The effect of body mass index on surgical outcomes and survival following pelvic exenteration☆
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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2019, European Journal of Surgical OncologyCitation Excerpt :BMI affected OS in univariate analysis but not in multivariate analysis. Obesity has not been shown to affect recurrence or OS in patients who undergo PE for a gynecological indication [23]. In multivariate analysis, only negative surgical resection margins (R0) and negative lymph node status had a positive effect on patient survival.
Performance and outcome of pelvic exenteration for gynecologic malignancies: A population-based study
2019, Gynecologic OncologyCitation Excerpt :This trend parallels to what is observed in the general U.S. population [12]. Increasing obesity is most likely a contributing factor to increasing medical comorbidity, resulting in more complications, as has also been demonstrated in other studies [23,24]. For instance, a prior study showed that obese patients had a significantly higher rate of early postoperative complications within 2 months of surgery compared to those of normal weight (82.8% versus 59.3%) [23].
Prediction of short-term surgical complications in women undergoing pelvic exenteration for gynecological malignancies
2019, Gynecologic OncologyCitation Excerpt :Here we observed an increase in the 30-day complication rate in women with morbid obesity, ranging from 19.0% for BMI 25–34.5 to 42.9% for BMI 35+ (p = 0.033). Iglesias et al. focused on the impact of BMI on PE, reported a prolonged hospital stay and increased risk of wound dehiscence but the overall late complication rate was not different to that of non-obese woman [10]. Consistent with data reported in literature from Huang et al. [11], advanced age, particularly those without multiple co-morbidities, is not an absolute contraindication to PE, with rates of both early and late complications being no different in young versus elderly women in our cohort.
Complications of Pelvic Exenteration
2018, Principles of Gynecologic Oncology SurgeryInfluence of tumor size on outcomes following pelvic exenteration
2017, Gynecologic OncologyCitation Excerpt :However, in select populations, such as cervical and endometrial cancer, radiation may beget improved survival and warrants further investigation [5,10]. As previously reported, obesity increases acute postoperative complications but does not affect OS and is consistent with our findings [21]. Furthermore, urologic literature on anterior exenterations for bladder cancer report a lower complication rate at 36% and supports our results of decreased morbidity with anterior exenterations [9].
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This work was supported in part by the Cancer Center Support Grant (NCI Grant P30 CA016672).