The Impact of Obesity on Surgical

Roger Noun
1
, Edward Riachy
1
, Claude Ghorra
2
, Thierry Yazbeck
1
, Cyril Tohme
1
,
Bassam Abboud
1
, Samah Naderi
2
, Viviane Chalhoub
3
, Eliane Ayoub
3
, Patricia Yazbeck
3
Departments of 1Digestive Surgery, 2Pathology, and 3Anesthesiology,
Hôtel-Dieu de France Hospital. Beirut, Lebanon
ABSTRACT
Context The effect of obesity on surgical
outcome is becoming an increasingly relevant
issue given the growing rate of obesity
worldwide.
Objective To investigate the specific impact
of obesity on pancreaticoduodenectomy.
Design A retrospective comparative study of
a prospectively maintained database was
carried out to investigate the specific impact
of obesity on the technical aspects and
postoperative
outcome
of
pancreaticoduodenectomy.
Patients Between 1999 and 2006, 92
consecutive
patients
underwent
pancreaticoduodenectomy
using
a
standardized technique. The study population
was subdivided according to the presence or
absence of obesity.
Results Nineteen (20.7%) patients were obese
and 73 (79.3%) patients were non-obese. The
two groups were comparable in terms of
demographics, American Society of
Anesthesiology (ASA) score as well as nature
and
type
of
pancreatico-digestive
anastomosis. The rate of clinically relevant
pancreatic fistula (36.8% vs. 15.1%; P=0.050)
and hospital stay (23.1±13.9 vs. 17.0±8.0
days; P=0.015) were significantly increased in
obese vs. non-obese patients, respectively.
Pancreatic fistula was responsible for one-half
of the deaths (2/4) and two ruptured
pseudoaneurysms. The incidence of the other
procedure-related and general postoperative
complications were not significantly different
between the two groups. Intrapancreatic fat
was increased in 10 obese patients (52.6%)
and correlated positively both with BMI
(P=0.001) and with the occurrence of
pancreatic fistula (P=0.003).
Conclusion Obese patients are at increased
risk for developing pancreatic fistula after
pancreaticoduodenectomy. Special surgical
caution as well as vigilant postoperative
monitoring are therefore recommended in
obese patients.
INTRODUCTION
Obesity, whose incidence is growing at
epidemic rates in the general population, has
been considered a risk factor for surgical
outcomes of patients undergoing abdominal
surgery [1, 2, 3]. The presence of excessive
fat tissue inside and outside the viscera has
often increased operative times and blood
losses while impairing surgical quality. Also,
many authors have consistently reported a
greater risk for leakage and postoperative
complications in the obese population as
compared to lean subjects [2, 3, 4, 5].
However, recent reports seem to challenge
this long-held opinion [6, 7].
Pancreaticoduodenectomy (PD) is still
considered a complex high-risk surgical
procedure. Although its operative mortality is

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now decreased to less than 5% in high-
volume institutions, its morbidity rates remain
unchanged, ranging from 23 to more than
40% [8, 9]. A leading cause of this morbidity
is represented by disruption of the pancreatic
anastomosis, with subsequent pancreatic
fistula, sepsis and hemorrhage [10, 11]. A
substantial risk factor for pancreatic fistula
after PD is the status of the pancreatic
remnant. It has been verified that a soft
pancreatic remnant without ductal dilatation is
associated with a high risk of leakage [12,
13].
Performing PD in the obese patient is more
challenging and hazardous. The presence of
obesity impairs the surgical procedure as a
result of massive fat deposition inside and
outside the pancreas.
The purpose of the present study was to
compare the results of PD in obese and non-
obese patients and to investigate the specific
impact of obesity on the technical aspects and
postoperative outcome of this procedure.
PATIENTS AND METHODS
Between 1999 and 2006, among 116
consecutive patients who had had
pancreaticoduodenal resection in the
Department of Digestive Surgery at Hôtel-
Dieu de France, 92 were included in the
present study. Patients who underwent total
pancreatectomy and patients who underwent
PD for chronic pancreatitis were excluded.
All procedures were carried out by the senior
author (RN). A retrospective review of a
prospectively maintained database was
performed. The study population was divided
into two groups (“Obese” and “Non-Obese”)
according to the presence or the absence of a
body mass index (BMI) value equal to or
higher than 30 kg/m2.
