E. H. Chang1, P. L. Rosen1, D. J. Gross1, V. Roudnitsky2, M. Muthusamy4, G. F. Coppa3, G. Sugiyama3, P. J. Chung4 1State University Of New York Downstate Medical Center,Department Of Surgery,Brooklyn, NY, USA 2Kings County Hospital Center,Division Of Trauma And Acute Care Surgery,Brooklyn, NY, USA 3Hofstra Northwell School Of Medicine,Department Of Surgery,Hempstead, NY, USA 4Coney Island Hospital,Department Of Surgery,Brooklyn, NY, USA
Introduction: An estimated 38% of US adults are obese. Obesity is associated with socioeconomic disparities and increased rates of comorbidities, and is a known risk factor for pancreatic cancer. Obese patients undergoing pancreaticoduodenectomy (PD) for pancreatic cancer have reduced long-term survival compared to non-obese patients, however the effects of increasing BMI on short-term postoperative outcomes are mixed. Therefore our goal is to elucidate the effects that morbid obesity has on outcomes after PD for pancreatic head cancer using a national, prospectively maintained clinical database.
Methods: Using the 2008-2015 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database we identified cases of PD (CPT 48150) for pancreatic head cancer (ICD 9 157.0), excluding cases that were emergent, had contaminated/dirty wound class, and missing outcomes data. Multiple imputation was performed for missing risk variables. Morbid obesity was defined as a BMI ≥35 kg/m2. Propensity score analysis was used to match morbidly obese patients to control. Outcomes of interest included 30-day postoperative mortality and complications (infectious, wound, pulmonary, renal, cardiovascular, and septic), and return to operating room, which were evaluated using conditional logistic regression.
Results: A total of 4,387 patients were identified and 390 (8. 9%) were morbidly obese. These patients were younger (mean 62.2 vs 66.4 years, p<0.0001), more likely to be female (60.0%, p<0.0001), have insulin-dependent diabetes (27.2% vs 15.1%, p<0.0001), dyspnea with moderate exertion (11.0% vs 5.8%, p=0.0007), hypertension (75.8% vs 55.3%, p=0.0001), and had higher proportions of patients who were African American (11.8% vs 8.8%, p=0.001), ASA class 3 (76.7% vs 69.8%, p=0.005), and had longer operative times (mean 421.7 vs 388.3 minutes, p<0.0001). Propensity score matching identified 381 morbidly obese to 1,102 control cases that were well balanced along all covariates. Morbid obesity was associated with higher risk of organ space surgical site infection (OR 1.54, 95%CI [1.09, 2.18], p=0.014), unplanned reintubation (OR 1.77, 95% CI [1.08, 2.89], p=0.023), pulmonary embolism (OR 2.92, 95%CI [1.02, 8.32], p=0.046), failure to wean from ventilator (OR 2.40, 95%CI [1.46, 3.94], p=0.00059), renal insufficiency (OR 2.87, 95%CI [1.14, 7.24], p=0.026), septic shock (OR 2.31, 95%CI [1.35, 3.93], p=0.0021), return to operating room (OR 1.81, 95%CI [1.14, 2.89], p=0.013), and mortality (OR 2.31, 95%CI [1.09, 4.89], p=0.029).
Conclusion: In this large observational study, morbid obesity in patients undergoing pancreaticoduodenectomy for head of pancreas cancer was associated with increased risk of postoperative complications and mortality. Clinicians should be aware of these increased risks and prospective studies to identify preoperative and perioperative factors that will mitigate these adverse outcomes are warranted.