The role of obesity in kidney transplantation outcome

Background

The number of obese kidney transplant candidates has been growing. However, there are conflicting results regarding to the effect of obesity on kidney transplantation outcome. The aim of this study was to investigate the association between the body mass index (BMI) and graft survival by using continuous versus categoric BMI values as an independent risk factor in renal transplantation.

Methods

We retrospectively reviewed 376 kidney transplant recipients to evaluate graft and patient survivals between normal-weight, overweight, and obese patients at the time of transplantation, considering BMI as a categoric variable.

Results

Obese patients were more likely to be male and older than normal-weight recipients (P = .021; P = .002; respectively). Graft loss was significantly higher among obese compared with nonobese recipients. Obese patients displayed significantly lower survival compared with nonobese subjects at 1 year (76.9% vs 35.3%; P = .024) and 3 years (46.2% vs 11.8%; P = .035).

Conclusions

Obesity may represent an independent risk factor for graft loss and patient death. Careful patient selection with pretransplantation weight reduction is mandatory to reduce the rate of early posttransplantation complications and to improve long-term outcomes.     

Oncologic outcomes after resection of rectal cancer: Laparoscopic versus open approach

Background

This study examined outcomes of laparoscopic and open rectal cancer surgery in a community hospital setting.

Methods

A community health care system cancer registry was reviewed retrospectively (2004-2007) for rectal cancer patients undergoing surgical treatment. Primary end points were rates of recurrence and survival.

Results

Both open and laparoscopic resection groups had similar demographic, treatment, and tumor characteristics. Most patients in the open resection and laparoscopic resection populations experienced no recurrence (79% vs 83%, respectively; P = .5). Overall, the groups had similar mean (88% vs 96%, respectively; P = .4) and disease-free (21 and 23 months, respectively; P = .5) survival.

Conclusions

In a community hospital setting, laparoscopic resection of rectal cancer was found to be as safe and effective as open resection in selected patients.     

Influence of stapler size used at ileal pouch-anal anastomosis on anastomotic leak, stricture, long-term functional outcomes, and quality of life

Background

The aim of this study was to evaluate whether stapler size used at ileal pouch-anal anastomosis (IPAA) influences outcomes.

Methods

Data of patients undergoing stapled IPAA (1983-2007) were obtained. Differences between groups A (stapler size 28-29 mm) and B (31-33 mm) for pre- and perioperative factors, stricture, leak, quality of life (QOL), and function were compared. Associations between stapler size and stricture or leak were assessed with a multivariable Cox model.

Results

Groups A (n = 1,221) and B (n = 899) had comparable age, diagnosis, body mass index (BMI), and albumin level. Group B had more males (P < .001) but fewer patients with ileostomy (P < .001). There was no significant difference in rates of leak (4.5% vs 6.2%, P = .08) or stricture (1.9% vs 2.7%, P = .1) for groups A and B. On multivariate analysis, female gender was associated with stricture, while greater BMI and male gender were associated with leak. Group A had greater urgency at 1 year and nighttime pad use at 15 years. The other determinants of function and QOL were similar.

Conclusions

There was no significant association between the size of stapler used at IPAA and long-term complications.     

Impact of Continuous Value of Body Mass Index on Graft Loss in Overweight Patients

Introduction

High body mass index (BMI) is associated with increased cardiovascular mortality and risk of progression to end-stage renal disease both among the general population and among renal transplant patients. However, in the latter condition no unequivocal studies have been reported in the literature. The aim of our study was to investigate continuous versus categorical values of BMI (World Health Organization classification) as an independent risk factor in renal transplantation.

Patients and methods

We retrospectively studied 194 renal transplant patients (128 males and 66 females) whose mean age at transplant was 43.9 years. They had 5 years follow-up. To investigate the association between BMI and graft survival, we performed univariate and multivariate analyses using the Cox regression model. This model was adjusted both for classical covariates (age, gender, time on dialysis, HLA mismatches, donor status) and other covariates as delayed graft function (DGF), acute rejection episodes (AR), and chronic allograft nephropathy (CAN), which are universally recognized to be predictors of graft loss as evidenced by a need for dialysis treatments.

