an optimal cohort to measure quality outcomes within a healthcare system. METHODS Data were collected for 5084 biliary operations performed by 68 surgeons in 11 surgical divisions in a health system including a tertiary academic hospital, two regional community hospitals, and two ambulatory surgery centers. A privacy protected dashboard was developed to compare surgeon performance and cost between July 2018 and June 2022. A sample cohort of patients ≥ 18 years who underwent cholecystectomy were compared by operative time, cost, and 30-day outcomes. RESULTS Over 4 years, 4568 cholecystectomy procedures were performed by 57 surgeons. Operations were done by 57 surgeons in four divisions and included 3846 (84.2%) laparoscopic cholecystectomies, 601 (13.2%) laparoscopic cholecystectomies with cholangiogram, and 121 (2.6%) open cholecystectomies. Patients were admitted from the emergency room in 2179 (47.7%) cases while 2389 (52.3%) cases were performed in the ambulatory setting. Individual surgeons were compared to peers for volume, intraoperative data, cost, and outcomes. Cost was lowest at ambulatory surgery centers, yet only 4.2% of elective procedures were performed at these facilities. Prepackaged kits with indocyanine green were more expensive than cholangiograms that used iodinated contrast. The rate of emergency department visits was lowest when cases were performed at ambulatory surgery centers. CONCLUSION Data generated from clinical dashboards can inform surgeons as to how they compare to peers regarding quality metrics such as cost, time, and complications. In turn, this may guide strategies to standardize care, optimize efficiency, provide cost savings, and improve outcomes for cholecystectomy procedures. Future application of clinical dashboards can assist surgeons and administrators to define value-based care.
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Affiliation(s)
| | - Doreen Chang
- Department of Surgery, Duke University, Durham, NC, USA
| | - Melissa Pressley
- Performance Services, Duke University Health System, Durham, NC, USA
| | - Makala Muhammed
- Performance Services, Duke University Health System, Durham, NC, USA
| | - Philip Fong
- Department of Surgery, Duke University, Durham, NC, USA
| | - Wendy Webster
- Department of Surgery, Duke University, Durham, NC, USA
| | - Garth Herbert
- Department of Surgery, Duke University, Durham, NC, USA
| | | | | | - Jin S Yoo
- Department of Surgery, Duke University, Durham, NC, USA
| | - Sabino Zani
- Department of Surgery, Duke University, Durham, NC, USA
| | | | - Peter J Allen
- Department of Surgery, Duke University, Durham, NC, USA
| | - Keri A Seymour
- Department of Surgery, Duke University, Durham, NC, USA.
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Enami Y, Aoki T, Tomioka K, Hirai T, Shibata H, Saito K, Nagaishi S, Takano Y, Seki J, Shimada S, Nakahara K, Takehara Y, Mukai S, Sawada N, Ishida F, Kudo SE. Optimal Timing of Laparoscopic Cholecystectomy After Conservative Therapy for Acute Cholecystitis. CANCER DIAGNOSIS & PROGNOSIS 2023; 3:571-576. [PMID: 37671304 PMCID: PMC10475920 DOI: 10.21873/cdp.10256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 08/04/2023] [Indexed: 09/07/2023]
Abstract
Background/Aim According to the Tokyo Guidelines 2018, the operation for acute cholecystitis is recommended to be performed as early as possible. However, there are cases in which early surgeries cannot be performed due to complications of patients or facility conditions, resulting in elective surgery. Hence, we retrospectively analyzed elective surgery cases in this study. Patients and Methods There were 345 patients who were underwent laparoscopic cholecystectomy (LC) at our hospital from January 2019 to December 2020 in this retrospective study. A total of 83 patients underwent LC more than 3 days after conservative treatment. The elective LC patients were divided into the Early group (4-90 days after onset, n=36) and the Delayed group [91 days or more (13 weeks or more) after onset, n=31], excluding 16 patients who underwent percutaneous transhepatic gallbladder drainage. Results As for operative time, there was a significant difference between the Delayed and Early groups (91.2 vs. 117 minutes, p=0.0108). And also, there was a significant difference in the postoperative hospital stay, which was significantly shorter in the Delayed group than in the Early group (3.4 vs. 5.9 days, p=0.0436). Although there were no significant differences in either conversion rates or complication rates, both of these were decreasing in the Delayed group. In particular, there were no complications in the Delayed group. Conclusion When the conservative treatment for acute cholecystitis precedes and precludes urgent/early LC within 3 days, delaying LC for at least 91 days (13 weeks or more) after onset could reduce operative time and postoperative hospital stay. Moreover, there would be no complications after LC, and the rates of conversion during LC may be kept low.
