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Obesity and Its Implications on Morbidity and Mortality After Appendectomy in Younger Adults
Maitham Moslim1, Toms Augustin*1, Stacy Brethauer1, Ann Rogers2, Diya Alaedeen1, Ali Aminian1, Matthew Kroh1, ERIC B. SCHNEIDER3, R Matthew Walsh1
1Cleveland Clinic, Cleveland, OH; 2PENN STATE HERSHEY, HERSHEY, PA; 3Johns Hopkins school of medicine, Baltimore, MD
Aim: Studies looking at the effect of obesity have treated this group as homogenous in terms of outcomes. The effect of worsening obesity in the context of an otherwise young and healthy patient has not been reported.
Methods: A retrospective analysis of the NSQIP (2005-2013), excluding patients 50 years of age and over. Comparisons were made of BMI 18.5-25 (normal) to (1) BMI 25-30(overweight) (2) 30-35(obese) (3) 35-50 (morbidly obese) and (4) ≥50 (severely obese). Clavien dindo score was created to assess the risk of serious complications
Results: 69,961 patients with a BMI≥18.5 were analyzed. All P values reflect comparison to normal weight (BMI 18.5-25) patients. Comparing demographics, patients with higher BMI were noted to be significantly older (normal BMI; 29 years vs. overweight; 32.5 years vs. obese; 33.2 years vs. morbid obesity 33.5 years vs. severe obesity; 33.7 years), with increasing prevalence of black race (4.7% vs. 5.7% vs. 8.1% vs. 11.5% vs. 12.6%), diabetes (1.1% vs. 1.7% vs. 3.4% vs. 6.2% vs. 9.7%), hypertension (2.0% vs. 5.1% vs. 9.9% vs. 16.7% vs. 24.3%), cardiac risk factors (0.3% vs. 0.5% vs. 0.8% vs. 1.0% vs. 1.3%), pulmonary risk factors (29.2% vs. 30.3% vs. 33.8% vs. 35.5% vs. 33.7%), and neurologic risk factors (0.17% vs. 0.3% vs. 0.36% vs. 0.46% vs. 0.54%) (all P values <0.05). Severely obese patients met the criteria for sepsis 38.9% of the times compared to 32.1% for normal weight (P value <0.05).
Prolonged surgery was associated with increasing BMI (35% longer time in severely obese, all P values <0.05). Risk of Clavien 4 complications noted a step wise increase across all groups of BMI, with severely obese patient patients having a 6 times greater odds of serious complications (all P value <0.05). Regarding mortality, there was a steep increase in odds (over 16 times) comparing severely obese patients to normal BMI patients (P value <0.005). On multivariate regression analyses, increasing BMI (over 25) and age were significant predictors of mortality (1-8% increase for every point increase in BMI over 25). In our model for Clavien 4 complications, increasing BMI, age, preoperative sepsis and perforated appendicitis all contributed significantly to mortality. For every point increase in BMI over 25, a 1% to 13% increase in odds of serious complications requiring ICU management was noted.
Conclusion: There is significantly increased risk of life threatening morbidity after appendectomy with increasing severity of obesity. Severely obese patients additionally have an increased risk of mortality that persists after adjusting for clinically relevant variables. Evaluating the risk of obesity using only a BMI greater than 30, dilutes the strong negative effects of morbid and severe obesity on post-operative outcomes and may be lead to severe underestimation of both populations and individual level risk.
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