Abstract
Background:
Patients with obesity have inferior outcomes after general surgery procedures, but studies evaluating post-liver transplant (LT) outcomes have been limited by small sample sizes or lack of granularity of outcomes. We evaluated the relationship between obesity and post-LT outcomes, including those observed in other populations to be obesity-related.
Methods:
Included were 1357 LT recipients prospectively enrolled in the ambulatory pre-LT setting at 8 U.S. centers. Recipient were categorized by body mass index (BMI, kg/m2): non-obese (BMI < 30), class 1 obesity (BMI 30–<35), and classes 2–3 obesity (BMI ≥ 35). Post-transplant complications were compared by BMI using Chi-square and rank-sum testing, logistic regression, Kaplan-Meier curves, and Cox regression.
Results:
Classes 2–3 obesity was associated with higher adjusted odds than non-obesity of venous thrombosis [adjusted odds ratio (aOR) 2.06, 95% CI 1.01–4.23, p = .047] and wound dehiscence (aOR 2.45, 95% CI 1.19–5.06, p = .02). Compared with non-obese recipients, post-LT hospital stay was significantly longer for recipients with classes 2–3 obesity [p = .01; median (Q1–Q3) 9 (6–14) vs. 8 (6–12) days) or class 1 obesity [p = .002; 9 (6–14) vs. 8 (6–11) days]. Likelihood of ICU readmission, infection, discharge to a non-home facility, rejection, 30-dayreadmission, and 1-year readmission were similar across BMI categories (all p > .05).
Conclusion:
Compared to non-obese recipients, obese recipients had similar post-LT survival but longer hospital stay and higher likelihood of wound dehiscence and venous thrombosis. These findings underscore that obesity alone should not preclude LT, but recipients with obesity should be monitored for obesity-related complications such as wound dehiscence and venous thrombosis.
Keywords: BMI, liver transplant, obesity, outcomes
1 |. INTRODUCTION
The national obesity epidemic has resulted in higher body mass indices (BMIs) for surgical patients, including liver transplant (LT) recipients. Obesity has been associated with higher risk of prolonged intubation, postoperative complications, and reoperation; longer intensive care unit (ICU) and hospital lengths of stay (LOS); and higher risk of non-home discharge location in various surgical populations.1–5 However, despite the rising proportion of LT candidates and recipients with obesity, there are mixed findings about the relationship between obesity and post-transplant complications. Careful assessment of the association between obesity and post-LT outcomes is critical, given that several American and European guidelines suggest a BMI≥40 as a relative contraindication for LT,6–8 a recommendation that is followed by over half of all U.S. LT centers.9
To date, studies examining the relationship between obesity and post-LT outcomes have been divided on whether BMI is associated with postoperative complications, including those such as wound infections, wound dehiscence, vascular complications, and herniation that are considered potentially obesity-related.10–14 There is similarly conflicting evidence about the relationship between obesity and post-LT graft and patient survival.12,15–18 Pelletier et al. found that LT recipients with classes 2–3 obesity had a higher mortality risk than recipients with a lower BMI,15 while Leonard et al. found that both early and late patient and graft survival were similar across BMI categories, even after accounting for ascites.16 These studies have frequently been limited by either having the granularity to evaluate postoperative complications or the power to evaluate longer-term outcomes such as graft and recipient survival, but they rarely are able to evaluate both.
Therefore, we sought to evaluate the relationship between obesity and both short- and long-term post-LT outcomes using a large, multicenter, prospective cohort of LT recipients. We evaluated complications occurring during the transplant hospitalization, discharge disposition, and longer-term post-LT outcomes including rejection, graft failure, and mortality.
2 |. METHODS
2.1 |. Study population
This study evaluated LT recipients from the multicenter Functional Assessment in Liver Transplantation (FrAILT) study, a prospective cohort study that includes eight LT centers in the U.S. (University of California San Francisco, Baylor, Columbia, Duke, Johns Hopkins, Loma Linda, Northwestern, and University of Pittsburgh) and evaluates the relationship between pre-LT physical frailty and liver waitlist and post-LT outcomes. Briefly, patients were eligible to enroll in the FrAILT Study if they1 had cirrhosis and were approved for listing for LT at participating sites,2 were evaluated in the ambulatory setting, and3 had a Model for End-Stage Liver Disease (MELD) score ≥12 at the time of enrollment. Excluded were those with severe cognitive dysfunction at the time of study screening (given concerns about ability to provide signed informed consent) and those who did not speak English, Spanish, or Chinese (given availability of written consent forms in other languages).19 All study procedures, including informed consent, were conducted in accord with the ethical standards of the institutions at which the study was conducted. For this study, we included all FrAILT study participants who received LT on or before January 31, 2020 and had post-LT outcomes data available. These recipients were enrolled in the FrAILT study between March 2012 and December 2020, and they received LT between June 2012 and December 2020. We excluded recipients without cirrhosis (N = 3). Body mass index (BMI) was categorized as non-obese (BMI < 18.5 kg/m2), Class 1 obesity (BMI of 30–< 35 kg/m2), and classes 2–3 obesity (BMI ≥ 35) per the WHO and Centers for Disease Control guidelines.20,21 While classes 2 and 3 obesity were categorized together due to limited sample size, we also performed a subgroup analysis among recipients with class 3 obesity.