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Affiliation(s)
- Yuta Enami
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
- Department of Gastrointestinal and General Surgery, Showa University, School of Medicine, Tokyo, Japan
| | - Takeshi Aoki
- Department of Gastrointestinal and General Surgery, Showa University, School of Medicine, Tokyo, Japan
| | - Kodai Tomioka
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
- Department of Gastrointestinal and General Surgery, Showa University, School of Medicine, Tokyo, Japan
| | - Takahito Hirai
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
- Department of Gastrointestinal and General Surgery, Showa University, School of Medicine, Tokyo, Japan
| | - Hideki Shibata
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
- Department of Gastrointestinal and General Surgery, Showa University, School of Medicine, Tokyo, Japan
| | - Kazuhiko Saito
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
- Department of Gastrointestinal and General Surgery, Showa University, School of Medicine, Tokyo, Japan
| | - Shodai Nagaishi
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
- Department of Gastrointestinal and General Surgery, Showa University, School of Medicine, Tokyo, Japan
| | - Yojiro Takano
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Junichi Seki
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Shoji Shimada
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Kenta Nakahara
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Yusuke Takehara
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Shumpei Mukai
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Naruhiko Sawada
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Fumio Ishida
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Shin-Ei Kudo
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
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Abi-Jaoude JG, Naiem AA, Edwards T, Lukaszewski MA, Obrand DI, Steinmetz OK, Bayne JP, MacKenzie KS, Gill HL, Girsowicz E. A systematic review and meta-analysis of the effect of obesity on patients undergoing lower extremity revascularization. J Vasc Surg 2022:S0741-5214(22)02637-4. [PMID: 36565774 DOI: 10.1016/j.jvs.2022.12.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 11/20/2022] [Accepted: 12/07/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE In the present review, we assessed the effect of obesity on clinical outcomes for patients with peripheral arterial disease who had undergone endovascular or open lower extremity revascularization surgery. METHODS A systematic search strategy of MEDLINE, EMBASE, CINAHL, Web of Science, and Cochrane Library was conducted. The included studies had compared obese and nonobese cohorts with peripheral arterial disease who had undergone endovascular or open lower extremity revascularization. The outcomes included mortality, major adverse cardiovascular events, major adverse limb events, surgical site infections, endovascular access site complications, and perioperative complications. RESULTS Eight studies were included with 171,648 patients. The obese patients (body mass index ≥30 kg/m2) were more likely to be women, to have diabetes, and to have more cardiovascular comorbidities despite being younger. No association was found between obesity and peripheral arterial disease severity. Obesity was associated with an overall 22% decreased mortality risk after lower extremity revascularization (risk ratio [RR], 0.78; 95% confidence interval [CI], 0.71-0.85; P < .001; I2 = 0%; GRADE (grading of recommendations assessment, development, evaluation), very low quality). A subgroup analysis by intervention type showed similar findings (endovascular: RR, 0.79; 95% CI, 0.71-0.87; P < .001; I2 = 0%; open: RR, 0.70; 95% CI, 0.51-0.95; P = .024; I2 = 43%). Obesity was associated with a 14% decreased risk of major adverse cardiovascular events for open surgery only (RR, 0.86; 95% CI, 0.76-0.98; P = .021; I2 = 0%; GRADE, very low quality). Obesity was associated with an increased risk of surgical site infections pooled across intervention types (RR, 1.69; 95% CI, 1.34-2.14; P < .001; I2 = 78%; GRADE, very low quality). No association was found between obesity and major adverse limb events (RR, 1.02; 95% CI, 0.93-1.11; P = .73; I2 = 15%; GRADE, very low quality) or endovascular access site complications (RR, 1.11; 95% CI, 0.76-1.63; P = .58; I2 = 86%; GRADE, very low quality). Pooled perioperative complications did not differ between the obese and nonobese cohorts (RR, 1.04; 95% CI, 0.84-1.28; P = .73; I2 = 92%; GRADE, very low quality). CONCLUSIONS Obesity was associated with reduced mortality risk with both endovascular and open surgery, although a reduction in major adverse cardiovascular events was only observed with open surgery. In addition, obese patients had an increased risk of surgical site infections. Obesity was not associated with major adverse limb events, endovascular access site complications, or perioperative complications. The GRADE quality of evidence was very low. The findings from the present review suggest a survival advantage for obese patients with peripheral arterial disease. Future studies could focus on prospectively investigating the effect of obesity on peripheral arterial disease outcomes. A nuanced evaluation of body mass index as a preoperative risk factor is warranted.
