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Are Surgeons Rising to the Challenge of Managing Morbidly Obese Patients Undergoing Hepatic Resection?  Comment on “Safety of Hepatic Resections in Obese Veterans”

J. Michael Millis, MD
Arch Surg. 2012;147(4):337. doi:10.1001/archsurg.2011.1547.
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The article by Saunders et al1 attempts to address an issue that is frequently confronted in all areas of surgery: what role, if any, does obesity play in surgical outcomes? As surgeons, we know that operations are more challenging, complications more frequent, and diagnosis of postoperative complications more difficult in obese patients and especially in morbidly obese patients. Does obesity make the job of the surgeon more difficult, or does it really impact outcomes? Saunders and colleagues attempt to answer the question for hepatic resections. In their review of 403 liver resections in the VASQIP, 297 patients were overweight or obese (BMI ≥25.0). The only decrement in survival identified was in the extremely obese group (BMI ≥40.0; n = 11), and the reason for a decrease in survival was from postoperative cardiac arrest. I would categorize this article as a further analysis of the question rather than an answer. It should be noted that the database used is not designed to specifically address hepatic surgery; therefore, no information is available in the database regarding the underlying hepatic disease or quality of the remnant hepatic lobe or segment, and the ability to obtain details on a set of patients is limited. The major conclusion by Saunders and colleagues that extreme obesity is an independent risk factor for mortality secondary to cardiac arrest is countered by the fact that there were no myocardial infarctions in this group of 11 patients. Can we conclude that the cardiac arrests were a result of noncardiac events such as multiple organ failure from postoperative complications, hemorrhage, and other factors routinely thought of as surgical in nature? The question surgeons really want answered is, how can we optimally manage obese patients with surgical problems of the liver? That question is left open for future studies.

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