Is There any Role of Visceral Fat Area for Predicting Difficulty of Laparoscopic Gastrectomy for Gastric Cancer?

Comprehensive assessment of body mass index effects on short-term and long-term outcomes in laparoscopic gastrectomy for gastric cancer: a retrospective study

To examine the influence of Body Mass Index (BMI) on laparoscopic gastrectomy (LG) short-term and long-term outcomes for gastric cancer. A retrospective analysis was conducted on gastric cancer patients undergoing LG at the Third Hospital of Nanchang City from January 2013 to January 2022. Based on WHO BMI standards, patients were categorized into normal weight, overweight, and obese groups. Factors such as operative time, intraoperative blood loss, postoperative complications, and overall survival were assessed. Across different BMI groups, it was found that an increase in BMI was associated with longer operative times (average times: 206.22 min for normal weight, 231.32 min for overweight, and 246.78 min for obese), with no significant differences noted in intraoperative blood loss, postoperative complications, or long-term survival among the groups. The impact of BMI on long-term survival following LG for gastric cancer was found to be insignificant, with no notable differences in survival outcome between different BMI groups. Although higher BMI is associated with increased operative time in LG for gastric cancer, it does not significantly affect intraoperative blood loss, postoperative complications, recovery, or long-term survival. LG is a feasible treatment choice for obese patients with gastric cancer.

Association of visceral adipose tissue with postoperative outcome in upper gastrointestinal cancer: a systematic review and meta-analysis

BACKGROUND

There is no consensus on the relation between visceral fat mass and long-term postoperative prognosis in patients with upper gastrointestinal (GI) cancer.

OBJECTIVES

The purpose of this study was to investigate the association of preoperative visceral fat mass with postoperative complications and overall survival (OS) in patients with upper GI cancer.

METHODS

We searched MEDLINE, the Cochrane Central Register of Controlled Trials, EMBASE (Dialog), the WHO International Clinical Trials Platform Search Portal, and ClinicalTrials.gov and identified observational studies published from inception through 20 July 2022. We conducted a systematic review and random-effects meta-analysis of studies including patients who were surgically treated for upper GI cancer and whose visceral fat mass was assessed on the basis of body composition. We independently assessed the risk of bias and quality of evidence using the Quality In Prognosis Studies and the Grading of Recommendations, Assessment, Development, and Evaluation approach, respectively. The primary outcome was OS. HRs and 95% CIs for OS were pooled.

RESULTS

Ninety-one studies (n = 20,583) were included. All studies used computed tomography (CT) to assess the body composition of patients. Twenty-four studies reported the relation between high visceral fat and postoperative outcomes, and their results were synthesized. Compared with low visceral adipose tissue, high visceral adipose tissue assessed by CT may improve OS (HR: 0.69; 95% CI: 0.55, 0.87; I2 = 65%; n = 3407). The risk of bias for OS in each study was moderate or high. The certainty of evidence for OS was very low because of inconsistency in the forest plot, the moderate or high risk of bias, and publication bias.

CONCLUSIONS

High visceral fat may be associated with improved OS after radical resection in patients with upper GI cancer. Further studies are needed to confirm these findings and mitigate the risk.

Preoperative High Visceral Fat Increases Severe Complications but Improves Long-Term Prognosis after Gastrectomy for Patients with Advanced Gastric Cancer: A Propensity Score Matching Analysis

This study investigated the paradox of high visceral fat mass increasing severe complications but improving long-term prognosis after radical gastrectomy for gastric cancer. This was a retrospective cohort study of consecutive patients with primary stage I–III gastric cancer who underwent gastrectomy between April 2008 and June 2018. The visceral adipose tissue index (VAI) was calculated by dividing the visceral fat mass preoperatively measured on computed tomography by the square of the height. Patients with VAIs below the median cut-off value were classified as low-VAI, while those above it were classified as high-VAI. We compared the postoperative complication rate and overall survival (OS) in the low- and high-VAI groups after adjusting patient characteristics using propensity score matching (PSM). There were 155 patients in both groups after PSM. After matching, there was no significant difference in factors other than BMI and VAI that were not adjusted. The high-VAI group had more severe postoperative complications (p = 0.018), but the OS was significantly better in the high-VAI group (hazard ratio 0.611, 95%CI 0.403–0.928, p = 0.021). Preoperative high visceral fat mass not only increased severe complications, but also improved OS after gastrectomy in patients with advanced gastric cancer.