2.2 |. Post-transplant outcomes
Recipients were evaluated for post-LT complications during the transplant hospitalization including intensive care unit (ICU) LOS, duration of intubation post-transplant, ICU readmission, early allograft dysfunction (bilirubin ≥10 mg/dL and/or INR ≥1.6 on post-LT day 7, or liver enzymes > 2000 IU/L within 7 days of LT), bleeding, biliary complications, wound dehiscence, infection, and venous thrombosis, and hospital LOS. Of these, we viewed wound dehiscence, infection, and venous thrombosis as potentially obesity-related. We also evaluated recipients for specific surgical interventions, including planned takeback (i.e., LT was performed in two stages, with the second stage typically including biliary anastomosis and/or closure) and reoperation during the transplant hospitalization. Post-discharge outcomes were also evaluated, including discharge location (facility vs. home; recipients who died during the transplant hospitalization had this value set to missing), readmission by 30 days and 1 year post-transplant, reason for first readmission, and rejection.
2.3 |. Statistical analysis
Recipient baseline characteristics and outcomes were described overall and by BMI group using frequencies and summary statistics, as appropriate. Differences by BMI group were tested using Chi-square tests for categorical variables and Kruskal-Wallis tests for continuous variables. Pairwise comparisons within categorical variables were evaluated using a post-hoc Dunn’s pairwise comparison test with Bonferroni correction. Logistic regression was used to evaluate odds of binary outcomes hypothesized to be associated with obesity (e.g., infection, wound dehiscence, and venous thrombosis). Time-to-event comparisons were visualized using Kaplan-Meier survival plots and analyzed using Cox regression; these outcomes included time to hospital readmission, graft failure, and death. These models were adjusted for covariates that were significant at a level of p < .1 on univariate analysis. However, logistic regression analysis for venous thrombosis and wound dehiscence was performed only adjusting for one covariate (presence of medication-treated ascites) due to low event rates for these two complications. Hypothesis tests were two-sided, and the significance threshold was set to .05. Statistical analyses were performed using SAS (Version 9.4, SAS Institute, Cary, NC), Stata (Version 17.1, StataCorp LLC, College Station, TX), and R (Version 4.2.1, R Foundation for Statistical Computing, Vienna, Austria) software.
3 |. RESULTS
3.1 |. Study population
Among 1357 LT recipients, 847 (62%) were non-obese (BMI < 30), 312 (23%) had class 1 obesity (BMI ≥ 30 and <35), and 198 (15%) had classes 2–3 obesity (BMI ≥ 35), which included 40 (2.9%) with class 3 obesity. Race (p = .002), primary diagnosis etiology (p < .001), receipt of a living donor transplant (p = .001), pre-transplant liver frailty index (LFI; p = .03), and Model for End-stage Liver Disease (MELD) score at transplant (p < .001) differed significantly by BMI (Table 1). In the non-obese, class 1 obesity, and classes 2–3 obesity groups, respectively, White race percentages were 81%, 90%, and 87%; primary diagnosis of non-alcoholic steatohepatitis (NASH) or non-alcoholic fatty liver disease (NAFLD) percentages were 12%, 28%, and 39%; receipt of living donor transplant percentages were 20%, 14%, and 11%; median pre-transplant LFI values were 3.82, 3.85, and 3.95; and median MELD score at transplant values were 19, 21, and 22 (Table 1). Recipients with class 3 versus class 2 obesity were qualitatively more likely to have NASH/NAFLD as an indication for transplant (45% vs. 37%) and were less likely to have ascites (48% vs. 64%). They were also less likely to receive an LDLT (3% vs. 7%; Table S1).
TABLE 1.
