Effect of body mass index on operative outcome after robotic-assisted Ivor-Lewis esophagectomy: retrospective analysis of 129 cases at a single high-volume tertiary care center

Weighing the outcomes: the role of BMI in complex robotic esophageal and hepatobiliary operations

BACKGROUND

The correlation between body mass index (BMI) and surgical outcomes has emerged as a critical consideration in complex abdominal operations. While elevated BMI is often associated with increased perioperative risk, its specific effects on the outcomes of robotic surgeries remain inadequately explored. This study assesses the impact of BMI on perioperative variables of complex esophageal and hepatopancreaticobiliary (HPB) robotic operations.

METHODS

Following IRB approval, we prospectively followed 607 patients undergoing pancreaticoduodenectomy, trans-hiatal esophagectomy (THE), major liver resection or distal pancreatectomy with splenectomy, all performed robotically. Perioperative data retrieved included operative duration, estimated blood loss (EBL), intraoperative and postoperative complications, conversions to an 'open' operation and length of stay (LOS). Z scores were assigned to each variable to standardize operations, and the variables were then regressed against BMI. For illustrative purposes, data are presented as median(mean ± standard deviation).

RESULTS

Between 2012 and 2020, surgeries included 71 THE, 122 distal pancreatectomies with splenectomies, 129 major hepatectomies and 285 pancreaticoduodenectomies. Median age was 67(65 ± 12.5) years old, and BMI was 27(28 ± 5.5) kg/m2. Operative duration for all operations was 349(355 ± 124.5) min and had a positive correlation with increasing BMI (p = 0.004), specifically for robotic THE and robotic pancreaticoduodenectomy, with both operative durations having positive correlation with increasing BMI (p = 0.02 and p = 0.05). No significant correlation with BMI was found for EBL, intraoperative or postoperative complications, conversion to 'open' surgery, or LOS.

CONCLUSION

Elevated BMI is associated with longer operative durations in select robotic surgeries, such as trans-hiatal esophagectomy and pancreaticoduodenectomy, and highlights the need for strategic planning in these patients.

Impact of Excess Body Weight on Postsurgical Complications

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.

Obesity and postoperative outcomes of the patients with laparoscopic adrenalectomy: a systematic review and meta-analysis

Background

Studies have suggested differences in postoperative outcomes between patients with obesity and those without following adrenalectomy, but these remained to be ascertained with synthesis of available evidence. The aim of this systematic review and meta-analysis was to investigate the association between obesity and outcomes of patients after laparoscopic adrenalectomy.

Methods

We searched EMBASE, PubMed, Global Index Medicus, and Web of Science, without language restriction, to identify cohort studies published between January 1, 2000 and November 6, 2019. We considered studies with data comparing outcomes of adults with and without obesity after laparoscopic adrenalectomy. Random-effects meta-analysis was used to pool study-specific estimates. This review was registered with PROSPERO, CRD42018117070.

Results

Five studies with data on a pooled sample of 353 patients with obesity and 828 without were included in the meta-analysis. The risk of bias was moderate to low. We found no association between obesity and the various stages of postoperative complications: Clavien-Dindo grade 1 (OR = 1.57; 95%CI = 0.55–4.48; I² = 44.6%), grade 2 (OR = 1.12; 95%CI = 0.54–2.32; I² = 0.0%), grade 3 (OR = 1.79; 95%CI = 0.58–5.47; I² = 0.0%;), grade 4 (OR = 0.43; 95%CI = 0.05–3.71; I² = 0.0%), and grade 5 (death) (OR = 0.43; 95% CI = 0.02–14.31). Furthermore, no association was found between obesity and readmission rates (OR = 0.7; 95% CI = 0.13–3.62) and conversion of laparoscopic to open surgery (OR = 0.62; 95% CI = 0.16–2.34; I² = 19.5%).

Conclusions

This study suggests that obesity is not associated with complications following laparoscopic adrenalectomy. This meta-analysis might have been underpowered to detect a true association between obesity and patient outcome after laparoscopic adrenalectomy due to the small number of included studies. Larger studies are needed to clarify the role of obesity in patients undergoing laparoscopic adrenalectomy.

Risk factors of postoperative pulmonary complications after minimally invasive anatomic resection for lung cancer

Purpose

This study investigated the perioperative risk factors of postoperative pulmonary complications (PPCs) after minimally invasive anatomic resection for lung cancer.

Patients and methods

We retrospectively reviewed the data from medical records of 729 lung cancer patients undergoing minimally invasive anatomic lung resections between January 2017 and December 2017. Univariate and binary logistic regression analyses were performed to select the independent risk factors for PPCs during the patient’s postoperative hospitalization after surgery.

Results

The incidence of PPCs was 24.8% (n=181/729). No patient died during the period of hospitalization. Logistic regression analysis revealed that body mass index (BMI) ≥24.0 kg/m² (vs <24.0 kg/m²: OR 1.514, 95% CI 1.057–2.167, P=0.024), single segmentectomy (vs single lobectomy: OR 2.115, 95% CI 1.150–3.891, P=0.016), bilobectomy or combined lobectomy and segmentectomy (vs single lobectomy: OR 2.731, 95% CI 1.013–7.361, P=0.047), and right lung lobe surgery (vs left lung lobe surgery: OR 1.519, 95% CI 1.046–2.205, P=0.028) were independent risk factors for PPCs in lung cancer patients who received minimally invasive anatomic lung resections.