Advantages of a robotic approach compared with laparoscopy gastrectomy for patients with high visceral fat area

BACKGROUND

Gastric cancer surgery for obese patients is regarded as a technically challenging procedure. The morbidity after gastrectomy has been reported to be significantly higher in patients with high visceral fat area (VFA). Robotic gastrectomy (RG) is expected to be advantageous for complicated operations. However, whether RG is superior to conventional laparoscopic gastrectomy (LG) for patients with visceral fat obesity remains unclear. The present study aimed to clarify the impact of RG on the short- and long-term outcomes of patients with high VFAs.

METHODS

This study included 1306 patients with clinical stage I/II gastric cancer who underwent minimally invasive gastrectomy between January 2012 and December 2020. The patients were subclassified according to VFA. The short- and long-term outcomes of RG were compared with those of LG in two VFA categories.

RESULTS

This study included 394 (high-VFA, 151; low-VFA, 243) and 882 patients (high-VFA, 366; low-VFA, 516) in the RG and LG groups, respectively. RG was associated with a significantly longer operative time than LG (high-VFA, P < 0.001; low-VFA, P < 0.001). The incidence rates of overall and intra-abdominal infectious complications in the high-VFA patients were lower in the RG group than in the LG group (P = 0.019 and P = 0.048, respectively) but not significantly different from those in the low-VFA patients. In the multivariate analysis, LG was identified as the only independent risk factor of overall (odds ratio [OR] 3.281; P = 0.012) and intra-abdominal infectious complications (OR 3.462; P = 0.021) in the high-VFA patients. The overall survival of high-VFA patients was significantly better in the RG group than in the LG group (P = 0.045).

CONCLUSIONS

For patients with visceral fat obesity, RG appears to be advantageous to LG in terms of reducing the risk of complications and better long-term survival.

Visceral fat area is a better indicator of surgical outcomes after laparoscopic gastrectomy for cancer than the body mass index: a propensity score-matched analysis

BACKGROUND

The number of overweight gastric cancer patients who are undergoing laparoscopic gastrectomy (LG) has increased in Japan. However, the relationship between obesity and surgical outcomes of LG remains unclear. Therefore, this study aimed to evaluate the effect of visceral fat area (VFA) on surgical outcomes of LG for gastric cancer compared to the body mass index (BMI).

METHODS

This study was a retrospective, cohort study that included 587 patients who underwent LG in our institution between January 2015 and December 2019. The patients were divided into two groups according to VFA (< 100 cm² and ≥ 100 cm²) and BMI (< 25 kg/m² and ≥ 25 kg/m²) values, respectively. Surgical outcomes and postoperative complications were compared between the low and high groups for each VFA and BMI value. Propensity score matching was used to minimize potential selection bias.

RESULTS

After propensity score matching, 144 pairs of patients in the VFA group and 82 pairs of patients in the BMI group were extracted. Operative time (p = 0.003), intraoperative blood loss (p = 0.0006), and CRP levels on postoperative day 1 (p = 0.002) and on postoperative day 3 (p = 0.004) were significantly higher in the high-VFA group than in the low-VFA group. However, these surgical outcomes were not significantly different between the high-BMI and low-BMI groups. There was no strong correlation between VFA and BMI (R² = 0.64). There were no significant differences in postoperative complications between the high and low groups for both VFA and BMI values. On multivariate analysis, high VFA was an independent predictor of operative time, but it was not significantly associated with the incidence of postoperative complications.

CONCLUSION

VFA is a better indicator of longer operative time than BMI. However, increased VFA did not affect postoperative complications.

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.

Trunk fat volume can be a predictor of postoperative complications after gastrectomy: a retrospective cohort study

Background

Obesity can affect postoperative outcomes of gastrectomy. Visceral fat area is superior to body mass index in predicting postoperative complications. However, visceral fat area measurement is time-consuming and is not optimum for clinical use. Meanwhile, trunk fat volume (TFV) can be easily measured via bioelectrical impedance analysis. Hence, the current study aimed to determine the ability of TFV to predict the occurrence of complications after gastrectomy.