Recipient, donor, and transplant characteristics by pre-transplant BMI.
| Pre-transplant BMI |
|||||
|---|---|---|---|---|---|
| Characteristic, n (%) | Overall, N = 1357 (100%) | <30, N = 847 (62.4%) | 30-< 35, N = 312 (23.0%) | >=35, N = 198 (14.6%) | p-value |
| Recipient characteristics | |||||
| Age (years), median (Q1-Q3) | 60 (53–65) | 60 (53–65) | 60 (54–65) | 59 (52–63) | .04 |
| Male sex | 909 (67%) | 552 (65%) | 218 (70%) | 139 (70%) | .19 |
| Race | .002 | ||||
| White | 1,138 (84%) | 685 (81%) | 280 (90%) | 173 (87%) | |
| Black | 77 (6%) | 57 (7%) | 9(3%) | 11 (6%) | |
| Other | 142 (10%) | 105 (12%) | 23 (7%) | 14 (7%) | |
| Etiology | <.001 | ||||
| Hepatitis C | 456 (34%) | 304 (36%) | 98 (32%) | 54 (27%) | |
| NASH/NAFLD | 270 (20%) | 105 (12%) | 88 (28%) | 77 (39%) | |
| Alcoholic liver disease | 267 (20%) | 163(19%) | 64 (21%) | 40 (20%) | |
| AIH/PSC/PBC | 182 (13%) | 143(17%) | 26 (8%) | 13 (7%) | |
| Hepatitis B | 66 (5%) | 49 (5%) | 13 (4%) | 4(2%) | |
| Other | 116(8%) | 83 (10%) | 23 (%) | 10 (5%) | |
| Ascites | .27 | ||||
| None | 863 (64%) | 550(65%) | 193 (62%) | 120 (61%) | |
| Mild/moderate | 373 (27%) | 232 (27%) | 83 (27%) | 58 (29%) | |
| Severe | 121 (9%) | 65 (8%) | 36 (11%) | 20 (10%) | |
| Ascites medications | .005 | ||||
| No | 577 (43%) | 379 (45%) | 135 (44%) | 63 (33%) | |
| Yes | 761 (57%) | 457(55%) | 173 (56%) | 131 (67%) | |
| Missing | 19 | 11 | 4 | 4 | |
| MELD at transplant, median (Q1-Q3) | 20(15–27) | 19(14–26) | 21 (15–28) | 22 (15–29) | <.001 |
| Pre-transplant Liver Frailty Index (LFI), median (Q1-Q3) | 3.9 (3.3–4.3) | 3.8 (3.3–4.3) | 3.9 (3.3–4.3) | 4.0 (3.5–4.5) | .03 |
| Frailty classification | .08 | ||||
| Robust/Pre-frail (LFI < 4.5) | 1087 (80%) | 685 (81%) | 255 (82%) | 147 (74%) | |
| Frail (LFI ≥ 4.5) | 270 (20%) | 162 (19%) | 57(18%) | 51 (26%) | |
| Donor characteristics | |||||
| Age (years), median (Q1-Q3) | 41(29–53) | 41(29–53) | 42(30–55) | 42 (31–54) | .34 |
| White race | 744 (58%) | 476 (60%) | 154 (52%) | 114 (60%) | .16 |
| Transplant characteristics | |||||
| Living donor transplant | 236(17%) | 172 (20%) | 42 (14%) | 22 (11%) | .001 |
| Simultaneous liver-kidney transplant | 89 (7%) | 64 (8%) | 13 (4%) | 12 (6%)I | .11 |
| Donation after circulatory death | 139(11%) | 88(11%) | 29(10%) | 22 (12%) | .73 |
Abbreviations: AIH,autoimmunehepatitis;LFI, liver frailty index; NASH,non-alcoholicsteatohepatitis;NAFLD, non-alcoholic fatty liver disease;PBC, primary biliary cirrhosis; PSC, primary sclerosing cholangitis; Q1-Q3,1st-3rd quartile.
3.2 |. Post-operative outcomes
Post-operative outcomes including ICU LOS, duration of intubation post-transplant, and likelihood of ICU readmission, early allograft dysfunction, bleeding, and biliary complications were similar among BMI categories (Table 2). Risk of infection was similar across BMI categories, even after accounting for donor, recipient, and transplant characteristics (Class I obesity vs. non-obese p = .46, classes 2–3 obesity vs. non-obese p = .36). Recipients with classes 2–3 obesity had higher odds of venous thrombosis than non-obese recipients (OR 2.24, 95% CI 1.10–4.57, p = .03); however, risk of venous thrombosis was similar for recipients with class I obesity and non-obese recipients (OR 1.24, 95% CI .60–2.57, p = .56). These inferences remained unchanged after adjusting for the presence of pre-transplant ascites (classes 2–3 obesity vs. non-obese, aOR 2.06, 95% CI 1.01–4.23, p = .047). Wound dehiscence differed significantly by BMI (non-obese: 2.7% vs. class 1: 4.6% vs. classes 2–3: 6.8%, p = .02). Recipients with classes 2–3 obesity had 2.67-fold higher odds of wound dehiscence than recipients without obesity (OR 2.67, 95% CI 1.32–5.41, p = .006). These inferences remained unchanged after adjusting for the presence of pre-transplant ascites (Classes 2–3 obesity vs. non-obese, aOR 2.45, 95% CI 1.19–5.06, p = .02). Risk of wound dehiscence was qualitatively higher among recipients with class 2 obesity than among recipients with class 3 obesity (7.9% vs. 2.5%; Table S2).
