Introduction: Obesity is associated with an increased risk of fatty liver disease, predisposing to liver fibrosis and cirrhosis, as well as increased occurrence of hepatocellular carcinoma. Obesity is intuitively considered a risk factor for increased post-hepatectomy morbidity and mortality. Nevertheless, peer-reviewed literature reveals significant heterogeneity between different cohorts contributing to varying conclusions. Outcomes in this cohort for Laparoscopic Liver Resection (LLR), especially in non-academic settings remain under-evaluated. The current study evaluated outcomes of LLR in obese patients, in a community health system. Methods: A retrospective analysis of all patients undergoing LLR at the flagship hospital in the community health system, between 2013 and 2020, was performed. Classified into two groups based on Body Mass Index (BMI): obese (BMI > 30 kg/m 2 ) vs non-obese (BMI < 30 kg/m 2 ). Variables between groups compared with univariate analysis (Fisher exact test, student t-test, or Mann Whitney U-test). Multivariate analysis using logistic regression, was performed to determine the association of obesity with composite complication score (including bile leak, infection, bleeding, and/or cardiorespiratory complication) (p-value < 0.05). Results: 90 patients underwent LLR during the 7-year period; obese = 38 and non-obese = 52. No statistically significant differences were noted between obese and non-obese cohorts, in baseline characteristics including age (53.1 ± 15.1 vs 56.8 ± 11.6 years), female gender (60.5% vs 53.8%), and ASA grade (3.13 ± 0.53 vs 3.02 ± 0.54) (all p > 0.05). Univariate analysis showed no statistically significant differences between obese and non-obese groups, comparing estimated blood loss [300 (100 - 500) vs. 200 (100 - 462.5) cc], operative time [177 (125 - 215) vs. 150.9 (111 - 207) minutes], bile leak (2.6% vs. 4.1%), post-operative bleeding (2.6% vs. 4.1%), infection (0% vs. 4.1%), cardiorespiratory complication (10.5% vs 12.2%), conversion rate (5.3% vs 5.8%), length of stay [4 (3 - 5) vs. 4 (2 - 5) days], 90-day reoperation (0% vs. 2%) and 90-day readmission (2.6% vs. 4.1%) (p > 0.05). Multivariate analysis showed no association between obesity and composite complication rate (p = 0.97), after adjusting for alcohol abuse, neoadjuvant therapy, and prior liver surgery. Conclusion: LLR is a key technique that can be replicated in the community setting to improve outcomes in obese patients requiring liver resection. Larger prospective multicenter studies are warranted to externally validate these findings.
KeywordsLiver ResectionLaparoscopicObesity
Hales, C.M., Carroll, M.D., Fryar, C.D. and Ogden, C.L. (2020) Prevalence of Obesity and Severe Obesity among Adults: United States, 2017-2018. NCHS Data Brief, No. 360, 1-8.
Després, J.P. and Lemieux, I. (2006) Abdominal Obesity and Metabolic Syndrome. Nature, 444, 881-887. https://doi.org/10.1038/nature05488
Kalupahana, N.S., Moustaid-Moussa, N. and Claycombe, K.J. (2012) Immunity as a Link between Obesity and Insulin Resistance. Molecular Aspects of Medicine, 33, 26-34. https://doi.org/10.1016/j.mam.2011.10.011
Powell-Wiley, T.M., Poirier, P., Burke, L.E., Després, J.P., Gordon-Larsen, P., Lavie, C.J., Lear, S.A., Ndumele, C.E., Neeland, I.J., Sanders, P., St-Onge, M.P., American Heart Association Council on Lifestyle and Cardiometabolic Health, Council on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology, Council on Epidemiology and Prevention, and Stroke Council (2021) Obesity and Cardiovascular Disease: A Scientific Statement from the American Heart Association. Circulation, 143, e984-e1010. https://doi.org/10.1161/CIR.0000000000000973
Kaw, R., Wong, J. and Mokhlesi, B. (2021) Obesity and Obesity Hypoventilation, Sleep Hypoventilation, and Postoperative Respiratory Failure. Anesthesia and Analgesia, 132, 1265-1273. https://doi.org/10.1213/ANE.0000000000005352
Marchesini, G., Moscatiello, S., Di Domizio, S. and Forlani, G. (2008) Obesity-Associated Liver Disease. The Journal of Clinical Endocrinology and Metabolism, 93, S74-S80. https://doi.org/10.1210/jc.2008-1399
Goodman, Z.D. (2014) The Impact of Obesity on Liver Histology. Clinics in Liver Disease, 18, 33-40. https://doi.org/10.1016/j.cld.2013.09.010
Milić, S., Lulić, D. and Štimac, D. (2014) Non-Alcoholic Fatty Liver Disease and Obesity: Biochemical, Metabolic and Clinical Presentations. World Journal of Gastroenterology, 20, 9330-9337.