Methods

We retrospectively reviewed patients who underwent curative gastrectomy for gastric cancer between November 2016 and November 2019. The trunk fat volume-to-the ideal amount (%TFV) ratio was obtained using InBody 770 before surgery. The patients were classified into the obese and nonobese groups according to %TFV (TFV-H group, ≥ 150%; TFV-L group, < 150%) and body mass index (BMI-H group, ≥ 25 kg/m²; BMI-L group, < 25 kg/m²). We compared the short-term postoperative outcomes (e.g., operative time, blood loss volume, number of resected lymph nodes, and duration of hospital stay) between the obese and nonobese patients. Risk factors for complications were assessed using logistic regression analysis.

Results

In total, 232 patients were included in this study. The TFV-H and BMI-H groups had a significantly longer operative time than the TFV-L (p = 0.022) and BMI-L groups (p = 0.006). Moreover, the TFV-H group had a significantly higher complication rate (p = 0.004) and a lower number of resected lymph nodes (p < 0.001) than the TFV-L group. In the univariate analysis, %TFV ≥ 150, total or proximal gastrectomy, and open gastrectomy were found to be potentially associated with higher complication rates (p < 0.1 for all). Moreover, the multivariate analysis revealed that %TFV ≥ 150 (OR: 2.73; 95% CI: 1.37–5.46; p = 0.005) and total or proximal gastrectomy (OR: 3.57; 95% CI: 1.79–7.12; p < 0.001) were independently correlated with postoperative morbidity.

Conclusions

%TFV independently affected postoperative complications. Hence, it may be a useful parameter for the evaluation of obesity and a predictor of complications after gastrectomy.

The effect of the body mass index on the short-term surgical outcomes of laparoscopic total gastrectomy: A propensity score-matched study

Purpose

This study aimed to evaluate the relationship between the body mass index (BMI) and the short-term outcomes of laparoscopic total gastrectomy (LTG).

Subjects and Methods

Data of patients who underwent LTG for gastric cancer at six institutions between 2004 and 2018 were retrospectively collected. The patients were classified into three groups: low BMI (<18.5 kg/m²), normal BMI (≥18.5 and <25 kg/m²) and high BMI (≥25 kg/m²). In these patients, clinicopathological variables were analysed using propensity score matching for age, sex, the American Society of Anaesthesiologists physical state, clinical stage, surgical method, D2 lymph node dissection, combined resection of other organs, anastomosis method and jejunal pouch reconstruction. The surgical results and post-operative outcomes were compared among the three groups.

Results

A total of 82 patients were matched in the analysis of the low BMI and normal BMI groups. There were no differences in operative time (P = 0.693), blood loss (P = 0.150), post-operative complication (P = 0.762) and post-operative hospital stay (P = 0.448). In the analysis of the normal BMI and high BMI groups, 208 patients were matched. There were also no differences in blood loss (P = 0.377), post-operative complication (P = 0.249) and post-operative hospital stay (P = 0.676). However, the operative time was significantly longer in the high BMI group (P = 0.023).

Conclusions

Despite the association with a longer operative time in the high BMI group, BMI had no significant effect on the surgical outcomes of LTG. LTG could be performed safely regardless of BMI.

Transperitoneal Laparoscopic Para-Aortic Lymphadenectomy and Body Mass Index: Is It Really a Limiting Factor for the Procedure?

Objective: To explore if obesity measured by body mass index (BMI) ≥30 kg/m² represents a limiting factor for para-aortic lymphadenectomy done with a transperitoneal laparoscopic approach. Materials and Methods: Retrospective observational study with 146 consecutive patients, diagnosed with a gynecological cancer submitted to para-aortic surgical staging between January 2010 and December 2018. The mean age was 52 years and the mean BMI was 27 kg/m². 72.6% (106 patients) had BMI <30 kg/m² and 27.4% (40 patients) had BMI ≥30 kg/m². Half of the patients did not have prior abdominal surgeries. Results: The statistical analysis showed that there were no significant differences between two groups depending on their BMI in the lymph node count: BMI <30 kg/m² 14 nodes versus BMI ≥30 kg/m² 10 nodes (P = .122); rate of intraoperative complications: BMI <30: 6.3% versus BMI ≥30: 0% (P = .180), postoperative complications: BMI <30: 6.6% versus BMI ≥30: 5% (P = .723); feasibility rate: BMI <30: 97.1% versus BMI ≥30: 95.6% (P = .063) or the mean hospital stay BMI <30: 2.47 ± 2.05 days (standard deviation [SD]), BMI ≥30: 2.64 ± 0.93 days (SD) (P = .171). The only significant difference observed was due to the operating time: BMI <30: 103.1 ± 60.8 (SD) versus BMI ≥30: 146.9 ± 82.5 (SD) (P = .019), being longer in obese patients. Conclusions: Obesity, estimated by BMI, does not seem to represent a limiting factor for this surgical procedure in our series. We feel it is a feasible and justified approach in obese patients when other surgical procedures have to be carried out in the same surgical act. Probably, other factors and anthropometric measurements are more accurate to select patients in which this approach is feasible.

