Impact of preoperative body mass index on perioperative outcomes is optimized by enhanced recovery protocols in laparoscopic radical cystectomy with intracorporeal urinary diversion

BackgroundWe aimed to examine whether body mass index (BMI) had an impact on clinical outcomes of laparoscopic radical cystectomy with intracorporeal urinary diversion. Furthermore, we analyzed the optimization of enhanced recovery protocols (ERPs) on the impact of BMI on clinical outcomes.MethodsBy searching our database, data of 83 consecutive patients were retrospectively collected, including 37 patients with a BMI <24 kg/m² (group A) and 46 patients with a BMI ≥24 kg/m² (group B). The baseline and peri-operative variables of the two groups were compared. Subgroup analysis was conducted for ERPs (11 patients in group A₁, 18 patients in group B₁) and conventional recovery protocols (CRPs; 26 patients in group A₂, 28 patients in group B₂). The primary outcomes were 30-day overall complication rate and ΔALB_min (reduction proportion of minimum albumin). The secondary outcomes were operative time and length of stay.ResultsThe baseline variables were similar between the two groups (P>0.05). The 30-day overall complication rate, operative time, and length of stay were similar between the two groups (P>0.05). But post-operative nausea and vomiting (PONV) was higher in group A than in group B (32.4% vs. 8.7%, P=0.014). Group A was associated with lower serum albumin level pre-operatively and on post-operative days 1–3. ΔALB_min was higher in group A than in group B (33.08%±9.88% vs. 27.92%±8.52%, P<0.05). In the subgroup analysis, the CRPs group presented similar results, with group A₂ showing higher PONV rate, lower albumin level pre- and post-operatively, and higher level of reduction proportion (P<0.05). For the ERPs group, the PONV rate, pre-operative albumin level, and reduction proportion were similar between group A₁ and B₁ (P>0.05). Multivariable analysis showed that PONV and CRPs were independently associated with ΔALB_min ≥34% (P<0.05).ConclusionsBMI had no impact on the 30-day overall complication rate, operative time, and length of stay of patients who underwent laparoscopic radical cystectomy with intracorporeal urinary diversion. BMI <24 kg/m² was associated with higher PONV rate and more albumin loss, both of which could be optimized by ERPs.     

Accuracy of non-invasive liver stiffness measurement and steatosis quantification in patients with severe and morbid obesity

BackgroundVibration controlled transient elastography (VCTE) and controlled attenuation parameter (CAP™) have shown reliable performance predicting fibrosis and steatosis in normal- to overweight patients but have not been validated in severe to morbid obesity. This study aimed at determining the accuracy of VCTE, CAP™ and the composite score FibroScan-AST (FAST) in patients with a body mass index (BMI) of ≥35 kg/m².MethodsPatients scheduled for bariatric-metabolic surgery underwent preoperative VCTE/CAP™ measurement, and intraoperative liver biopsy. The feasibility and accuracy of VCTE, CAP™ and the composite score FAST were retrospectively analysed to evaluate fibrosis, steatosis and active fibrotic non-alcoholic steatohepatitis [NASH + non-alcoholic fatty liver disease (NAFLD) activity score ≥4 + fibrosis grade ≥2] using per protocol (PP) and intent to diagnose (ITD) calculation.ResultsIn total, 170 patients (median BMI 44.4 kg/m²) were included in the study. Liver biopsy showed NASH, simple steatosis, and normal livers in 60.6% (n=103), 28.8% (n=49), and 10.6% (n=18), respectively. VCTE and CAP™ delivered reliable results in 90.6% (n=154/170) and 90.5% (n=134/148). The AUC (PP) of VCTE, CAP™, and FAST were 0.687 (≥F2), 0.786 (≥F3), 0.703 (≥S2), 0.738 (S3), and 0.780 (active fibrotic NASH). The AUC increased to 0.742 (≥F2), 0.842 (≥F3), 0.712 (≥S2), 0.780 (S3), and 0.836 (active fibrotic NASH) in patients below the median BMI of 44.4 kg/m².ConclusionsVCTE, CAP™ and FAST show acceptable accuracy for the detection of fibrosis, steatosis and NASH in a real-life cohort of patients with obesity. Accuracy improves in patients with a BMI <44.4 kg/m².     

Potential Link between Ossification of Nuchal Ligament and the Risk of Cervical Ossification of Posterior Longitudinal Ligament: Evidence and Clinical Implication from a Meta‐Analysis of 8429 Participants