Conventional PD was performed in all
patients [14]. A pancreaticojejunostomy or
pancreaticogastrostomy were performed end-
to-side using a single layer of Prolene® 5/0
either with the pancreatic stump cut surface
(stump anastomosis) in patients with a small
duct (less than 3 mm) or included the
pancreatic ductal wall (ductal anastomosis) in
patients with a dilated duct. Pancreatic duct
stent and fibrin glue were not used.
Hepaticojejunal anastomosis was performed
end-to-side without stenting followed by a
standard end-to-side gastrojejunostomy. In all
patients, a silicone rubber closed-suction
drain was placed in front of and behind the
pancreatic anastomosis and the abdomen was
closed with continuous sutures. Vagotomy,
tubal gastrostomy or feeding jejunostomy
were not performed on any patient. The
majority of patients received erythromycin
lactobionate as a prophylaxis for delayed
gastric emptying and octreotide prophylaxis
as a prophylaxis for pancreatic fistula.
After surgery, the patients were monitored in
the intensive care unit and were returned to
the wards at the discretion of the intensivist.
Abdominal drainage fluids were stented for
amylase and lipase levels when a pancreatic
fistula was suspected. A routine abdominal
CT scan was carried out at day 7 or on any
patient with a suspected infected collection.
All fluid collections were drained
percutaneously with amylase dosage and
bacteriologic cultures.
The main endpoints assessed were in-hospital
mortality and morbidity rates, intraoperative
data, incidence, nature and number of
postoperative complications, and the length of
hospital stay. Pancreatic fistula was defined as
any measurable drainage (from an operatively
placed drain or a subsequently placed
percutaneous drain) having an amylase
content greater than 3 times the upper limit of
the reference serum amylase level requiring
specific management (grade B and C fistulas
according to the International Study Group on
pancreatic fistula [15]). Surgical pathology
specimens from the pancreatic neck of the
obese group were studied further for the
amount of intrapancreatic fat, and were
graded from absent to massive on a 4-point
pancreatic fat scale: 0-absent, 1-normal, 2-
high, 3-massive.
ETHICS
The study was approved by the Ethics and
Research Committee of the Hôtel-Dieu de
France Hospital, Beirut, Lebanon. Oral
informed consent was obtained from each

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patient and the study protocol conforms to the
ethical guidelines of the Declaration of
Helsinki.
STATISTICS
All data and statistical procedures were
carried out using the SPSS version 14.0 for
Windows statistical package (SPSS Inc.,
Chicago, IL, USA). Results are reported as
mean±SD and range or as frequencies, as
appropriate. Statistical analysis was
conducted by using the Fisher’s exact and the
linear-by-linear association tests for
qualitative variables, the ANOVA for the
comparison of means, and the Spearman rank
for testing correlations. Two-tailed P values
less than 0.05 were considered to be
significant.
RESULTS
Population Characteristics
The study population included 92 patients
with a mean age of 62.9±12.5 years (range:
23-82 years). There were 57 (62.0%) men and
35 (38.0%) women. Forty-seven (51%)
patients were classified as American Society
of Anesthesiology (ASA) score I. The Obese
Group included 19 (20.7%) patients and the
Non-Obese Group included 73 (79.3%)
patients. The BMI was 31.8±2.2 kg/m2
(range: 30-38 kg/m2vs. 24.2±2.6 kg/m2
(range: 17-28 kg/m2) in the Obese and Non-
Obese groups, respectively (P<0.001). As
shown in Table 1, the two groups were
comparable in terms of demographics and
ASA score.
Intraoperative Course
Pancreatico-gastrostomy was performed in 53
(57.6%) patients and pancreatico-jejunostomy
in 39 (42.4%) patients. A pancreatico-
digestive anastomosis was performed with the
pancreatic stump cut surface in 71 (77.2%)
and included the pancreatic ductal wall in 21
(22.8%). The intraoperative parameters of the
two groups are listed in Table 2. The two
groups were comparable according to the
Table 1. Demographic and clinical characteristics.