TABLE 2.
Liver transplant outcomes by pre-transplant BMI.
| Pre-transplant BMI |
|||||
|---|---|---|---|---|---|
| Outcome, n (%) | Overall, N = 1357 (100%) | <30, N = 847 (62.4%0 | 30to< 35, N = 312 (23.0%) | >=35, N = 198 (14.6%) | p-value |
| Transplant hospitalization | |||||
| Liver enzyme elevation | 171 (69%) | 96 (68%) | 43 (67%) | 32 (74%) | .67 |
| Biliary complication | 44 (3%) | 30 (4%) | 6 (2%) | 8 (4%) | .31 |
| Early allograft dysfunctiona | 255(19%) | 146 (18%) | 65 (21%) | 44 (23%) | .15 |
| Venous thrombosis | 47 (4%) | 24 (3%) | 11 (4%) | 12 (6%) | .08 |
| Bleeding | 54 (4%) | 40 (5%) | 5 (2%) | 9 (5%) | .05 |
| Wound dehiscence | 49 (4%) | 22 (3%) | 14 (5%) | 13 (7%) | .02 |
| Infectionb | 270 (21%) | 165 (20%) | 62 (20%) | 43 (23%) | .75 |
| Reoperation | 161 (12%) | 109(13%) | 25 (8%) | 27(14%) | .049 |
| Duration of intubation (days), median (Q1-Q3) | 0(0–1) | 0(0–1) | 0(0–1) | 0(0–1) | .09 |
| ICU readmission | 126(10%) | 81 (10%) | 21 (7%) | 24(12%) | .11 |
| ICU length of stay (LOS; days), median (Q1-Q3) | 2 (1–3) | 2(1–3) | 2(1–3) | 2(1–4) | .08 |
| Hospital LOS (days), median (Q1-Q3) | 8(6–12) | 8(6–12) | 8(6–11) | 9(6–14) | .005 |
| Post-discharge | |||||
| Discharge disposition | .10 | ||||
| Home | 1201 (90%) | 759(91%) | 272 (88%) | 170 (86%) | |
| Acute rehab, acute care, or skilled nursing facility | 110 (8%) | 58 (7%) | 32(11%) | 20 (10%) | |
| Death | 27(2%) | 16(2%) | 4 (1%) | 7(4%) | |
| 30-day readmission | 380 (28%) | 245 (29%) | 76(25%) | 59 (30%) | .27 |
| 1-year readmission | 618 (46%) | 369 (44%) | 155 (50%) | 94 (48%) | .15 |
| Time to first readmission (days), median (Q1-Q3)c | 29(9–96) | 29(9–94) | 32(10–126) | 24 (8–96) | .49 |
| Rejection | |||||
| Acute cellular rejection | 168(12%) | 108 (13%) | 34(11%) | 26(13%) | .66 |
| Antibody-mediated rejection | 7(1%) | 5(1%) | 2 (1%) | 0 (0%) | .55 |
| Chronic rejection | 12 (1%) | 11 (1%) | 1 (.3%) | 0 (0%) | .10 |
| Other rejection | 8(1%) | 5(1%) | 1 (.3%) | 2 (1%) | .61 |
Bilirubin ≥10 mg/dL and/or INR ≥1.6 on post-transplant day 7, or liver enzymes > 2000 IU/L within 7 days of transplant surgery.
Within 90 days of liver transplant surgery.
Among patients who were readmitted within 1 year of transplant surgery.
BMI category was not significantly associated with planned return to the operating room (p = .61) but was associated with reoperation during the transplant hospitalization (non-obese: 13.1% vs. Class 1: 8.1% vs. classes 2–3: 14.0%, p = .049). Post-LT hospital LOS differed significantly by BMI [p = .005; non-obese: median (Q1–Q3) 86–12 vs. class 1: 86–11 vs. classes 2–3: 96–14 days].
