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Introduction: With national and worldwide increases in both esophageal cancer and obesity, the number of esophagectomies in morbidly obese patients will increase. Proper surgical risk stratification and patient counseling require a better understanding of the esophagectomy morbidity associated with obesity.
Methods: We studied non-emergent, subtotal or total esophagectomies with reconstruction in the National Surgical Quality Improvement Project database from 2005-2009. After excluding patients with disseminated disease and with body mass index (BMI) <18.5, the outcomes of normal BMI patients, (BMI 18.5 - 25) were compared to morbidly obese patients (BMI ≥ 35). Outcomes were mortality, aggregated morbidity, wound, pulmonary and cardiac morbidity. Multivariable regression controlled for pre-operative comorbidities differing between groups (p<0.2) and established confounders of outcomes.
Results: Of the 483 patients, 373 (77%) had a normal BMI and 315 (29%) were morbidly obese. The overall population was 77% male, with a mean age of 62 years with 43% of patients older than 65 years. Normal BMI patients were older (p=0.02) and more likely to smoke (37% v. 15%, p<0.001). Pre-operative co-morbidities were similar except for a significantly higher incidence of hypertension (62% v. 48%) and diabetes (24% v. 13%) and a lower incidence of preoperative weight loss of ≥10% (11% v. 23%) in the obese population (p<0.001). Morbidly obese patients received fewer red cell transfusions intraoperatively (12% v. 22%, p=0.02). Overall, the rate of major morbidity was 51% and mortality was 3.5%; there was no difference between the groups. On multivariable analysis, all outcomes were the same between groups except deep space infections (DSI). Morbidly obese patients were at 70% higher risk (OR 1.7, 95% CI 1.04 - 2.8, p=0.04) of DSI.
Conclusions: In our study, there were no differences in post-operative mortality or pulmonary, cardiac, and thrombo-embolic morbidity between morbidly obese and normal BMI patients. Morbidly obese patients had elevated odds of deep wound infections. Overall, a BMI > 35 does not confer significant morbidity after esophagectomy. Obese patients with esophageal pathology should not be denied resection based on BMI alone.

Table 1. - Adjusted Odds of Morbidity with Morbid Obesity

	Adjusted Odds Ratio	Confidence Interval	p-value
Death	1.1	0.7 - 1.7	0.8
Any Morbidity	1.1	0.9 - 1.3	0.2
Superficial SI	1.2	0.9 - 1.5	0.1
Deep SI	1.7	1.04 - 2.8	0.04
Organ SI	0.9	0.7 - 1.3	0.7
Pneumonia	1	0.8 - 1.2	0.7
Reintubation	1	0.9 - 1.3	0.7
Fail to Wean	1	0.8 - 1.2	0.9
PE	1.4	1.0 - 2.1	0.09
DVT	1.3	0.9 - 1.8	0.2
Cardiac Arrest	0.6	0.3 - 1.3	0.2
Myocardial Infarction	1.4	0.5 - 3.5	0.5
Bleeding	1.6	0.6 - 4.1	0.3
Sepsis	1	0.8 - 1.2	0.3
Shock	1.1	0.9 - 1.4	0.4
Return to OR	0.9	0.7 - 1.1	0.3

** compared to normal-weight patients † Adjusted for age, smoking, diabetes, hypertension, red cell transfusion, American Society of Anesthesiologists class >=3, and weight loss of > 10 % .