ObjectiveThe aim of the present paper was to evaluate the strength and the magnitude of the association between ossification of the nuchal ligament (ONL) and the risk of cervical ossification of the posterior longitudinal ligament (COPLL) and to determine whether there is a direct association or whether COPLL is a consequence of shared risk factors.MethodsMedline, Web of Science, Cochrane Library, and Embase databases were searched for studies evaluating the association of COPLL‐ONL published before July 2020. Eligible studies were selected based on certain inclusion and exclusion criteria. Two investigators independently conducted the quality assessment and extracted the data, including study designs, countries, patients'' age, gender, body mass index (BMI), and the risk of COPLL between individuals with and without ONL. A meta‐analysis of homogenous data, a sensitivity analysis, a publication bias assessment, and a subgroup analysis were performed using Stata 12.0 software.ResultsA total of 10 cohort studies involving 8429 participants were incorporated into this analysis. Pooled results demonstrated a statistically significant association between the presence of ONL and the increased COPLL risk (odds ratio [OR] 3.84; 95% confidence interval [CI] 2.68–5.52, P < 0.001). Furthermore, subgroup analyses indicated that this association was independent of study design (6.36‐fold in case‐control studies vs 3.22‐fold in cross‐sectional studies), sex (6.33‐fold in male–female ratio >2.5 vs 2.91‐fold in male–female ratio <2.5), age (4.28‐fold in age ≥55 years vs 3.45‐fold in age <55 years), and BMI (3.88‐fold in BMI ≥ 25 kg/m² vs 2.43‐fold in BMI < 25 kg/m²), which also indicated that obese, older male patients with ONL had a higher risk of OPLL. Moreover, combined two articles revealed that patients with larger‐type ONL had a significantly higher risk of long‐segment COPLL compared with controls (OR 1.86; 95% CI 1.41–2.47, P < 0.001).ConclusionThis is the first meta‐analysis to demonstrate a strong and steady association between ONL and higher risk of COPLL. This association was independent of sex, age, and BMI. Considering that ONL is generally asymptomatic and easily detectable on X‐ray, our findings implied that ONL might serve as an early warning sign of the onset of COPLL and provide clinicians an opportunity for early detection and early intervention.     

Impact of pathological response after preoperative transcatheter arterial chemoembolization (TACE) on incidences of microvascular invasion and early tumor recurrence in hepatocellular carcinoma: a multicenter propensity score matching analysis

BackgroundTo study the influence of pathological responses (PR) after transcatheter arterial chemoembolization (TACE) on incidences of microvascular invasion (MVI) and early recurrence in hepatocellular carcinoma (HCC) patients.MethodsBetween 2013 to 2015, consecutive HCC patients who underwent liver resection with “curative” intent at three hospitals were enrolled in this study. Patients with different areas of PR after preoperative TACE were compared with those without preoperative TACE on the incidences of MVI, early recurrence rates and patterns of recurrence before and after propensity score matching (PSM).ResultsOf 1,970 patients, 737 patients who received preoperative TACE were divided into three groups according to the areas of PR: ≥90% (n=226), 60–90% (n=447), and <60% (n=64). PR ≥90% was an independent protective factor of incidences of MVI [odds ratio (OR), 0.144; 95% confidence interval (CI), 0.082–0.245, P<0.001) and early recurrence (HR, 0.742; 95% CI, 0.561–0.963, P=0.032); while PR<60% was an independent risk factor of incidences of MVI (OR, 6.076; 95% CI, 3.004–11.728, P<0.001) and early recurrence (HR, 1.428; 95% CI, 1.095–1.929; P=0.009). Furthermore, patients with PR <60% were significantly more likely to develop multiple intrahepatic recurrences involving multiple hepatic segments when compared with patients without preoperative TACE.ConclusionsThis study indicated the area of PR after TACE was closely associated with the incidences of MVI and early tumor recurrence. Patients with PR <60% were at significantly higher risks of having more MVI, early and multiple tumor recurrences     

Comparison of postoperative complications of ileal conduits versus orthotopic neobladders

BackgroundRadical cystectomy (RC) and urinary diversion (UD), with either an ileal conduit (IC) or an orthotopic neobladder (NB), is a complex surgery, in which various complications can occur. In this study, we compared postoperative complication rates after a RC and UD performed for the treatment of muscle-invasive bladder cancer or recurring high-risk non-muscle-invasive bladder cancer in our center.MethodsWe retrospectively included 604 patients that underwent UDs from December 1996 to August 2015. Complications were classified by type and severity according to the Clavien-Dindo classification (CDC). Univariate and multivariate analyses were performed to identify predictive factors of short-term (≤30 d), intermediate-term (31–90 d), and long-term (>90 d) complications.ResultsFour hundred and forty-five (74%) and 159 (26%) patients received ICs and NBs, respectively. These groups had significantly different long-term complication rates (IC: 39.7% vs. NB: 49%, P=0.046), but similar short-term (P=0.319) and intermediate-term complication rates (P=0.397). Short-term complications (CDC I–V) were predicted by male gender, age-adjusted Charlson comorbidity index (aCCI) ≥3, and American Society of Anesthesiologists (ASA) score ≥3. Compared to minor short-term complications (CDC I–II), major short-term complications (CDC III–V) were predicted by male gender and a previous abdominal/pelvic surgery, and long-term major complications were predicted by the type of UD (NB).ConclusionsThe increasing risk of short-term complications with increasing aCCI and ASA score can be used when counseling the patients who are planned to undergo a RC with UD. Patients that receive NBs should be informed of the increased risk of reoperations compared to an IC.     