Williams, C.D., Stengel, J., Asike, M.I., Torres, D.M., Shaw, J., Contreras, M., Landt, C.L. and Harrison, S.A. (2011) Prevalence of Nonalcoholic Fatty Liver Disease and Nonalcoholic Steatohepatitis among a Largely Middle-Aged Population Utilizing Ultrasound and Liver Biopsy: A Prospective Study. Gastroenterology, 140, 124-131. https://doi.org/10.1053/j.gastro.2010.09.038
Marengo, A., Rosso, C. and Bugianesi, E. (2016) Liver Cancer: Connections with Obesity, Fatty Liver, and Cirrhosis. Annual Review of Medicine, 67, 103-117. https://doi.org/10.1146/annurev-med-090514-013832
Surgical Outcomes
Minimally-Invasive
Kew, M.C. (2015) Obesity as a Cause of Hepatocellular Carcinoma. Annals of Hepatology, 14, 299-303. https://doi.org/10.1016/S1665-2681(19)31267-0
Huang, D.Q., El-Serag, H.B. and Loomba, R. (2021) Global Epidemiology of NAFLD-Related HCC: Trends, Predictions, Risk Factors and Prevention. Nature Reviews. Gastroenterology & Hepatology, 18, 223-238. https://doi.org/10.1038/s41575-020-00381-6
DeMaria, E.J. and Carmody, B.J. (2005) Perioperative Management of Special Populations: Obesity. The Surgical Clinics of North America, 85, 1283-1289. https://doi.org/10.1016/j.suc.2005.09.002
Valentijn, T.M., Galal, W., Tjeertes, E.K., Hoeks, S.E., Verhagen, H.J. and Stolker, R.J. (2013) The Obesity Paradox in the Surgical Population. The Surgeon: Journal of the Royal Colleges of Surgeons of Edinburgh and Ireland, 11, 169-176. https://doi.org/10.1016/j.surge.2013.02.003
Ome, Y., Hashida, K., Yokota, M., Nagahisa, Y., Okabe, M. and Kawamoto, K. (2019) The Safety and Efficacy of Laparoscopic Hepatectomy in Obese Patients. Asian Journal of Surgery, 42, 180-188. https://doi.org/10.1016/j.asjsur.2017.10.002
Heise, D., Bednarsch, J., Kroh, A., Schipper, S., Eickhoff, R., Coolsen, M., Van Dam, R., Lang, S., Neumann, U. and Ulmer, F. (2021) Laparoscopic Hepatectomy Reduces Postoperative Complications and Hospital Stay in Overweight and Obese Patients. World Journal of Gastrointestinal Surgery, 13, 19-29. https://doi.org/10.4240/wjgs.v13.i1.19
Kwan, B., Waters, P.S., Keogh, C., Cavallucci, D.J., O’Rourke, N. and Bryant, R.D. (2021) Body Mass Index and Surgical Outcomes in Laparoscopic Liver Resections: A Systematic Review. ANZ Journal of Surgery, 91, 2296-2307. https://doi.org/10.1111/ans.16674