Periaortic Abdominal Fat Area as a Predictor of Surgical Difficulties during Extraperitoneal Laparoscopic Para-aortic Lymphadenectomy

STUDY OBJECTIVE

To evaluate whether obesity is a marker of surgical difficulty during extraperitoneal para-aortic lymphadenectomy.

DESIGN

Retrospective observational cohort study.

SETTING

Tertiary medical center in the Kanazawa area of Japan.

PATIENTS

Eighty-four patients with primary endometrial cancer who underwent extraperitoneal laparoscopic para-aortic lymphadenectomy (LPAND) between January 2005 and December 2017 were included.

INTERVENTIONS

We investigated the correlation between operative times and body mass indexes, visceral fat areas, and periabdominal artery fat areas (PAFAs). The number of lymph nodes harvested was used as an indicator of the degree of surgical completion.

MEASUREMENTS AND MAIN RESULTS

There was no correlation between the operative time and body mass index. Significant correlations were observed between operative time and visceral fat area (p = .026; r = 0.243) and between operative time and PAFA (p = .007; r = 0.293). A multivariate analysis showed that PAFA was a significant independent marker that could be used to predict prolonged operative times for extraperitoneal LPAND (p = .045; odds ratio, 3.05). The number of para-aortic lymph nodes harvested was not significant in the high- and low-PAFA groups (22 and 25, respectively; p = .525).

CONCLUSION

PAFA is an adequate marker of prolonged operative time for extraperitoneal LPAND among patients with endometrial cancer.

Feasibility of laparoscopy gastrectomy for gastric cancer in the patients with high body mass index: A systematic review and meta-analysis

The aim of this study was to evaluate the impact of high body mass index (BMI) on surgical outcome of laparoscopic gastrectomy for gastric cancer (GC). Systematic literature search was performed using PubMed and Embase databases. The relevant data were extracted, and surgical outcomes and postoperative complications were compared between BMI≥25 kg/m² and BMI<25 kg/m² group using a fixed effect model or random effect model. 16 studies, with a total of 9572 GC patients, were included in this meta-analysis. The results indicated that operation time was significantly longer (WMD:16.22, 95% CI: 14.10-18.34, P < 0.001; I² = 0%) and the number of lymph nodes retrieved was significantly fewer (WMD:-2.11, 95%CI: -3.14, -1.07, P < 0.001; I² = 64.0%) in high BMI patients than in other patients. In addition, the amount of intraoperative blood loss was significantly larger in high BMI patients (WMD: 23.43, 95%CI: 20.05-26.81, P < 0.001; I² = 40.3%). Compared with non-high BMI patients, overweight and obese patients had a higher risk of postoperative complications (RR:1.26, 95%CI: 1.11-1.43, P < 0.001; I² = 39.1%), especially for wound infection (RR:1.62, 95%CI: 1.15-2.29, P < 0.01; I² = 18.8%) and postoperative ileus (RR:1.80, 95% CI: 1.05-3.09, P < 0.05; I² = 0%). However, there was no significant difference between two patient groups for postoperative recovery, major surgery-related complications (eg: anastomotic leakage, pancreatic fistula and intra-abdominal bleeding) and postoperative mortality. Despite increased technical challenge and risk of postoperative complications, the majority of these complications may be minor and cured. Laparoscopic gastrectomy for GC was a feasible and safe procedure even for high BMI patients.

Impact of body mass index on short-term outcomes of laparoscopic gastrectomy in Asian patients: A meta-analysis

AIM

To perform a meta-analysis to investigate the correlation between body mass index (BMI) and the short-term outcomes of laparoscopic gastrectomy (LG) for gastric cancer (GC) in Asian patients.