Incidence and correlation of metabolic syndrome and kidney stones in a healthy screening population

BackgroundTo study the incidence of metabolic syndrome (MetS) and kidney stones in a healthy screening population and to explore the correlation between them.MethodsThe physical examination data of 11,827 people screened at the First Affiliated Hospital of Soochow University from August 2019 to July 2020 were analyzed. MetS diagnostic criteria were based on the 2004 guidelines of Chinese Diabetes Society (CDS). Multivariate logistic regression was used to analyze the correlation between MetS and various characteristics and kidney stones. Trend analysis was represented by P value, and P<0.05 indicated statistical significance.ResultsThe present study comprised 6,570 males (55.6%, aged 46.15±13.653 years) and 5,257 females (44.4%, aged 41.41±11.712 years). Of these, 1,036 (8.8%) had kidney stones and 1,552 (13.1%) had MetS. Among the MetS patients, 35.1% had a body mass index (BMI) ≥25, 27.7% had hypertension, 10.8% had hyperglycemia, and 31.2% had dyslipidemia. Kidney stone morbidity was 14.5% in the MetS group and 7.9% in the non-MetS group (P<0.05). As the number of MetS characteristics increased, kidney stone morbidity showed a linear increasing trend (P<0.05 for trend). With an increase in BMI and blood triglycerides (TG), and a decrease in lipoprotein cholesterol (HDL-C), the incidence of kidney stones had an increasing trend (P<0.05 for trend). Sex, age and MetS were independent risk factors for the occurrence of kidney stones, with and odds ratio (OR) of 1.493 [95% confidence interval (CI): 1.264–1.763] for MetS. Of the MetS characteristics, BMI ≥25 and blood pressure (BP) ≥140/90 mmHg were independent risk factors for kidney stones, with OR values of 1.209 (95% CI: 1.047–1.396) and 1.248 (95% CI: 1.071–1.453), respectively.ConclusionsMetS is an independent risk factor for kidney stones. Appropriate medication and dietary advice may help to correct urinary metabolic abnormalities and prevent the recurrence of kidney stones.     

Effect of body mass index on the outcomes of patients with upper and lower urinary tract cancers treated by radical surgery: Results from a Canadian multicenter collaboration

ObjectiveTo evaluate the effect of body mass index (BMI) on the outcomes of patients with urinary tract carcinoma treated with radical surgery.Materials and methodsData were collected from 10 Canadian centers on patients who underwent radical cystectomy (RC) (1998–2008) or radical nephroureterectomy (RNU) (1990–2010). Various parameters among subsets of patients (BMI<25, 25≤BMI<30, and BMI≥30 kg/m²) were analyzed. Kaplan-Meier and multivariate analyses were performed to assess the effect of BMI on overall survival, disease-specific survival, and recurrence-free survival (RFS).ResultsAmong the 847 RC and 664 RNU patients, there was no difference in histology, stage, grade, and margin status among the 3 patient subsets undergoing either surgery. However, RC patients with lower BMIs (<25 kg/m²) were significantly older (P = 0.004), had more nodal metastasis (P = 0.03), and trended toward higher stage (P = 0.052). RNU patients with lower BMIs (<25 kg/m²) were significantly older (P = 0.0004) and fewer received adjuvant chemotherapy (P = 0.04) compared with those with BMI≥30 kg/m²; however, there was no difference in tumor location (P = 0.20), stage (P = 0.48), and management of distal ureter among the groups (P = 0.30). On multivariate analysis, BMI was not prognostic for overall survival, disease-specific survival, and RFS in the RC group. However, BMI≥30 kg/m² was associated with more bladder cancer recurrences and worse RFS in the RNU group (HR = 1.588; 95% CI: 1.148–2.196; P = 0.0052).ConclusionsIncreased BMI did not influence survival among RC patients. BMI≥30 kg/m² is associated with worse bladder cancer recurrences among RNU patients; whether this is related to difficulty in obtaining adequate bladder cuff in patients with obesity requires further evaluation.     

Is Obesity Associated with Higher Complication Rates in Total Hip Arthroplasty for High-Riding Dysplastic Hips?

ObjectiveDevelopmental dysplasia of the hip (DDH) is a disabling pathology leading to hip problems, such as painful arthritic hip, unstable hip, etc. Total hip arthroplasty (THA) is an effective treatment modality for this condition. Obesity has been shown to be associated with increased rates of complications following orthopaedic surgeries (Journal of Arthroplasty 20:46–50). The hypothesis of this study was that patients with a body mass index (BMI) greater than 30 (obese), who undergo total hip arthroplasty for dysplastic hip, are associated with longer operative and anaesthetic times, longer hospital stays and higher re-admission rates within 30 days.MethodsAll the cases of total hip arthroplasty in patients with high-riding dysplastic hips were reviewed. Evaluation was made of a total of 68 patients comprising 64 females and 4 males, classified into two groups. Patients with BMI < 30 kg/m² formed the non-obese group and patients with BMI ≥ 30 kg/m² the obese group.ResultsThe mean age was 44.67 ± 6.49 years. BMI was < 30 in 44 (64.7%) patients and > 30 in 24 (35.3%) patients. The data analysis showed that mean surgical time, anaesthesia duration and re-admission rate were significantly higher in the group with BMI ≥ 30(obese) as compared to the group with BMI < 30 (non-obese) (p < 0.01). The complication rate was determined to be higher in the obese group (p < 0.05).ConclusionObese patients performed with total hip arthroplasty for high-riding dysplastic hips had more complications and higher rates of re-admission to hospital compared with the non-obese patients.     

