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AUSTIN, Texas -- Increasingly severe obesity drives up complication rates after hysterectomy, and outcomes continually worsen with rising body mass index, according to results from a study reported here.

As women's body mass index (BMI) increased from obese to morbidly obese to super obese, so did the likelihood of conversion from minimally invasive to open surgery, Lauren Winfree, BS, said at the Society of Gynecologic Oncology meeting. Among the 16% of patients slated for minimally invasive procedures who required conversion to open surgery, the need for conversion was associated with a significantly higher BMI (47.3 versus 40.6, P<0.001).

The feasibility and adequacy of lymphadenectomy continually decreased with rising BMI, such that a third as many super-obese patients had lymphadenectomy as compared with obese patients. Moreover, 50% fewer nodes were sampled in the super-obese subgroup, noted Winfree, a medical student at the University of Virginia in Charlottesville.

Complications involving blood loss, transfusion, bowel injury, and pneumonia all increased with the severity of obesity.

"All obese women are not equal," said Winfree. "Complications continue to increase with increasing obesity."

"As obesity increased, the feasibility of full surgical staging decreased," she continued. "Both surgeons and patients need to have a realistic understanding of obesity-specific outcomes."

In general, minimally invasive surgery was associated with fewer complications and improved lymph-node dissection than was open surgery, across all categories of obesity, Winfree added.

Often overlooked in the ongoing obesity epidemic, different categories of obesity are increasing at different rates. From 2001 to 2005, the super-obese population (BMI ≥50) increased by 75% and the morbidly obese group (BMI 40 to 49) by 52%, compared with a 24% increase in the number of obese individuals (BMI 30 to 39).

"The most extreme groups of obesity are increasing at the fastest rates, and this will profoundly affect surgeons," said Winfree.

To see how the obesity trends are affecting gynecologic oncologists, investigators performed a retrospective chart review of obese women who underwent hysterectomy for uterine cancer or endometrial hyperplasia. The search of medical records produced 659 women for the analysis.

The group had a mean age of 58, mean weight of 250 lbs., and mean BMI of 43. Obese patients accounted for 39% of the population, morbidly obese for 42%, and super obese for 19%. About 90% of the women had uterine cancer, which was stage I in 80.5% of cases.

Comparison of the obese, morbidly obese, and super-obese patients showed that women in the two latter categories were younger (57 and 54, respectively, versus 60 for obese patients, P<0.001) and had a higher prevalence of diabetes (36% and 46.3% versus 33%, P=0.038).

The mean BMI was 34.9 for the obese group, 44.2 for the morbidly obese, and 57.8 for the super obese.

The records showed that 379 women had open surgery and 280 had minimally invasive procedures, including laparoscopic and robotic hysterectomy. Of the women who had open surgery, 359 underwent total abdominal hysterectomy.

The minimally invasive and open-surgery groups differed significantly in several respects. Patients who had total abdominal hysterectomy were heavier (255 versus 244 lbs., P=0.004), had a higher BMI (44 versus 41.7, P=0.003), and were less likely to have stage I uterine cancer (77% versus 86%, P=0.008).

The open-surgery group also was significantly less likely to undergo lymphadenectomy (P<0.001).

Severity of obesity had a significant impact on lymphadenectomy. Winfree reported that 63.8% of obese patients had lymphadenectomies, involving an average of 20.4 nodes. Figures for the morbidly obese were 37.1% and 15.1 nodes, and 20.3% and 10.0 nodes for the super obese (P<0.001 for percentage and number of nodes).

Morbidly obese and super-obese patients also had significantly more wound complications (P=0.001), ICU admissions (P=0.001), and total complications (P<0.001) compared with obese patients. Patients in the two highest categories of obesity also had longer hospitalizations (P<0.001).

Compared with minimally invasive procedures, open surgery was associated with significantly more complications, irrespective of obesity category:

• Excess blood loss, 365.7 versus 173.9 mL, P<0.001
• Transfusion, 12.4% versus 2.9%, P<0.001
• Wound infection, 20.5% versus 4.7%, P<0.001
• Ileus, 11.9% versus 3.6%, P<0.001
• Discharge to nursing facility, 2.8% versus 0.4%, P=0.025
• Readmission, 10.0% versus 4.7%, P=0.012

Multivariate analysis showed that both surgery type and obesity category had significant associations with superficial wound complications (P<0.001), wound care (P<0.001), and any complication (P=0.003). Additionally, open surgery was associated with postoperative blood transfusion (P<0.001), readmission (P=0.025), and postoperative ileus (P<0.001).

Obesity category also was associated with postoperative ICU admission (P<0.001).

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