METHODS

The PubMed, Cochrane, EMBASE, and Web of Science databases were searched for studies that focused on the impact of obesity on the short-term outcomes of LG for GC in Asian patients who were classified into a high BMI (BMI ≥ 25 kg/m²) or low BMI group (BMI < 25 kg/m²). The results are expressed using the pooled odds ratio (OR) for binary variables and standard mean difference (SMD) for continuous variables with 95% confidence interval (CI), and were calculated according to the fixed-effects model while heterogeneity was not apparent or a random-effects model while heterogeneity was apparent.

RESULTS

Nine studies, with a total sample size of 6077, were included in this meta-analysis. Compared with the low BMI group, the high BMI group had longer operative time (SMD = 0.26, 95%CI: 0.21 to 0.32, P < 0.001), greater blood loss (SMD = 0.19, 95%CI: 0.12 to 0.25, P < 0.001), and fewer retrieved lymph nodes (SMD = -0.13, 95%CI: 0.18 to 0.07, P < 0.001). There was no significant difference between the high and low BMI groups in postoperative complications (OR = 1.12, 95%CI: 0.95 to 1.33, P = 0.169), the duration of postoperative hospital stay (SMD = 0.681, 95%CI: -0.05 to 0.07, P = 0.681), postoperative mortality (OR = 1.95, 95%CI: 0.78 to 4.89, P = 0.153), or time to resuming food intake (SMD = 0.00, 95%CI: -0.06 to 0.06, P = 0.973).

CONCLUSION

Our meta-analysis provides strong evidence that despite being associated with longer operative time, greater blood loss, and fewer retrieved lymph nodes, BMI has no significant impact on the short-term outcomes of LG for GC in Asian patients, including postoperative complications, the duration of postoperative hospital stay, postoperative mortality, and time to resuming food intake. BMI may be a poor risk factor for short-term outcomes of LG. Other indices should be taken into account.

Prediction of the Risk of Laparoscopy-Assisted Gastrectomy by Comparing Visceral Fat Area and Body Mass Index

Propose

The purpose of this study was to compare the accuracy of visceral fat area (VFA) and body mass index (BMI) in predicting the risk of laparoscopic-assisted gastrectomy.

Methods

Clinicopathological and imaging data of 133 patients who underwent laparoscopy-assisted gastrectomy were recorded, including 17 cases of conversion to open surgery. The remaining 116 patients were retrospectively analyzed after we excluded 17 patients who had been transferred to laparotomy. The patients were divided into two groups according to BMI (≤25 kg/m²: BMI-L group; >25 kg/m²: BMI-H group) and VFA (≤100 cm²: VFA-L group; >100 cm²: VFA-H group). Clinical outcomes were compared between the BMI and VFA subgroups.

Results

There were no differences in intraoperative blood loss and the number of harvested lymph nodes between low and high patients defined by BMI and VFA (p > 0.050). However, in the comparison of patients who underwent laparoscopic resection only, it was found that the operation time and intraoperative blood loss of the VFA-H group were more than those of the VFA-L group (p < 0.050). Compared to the VFA-L group, the VFA-H group had later first exhaust time (p = 0.018), more complications (p < 0.001), and longer hospital stays (p = 0.049). However, no similar conclusion was obtained in the BMI group (p > 0.050).

Conclusion

This study demonstrates that VFA better evaluates the difficulty of laparoscopy-assisted gastrectomy and the risk of postoperative complications than BMI.

Status and Prospects of Robotic Gastrectomy for Gastric Cancer: Our Experience and a Review of the Literature

Since the first report of robotic gastrectomy, experienced laparoscopic surgeons have used surgical robots to treat gastric cancer and resolve problems associated with laparoscopic gastrectomy. However, compared with laparoscopic gastrectomy, the superiority of robotic procedures has not been clearly proven. There are several advantages to using robotic surgery for gastric cancer, such as reduced estimated blood loss during the operation, a shorter learning curve, and a larger number of examined lymph nodes than conventional laparoscopic gastrectomy. The increased operation time observed with a robotic system is decreasing because surgeons have accumulated experience using this procedure. While there is limited evidence, long-term oncologic outcomes appear to be similar between robotic and laparoscopic gastrectomy. Robotic procedures have a significantly greater financial cost than laparoscopic gastrectomy, which is a major drawback. Recent clinical studies tried to demonstrate that the benefits of robotic surgery outweighed the cost, but the overall results were disappointing. Ongoing studies are investigating the benefits of robotic gastrectomy in more complicated and challenging cases. Well-designed randomized control trials with large sample sizes are needed to investigate the benefits of robotic gastrectomy compared with laparoscopic surgery.