Relationship between urine specific gravity and the prevalence rate of kidney stone

BackgroundThe purpose of this study was to evaluate the relationship between urine specific gravity (USG) and the prevalence rate of kidney stone.MethodsWe conducted a cross-sectional study of adult participants (≥20 years) of the National Health and Nutrition Examination Survey (NHANES) from 2007 to 2008. The USG was divided into three groups: <1.008, 1.008–1.020 and >1.020. Univariate and multivariate logistic regression analysis was used to determine the effect of USG on the prevalence rate of kidney stone.ResultsA total of 4,791 patients were included in this study, of which 464 (9.7%) reported a history of kidney stone. Univariate logistic regression analysis showed that age, gender, race, hypertension, diabetes, body mass index (BMI), estimated glomerular filtration rate (eGFR), USG and urine creatinine were closely related to the prevalence of kidney stones. After adjusting for known confounding factors, multivariate logistic regression showed that the prevalence rate of kidney stone increased with the increase of USG (1.008–1.020 vs. <1.008, OR =1.31, 95% CI, 0.09–1.91, P=0.155; >1.020 vs. <1.008, OR =1.71, 95% CI, 1.16–2.54, P=0.007).ConclusionsThe increase of USG was significantly correlated with self-reported kidney stone. This finding helps to identify risk factors for kidney stones as early as possible in the United States.     

Functional assessment of liver regeneration after major hepatectomy

BackgroundLiver regeneration is crucial to restore the functional liver mass after liver resection. The aim of this study was to evaluate the early postoperative changes in remnant liver function, volume and liver stiffness after major liver resection and their correlation with postoperative outcomes.MethodsPatients undergoing major liver resection (≥3 segments) between February and November 2018 underwent both functional assessment using technetium-99m mebrofenin hepatobiliary scintigraphy (HBS) and CT-volumetry of the (future) remnant liver on preoperative day 1, the 5^th postoperative day, and 4–6 weeks after resection. At the same time points, patients underwent transient elastography (TE) for the assessment of liver stiffness. Severe postoperative complications (Clavien-Dindo ≥ 3A) and mortality were correlated with the functional and volumetric increases of the remnant liver. Liver failure was graded according to the International Study Group of Liver Surgery (ISGLS) criteria.ResultsA total of 18 patients were included of whom 10 (56%) had severe complications and one patient (5%) developed liver failure. Function and volume of the remnant liver had increased by the 5^th postoperative day from 6.9 (5.4–10.9) to 9.6 (6.7–13.8) %/min/m², P=0.004 and from 795.5 (538.3–1,037.5) to 1,080.0 (854.0–1,283.3) mL, P<0.001, respectively. After 4–6 weeks, remnant liver volume had further increased [from 1,080.0 (854.0–1,283.3) to 1,222.0 (1,016.0–1,380.5) mL, P=0.035], however, liver function did not show any significant, further increase [from 9.6 (6.7–13.8) to 10.9 (8.8–13.6) %/min/m², P=0.177]. Liver elasticity of the future remnant liver (FRL) increased [from 10.8 (5.7–18.7) to 17.5 (12.4–22.6) kPa, P=0.018] and gradually recovered after 4–6 weeks to a median of 10.9 (5.7–18.8) kPa (T3 vs. T4, P=0.079). Patients who had severe postoperative complications did not show a significant increase in liver function on the 5^th postoperative day (P=0.203), despite increase of volume (P<0.01).ConclusionsFunctional regeneration of the remnant liver predominantly occurs during the first 5 days after resection. In case of severe complications, functional regeneration is delayed, in contrast to volume increase.     

Laparoscopic incisional and ventral hernia repair in a district general hospital

IntroductionThe laparoscopic approach to repairing ventral and incisional hernias has gained increasing popularity worldwide. We reviewed the experience of laparoscopic ventral hernia repair at a district general hospital in the UK with particular reference to patients with massive defects (diameter ≥15cm) and the morbidly obese.MethodsA total of 144 patients underwent laparoscopic ventral (incisional or umbilical/paraumbilical) hernia repair between April 2007 and September 2012.ResultsThe prevalence of conversion to open surgery was 2.8%. The prevalence of postoperative complications was 3.5%. Median postoperative follow-up was 30.2 months. A total of 5.6% cases suffered late complications and 2.8% developed recurrence. Thirty-four patients underwent repair of defects ≥10cm in diameter with a prevalence of recurrence of 5.6%. Sixteen patients underwent repair of ‘massive’ incisional hernia (diameter ≥15cm) with a prevalence of recurrence of 12.5%. Sixteen patients with a body mass index (BMI) ≥40kg/m² (range, 40–61kg/m²) underwent laparoscopic repair with a prevalence of recurrence of 6.3% (p>0.05 vs BMI <40kg/m²).ConclusionsLaparoscopic ventral hernia repair can be carried out safely with a low prevalence of recurrence. It may have advantages in morbidly obese patients in whom open repair would represent a significant undertaking. Laparoscopic ventral hernia repair may be used in cases of large and massive hernias, in which the risk of recurrence increases but is comparable with open repair and associated with low morbidity.     