Results

At the time of transplantation, the BMI averaged 24.4 ± 2.65 kg/m². Upon univariate analysis, age (P = .049), BMI (P = .005), DGF (P = .009), ARE (P < .0001), and CAN (P = .001) were significantly related to poor transplant outcomes. Upon multivariate analysis, only the BMI value, considered as continuous value (P = .013), DGF (P = .030), and ARE (P < .0001) were significantly related to graft loss.

Conclusions

BMI as a continuous value represented an independent risk factor for renal transplant loss at 5 years. Correction of pretransplant body weight both in overweight (25 ≤ BMI ≤ 30) and normal-weight patients is essential to avoid graft loss.     

Outcomes of laparoscopic colorectal surgery in obese and nonobese patients: a case-matched study of 180 patients

Background

Because it has been suggested that obese patients may be at higher risk of morbidity and mortality after surgery, we conducted a prospective case-matched study to compare outcomes of elective laparoscopic colorectal surgery in obese and nonobese patients.

Methods

Sixty-two consecutive nonselected obese patients (body mass index ≥30 kg/m²) were matched with 118 nonobese patients. Postsurgical mortality and morbidity were defined as in-hospital death and complications.

Results

Cardiopulmonary comorbidities were significantly more frequent in obese compared with nonobese patients (44% vs 24%, P < .01). Obesity was significantly associated with increased mean operating time (268 ± 74 min vs 232 ± 59 min, P < .001), and conversion rate (32% vs 14%, P < .01). The mortality rate was nil. The overall postsurgical morbidity rate (31% vs 19%, P = not significant) and mean hospital stay (11 ± 10 days vs 9 ± 8 days, P = not significant) were similar in obese and nonobese patients.

Conclusions

The results of this large case-matched study suggest that laparoscopic approach for colorectal surgery is feasible and safe in obese patients.     

Gamma probe identification of normal parathyroid glands during central neck surgery can facilitate parathyroid preservation

Background

We evaluated gamma probe identification (GPI) of sestamibi-labeled normal parathyroid glands during central neck surgery.

Methods

GPI was judged to be helpful if it resulted in the identification of parathyroid glands not identified by direct inspection.

Results

GPI was performed in 54 patients and was helpful in 20, including 9 patients in whom GPI identified intact parathyroid glands in vivo and 11 patients in whom GPI identified incidentally excised parathyroid glands ex vivo in the central neck dissection (CND) specimen. GPI was more commonly helpful in patients who underwent reoperation (9/16, 56%) compared with primary surgery (11/38, 29%; P = .04) and was more commonly helpful in patients who underwent CND (17/28, 61%) compared with thyroidectomy without CND (2/26, 8%; P < .0001). In 11 patients, normal parathyroid glands were salvaged by GPI from the ex vivo CND specimens and autografted.

Conclusions

GPI is a relatively simple and effective technique that may help maximize parathyroid preservation.     

Typical carcinoids and neuroendocrine carcinomas of the stomach: differing clinical courses and prognoses

Background

Gastric endocrine tumors are usually classified as 3 types of well-differentiated endocrine tumors (typical carcinoids or carcinoids) and poorly differentiated carcinomas (neuroendocrine carcinomas [NECs]).

Methods

From 1993 to 2008, 97 patients (73 men and 24 women) were diagnosed with gastric neuroendocrine tumors at the Asan Medical Center.

Results

Of the 45 patients with typical carcinoids, 37 underwent surgery (eg, endoscopic resection). Of the 52 patients with NECs, 43 underwent surgery (eg, radical gastrectomy). One patient died of recurrence of the typical carcinoids, whereas 26 patients with NECs died of related diseases (P < .05). The rates of survival and recurrence did not significantly differ by type of typical carcinoid (P > .05).

Conclusions

Regardless of the type, carcinoids that are not yet advanced can be effectively treated with minimal endoscopic or laparoscopic surgery. However, all NECs and advanced carcinoids should be treated with radical gastrectomy.     

Does obesity impact lymph node retrieval in colon cancer surgery?

Background

Evaluation of lymph nodes is important for the optimal treatment of colon adenocarcinoma. Few studies have assessed whether lymph node harvest is compromised by obesity. We hypothesized that lymph node retrieval in colon cancer resection would be reduced in obese patients.

Methods

Patients undergoing resection for colon adenocarcinoma diagnosed from 2000 to 2007 were reviewed retrospectively and stratified by body mass index (BMI). Lymph node harvest was evaluated.