Abu Hilal, M., Aldrighetti, L., Dagher, I., Edwin, B., Troisi, R.I., Alikhanov, R., Aroori, S., Belli, G., Besselink, M., Briceno, J., Gayet, B., D’Hondt, M., Lesurtel, M., Menon, K., Lodge, P., Rotellar, F., Santoyo, J., Scatton, O., Soubrane, O., Sutcliffe, R. and Cherqui, D. (2018) The Southampton Consensus Guidelines for Laparoscopic Liver Surgery: From Indication to Implementation. Annals of Surgery, 268, 11-18. https://doi.org/10.1097/SLA.0000000000002524
Ejaz, A. and Pawlik, T.M. (2020) Review of the Southampton Consensus Guidelines for Laparoscopic Liver Surgery. JAMA Surgery, 155, 659-660. https://doi.org/10.1001/jamasurg.2020.0802
Strasberg, S.M. and Phillips, C. (2013) Use and Dissemination of the Brisbane 2000 Nomenclature of Liver Anatomy and Resections. Annals of Surgery, 257, 377-382. https://doi.org/10.1097/SLA.0b013e31825a01f6
Rahbari, N.N., Garden, O.J., Padbury, R., Brooke-Smith, M., Crawford, M., Adam, R., Koch, M., Makuuchi, M., Dematteo, R.P., Christophi, C., Banting, S., Usatoff, V., Nagino, M., Maddern, G., Hugh, T.J., Vauthey, J.N., Greig, P., Rees, M., Yokoyama, Y., Fan, S.T., Nimura, Y., Figueras, J., Capussotti, L., Buchler and Weitz, J. (2011) Posthepatectomy Liver Failure: A Definition and Grading by the International Study Group of Liver Surgery (ISGLS). Surgery, 149, 713-724. https://doi.org/10.1016/j.surg.2010.10.001
Koch, M., Garden, O.J., Padbury, R., Rahbari, N.N., Adam, R., Capussotti, L., Fan, S.T., Yokoyama, Y., Crawford, M., Makuuchi, M., Christophi, C., Banting, S., Brooke-Smith, M., Usatoff, V., Nagino, M., Maddern, G., Hugh, T.J., Vauthey, J.N., Greig, P., Rees, M., Nimura, Y., Figueras, J., DeMatteo, R.P., Buchler, M.W. and Weitz, J. (2011) Bile Leakage after Hepatobiliary and Pancreatic Surgery: A Definition and Grading of Severity by the International Study Group of Liver Surgery. Surgery, 149, 680-688. https://doi.org/10.1016/j.surg.2010.12.002
Dindo, D., Demartines, N. and Clavien, P.A. (2004) Classification of Surgical Complications: A New Proposal with Evaluation in a Cohort of 6336 Patients and Results of a Survey. Annals of Surgery, 240, 205-213. https://doi.org/10.1097/01.sla.0000133083.54934.ae
Goodwin, P.J. and Stambolic, V. (2015) Impact of the Obesity Epidemic on Cancer. Annual Review of Medicine, 66, 281-296. https://doi.org/10.1146/annurev-med-051613-012328
Miles, R.H., Carballo, R.E., Prinz, R.A., McMahon, M., Pulawski, G., Olen, R.N. and Dahlinghaus, D.L. (1992) Laparoscopy: The Preferred Method of Cholecystectomy in the Morbidly Obese. Surgery, 112, 818-823.