Low Albumin Levels,More Than Morbid Obesity,Are Associated With Complications After TKA

Background

Morbid obesity and malnutrition are thought to be associated with more frequent perioperative complications after TKA. However, morbid obesity and malnutrition often are co-occurring conditions. Therefore it is important to understand whether morbid obesity, malnutrition, or both are independently associated with more frequent perioperative complications. In addition, assessing the magnitude of an increase in complications and whether these complications are major or minor is important for both conditions.

Questions/purposes

We asked: (1) Is morbid obesity independently associated with more frequent major perioperative complications after TKA? (2) Are major perioperative complications after TKA more prevalent among patients with a low serum albumin?

Methods

The National Surgical Quality Improvement Program (NSQIP) database was analyzed from 2006 to 2013. Patients were grouped as morbidly obese (BMI ≥ 40 kg/m²) or nonmorbidly obese (BMI ≥ 18.5 kg/m² to < 40 kg/m²), or by low serum albumin (serum albumin level < 3.5 mg/dL) or normal serum albumin (serum albumin level ≥ 3.5 mg/dL). The study cohort included 77,785 patients, including 35,573 patients with a serum albumin level of 3.5 g/dL or greater and 1570 patients with a serum albumin level less than 3.5 g/dL. Therefore, serum albumin levels were available for only 37,173 of the 77,785 of the patients (48%). There were 66,382 patients with a BMI between 18.5 kg/m² and 40 kg/m² and 11,403 patients with a BMI greater than 40 kg/m². Data were recorded on patient mortality along with 21 complications reported in the NSQIP. We also developed three composite complication variables to represent risk of any infections, cardiac or pulmonary complications, and any major complications. For each complication, multivariate logistic regression analysis was performed. Independent variables included patient age, sex, race, BMI, American Society of Anesthesiologists classification, year of surgery, and Charlson comorbidity index score.

Results

Mortality was not increased in the morbidly obese group (0.14% vs 0.14%; p = 0.942). Patients who were morbidly obese were more likely to have progressive renal insufficiency (0.30% vs 0.10%; odds ratio [OR], 2.47; 95% CI, 1.27–4.29; p < 0.001), superficial infection (1.07% vs 0.55%; OR, 1.87; 95% CI, 1.39–2.51; p < 0.001), and sepsis (0.36% vs 0.23%; OR, 1.70; 95% CI, 1.04–2.53; p = 0.034) compared with patients who were not morbidly obese. Patients who were morbidly obese were less likely to require blood transfusion (8.68% vs 12.06%; OR, 0.70; 95% CI, 0.63–0.77; p < 0.001) compared with patients who were not morbidly obese. Morbid obesity was not associated with any of the other 21 perioperative complications recorded in the NSQIP database. With respect to the composite complication variables, patients who were morbidly obese had an increased risk of any infection (3.31% vs 2.41%; OR, 1.38; 95% CI, 1.16–1.64; p < 0.001) but not for cardiopulmonary or any major complication. The group with low serum albumin had higher mortality than the group with normal serum albumin (0.64% vs 0.15%; OR, 3.17; 95% CI, 1.58–6.35; p = 0.001). Patients in the low serum albumin group were more likely to have a superficial surgical site infection (1.27% vs 0.64%; OR, 1.27; 95% CI, 1.09–2.75; p = 0.020); deep surgical site infection (0.38% vs 0.12%; OR, 3.64; 95% CI, 1.54–8.63; p = 0.003); organ space surgical site infection (0.45% vs 0.15%; OR, 2.71; 95% CI, 1.23–5.97; p = 0.013); pneumonia (1.21 vs 0.29%; OR, 3.55; 95% CI, 2.14–5.89; p < 0.001); require unplanned intubation (0.51% vs 0.17%, OR, 2.24; 95% CI, 1.07–4.69; p = 0.033); and remain on a ventilator more than 48 hours (0.38% vs 0.07%; OR, 4.03; 95% CI, 1.64–9.90; p = 0.002). They are more likely to have progressive renal insufficiency (0.45 % vs 0.12%; OR, 2.71; 95% CI, 1.21–6.07; p = 0.015); acute renal failure (0.32% vs 0.06%; OR, 5.19; 95% CI, 1.96–13.73; p = 0.001); cardiac arrest requiring cardiopulmonary resuscitation (0.19 % vs 0.12%; OR, 3.74; 95% CI, 1.50–9.28; p = 0.005); and septic shock (0.38% vs 0.08%; OR, 4.4; 95% CI, 1.74–11.09; p = 0.002). Patients in the low serum albumin group also were more likely to require blood transfusion (17.8% vs 12.4%; OR, 1.56; 95% CI, 1.35–1.81; p < 0.001). In addition, among the three composite complication variables, any infection (5.0% vs 2.4%; OR, 2.0; 95% CI, 1.53–2.61; p < 0.001) and any major complication (2.4% vs 1.3%; OR, 1.41; 95% CI, 1.00–1.97; p = 0.050) were more prevalent among the patients with low serum albumin. There was no difference for cardiopulmonary complications.