Obese
(No. 19)
Non-Obese
(No. 73)
P value
Age, years: mean±SD (range)
61.7±13.0 (36-76)
63.2±12.5 (23-82)
0.657
Gender:
- Male
- Female
13 (68.4%)
6 (31.6%)
44 (60.3%)
29 (39.7%)
0.602
ASA score:
- I
- II or more
9 (47.4%)
10 (52.6%)
38 (52.1%)
35 (47.9%)
0.799
BMI, kg/m2: mean±SD (range)
31.8±2.2 (30-38)
24.2±2.6 (17-28)
<0.001
Table 2. Intraoperative parameters.
Obese
(No. 19)
Non-Obese
(No. 73)
P value
Nature of anastomosis:
- Pancreatico-gastrostomy
- Pancreatico-jejunostomy
13 (68.4%)
6 (31.6%)
40 (54.8%)
33 (45.2%)
0.312
Type of anastomosis:
- Ductal
- Stump
5 (26.3%)
14 (73.7%)
16 (21.9%)
57 (78.1%)
0.761
Transfusion
7 (36.8%)
25 (34.2%)
1.000
Units of transfusion: mean±SD (range)
1.47±1.47 (1-4)
1.20±1.38 (1-7)
0.459
Vein resection
1 (5.3%)
6 (8.2%)
1.000
Operative time, hours: mean±SD (range)
6.7±1.0 (5.0-7.5)
6.4±0.9 (4.5-7.5)
0.280

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nature and type of pancreatico-digestive
anastomosis. Sixty patients (65.2%) did not
require a blood transfusion during surgery
while the remaining 32 (34.8%) received
blood transfusions with a mean of 1.26±1.38
units of red blood cells. Seven (7.6%) patients
underwent resection of portions of either the
portal vein or the superior mesenteric vein.
Although the operating time was longer in the
Obese Group (6.7±1.0 h) than in the Non-
Obese Group (6.4±0.9 h), the difference did
not reach the statistical significance
(P=0.280).
Postoperative Course
There were 4 postoperative deaths, 2 in each
group for an in-hospital mortality rate of
4.3%. The cause of death was sepsis in the
setting of pancreatic fistula in two patients of
the Obese Group, a myocardial infarction and
a death resulting from a catastrophic scenario
following percutaneous biliary drainage in the
Non-Obese Group.
Thirty three (35.9%) patients developed a
postoperative complication (Table 3). The
overall rate of clinically relevant pancreatic
fistula was 36.8% in the Obese Group and
15.1% in the Non-Obese Group (P=0.050).
Analysis of the incidence of pancreatic fistula
revealed that it was not significantly
influenced by the nature (pancreatico-
gastrostomy vs. pancreaticojejunostomy) and
the type (ductal vs. stump) of pancreatic
anastomosis in all patients and within each of
the two groups (Table 4). The incidence of the
other postoperative complications was not
significantly different between the two groups
(Table 3). Seven (7.6%) patients presented
postoperative hemorrhage (2 in the Obese
group and 5 in the Non-Obese group). Three
were re-operated on, including hemostasis of
a bleeding artery of the pancreatic capsule in
one obese patient, and completion
pancreatectomy in two non-obese patients
(one for early pancreatic anastomotic bleeding
and one for a bleeding pseudoaneurysm of the
Table 3. Postoperative factors and complications.
Obese
(No. 19)
Non-Obese
(No. 73)
P value
Pancreatic fistula: grade B or greater
7 (36.8%)
11 (15.1%)
0.050
Delayed gastric emptying
2 (10.5%)
13 (17.8%)
0.728
Intra-abdominal abscess
2 (10.5%)
6 (8.2%)
0.667
Wound infection
3 (15.8%)
8 (11.0%)
0.691
Hemorrhage
2 (10.5%)
5 (6.8%)
0.631
Pneumonia
1 (5.3%)
5 (6.8%)
1.000
Re-operation
1 (5.3%)
2 (2.7%)
0.505
Morbidity
7 (36.8%)
26 (35.6%)
1.000
Mortality
2 (10.5%)
2 (2.7%)
0.188
Postoperative hospital stay, days: mean±SD (range)
23.1±13.9 (9-67)
17.0±8.0 (6-61)
0.015
Table 4. Frequency of pancreatic fistula according to the nature and type of pancreatic anastomosis.
