The effect of body mass index on surgical outcomes and survival following pelvic exenteration

https://doi.org/10.1016/j.ygyno.2012.01.010Get rights and content

Abstract

Objective

We sought to evaluate whether preoperative body mass index (BMI) impacts surgical outcomes, complication rates, and/or recurrence rates in women undergoing pelvic exenteration.

Methods

All women who underwent pelvic exenteration for gynecologic indications at our institution from 1993 through 2010 were included. Women were stratified into 3 groups based on BMI. Baseline characteristics, surgical outcomes, early (< 60 days) and late (≥ 60 days) postoperative complications, and recurrence/survival outcomes were collected. Multivariate logistic regression analyses were performed. Kaplan–Meier survival curves were compared using log-rank test.

Results

161 patients were included (59 normal weight, 44 overweight, 58 obese). Median follow-up times were 22, 29, and 25 months. Most patients underwent total pelvic exenteration (68%); 64.6% had a vaginal reconstruction. On multivariate analysis, both overweight and obese patients had a higher risk of early superficial wound separation compared to normal weight patients — OR 10.74 (3.33–34.62, p < 0.001) and OR 4.35 (1.40–13.52, p = 0.011), respectively. Length of surgery was significantly longer for overweight (9.6 h, OR 1.26, 1.02–1.55, p = 0.032) and obese (10.1 h, OR 1.24, 1.04–1.47, p = 0.014) patients than for normal weight patients (8.7 h). Late postoperative complications for patients in the normal weight, overweight, and obese groups were 47.5%, 45.5%, and 43.1% (p = 0.144). There were no differences in time to recurrence (p = 0.752) or overall survival (p = 0.103) between groups.

Conclusion

Although operative times were longer and risk for superficial wound separation was significantly higher, pelvic exenteration appears to be feasible and safe in overweight and obese women with overall complication rates and survival outcomes comparable to normal weight women.

Highlights

► Increasing body mass index was associated with increasing length of surgery in women undergoing pelvic exenteration. ► Superficial wound separation was significantly higher in overweight and obese patients compared to normal weight women. ► Preoperative BMI was not associated with long term complications, recurrence rates, or overall survival in woman after pelvic exenteration.

Introduction

First described by Brunschwig in 1948 [1], pelvic exenteration involves the en bloc radical resection of the pelvic viscera and historically has been used in the management of recurrent gynecologic malignancies confined to the central pelvis. The most common indication for pelvic exenteration is central recurrence or persistence of cervical carcinoma [2]. The procedure varies based on the location and extent of disease, with the goal being to obtain negative surgical margins.

While pelvic exenteration is commonly performed with curative intent, it is associated with a significant risk of morbidity. Post-operative complications have been reported in up to 45–84% of cases [3], [4], [5], [6], [7], [8], [9], [10], [11]. Pelvic exenteration has also been associated with a significant risk of operative mortality, 2–10% [6], [7], [9], [12], [13], [14], [15], although these figures have decreased in recent years [16], [17]. Despite these risks, pelvic exenteration has the potential to provide a significant survival benefit; 5-year survival rates of 20–60% following exenteration have been reported [4], [7], [8], [10], [13], [14], [15], [18], [19].

Obesity is a known risk factor for surgical complications including increased intra-operative blood loss, longer operative times, and increased intra-operative and post-operative complication rates. For this reason, obesity has been considered a relative contraindication to complex surgical procedures [20], [21], [22], [23]. A recent Gynecologic Oncology Group study of patients with early stage endometrial cancer who underwent comprehensive surgical staging suggested that obesity is associated with higher non-cancer mortality and wound complications [24]. Furthermore, obesity has also been associated with lower physical well-being and quality-of-life scores following gynecologic surgery [25]. A few investigators have evaluated whether a patient's weight affects the extent of surgery, surgical outcomes, and survival following exenteration, with conflicting results [4], [11], [14], [17]. However, these studies, did not stratify patients into weight classifications based on BMI for comparison, and one excluded morbidly obese patients (BMI > 35 kg/m2) [4]. Thus, data on the impact of obesity in the setting of pelvic exenteration are limited. The purpose of this study was to evaluate whether pre-operative BMI affects surgical outcomes, complication rates, and/or recurrence rates in women undergoing pelvic exenteration at our institution.

Section snippets

Methods

Following Institutional Review Board approval, a retrospective review of all women who underwent pelvic exenteration for gynecologic indications at M.D. Anderson Cancer Center between January 1993 and December 2010 was performed. Operative reports, pathology records, and clinic and hospital notes were reviewed and data were abstracted pertaining to baseline patient characteristics, surgical and pathological outcomes, early and late complications, and disease recurrence.

The cases were stratified

Results

Between 1993 and 2010, a total of 161 pelvic exenterations were performed for oncologic indications by the gynecologic oncology service at M.D. Anderson Cancer Center. In this analysis, three patients required a second exenterative procedure and were considered twice. One patient initially had an anterior exenteration for recurrent endometrial carcinoma and 3 years later underwent a posterior exenteration for recurrent disease associated with obstruction of the rectosigmoid colon. Two patients

Discussion

To our knowledge, this study is the first to specifically evaluate the impact of BMI on surgical outcomes, postoperative complications, recurrence rates, and survival outcomes following pelvic exenteration in patients with a gynecologic malignancy. Aside from length of surgery and superficial wound separation in the early postoperative period, we found that higher BMI was not associated with increased risk of other intraoperative or postoperative complications. Importantly, increasing BMI was

Conflict of interest statement

The authors do not have any conflicts of interest to declare.

Acknowledgments

Sunita Patterson of MD Anderson's Department of Scientific Publications provided editorial assistance.

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    This work was supported in part by the Cancer Center Support Grant (NCI Grant P30 CA016672).

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