Conclusions

Morbid obesity is not independently associated with the majority of perioperative complications measured by the NSQIP and was associated only with increases in progressive renal insufficiency, superficial surgical site infection, and sepsis among the 21 perioperative variables measured. However, low serum albumin was associated with increased mortality and multiple additional major perioperative complications after TKA. Low serum albumin, more so than morbid obesity, is associated with major perioperative complications. This is an important finding, as low serum albumin may be more modifiable than morbid obesity in patients who are immobile or have advanced knee osteoarthritis.

Level of Evidence

Level III, prognostic study.     

A Comparison of Open Surgery,Robotic-Assisted Surgery and Conventional Laparoscopic Surgery in the Treatment of Morbidly Obese Endometrial Cancer Patients

Methods:Morbidly obese (body mass index [BMI] > 40 kg/m²) patients with endometrial cancer who underwent OS, robotic-assisted laparoscopic surgery (RS), or conventional laparoscopic surgery (LS) were eligible. We sought to discern any outcome differences with regard to operative time, perioperative complications, and hospital stay.Results:Sixteen patients were treated with LS (BMI = 47.9 kg/m²), 13 were managed via RS (BMI = 51.2 kg/m²), and 24 underwent OS (BMI = 53.7 kg/m²). The OS (1.35 hours) patients had a significantly shorter operative duration than the LS (1.82 hours) and RS (2.78 hours) patients (P < .001); blood loss was greater in the OS (250 mL) group in comparison with the RS (100 mL) and LS (175 mL) patients (P = .002). Moreover, the OS (4 days) subjects had a significantly longer hospital stay than the LS (2 days) and RS (2 days) patients (P = .002).Conclusion:In the present study, we ascertained that minimally invasive surgery was associated with longer operative times but lower rates of blood loss and shorter hospital stay duration compared with treatment comprising an open procedure.     

Early discharge after thoracoscopic anatomical pulmonary resection for non-small-cell lung cancer

 Open in a separate windowOBJECTIVESAlthough video-assisted thoracic surgery (VATS) has shortened hospitalization duration for non-small-cell lung cancer (NSCLC) patients, the factors associated with early discharge remain unclear. This study aimed to identify patients eligible for a 72-h stay after VATS anatomical resection.METHODSMonocentric retrospective study including all consecutive patients undergoing VATS anatomical resection for NSCLC between February 2010 and December 2019. Two groups were defined according to the discharge: ‘early discharge’ (within 72 postoperative hours) and ‘routine discharge’ (at >72 postoperative hours).RESULTSA total of 660 patients with a median age of 66.5 years (interquartile range 60–73 years) (female/male: 321/339) underwent VATS anatomical pulmonary resection for NSCLC [segmentectomy in 169 (25.6%), lobectomy in 481 (72.9%), bilobectomy in 8 (1.2%) and pneumonectomy in 2 (0.3%) patients]. The cardiopulmonary and Clavien–Dindo III–IV postoperative complication rates were 32.6% and 7.7%, respectively. The median postoperative length of stay was 6 days (interquartile range 4–10 days). In total, 119 patients (18%) could be discharged within 72 h of surgery. On multivariable analysis, the factors significantly associated with an increased likelihood of early discharge were: body mass index >20 kg/m² [odds ratio (OR) 2.37], absence of prior cardiopathy (OR 2), diffusing capacity of the lung for carbon monoxide >60% (OR 1.82), inclusion in an enhanced recovery after surgery protocol (OR 2.23), use of a single chest tube (OR 5.73) and postoperative transfer to the ward (OR 4.84). Factors significantly associated with a decreased likelihood of early discharge were: age >60 years (OR 0.53), American Society of Anaesthesiologists score >2 (OR 0.46) and use of an epidural catheter (OR 0.41). Readmission rates were not statistically different between both groups (5.9% vs 3.1%; P = 0.17).CONCLUSIONSAge, pulmonary functions and comorbidities may influence discharge after VATS anatomical resection. The early discharge does not increase readmission rates.     

Association between red blood cell distribution width and non-valvular atrial fibrillation in hemodialysis patients: a single-center Chinese population study