Conclusion

Individual factors such as BMI ≥24.0 kg/m², single segmentectomy, bilobectomy or combined lobectomy and segmentectomy, and right lung lobe surgery were independent risk factors of PPCs, which should be helpful for risk stratification, patient counseling, and perioperative care for lung cancer patients.

Anastomotic leak and neoadjuvant chemoradiotherapy in esophageal cancer

Background

Anastomotic leaks (AL) cause significant morbidity after esophagectomy. Most patients receive neoadjuvant chemoradiation (NCR) prior to esophagectomy which has been associated with increase perioperative complications and mortality. We report on a comparison of AL rates in upfront surgical (UFS) and NCR patients.

Methods

An esophagectomy database was queried for UFS and NCR patients treated between 1996 and 2015. Predictors of AL rate were identified using univariate and multivariate (MVA) analysis and propensity score matching (PSM).

Results

We identified 820 patients (UFS, 288; NCR, 532). Overall AL rate was 5.4%. Decreased AL rate was observed in NCR patients on MVA (8.0% vs. 4.1%; P=0.02) but no difference was seen after PSM (7.7% vs. 4.2%; P=0.14). MVA of factors associated with decreased AL in UFS patients included distal esophageal tumors and body mass index (BMI) >25. Age, gender, year of surgery, histology, anastomotic location, and diabetes were not prognostic. Before PSM, MVA of NCR patients of factors associated with decreased AL revealed that only thoracic anastomosis was prognostic. However, this was not observed after PSM. MVA of factors associated with decreased AL in all patients revealed thoracic anastomosis, NCR, and BMI 25-30. After PSM, only distal esophageal tumors and thoracic anastomosis were prognostic for decreased AL.

Conclusions

There is no difference in the AL rate between UFS and NCR patients. Decreased AL rate was observed in patients with distal esophageal tumors and thoracic anastomosis.

Upper Gastrointestinal Surgery: Robotic Surgery versus Laparoscopic Procedures for Esophageal Malignancy

Background

The evolution of minimally invasive surgery (MIS) also extends to the field of esophageal surgery and has brought forth the development of several approaches of minimally invasive esophagectomy (MIE). Hybrid and total minimally invasive operative techniques have proven beneficial compared to open surgery and are currently evaluated against robotic-assisted minimally invasive esophagectomy (RAMIE). We aim to review the current literature regarding the position of MIE versus RAMIE.

Methods

A systematic review of the relevant literature on minimally invasive esophageal surgery for cancer is presented. A PubMed search was carried out for the period of 1992-2018 with the following search terms: 'esophageal cancer', 'minimally invasive surgery', 'resection', 'transhiatal', 'transthoracic', 'MIE', 'hybrid', 'robotic resection', 'RAMIE', 'RATE'.

Results

Hybrid and total minimally invasive operative techniques have proven beneficial, especially with regard to pulmonary complications, compared to open surgery. Oncologic outcomes appear equivalent between open and minimally invasive techniques. Currently, the position of RAMIE is being evaluated against other minimally invasive techniques.

Conclusion

All minimally invasive techniques confer the expected reduction in perioperative morbidity compared to open surgery. However, MIS is still evolving with regard to specific technical challenges, especially anastomotic techniques.

Robotic-assisted Ivor Lewis esophagectomy: technique and early outcomes

Esophagectomy is pivotal for the long-term survival in patients with early stage and advanced esophageal cancer, and improved perioperative care and advanced surgical techniques have contributed to reduced postoperative morbidity. However, despite these advances, esophagectomy continues to be associated with significant morbidity and mortality. Minimally invasive esophageal surgery (MIE) has been increasingly used in patients undergoing surgery for esophageal cancer. Potential advantages of MIE include the decreased postoperative pain; lower postoperative wound infection, decreased pulmonary complications, and decreased length of hospitalization. Robotic esophageal surgery has the ability to overcome some of the limitations of laparoscopic and thoracoscopic approaches to esophagectomy while maintaining the benefits of the minimally invasive approach. In this article, we will review the clinical efficacy and outcomes associated with robotic-assisted Ivor Lewis esophagectomy (RAIL).

Robotic surgery for esophageal cancer: Merits and demerits

Since the introduction of robotic systems in esophageal surgery in 2000, the number of robotic esophagectomies has been gradually increasing worldwide, although robot‐assisted surgery is not yet regarded as standard treatment for esophageal cancer, because of its high cost and the paucity of high‐level evidence. In 2016, more than 1800 cases were operated with robot assistance. Early results with small series demonstrated feasibility and safety in both robotic transhiatal (THE) and transthoracic esophagectomies (TTE). Some studies report that the learning curve is approximately 20 cases. Following the initial series, operative results of robotic TTE have shown a tendency to improve, and oncological long‐term results are reported to be effective and acceptable: R0 resection approaches 95%, and locoregional recurrence is rare. Several recent studies have demonstrated advantages of robotic esophagectomy in lymphadenectomy compared with the thoracoscopic approach. Such technical innovations as three‐dimensional view, articulated instruments with seven degrees of movement, tremor filter etc. have the potential to outperform any conventional procedures. With the aim of preventing postoperative pulmonary complications without diminishing lymphadenectomy performance, a nontransthoracic radical esophagectomy procedure combining a video‐assisted cervical approach for the upper mediastinum and a robot‐assisted transhiatal approach for the middle and lower mediastinum, transmediastinal esophagectomy, was developed; its short‐term outcomes are promising.

Thus, the merits or demerits of robotic surgery in this field remain quite difficult to assess. However, in the near future, the merits will definitely outweigh the demerits because the esophagus is an ideal organ for a robotic approach.