Woodham, B.L., Cox, M.R. and Eslick, G.D. (2012) Evidence to Support the Use of Laparoscopic over Open Appendicectomy for Obese Individuals: A Meta-Analysis. Surgical Endoscopy, 26, 2566-2570. https://doi.org/10.1007/s00464-012-2233-4
Buell, J.F., Cherqui, D., Geller, D.A., O’Rourke, N., Iannitti, D., Dagher, I., Koffron, A.J., Thomas, M., Gayet, B., Han, H.S., Wakabayashi, G., Belli, G., Kaneko, H., Ker, C.G., Scatton, O., Laurent, A., Abdalla, E.K., Chaudhury, P., Dutson, E., Gamblin, C. and World Consensus Conference on Laparoscopic Surgery (2009) The International Position on Laparoscopic Liver Surgery: The Louisville Statement, 2008. Annals of Surgery, 250, 825-830. https://doi.org/10.1097/SLA.0b013e3181b3b2d8
Lin, C.W., Tsai, T.J., Cheng, T.Y., Wei, H.K., Hung, C.F., Chen, Y.Y. and Chen, C.M. (2016) The Learning Curve of Laparoscopic Liver Resection after the Louisville Statement 2008: Will It Be More Effective and Smooth? Surgical Endoscopy, 30, 2895-2903. https://doi.org/10.1007/s00464-015-4575-1
Wakabayashi, G., Cherqui, D., Geller, D.A., Buell, J.F., Kaneko, H., Han, H.S., Asbun, H., O'Rourke, N., Tanabe, M., Koffron, A.J., Tsung, A., Soubrane, O., Machado, M.A., Gayet, B., Troisi, R.I., Pessaux, P., Van Dam, R.M., Scatton, O., Abu Hilal, M., Belli, G., Kwon, C.H.D., Edwin, B., Choi, G.H., Aldrighetti, L.A., Cai, X., Cleary, S., Chen, K., Schon, M.R., Sugioka, A., Tang, C., Herman, P., Pekolj, J., Chen, X., Dagher, I., Jarnagin, W., Yamamoto, M., Strong, R., Jagannath, P., Lo, C., Clavein, P., Kokudo, N., Barkun, J. and Strasberg, S.M. (2015) Recommendations for Laparoscopic Liver Resection: A Report from the Second International Consensus Conference Held in Morioka. Annals of Surgery, 261, 619-629.
Fuks, D., Aldrighetti, L., Jiao, L.R., Wakabayashi, G. and Limongelli, P. (2017) Laparoscopic Management of Hepatocellular Carcinoma: A Critical Reappraisal. Surgical Laparoscopy, Endoscopy & Percutaneous Techniques, 27, 203-205. https://doi.org/10.1097/SLE.0000000000000415
Cheung, T.T., Han, H.S., She, W.H., Chen, K.H., Chow, P., Yoong, B.K., Lee, K.F., Kubo, S., Tang, C.N. and Wakabayashi, G. (2018) The Asia Pacific Consensus Statement on Laparoscopic Liver Resection for Hepatocellular Carcinoma: A Report from the 7th Asia-Pacific Primary Liver Cancer Expert Meeting Held in Hong Kong. Liver Cancer, 7, 28-39. https://doi.org/10.1159/000481834
Fung, A., Trabulsi, N., Morris, M., Garfinkle, R., Saleem, A., Wexner, S.D., Vasilevsky, C.A. and Boutros, M. (2017) Laparoscopic Colorectal Cancer Resections in the Obese: A Systematic Review. Surgical Endoscopy, 31, 2072-2088. https://doi.org/10.1007/s00464-016-5209-y
Tsekrekos, A., Lovece, A., Chrysikos, D., Ndegwa, N., Schizas, D., Kumagai, K. and Rouvelas, I. (2022) Impact of Obesity on the Outcomes after Gastrectomy for Gastric Cancer: A Meta-Analysis. Asian Journal of Surgery, 45, 15-26. https://doi.org/10.1016/j.asjsur.2021.04.033
Ishihara, A., Tanaka, S., Shinkawa, H., Yoshida, H., Takemura, S., Amano, R., Kimura, K., Ohira, G., Nishio, K. and Kubo, S. (2021) Superiority of Laparoscopic Liver Resection to Open Liver Resection in Obese Individuals with Hepatocellular Carcinoma: A Retrospective Study. Annals of Gastroenterological Surgery, 6, 135-148. https://doi.org/10.1002/ags3.12506