BackgroundRed blood cell distribution width (RDW) has emerged as a prognostic marker of atrial fibrillation (AF) in various clinical settings. However, the relationship by which RDW was linked to AF in hemodialysis (HD) patients was not clear. We sought to reveal the relationship between RDW and AF occurrence in HD patients.MethodsWe enrolled 170 consecutive maintenance HD patients, including 86 AF patients and 84 non-AF patients. All participants’ medical history and detailed clinical workup were recorded before the first dialysis session of the week. Electrocardiography, laboratory and transthoracic echocardiography examination indices were compared between the AF group and non-AF group. Multivariable logistic regression analysis was performed to identify the independent predictors of AF occurrence in HD patients.ResultsThere were all paroxysmal AF patients in AF group. Compared to the non-AF group, patients with AF group had a significantly older age (61.0 ± 1.48 vs. 49.71 ± 1.79, p < 0.001), lower BMI (24.3 ± 4.11 vs. 25.8 ± 3.87, p < 0.05), higher RDW (15.10 ± 0.96 vs. 14.26 ± 0.82, p < 0.001) and larger LAD (39.87 ± 3.66 vs. 37.68 ± 5.08, p < 0.05). Multivariable logistic regression analyses demonstrated that values of age (OR: 1.030, 95%CI: 1.004-1.057, per one- year increase), BMI (OR: 0.863, 95%CI: 0.782–0.952, per 1 kg/m² increase), RDW (OR: 2.917, 95%CI: 1.805–4.715, per 1% increase) and LAD (OR: 1.097, 95%CI: 1.004–1.199, per 1 mm increase) were independently associated with AF occurrence (p < 0.05, respectively). The best cutoff value of RDW to predict AF occurrence was 14.65% with a sensitivity of 68.6% and a specificity of 72.6%.ConclusionsThe increased RDW was significantly associated with the paroxysmal AF occurrence in HD patients.     

Positive association between preoperative lymphocyte-to-monocyte ratio and risk of the status of positive surgical margins by prostate cancer: results in 497 consecutive patients treated only by radical prostatectomy

BackgroundPositive surgical margins (PSM) is one of the most important factors affecting the prognosis of prostate cancer (PCa) patients after radical prostatectomy (RP). Although some studies have found the preoperative systematic inflammation-based scores the neutrophil-to-lymphocyte ratio (NLR), the platelet-to-lymphocyte ratio (PLR), lymphocyte-to-monocyte ratio (LMR) can predict the incidence and prognosis of PCa, few studies have explored the predictive value of preoperative systematic inflammation-based scores on the PSMs for PCa patients after RP.MethodsFrom June 2014 to September 2020 a total of 497 patients underwent RP at our institution. Blood samples from all patients were collected within one week before surgery. Preoperative clinical characteristics including age, body mass index (BMI), prostate-specific antigen (PSA), and biopsy Gleason sum (BGS) were assessed. Postoperatively pathological specimens were assessed for pathological Gleason sum (PGS), pathological stage, and margin status.ResultsIn the multivariable analysis including preoperative variables, PSA and LMR were the independent predictive factors for PSM (OR: 2.817; 95% CI, 1.836–4.320, P<0.001; OR: 1.124; 95% CI, 1.018–1.240, P=0.021. Considering pre-, intra-, and postoperative variables, BGS, perineural invasion, seminal vesicle invasion (SVI), pathologic Gleason sum (PGS) combined, were associated with increased risk of PSM in the univariable analysis (P<0.001 for all variables). However, in the multivariable analysis, perineural invasion (OR: 2.672; 95% CI, 1.649–4.330; P<0.001), PGS (OR: 2.52; 95% CI, 1.556–4.082; P<0.001) were independent predictive factors for the incidence of PSM. Finally, LMR was shown to be an independent predictive factor (OR: 0.881; 95% CI, 0.779–0.996; P=0.043) for apical PSMs, with increasing LMR predicting the lower incidence of apex location. And we also found that LMR was an independent factor that predicts multifocal positive margins (OR: 1.179; 95% CI, 1.023–1.358; P=0.023).ConclusionsPreoperative LMR could be used as an independent predictor to predict the incidence of PSMs after RP. And Considering pre-, intra-, and postoperative variables, we also found that preoperative LMR could predict the occurrence of apical and multifocal PSMs.     

Obesity and recovery from low back pain: a prospective study to investigate the effect of body mass index on recovery from low back pain

INTRODUCTION

We describe a prospective cohort study to investigate any association between recovery from low back pain and body mass index (BMI) in patients with low back pain undergoing physiotherapy.

PATIENTS AND METHODS

A total of 140 patients with low back pain and no evidence of neurological deficit were divided into three groups based on their BMI. All patients underwent a back-specific physiotherapy programme for 6 or 12 weeks. Recovery parameters such as pain intensity (visual analogue scale scores) and physical impairment index scores were measured. The range of motion of the lumber spine was also recorded. These variables were compared pre- and post-treatment.

RESULTS

Mean age of the patients was 38 years (range, 18–67 years) with 62% males and 38% females. The treatment resulted in significant improvements in all the recovery parameters (P < 0.005, paired t-test). No significant association was detected between the BMI of subjects and percentage changes in pain intensity, physical impairment index, and range of motion of the lumbar spine. A comparative analysis of the after treatment recovery parameter scores in normal (BMI ≤ 24.9 kg/m²), overweight (BMI 25–29.9 kg/m²) and obese (BMI ≥ 30 kg/m²) patients revealed no significant differences in the mean pain intensity and mean self-experienced impairment and disability scores amongst the groups.

CONCLUSIONS

This study demonstrates that BMI does not influence the overall recovery from low back pain in patients undergoing physiotherapy treatment.     