Results

A total of 401 patients were included. Their mean age was 72.8 years, and 44% were men. Their mean BMI was 28.2 kg/m². Mean lymph node recovery among BMI groups was as follows: BMI less than 18.5 was 20.6; BMI of 18.5 to 24.9 was 25.1; BMI of 25 to 29.9 was 23.1; BMI of 30 to 34.9 was 22.4; BMI of 35 to 39.9 was 19.0; and BMI of 40 or greater was 21.1 nodes (P = .321). Surgical time increased with increasing BMI (P = .005). Adequacy of node harvest differed by stage (P = .007), left-sided versus right-sided resections (P = .001), and pathology technician (P = .001).

Conclusions

Lymph node retrieval was not affected by BMI.     

Childhood obesity: a risk factor for injuries observed at a level-1 trauma center

Purpose

Obesity is an independent risk factor in trauma-related morbidity in adults. The purpose of this study was to investigate the effect of obesity in the pediatric trauma population.

Methods

All patients (6-20 years) between January 2004 and July 2007 were retrospectively reviewed and defined as non-obese (body mass index [BMI] <95th percentile for age) or obese (BMI ≥95th percentile for age). Groups were compared for differences in demographics, initial vital signs, mechanisms of injury, length of stay, intensive care unit stay, ventilator days, Injury Severity Score, operative procedures, and clinical outcomes.

Results

Of 1314 patients analyzed, there were 1020 (77%) nonobese patients (mean BMI = 18.8 kg/m²) and 294 (23%) obese patients (mean BMI = 29.7 kg/m²). There was no significant difference in sex, heart rate, length of stay, intensive care unit days, ventilator days, Injury Severity Score, and mortality between the groups. The obese children were significantly younger than the nonobese children (10.9 ± 3.3 vs 11.5 ± 3.5 years; P = .008) and had a higher systolic blood pressure during initial evaluation (128 ± 17 vs 124 ± 16 mm Hg, P < .001). In addition, the obese group had a higher incidence of extremity fractures (55% vs 40%; P < .001) and orthopedic surgical intervention (42% vs 30%; P < .001) but a lower incidence of closed head injury (12% vs 18%; P = .013) and intraabdominal injuries (6% vs 11%; P = .023). Evaluation of complications showed a higher incidence of decubitus ulcers (P = .043) and deep vein thrombosis (P = .008) in the obese group.

Conclusion

In pediatric trauma patients, obesity may be a risk factor for sustaining an extremity fracture requiring operative intervention and having a higher risk for certain complications (ie, deep venous thrombosis [DVT] and decubitus ulcers) despite having a lower incidence of intracranial and intraabdominal injuries. Results are similar to reports examining the effect(s) of obesity on the adult population.     

Outcome of renal transplantation in Alport's syndrome: a single-center experience

Background

Anti-glomerular basement membrane (anti-GBM) nephritis post-renal transplantation (RTx) is known to cause graft loss in Alport's syndrome (AS). We evaluated the results of RTx in AS patients vis à vis patient and graft survivals, incidence of anti-GBM nephritis, and causes of graft failure.

Materials and methods

Between 1993 and 2009 we performed 31 RTx on AS patients (28 males and three females) of overall mean age of 22 ± 7.9 years from six deceased and 27 living donors. Two patients underwent second RTx.

Results

Over a follow-up of 1, 3, 5, and 10 years, the mean serum creatinines (mg/dL) were 1.51 ± 0.52, 1.59 ± 0.26, 1.61 ± 0.30, and 1.63 ± 0.32, respectively. Patient survivals at 1, 5, and 10 years were 89.71%, 81.32% and 81.32% with graft survival for all periods of 81.2%. Twenty-one percent experienced biopsy-proven acute rejection episodes. Graft failures were due to anti-GBM nephritis in 12.2% (n = 4), chronic allograft nephropathy in 3.2% (n = 1), and acute rejection or cyclosporine toxicity 3.2% (n = 1 each). The mean duration to graft loss was 4.9 ± 2.4 months.

Conclusion

Graft and patient survivals were acceptable among transplant recipients with AS despite the risk of anti-GBM nephritis.     

Prognosis After Heart Transplant in Patients With Pulmonary Hypertension Secondary to Cardiopathy

Introduction

Pulmonary hypertension (PHT) is associated with greater posttransplant mortality. In the last few years, many vasodilator drugs have been developed and some patients have therefore been transplanted. However, conflicting data exist regarding the impact of reversible PHT on posttransplant outcomes. The aim of this study was to determine the evolution of our transplanted patients with reactive PHT and the causes of right cardiac insufficiency and perioperative mortality.