All patients
(No. 92)
Obese
(No. 19)
Non-Obese
(No. 73)
P value
Nature of anastomosis:
- Pancreatico-gastric
- Pancreatico-jejunal
12/53 (22.6%)
6/39 (15.4%)
P=0.436
5/13 (38.5%)
2/6 (33.3%)
P=1.000
7/40 (17.5%)
4/33 (12.1%)
P=0.744
0.140
0.224
Type of anastomosis:
- Ductal
- Stump
2/21 (9.5%)
16/71 (22.5%)
P=0.228
1/5 (20.0%)
6/14 (42.9%)
P=0.603
1/16 (6.3%)
10/57 (17.5%)
P=0.437
0.429
0.070

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gastroduodenal arterial stump in the setting of
pancreatic fistula). Two patients necessitated
embolization of the hepatic artery, the first
(obese) for a bleeding pseudoaneurysm of the
gastroduodenal arterial stump in the setting of
pancreatic fistula which resulted in biliary
ischemia, and the second (non-obese), who is
included in the 4 in-hospital deaths, for
uncontrollable hemobilia from a percutaneous
transhepatic biliary drain which resulted in
acute liver necrosis and death. The remaining
2 non-obese patients responded to
conservative management. All the re-
operations were performed for bleeding. The
mean length of hospital stay was significantly
longer (P=0.015) in the Obese Group
(23.1±13.9 days; range: 9-67 days) as
compared with the Non-Obese Group
(17.0±8.0 days; range: 6-61 days).
The final pathologic diagnoses of the resected
specimens
revealed
periampullary
adenocarcinoma in 13 (68.4%) patients of the
Obese Group and in 52 (71.2%) patients of
the Non-Obese Group (P=0.785). Surgical
pathology specimens from the pancreatic neck
of the Obese group showed that the amount of
intrapancreatic fat was increased in 10
patients (52.6%; pancreatic fat scale equal to
2 or 3) and correlated positively both with
BMI (P=0.001; Figure 1) and with the
occurrence of pancreatic fistula (P=0.003;
Figure 2).
DISCUSSION
Johns Hopkins Hospital, as well as other
high-volume centers worldwide, have
reported a substantial decrease in hospital
mortality for PD, about 5% or lower [8, 9, 16,
17]. In addition to careful patient selection,
improved
surgical
technique
and
improvements in perioperative care, the high-
volume of PD made have contributed to this
drop. The current series was performed in a
tertiary care and academic institution having
the aforementioned prerequisites and resulted
in an operative mortality rate which is in
accordance with experienced centers. During
the last 5 years, the annual caseload has
increased to more than 15 resections which
might have contributed in part to the
improved outcome. Furthermore, because of
the high volume, intraoperative mishaps were
not encountered, and operative time and blood
administration were comparable to other
series.
Despite a substantial drop in mortality after
PD, the morbidity rates remained unchanged
ranging from 23 to more than 40% and were
led by the occurrence of a pancreatic fistula
[8, 9, 16, 17, 18, 19]. It has repeatedly been
demonstrated that both soft pancreatic
remnant texture and small duct size are major
risk factors for pancreatic fistula [12, 13].
Although, obesity was recently identified as
an additional risk factor for leakage after
distal pancreatectomy, the current study
highlights the increased risk after PD [20].
Our results demonstrated that the presence of
obesity more than doubled the risk of
Figure 2. Correlation between the occurrence of
pancreatic fistula and intrapancreatic fat graded from
absent to massive on a four-point scale (linear-by-
linear association test).
Figure 1. Correlation between BMI and intrapancreatic
fat graded from absent to massive on a four-point scale
(Spearman rank correlation test).

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pancreatic fistula after PD despite a
standardized technique which was performed
by the same surgeon.
Obesity seems to affect both the texture of the
pancreatic remnant and the quality of
pancreatic anastomosis construction. It is well
known that, in almost every individual, there
is a variable amount of intrapancreatic fat
which varies from 3 to 20%, according to the
nutritional state [21]. Our results
demonstrated that the amount of
intrapancreatic fat was increased in 50% of
our obese patients and that this increase
correlated positively with BMI. As illustrated
in Figure 3, fat infiltration of the pancreatic
remnant makes it prone to laceration during
suturing or tying. In addition, the presence of
a bulky pancreatic remnant with obscure
demarcation in a deep operating field would
affect technical precision in anastomosis
construction which are essential factors for
the prevention of pancreatic fistula.