Effects of radical cystectomy,radiotherapy, and chemotherapy on the risk of long-term heart-specific death in bladder cancer patients

BackgroundAt present, the low risk of bladder cancer (BCa)-specific death has allowed for investigation into treatment-related cardiotoxicity. To aid clinicians in selecting appropriate cardiovascular disease screening strategies and interventions, this study explored the heart-specific mortality and prognostic factors of patients with BCa after radical cystectomy (RC), radiotherapy (RT), or chemotherapy (CT), and compared their long-term heart-specific mortality with that of the general male population.MethodsWe identified three different treatments for BCa patients from the Surveillance, Epidemiology, and End Results (SEER) database: RC, RT, and CT. Patients were included from 2000 to 2012 and followed through 2015. A cumulative mortality curve and competitive risk regression model were applied to evaluate the prognostic factors of heart-specific mortality, and standardized mortality ratios (SMRs) were calculated.ResultsOf 39,500 men, 30.3%, 18.8%, and 50.9% received RC, RT, and CT, respectively. For patients with a survival period of less than 50 months, tumor-specific death exhibited a rapidly increasing trend, which subsequently flatlined. However, the rates heart-specific mortality and other causes exhibited a tendency to increase stably. The heart-specific and all-cause mortality rates of patients in any age group treated with the three abovementioned strategies were higher than those of the general population. The heart-specific mortality of patients with carcinoma in situ treated with RC and CT exceeded their all-cause mortality, while that of other tumor stages did not. The risks of heart-specific [sub-distribution hazard ratio (SHR) =1.38; 95% confidence interval (CI): 1.22–1.57] and tumor-specific (SHR =1.68; 95% CI: 1.60–1.77) deaths in patients who received RT were higher than those of patients who underwent CT.ConclusionsThe risks of heart-specific and tumor-specific deaths in patients who received RT were higher than those of the RC and CT groups, especially in patients over 65 years of age who received RT.     

Elevated Body Mass Index Is a Risk Factor for Failure to Achieve the Knee Disability and Osteoarthritis Outcome Score-Physical Function Short Form Minimal Clinically Important Difference Following Total Knee Arthroplasty

BackgroundThe aims of this study are (1) to assess the association between body mass index (BMI) and failure to achieve the 1-year Knee Disability and Osteoarthritis Outcome Score-Physical Function Short Form (KOOS-PS) minimal clinically important difference (MCID) for total knee arthroplasty (TKA) patients and (2) to determine if there is a BMI threshold beyond which the risk of failing to achieve the MCID is significantly increased.MethodsA regional arthroplasty registry was queried for TKA patients from 2016 to 2019 with completion of preoperative and 1-year postoperative KOOS-PS. The MCID threshold was derived using a distribution-based approach. Demographic and patient-reported outcome measure variables were collected. BMI was analyzed continuously and categorically using cutoffs defined by the Centers for Disease Control and Prevention. The association between failure to achieve 1-year MCID and BMI was analyzed using multiple logistic regression. A BMI threshold was determined using the Youden index and receiver operating characteristic curve.ResultsIn total, 1059 TKAs were analyzed. BMI assessed continuously was significantly associated with failure to achieve the KOOS-PS MCID (odds ratio 1.03, 95% confidence interval 1.00-1.05, P = .025). Analysis of BMI categorically revealed that “overweight” (25-30 kg/m²), “obese class I” (30-35 kg/m²), “obese class II” (35-40 kg/m²), and “obese class III” (>40 kg/m²) patients faced 77%, 76%, 83%, and 106% greater risk, respectively, of failing to achieve the KOOS-PS MCID compared to “normal BMI” (<25 kg/m²) patients.ConclusionElevated BMI was associated with an increased risk of failure to achieve the 1-year KOOS-PS MCID following TKA.     

Impact of body mass index on hepatocellular carcinoma recurrence after liver transplantation through long-term follow-up

BackgroundObesity is associated with increased oncological risk and outcomes but the evidence surrounding the effect of body mass index (BMI) on increased risk of hepatocellular carcinoma (HCC) recurrence after liver transplantation (LT) is still questionable. The purpose of this retrospective study of a large cohort of adult patients transplanted for HCC was to investigate the effect of BMI on the incidence of HCC recurrence and outcome.MethodsData from 427 adult recipients transplanted for HCC between 2000 and 2017 were collected. Patients were classified at time of LT according to the World Health Organization BMI classification into 3 groups; group 1: BMI <25 (n=166), group 2: BMI 25–29.9 (n=150) and group 3: BMI ≥30 (n=111).ResultsThere were no significant changes of mean BMI overtime 26.8±5.0 kg/m2 at time of LT and 28.8±23.1 at 5 years. The recurrence rates of HCC after LT in the three groups were 19%, 16% and 17% respectively. The 5, 10 and 15-year recurrence free survival (RFS) rates were respectively 68.6%, 47.3% and 40.8% in group 1, 73.3%, 66.2% and 49.5% in group 2 and 68.8%, 57.5% and 47.7% in group 3 (log rank P=0.47).ConclusionsRecipient BMI at time of transplant and during follow-up didn’t impact the incidence of HCC recurrence nor long-term patient survival, irrespective to the status of the patients and their tumor characteristic at time of LT. The present study clearly confirms that obesity should not be considered, when selecting patients with HCC to LT, as a predictive factor of recurrence.