Material and Methods

We performed a retrospective analysis of 39 consecutive heart transplant recipients from January 2005 to December 2006. We analyzed significant pretransplant PHT, the percentage of emergency transplants, surgical technique, as well as ischemia and extracorporeal circulation times.

Results

Before transplantation, significant PHT was present in 12 patients (30.8%), all of whom had a positive acute vasoreactivity test or response to oral treatment with pulmonary vasodilators. A nonsignificant tendency to increased posttransplant mortality was observed among patients with pretransplant PHT. We observed a significant increase in mortality in patients with prolonged operative times, over the third percentile, odds ratio (OR) for ECC of 21% (P = .001) and OR for prolonged ischemia time of 9.5% (P = .022). However, mortality did not increase significantly in cases of emergent transplantation (P = .08) or in the use of the Shumway bicaval surgical technique (P = .9).

Conclusions

There seemed to be a slight tendency to increased mortality among patients with reversible HTP, suggesting that high-risk patients need closer monitoring but are not absolutely contraindicated for transplantation.     

Antioxidant enzymes, presbycusis, and ethnic variability

Objective

A proposed mechanism for presbycusis is a significant increase in oxidative stress in the cochlea. The enzymes glutathione S-transferase (GST) and N-acetyltransferase (NAT) are two classes of antioxidant enzymes active in the cochlea. In this work, we sought to investigate the association of different polymorphisms of GSTM1, GSTT1, and NAT2 and presbycusis and analyze whether ethnicity has an effect in the genotype-phenotype associations.

Study Design

Case-control study of 134 DNA samples.

Setting

University-based tertiary care center.

Subjects and Methods

Clinical, audiometric, and DNA testing of 55 adults with presbycusis and 79 control patients with normal hearing.

Results

The GSTM1 null genotype was present in 77 percent of white Hispanics and 51 percent of white non-Hispanics (Fisher's exact test, 2-tail, P = 0.0262). The GSTT1 null genotype was present in 34 percent of control patients and in 60 percent of white presbycusis subjects (P = 0.0067, odds ratio [OR] = 2.843, 95% confidence interval [95% CI] = 1.379-5.860). The GSTM1 null genotype was more frequent in presbycusis subjects, i.e., 48 percent of control patients and 69 percent of white subjects carried this deletion (P = 0.0198, OR = 2.43, 95% CI = 1.163-5.067). The NAT2*6A mutant genotype was more frequent among subjects with presbycusis (60%) than in control patients (34%; P = 0.0086, OR = 2.88, 95% CI = 1.355-6.141).

Conclusion

We showed an increased risk of presbycusis among white subjects carrying the GSTM1 and the GSTT1 null genotype and the NAT*6A mutant allele. Subjects with the GSTT1 null genotypes are almost three times more likely to develop presbycusis than those with the wild type. The GSTM1 null genotype was more prevalent in white Hispanics than in white non-Hispanics, but the GSTT1 and NAT2 polymorphisms were equally represented in the two groups.     

Circulating levels of osteopontin are related with calcification parameters in patients with renal transplantations

Background

Although osteopontin (OPN) is a local inhibitor of calcification, it may also be an indirect marker of ongoing systemic calcification. There are few data about clinical and laboratory parameters associated with serum OPN levels in renal transplant (RT) patients. We investigated the relationship between insulin resistance and calcification parameters as estimated with OPN after RT.

Methods

Between 1996 and 2006, the study enrolled 81 patients undergoing RT including 26 females and 55 males of overall mean age of 38 ± 10 years. We evaluated demographic features, medications, smoking history, blood pressure values daily proteinuria as well as laboratory values of calcium-phosphate product (Ca × P), body mass index (BMI) and serum OPN. According to OPN values, we stratified patients as: group 1: OPN <8; group 2: OPN 8 to 45 and group 3: OPN ≥ 45.

Results

Serum OPN correlated with first month phosphorus (r = 0.33, P = .00), Ca × product (r = 0.41, P = .02), and proteinuria (r = 0.34, P = .00) with negative relations to serum insulin (r = 0.28, P = .04). Serum calcium, Ca × product, low-density lipoprotein cholesterol, alkaline phosphatase, Creactive protein and vitamin D values were significantly higher among group 3. Regression analysis showed only Ca × product to be an independent variable affecting serum OPN levels (β = 0.68, P < .01).