Inoue, Y., Ishii, M., Fujii, K., Nihei, K., Suzuki, Y., Ota, M., Kitada, K., Kuramoto, T., Shima, T., Kodama, H., Matsuo, K., Miyaoka, Y., Miyamoto, T., Yokohama, K., Ohama, H., Imai, Y., Tanaka, R., Sanda, M., Osumi, W., Tsuchimoto, Y., Terazawa, T., Ogura, T., Masubuchi, S., Yamamoto, M., Asai, A., Shirai, Y., Inoue, M., Fukunishi, S., Nakahata, Y., Takii, M., Goto, M., Kimura, F., Higuchi, K. and Uchiyama, K. (2021) Safety and Efficacy of Laparoscopic Liver Resection for Colorectal Liver Metastasis with Obesity. The American Surgeon, 87, 919-926. https://doi.org/10.1177/0003134820952448
Toriguchi, K., Hatano, E., Sakurai, T., Seo, S., Taura, K. and Uemoto, S. (2015) Laparoscopic Liver Resection in Obese Patients. World Journal of Surgery, 39, 1210-1215. https://doi.org/10.1007/s00268-014-2927-y
Uchida, H., Iwashita, Y., Saga, K., Takayama, H., Watanabe, K., Endo, Y., Yada, K., Ohta, M. and Inomata, M. (2016) Benefit of Laparoscopic Liver Resection in High Body Mass Index Patients. World Journal of Gastroenterology, 22, 3015-3022. https://doi.org/10.3748/wjg.v22.i10.3015
Nomi, T., Fuks, D., Ferraz, J.M., Kawaguchi, Y., Nakajima, Y. and Gayet, B. (2015) Influence of Body Mass Index on Postoperative Outcomes after Laparoscopic Liver Resection. Surgical Endoscopy, 29, 3647-3654. https://doi.org/10.1007/s00464-015-4121-1
Yu, H.B., Dong, Y.D., Wang, L.C., Tian, G.J., Mu, S.M., Cao, Y., Peng, Y.N., Lou, C.Y., Liu, P. and Li, D.Y. (2016) Laparoscopic Liver Resection Can Be an Effective Way in Obese Patients: A Single Center of 2-Year Experience. Surgical Laparoscopy, Endoscopy & Percutaneous Techniques, 26, e69-e72. https://doi.org/10.1097/SLE.0000000000000268
He, J., Liu, H., Deng, L., Wei, X., Chen, T., Xia, S. and Liu, Y. (2019) Influence of Obesity on In-Hospital and Postoperative Outcomes of Hepatic Resection for Malignancy: A 10-Year Retrospective Analysis from the US National Inpatient Sample. BMJ Open, 9, e029823. https://doi.org/10.1136/bmjopen-2019-029823
Zhang, Q., Liu, Q., Chen, J., Mei, S., Liang, J. and Wang, Z. (2021) Short-Term Outcomes for Laparoscopic Surgery for BMI ≥ 30 Patients with Rectal Cancer. Asian Pacific Journal of Cancer Prevention: APJCP, 22, 3705-3709. https://doi.org/10.31557/APJCP.2021.22.11.3705
Wang, Z., Zhang, X., Liang, J., Hu, J., Zeng, W. and Zhou, Z. (2015) Short-Term Outcomes for Laparoscopy-Assisted Distal Gastrectomy for Body Mass Index ≥ 30 Patients with Gastric Cancer. The Journal of Surgical Research, 195, 83-88. https://doi.org/10.1016/j.jss.2014.12.044
Rudasill, S.E., Dillon, D., Karunungan, K., Mardock, A.L., Hadaya, J., Sanaiha, Y., Tran, Z. and Benharash, P. (2021) The Obesity Paradox: Underweight Patients Are at the Greatest Risk of Mortality after Cholecystectomy. Surgery, 170, 675-681. https://doi.org/10.1016/j.surg.2021.03.034
Lee, S. (2017) The Obesity Paradox in Colorectal Cancer Surgery: An Analysis of Korean Healthcare Big Data, 2012-2013. Nutrition and Cancer, 69, 248-253. https://doi.org/10.1080/01635581.2017.1263744