Page 333 - Read Online

Lee et al. Liver resection in obese

As early as 1972, a Veterans Affairs study demonstrated Patients were evaluated in 4 weight groups: normal
that obese patients have a significantly higher (BMI < 25), overweight (BMI ≥ 25), obese (BMI ≥
incidence of pre-operative co-morbidities, specifically 30), and severely obese (BMI ≥ 35). Based on World
[4]
hypertension and diabetes. Lending to this fact Health Organization (WHO) classifications of obesity,
obese patients subsequently had a higher incidence there were 78 (20%) normal weight patients, 209
of post-operative complications, including atelectasis (52%) overweight patients, 86 (22%) obese, referred
and wound infection. Not surprisingly, the incidence by the WHO as class I obesity, and 23 (6%) severely
of wound infections were most pronounced in obese obese, referred by WHO as class II and III obesity. [11]
diabetics, placing them at three fold increasing risk of
post-operative mortality. The power of this study was Patient demographics, clinical status, tumor characteristics,
limited because only 5% of the study cohort meets operative and postoperative outcomes, as well as
criteria for obesity at that time. Unfortunately, in the clinicopathologic data were analyzed among each
subsequent three decades, the landscape of mean weight class against the normal BMI group. The
body mass index and the incidence of obesity has surgical technique of laparoscopic hepatectomy
dramatically changed. utilized by this surgeon has been well reported in the
literature. [12] Laparoscopic hepatectomy was selectively
[5]
Dindo et al. first presented a classification system performed with hand port assistance based on tumor
designed to identify and define post-operative location, accessibility and condition of the underlying
complications. Their study examined and analyzed the liver parenchyma.
outcomes of over six thousand open general surgery
patients. This analysis identified the only increased Statistical analysis
complication in the obese patient was the rate of Continuous variables were compared between groups
wound infections, and failed to identify an increased using Student’s t-test; categorical variables were
rate of any additional complications. This observation compared using chi-squared test. Serial values were
was not only true for the obese patient, but also for compared using analysis of variance. A univariate
the severely obese patients with body mass index model was used to identify all variables significantly
(BMI) greater than 35. In their final analysis they associated with post-operative complications. To
concluded and advocated for surgical intervention in examine the effect of obesity on the laparoscopic
the “rapidly expanding obese population”. approach a full cohort analysis of all resections
was performed while a second analysis of only
Ironically this is in sharp contrast with the early laparoscopic resections was carried out. A multivariate
National Institutes of Health guidelines for laparoscopy regression model was then developed to identify the
cholecystectomy that excluded the morbidly obese independent variables that maintained significance
[6]
patients. Despite this consensus guideline, surgeons in multivariate analysis. A P-value of < 0.05 was
quickly identified laparoscopy was an ideal approach considered statistically significant.
for obese patients. Theoretically, laparoscopy lends
to improved visualization, smaller incisions, and less RESULTS
physiologic impact. These advantages result in: (1)
shorter hospital stays; (2) rapid return to normal diet; Several demographic differences were noted between
[7]
and (3) fewer complications. However, it would be the study groups. Mean age was similar, while
decades before Tsinberg first examined the effect severe obesity and malignant disease had a higher
of obesity in a small cohort of minor laparoscopic association with male gender. The incidence of co-
[8]
hepatic resections. This, and subsequent studies, morbidities including hypertension and diabetes
have confirmed the benefits of laparoscopy but increased with increasing weight class. American
only at the expense of increased operative times Society of Anesthesiologists (ASA) score increased
with the occurrence of Clavien-Dindo class I and II concordantly with patients’ body weight. However,
complications. [9,10] Our current study seeks to evaluate the incidence of cirrhosis, the number of segments
the effect of laparoscopy on a large group of open and resected and the percentage of major resections were
laparoscopic minor and major resections. similar across all weight groups [Table 1].

METHODS Outcome data identified an increase of blood loss,
transfusions, and complications in patients moving
From January 2001 to September 2015, 640 patients from normal, overweight, obese and severely obese
underwent liver resection by a single surgeon. patients. Surgical margins were similar across groups.
Of those, 396 patients underwent a laparoscopic Clavien-Dindo I-V complications were significantly
hepatectomy. All patients were included in this study. different between the severely obese and the other
324 Hepatoma Research ¦ Volume 2 ¦ December 13, 2016