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Affiliation(s)
- Joanne G Abi-Jaoude
- Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada
| | - Ahmed A Naiem
- Division of Vascular Surgery, McGill University, Montreal, QC, Canada
| | - Thomas Edwards
- Northern Ontario School of Medicine, Sudbury, ON, Canada
| | | | - Daniel I Obrand
- Division of Vascular Surgery, McGill University, Montreal, QC, Canada
| | - Oren K Steinmetz
- Division of Vascular Surgery, McGill University, Montreal, QC, Canada
| | - Jason P Bayne
- Division of Vascular Surgery, McGill University, Montreal, QC, Canada
| | - Kent S MacKenzie
- Division of Vascular Surgery, McGill University, Montreal, QC, Canada
| | - Heather L Gill
- Division of Vascular Surgery, McGill University, Montreal, QC, Canada
| | - Elie Girsowicz
- Division of Vascular Surgery, McGill University, Montreal, QC, Canada.
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Wong A, Naidu S, Lancashire RP, Chua TC. The impact of obesity on outcomes in patients undergoing emergency cholecystectomy for acute cholecystitis. ANZ J Surg 2022; 92:1091-1096. [PMID: 35119791 PMCID: PMC9305243 DOI: 10.1111/ans.17513] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 01/05/2022] [Accepted: 01/16/2022] [Indexed: 12/24/2022]
Abstract
Background Obesity is a perceived risk factor for poorer surgical outcomes, including increased complication rates and mortality. As obesity rates rise annually, evaluating surgical outcomes in the obese population has become increasingly important. This study examines the impact of obesity on outcomes following emergency laparoscopic cholecystectomy (LC) for acute cholecystitis. Methods A retrospective review of patients who underwent emergency LC for acute cholecystitis between March 2018 and March 2021 was performed. A total of 326 patients were included and stratified by body mass index (BMI) into two groups: obese (BMI ≥30 kg/m2, n = 156) and non‐obese (BMI <30 kg/m2, n = 170). Primary outcomes included length of stay, time to definitive surgery, and postoperative complications. Secondary outcomes included total operative time and intraoperative findings. Results Obese patients were younger than non‐obese patients (median, 45 [34.3–56.8] and 48.5 [34.0–66.3] years; p < 0.001) and had a higher prevalence of diabetes (13.5% versus 6.5%; p = 0.034). Higher American Society of Anesthesiologists (ASA) classification (p < 0.001) and operative grading scores were observed in the obese group (76.3% versus 40.6%, p < 0.001), who were more likely to have a distended gallbladder (19.9% versus 11.2%, p = 0.030) and gallstone impaction (23.1% versus 11.8%, p = 0.007) in comparison to the non‐obese group. Length of hospital stay, time to definitive surgery, and postoperative complication rates were similar between groups. Conclusion Although obesity is associated with greater technical difficulty during surgery than non‐obese patients, similar postoperative outcomes were achieved. Obesity should not be a contraindication for LC and can be safely performed in the emergency setting.