Conclusion

OPN has been implicated in numerous physiological and pathological events including calcification, inflammation, and insulin resistance. Serum OPN may be a marker for increased cardiovascular risk in RT patients.     

Posttransplant inflammation associated with onset of chronic kidney disease

Background

Chronic allograft nephropathy (CAN), a major complication in renal transplant patients, is an important cause of graft loss. Inflammation as measured in the pretransplant and posttransplant phases, using various markers, has been associated with worse renal function and a greater risk of cardiovascular disease and of long-term graft loss.

Objective

The objective of our study was to evaluate whether worsening inflammation in the first 3 months postoperatively was a risk factor for developing CAN.

Patients and methods

We performed a cross-sectional study in 207 patients. The following markers of inflammation (MIF) were determined pretransplant and at 3 months after grafting: C-reactive protein (CRP) (mg/L), interleukin (IL)-6 (pg/mL), IL-10 (pg/mL), tumor necrosis factor (TNF)-α (pg/mL), and its soluble receptor (ng/mL), soluble-IL2R (UI/mL), pregnancy-associated plasma protein A (PAPP-A; mUI/L), and IL-4 (pg/mL). We also calculated the ratio at 3 months versus the pre value of MIF.

Results

CAN was diagnosed after the first year in 23 patients (11.3%) always by renal biopsy performed for clinical indications. Patients with CAN showed worse inflammation, eg, MIF ratios over one, with statistically significant differences for the ratios of TNF-α and PAPP-A (P = .032 and P = .051 respectively). Upon multivariate logistic regression analysis, using CAN as the dependent variable and age, sex, donor age, months on dialysis, acute tubular necrosis, acute rejection, and MIF ratios as covariates, we observed that an acute rejection episode (OR = 13.03; CI = 2.8-60.9; P = .001), CRP ratio (OR = 1.36; CI = 1.07-1.73; P = .013), and PAPP-A ratio (OR = 1.80; CI = 0.92-3.53; P = .005) were independent markers of CAN.

Conclusions

Among other factors, inflammation may determine the onset of CAN as diagnosed by renal biopsy.     

Does type of mesh used have an impact on outcomes in laparoscopic inguinal hernia?

Background

Theoretically, a lighter and softer mesh may decrease nerve entrapment and chronic pain by creating less fibrosis and mesh contracture in laparoscopic inguinal hernia repair.

Methods

We performed a telephone survey of patients who underwent laparoscopic inguinal hernia surgery between 2001 and 2007. We recorded patient responses for chronic pain, foreign body sensation, recurrence, satisfaction, and return to work, and then studied the effect of type of mesh (polypropylene vs polyester) on these factors.

Results

Of 109 consecutive patients surveyed (mean age, 54.5 y), 67 eligible patients underwent 84 transabdominal extraperitoneal procedures and 2 transabdominal preperitoneal procedures. Patients with polypropylene mesh had a 3 times higher rate of chronic pain (P = .05), feeling of lump (P = .02), and foreign body perception (P = .05) than the polyester mesh group. Our overall 1-year recurrence rate was 5.9%. The recurrence rate was 9.3% for the polypropylene group and 2.9% for the polyester group (P = .26).

Conclusions

A lightweight polyester mesh has better long-term outcomes for chronic pain and foreign body sensation compared with a heavy polypropylene mesh in laparoscopic inguinal hernia repair. We also saw a trend toward higher recurrence in the polypropylene group.     

Obesity in kidney transplantation affects renal function but not graft and patient survival

Introduction

The number of overweight and obese patients undergoing renal transplantation has increased dramatically over the past two decades. Studies on graft survival and posttransplantation complications have often yielded conflicting results. Some authors have reported similar results for graft and patient survivals between obese and normal weight patients, but with a marginally increased rate of postoperative complications. In contrast, other reports note higher percentage of graft losses as well as increased mortality. In our study, we analyzed early- and long-term outcomes among obese versus nonobese kidney transplant recipients.

