Does morbid obesity worsen outcomes after esophagectomy?

With worldwide increases in esophageal cancer and obesity, esophagectomies in the morbidly obese (MO) will only increase. Risk stratification and patient counseling require more information on the morbidity associated with esophagectomy in the obese.

We studied nonemergent subtotal or total esophagectomies with reconstruction in the National Surgical Quality Improvement Project (NSQIP) database from 2005 to 2010. After excluding patients with disseminated disease and body mass index (BMI) less than 18.5, we compared outcomes of patients with normal BMI (18.5-25) to those of MO patients (BMI ≥ 35). Outcomes were mortality and morbidity. Multivariable regression controlled for age and comorbidities differing between groups.

Of 794 patients, 578 (73%) had a normal BMI and 216 (27%) patients were morbidly obese (MO). The population was 75% men, with a mean age of 62 years. Patients with a normal BMI were older and more likely to smoke (p < 0.001). MO patients had a higher incidence of hypertension (65% versus 41%) and diabetes (20% versus 10%), and fewer had preoperative weight loss greater than 10% (9% versus 31%) (p < 0.001). Overall, morbidity was 48.5% and mortality was 3%; there was no difference between the groups. On multivariable analysis, all outcomes were the same between groups except deep space infections and pulmonary embolism (PE), for which the obese were at 52% and 48% higher risk, respectively (p = 0.02).

In our study, postoperative mortality and pulmonary, cardiac, and thromboembolic morbidity were similar between MO patients and patients with a normal BMI. MO increased the odds of deep wound infections. Overall, BMI greater than 35 does not confer significant morbidity after esophagectomy. Patients with esophageal pathologic conditions should not be denied resection based on MO alone.