The impact of obesity on the technical
difficulty of many abdominal procedures has
previously been reported and has translated
into longer operating times and increased
blood losses than in lean subjects [5, 22]. In
this study, we have noted that, in the obese
patients, some stages of the procedure were
more laborious, particularly transection of the
mesentery of the first jejunal loop, complete
excision of the retroportal pancreatic process
as well as complete dissection of the right
side of the superior mesenteric artery and of
the portal vein. However, intraoperative
difficulty has not significantly altered
intraoperative parameters (blood transfusions
and operating time) in the obese group. This
is probably related to the fact that except for
one mesentericoportal venous reconstruction,
all were performed in the non-obese group.
No one can ignore the fact that blood
transfusions and operating time are increased
in patients undergoing PD with venous
reconstruction [23, 24].
Pancreatic fistula is the factor most strongly
linked with death in the majority of case
series and remains the leading cause of
morbidity after PD [9, 25]. Analysis of the
cause of mortality in the current series
revealed that pancreatic fistula was
responsible of one-half (2/4) of the deaths. In
addition, pancreatic fistula resulted in two
life-threatening bleeding pseudoaneurysms
which are known to result from sepsis in the
pancreatic bed [26, 27, 28]. According to our
results, the pancreatic surgeon, while
performing PD in an obese patient, must be
prepared for an increased risk of anastomotic
leak and for subsequent, often lethal,
hemorrhage. Like others, we advocate trying
to avoid vascular injuries during
lymphadenectomy, meticulous anastomosis,
wrapping of the dissected vessels and
adequate abdominal drainage [27]. We also
anticipate the problems related to interrupting
the hepatic arterial flow after PD where its
consequences may be disastrous as we
observed in two of our patients [28, 29]. We
therefore recommend a gastroduodenal
arterial stump of at least 1 cm in length in
order to enable safe microcoil embolization in
the case of bleeding from the arterial stump.
Postoperatively, percutaneous placement of a
covered stent in the hepatic artery can arrest
pseudoaneurysm bleeding while preserving
common hepatic artery patency [30, 31].
The effects of obesity on surgical outcome
after major abdominal surgery are becoming
an increasingly relevant issue given the
growing rate of obesity worldwide. In the
current series, 19 out of 92 patients (21%)
undergoing PD were obese (i.e., a BMI equal
to or greater than 30 kg/m2). Obesity is known
Figure 3. Typical histological specimen of the
pancreatic neck cut surface showing massive
intrapancreatic fat deposition (H&E, x4).

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to affect surgical outcome through both
procedure-related and general complications.
In the present study, in addition to the
increased risk of pancreatic fistula which
lengthened the hospital stay in obese patients,
one unexpected result was the same trend for
general complications when compared to non-
obese patients. Because the majority of obese
patients were mildly obese (17 out of 19
patients had a BMI ranging from 30.0 to 34.9
kg/m2), associated comorbidity conditions
such as cardiovascular disease, pulmonary
dysfunction and diabetes were infrequent as
reflected by the comparable ASA scores. Like
others, we believe that obesity alone is not a
risk factor for postoperative general
complications [7, 32]. Rather, their likelihood
seems more related to ASA score. In addition,
we believe that mild obesity without
associated comorbidities is relatively
protective for patients undergoing PD for
malignancy owing to relatively preserved
nutritional and immunological status.
CONCLUSION
The current single-institution retrospective
study showed that obese patients are at
increased risk for developing pancreatic
fistula after PD. Special surgical caution as
well as vigilant postoperative monitoring are
therefore recommended when performing PD
in obese patients.
Received February 16th, 2008 - Accepted
April 10th, 2008
Keywords Obesity; Pancreatic Fistula;
Pancreaticoduodenectomy
Abbreviations
PD:
pancreaticoduodenectomy
Conflict of interest The authors have no
potential conflicts of interest
Correspondence
Roger Noun
Department of Digestive Surgery
Hôtel-Dieu de France Hospital
Bd Alfred Naccache
Achrafieh B.P
166830, Beirut
Lebanon
 
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