Patients and Methods

Between January 2000 and December 2008, we performed 563 cadaveric kidney transplantations. Recipients were classified in 1 of 5 groups based on their body mass index (BMI) at the time of transplantation: group A (n = 68; BMI < 18.5); group B (n = 310; 18.6 < BMI < 24.9); group C (n = 143; 25 < BMI < 29.9); group D (n = 32; 30 < BMI < 34.9); and group E (n = 10; BMI ≥ 35). The comparative analysis included patient and graft survivals, postoperative complications, onset of delayed graft function (DGF), acute rejection episodes, hospital stay, and serum creatinine values in the first 3 years posttransplantation.

Results

At a mean follow-up of 53 months (range, 3-112 months), DGF was observed in 20 patients in group A (29.4%), 82 in group B (26.4%), 43 in group C (30%), 16 in group D (50%), and 4 in group E (40%). Nevertheless, obese patients (groups D and E) showed higher mean serum creatinine values and worse renal function at 6 months (P = .001), 1 year (P < .001), and 3 years (P = .001). Moreover, they were at increased risk of an acute rejection episode (P = .01) and more susceptible to cardiovascular and metabolic complications (P = .01). Morbidly obese patients displayed a higher incidence of postsurgical complications (P = .002). There were no differences in the incidences of chronic allograft nephropathy (CAN) or infectious complications. Despite the differences in morbidity among the 5 groups, we failed to observe significant differences in patient or graft survivals at 6, 12, 36, or 60 months.

Conclusion

Our findings suggested that obese patients should not be discriminated against simply based on the BMI. At our center, obese (BMI >35) transplantation candidates undergo a thorough cardiac evaluation, as well as pulmonary, endocrine, and nutritional counseling seeking to minimize medical and surgical complications and improve survival and quality of life.     

Structured operative reporting: a randomized trial using dictation templates to improve operative reporting

Background

Few studies have addressed the quality of dictated operative reports (ORs). This study documents changes in resident dictation after the introduction of a standardized OR template.

Methods

Twenty residents dictated an OR based on a surgical procedure video. Residents were randomized to receive an OR template or no intervention. Residents dictated another report 3 months later. Outcomes measures were dictation quality using a previously validated tool and resident comfort with dictation.

Results

There was no overall difference in quality in the intervention group as measured by the Structured Assessment Form (SAF) (28.6 vs 30.0, P = .36) and Global Quality Ratings Scale (GQRS) (21.7 vs 21.8, P = .96). However, junior resident subgroup analysis revealed an improvement in the intervention group on both the SAF (23.2 vs 28.3, P = .02) and GQRS (17.1 vs 20.4, P = .02). Subjective comfort level improved in the intervention group (P = .02).

Conclusions

The operative dictation template can significantly improve resident comfort level with dictation and has the potential to improve the quality of junior resident dictations.     

Postoperative sternal dehiscence in obese patients: incidence and prevention

Background

Obesity has been identified as the single most important risk factor for postoperative sternal infection in coronary bypass surgery patients. It is also a major risk factor for sternal dehiscence, with or without infection, for any type of cardiac operation. We assessed whether prophylactic measures could prevent this complication.

Methods

Two studies were conducted. In study A, 3,158 heart surgery patients were analyzed at 3 cardiac units. Obesity was defined as body mass index (BMI) more than 30. Group I (1,253 obese [39.7%]) was compared with group II (1,905 nonobese [60.3%]). Sternal closure was done at the surgeon's preference: (a) plain wires through and through the bone; (b) peristernal figure-of-eight wires; or (c) peristernal method, using stainless-steel cables. In study B, 123 obese patients were prospectively divided into 2 subgroups. Group B-1 (54 patients) underwent lateral prophylactic sternal reinforcement before placement of peristernal wires. Group B-2 (69 patients) had standard sternal closure, as in study A.

Results

In study A, group I had 81 dehiscences (6.46%); 78 also suffered deep sternal infection and mediastinitis (96%). Despite treatment, dehiscence recurred in 13, and mortality was 38.4%. In group II nonobese patients, 31 dehisced (1.6%, p = 0.000), with no mortality. In study B, group B-1 (54) had 0% dehiscence versus group B-2 (69) with 6 dehiscences (8.7%).

Conclusions

In our study, the rate of obesity is high (∼ 40%). Sternal dehiscence is real when the BMI is more than 30 (6.46%), and has high morbidity and mortality. Prophylactic sternal reinforcement seems to prevent this complication.