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Metabolic Syndrome Is Associated With Increased Post-Operative Morbidity and Hospital Resource Utilization in Patients Undergoing Elective Pancreatectomy: a NSQIP Study of 16,562 Cases
May C. Tee*1, Dan S. Ubl2, Elizabeth B. Habermann2, David M. Nagorney1, Michael L. Kendrick1, Michael G. Sarr1, Mark J. Truty1, Florencia G. Que1, Kmarie Reid Lombardo1, Rory Smoot1, Michael B. Farnell1
1Surgery, Mayo Clinic, Rochester, MN; 2Surgical Outcomes, Mayo Clinic, Rochester, MN
Purpose: In patients undergoing elective pancreatectomy (distal, proximal, and total), our aim was to evaluate the effect of the Metabolic Syndrome (MS) on postoperative mortality, morbidity, and hospital resource utilization. Our hypothesis was that MS is associated with worse surgical outcomes following pancreatectomy.
Methods: 16,562 patients undergoing elective pancreatectomy from 2005 through 2012 were identified in the Participant Use File of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP). Univariable and multivariable analyses were performed examining the association of MS (defined as body mass index ≥ 30 kg / m2, hypertension requiring medications, and diabetes requiring medications and / or insulin) and risk of 30-day mortality, morbidity, and hospital resource utilization (risk of blood transfusion in the first 72 hours after surgery and prolonged hospital stay, defined as ≥ 13 days, which was the 75th percentile of this cohort). Multivariable logistic regression models controlled for age, sex, race, procedure, smoker status, ethanol use, COPD, functional status, steroid use, albumin, INR, creatinine, bilirubin, hematocrit, and any cardiac or vascular disease.
Results: 1,113 (6.7%) patients had MS (Table). MS was statistically significantly associated with increased postoperative morbidity, major morbidity, surgical site infection, sepsis, cardiac event, respiratory failure, pulmonary embolism, blood transfusion, and prolonged duration of hospital stay (p<0.05 for all analyses). After controlling for potentially confounding variables, there was a 19% increased odds of major morbidity (p=0.017), 33% increased odds of surgical site infection (p<0.001), 38% increased odds of respiratory failure (p=0.011), 26% increased odds of blood transfusion (p=0.016), and 20% increased odds of prolonged hospital stay (p=0.015) in patients with MS compared to patients without MS. MS was not significantly associated with 30-day mortality following elective pancreatectomy (p=0.340). Subgroup analysis was performed by malignant diagnosis. Patients with MS and benign disease had 37% increased odds of major morbidity (p=0.016) and 52% increased odds of blood transfusion (p= 0.027) on multivariable analyses. For patients with malignant disease, MS was not significantly associated with increased risk of major morbidity (p=0.189) nor blood transfusion (p=0.107).
Conclusion: Metabolic Syndrome is an under-emphasized predictor of increased postoperative morbidity and hospital resource utilization in patients undergoing elective pancreatectomy. The effect of MS on these postoperative outcomes appears to be more pronounced for patients with benign rather than malignant indications for pancreatectomy, which may help inform patient selection and optimization of co-morbidities prior to elective surgery.
Table: Effect of Metabolic Syndrome on Post-Operative Outcomes Following Elective Pancreatectomy (N = 16,562)
| Outcome | Patients (%) | Patients (%) | Univariate Analysis | Multivariate Analysis* |
| No Metabolic Syndrome | Metabolic Syndrome | Odds Ratio | P-Value | Odds Ratio | P-Value |
| Mortality | 325
(2.1) | 32
(2.9) | 1.38 | 0.087 | 1.20 | 0.340 |
| Any Morbidity | 4807
(31.1) | 411
(36.9) | 1.30 | <0.001 | 1.27 | <0.001 |
| Any Major Morbidity | 3694
(23.9) | 312
(28.0) | 1.24 | 0.002 | 1.19 | 0.017 |
| Any SSI | 2754
(17.8) | 243
(21.8) | 1.29 | <0.001 | 1.33 | <0.001 |
| Deep / Organ SSI | 1660
(10.7) | 140
(12.6) | 1.20 | 0.058 | 1.20 | 0.055 |
| Any Sepsis | 1752
(11.3) | 149
(13.4) | 1.21 | 0.039 | 1.16 | 0.114 |
| Cardiac Event | 234
(1.5) | 28
(2.5) | 1.68 | 0.010 | 1.41 | 0.100 |
| Respiratory Failure | 781
(5.1) | 84
(7.5) | 1.53 | <0.001 | 1.38 | 0.011 |
| Pulmonary Embolus | 140
(0.9) | 18
(1.6) | 1.80 | 0.018 | 1.61 | 0.065 |
| Any Blood Transfusion** | 1860
(22.3) | 186
(27.6) | 1.33 | 0.001 | 1.26 | 0.016 |
| Prolonged Duration of Stay | 4047
(26.2) | 329
(29.6) | 1.18 | 0.014 | 1.20 | 0.015 |
SSI = Surgical Site Infection.
*Odds Ratios and P-values of multivariable analysis are indicative of Metabolic Syndrome and adjusted for: age, sex, race, procedure (proximal / distal / total pancreatectomy), current smoker, ethanol use, functional status, severe chronic obstructive pulmonary disease, steroid use, serum albumin, INR, creatinine, bilirubin, hematocrit, any cardiac disease, and any vascular disease.
**Any Blood Transfusion: total patients analyzed for this outcome were n = 9,031 due to changes in the definition of blood transfusion. The 2010 ACS-NSQIP definition of any postoperative blood transfusion within 72 hours of surgery was used; thus, only 2010-2012 data is presented.
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