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Affiliation(s)
- Alixandra Wong
- Department of Surgery, QEII Jubilee Hospital, Brisbane, Queensland, Australia.,School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Sanjeev Naidu
- Department of Surgery, QEII Jubilee Hospital, Brisbane, Queensland, Australia
| | | | - Terence C Chua
- Department of Surgery, QEII Jubilee Hospital, Brisbane, Queensland, Australia.,School of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,School of Medicine, Griffith University, Gold Coast, Queensland, Australia
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Operative Difficulty, Morbidity and Mortality Are Unrelated to Obesity in Elective or Emergency Laparoscopic Cholecystectomy and Bile Duct Exploration. J Gastrointest Surg 2022; 26:1863-1872. [PMID: 35641812 PMCID: PMC9489587 DOI: 10.1007/s11605-022-05344-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 04/30/2022] [Indexed: 01/31/2023]
Abstract
OBJECTIVES The challenges posed by laparoscopic cholecystectomy (LC) in obese patients and the methods of overcoming them have been addressed by many studies. However, no objective tool of reporting operative difficulty was used to adjust the outcomes and compare studies. The aim of this study was to establish whether obesity adds to the difficulty of LC and laparoscopic common bile duct exploration (LCBDE) and affects their outcomes on a specialist biliary unit with a high emergency workload. METHODS A prospectively maintained database of 4699 LCs and LCBDEs performed over 19 years was analysed. Data of patients with body mass index (BMI) ≥ 35, defined as grossly obese, was extracted and compared to a control group. RESULTS A total of 683 patients (14.5%) had a mean BMI of 39.9 (35-63), of which 63.4% met the definition of morbidly obese. They had significantly more females and significantly higher ASA II classifications. They had equal proportions of emergency admissions, similar incidence of operative difficulty grades 4 or 5 and no open conversions and were less likely to undergo LCBDE than non-obese patients. There were no significant differences in median operative times, morbidity, readmission or mortality rates. CONCLUSIONS This study, the first to classify gall stone surgery in obese patients according to operative difficulty grading, showed no difference in complexity when compared to the non-obese. Refining access and closure techniques is key to avoiding difficulties. Index admission surgery for biliary emergencies prevents multiple admissions with potential complications and should not be denied due to obesity.
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Plassmeier L, Hankir MK, Seyfried F. Impact of Excess Body Weight on Postsurgical Complications. Visc Med 2021; 37:287-297. [PMID: 34540945 PMCID: PMC8406338 DOI: 10.1159/000517345] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 05/19/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Obesity is considered a risk factor for postoperative complications as it can limit exposure to the operation field, thereby significantly prolonging surgery time. Obesity-associated comorbidities, such as low-grade systemic inflammation, impaired functional status, and type 2 diabetes, are independent risk factors for impaired anastomotic wound healing and nonsurgical site infections. If obesity itself is an independent risk factor for surgical complications remains controversial, but the reason for this is largely unexplored. SUMMARY A MEDLINE literature search was performed using the terms: "obesity," "excess body weight," and "surgical complications." Out of 65,493 articles 432 meta-analyses were screened, of which 25 meta-analyses were on the subject. The vast majority of complex oncologic procedures in the field of visceral surgery have shown higher complication rates in obese patients. Meta-analyses from the last 10 to 15 years with high numbers of patients enrolled consistently have shown longer operation times, higher blood loss, longer hospital stay for colorectal procedures, oncologic upper gastrointestinal (GI) procedures, and pancreatic surgery. Interestingly, these negative effects seem not to affect the overall survival in oncologic patients, especially in esophageal resections. A selection bias in oncologic upper GI patients may have influenced the results with higher BMI in upper GI cancer to be a predictor for better nutritional and performance status. KEY MESSAGES Contrary to bariatric surgery, only limited evidence indicated that site and type of surgery, the approach to the abdominal cavity (laparoscopic vs. open), institutional factors, and the type of perioperative care such as ERAS protocols may play a role in determining postsurgical complications in obese patients. The initial question remains therefore partially unanswered. Large nationwide register-based studies are necessary to better understand which aspects of obesity and its related comorbidities define it as a risk factor for surgical complications.
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Affiliation(s)
- Lars Plassmeier
- Department of General, Visceral, Transplantation, Vascular, and Pediatric Surgery, University Hospital, Wuerzburg, Germany
| | | | - Florian Seyfried
- Department of General, Visceral, Transplantation, Vascular, and Pediatric Surgery, University Hospital, Wuerzburg, Germany
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