3.3 |. Post-hospitalization outcomes
Among recipients who were alive at hospital discharge and had an available discharge disposition (N = 1311), likelihood of discharge to a non-home location was similar across BMI categories (Class I obesity vs. non-obese p = .20, classes 2–3 obesity vs. non-obese p = .41), as was likelihood of readmission at 30 days post-LT (non-obese: 29%; class 1 obesity: 25%; classes 2–3 obesity: 30%, p = .27) and 1-year post-LT (non-obese: 44%; class 1 obesity: 50%; classes 2–3 obesity: 48%, p = .15). Risk of first readmission post-LT was also similar across BMI categories (Class 1 obesity vs. non-obese: aHR .87, 95% CI .72–1.04, p = .12; classes 2–3 obesity vs. non-obese aHR .87, 95% CI .70–1.09, p = .23; Figure 1), as was risk of graft failure (Class 1 obesity vs. non-obese: aHR .77, 95% CI .51–1.14, p = .19; classes 2–3 obesity vs. non-obese aHR .91, 95% CI .58–1.42, p = .68; Figure 2A). Reason for first readmission was similar by BMI category (p = .43). Mortality risk was also similar across BMI categories (Class 1 obesity vs. non-obese: aHR .79, 95% CI .51–1.23, p = .30; classes 2–3 obesity vs. non-obese aHR 1.01, 95% CI .62–1.63, p = .98; Figure 2B). Across BMI categories, there were no significant differences in overall risk of rejection (non-obese: 18% vs. class 1: 14% vs. classes 2–3: 18%, p = .23) or of risk of acute (p = .66) or chronic (p = .10) rejection.
FIGURE 1.
Risk of readmission by time since liver transplant hospitalization and pre-transplant body mass index.
FIGURE 2.
Risk of (A) graft failure and (B) mortality by time since liver transplant and pre-transplant body mass index.
4 |. DISCUSSION
In this multicenter prospective cohort study of over 1300 LT recipients, we found that recipients with obesity had longer hospital LOS and higher likelihood of post-LT wound dehiscence and venous thrombosis. However, the likelihood of other potentially obesity-related complications, including wound infection, and the risk of post-transplant mortality were similar among recipients with and without obesity. Overall, we found that transplant recipients with obesity, even those with classes 2–3 obesity, had excellent post-LT outcomes.
Our findings of similar rates of most complications across BMI categories stands in contrast to the deep-rooted concern about offering transplant to patients with obesity in the solid organ transplant community. While there is likely selection bias in our sample influencing which patients with obesity are considered for and receive a LT, we believe that our findings underscore the fact that recipients with obesity—even those with classes 2 or 3 obesity—hav overall excellent outcomes after LT. These findings are consistent with findings in other surgical fields, including other hepatobiliary surgeries, that obesity can be associated with higher technical difficulty but typically similar postoperative outcomes in the modern era.22–24
Among the complications examined in this study, we had hypothesized that wound dehiscence, venous thrombosis, and wound infection would be more likely to occur among LT recipients with obesity than among recipients without obesity, based on smaller studies of LT recipients,10–14 studies of kidney transplant recipients,25 and general surgery literature.26–29 Arthurs et al. found that patients in the general population who were overweight were three times as likely to have postoperative wound complications.30 These complications are theorized to be associated with obesity due to multiple factors, including increased abdominal pressure, excess tension, creation of additional potential space for fluid accumulation (e.g., hematoma, seroma), inadequate nutrition, and higher likelihood of other comorbidities that might affect wound healing (e.g., diabetes, hypertension, cardiovascular disease).27,29,31,32 While our analyses were limited by overall low event rates for these complications—a testament to the excellent outcomes of these LT recipients—we did find that recipients with classes 2–3 obesity had over two-fold higher odds of venous thrombosis and of wound dehiscence than recipients without obesity, even after accounting for the presence of pre-transplant ascites. In contrast, other complications, which we had not hypothesized as being associated with obesity, did not significantly differ by BMI category.
Limitations of this study include a low event rate, which curtailed our ability to adjust for recipient factors beyond obesity and ascites that might affect outcomes. Additionally, the limited number of recipients with classes 2 or 3 obesity reduced our power to detect statistically significant differences between this group and the other BMI categories, or between recipients with Class 2 and Class 3 obesity. While our dataset included robust information on this prospective cohort, we did not have access to information about other potentially obesity-related complications, such as hernia development, which have previously been reported in the literature after other types of surgery,10 and could therefore not evaluate these complications in our study population. Further research is needed on additional obesity-relation complications such as hernia development, as well as on long-term complications (e.g., cardiac complications). Additionally, evaluation of access to transplant for patients with obesity through evaluation of the percentage of patients declined for listing based on BMI, as well as evaluation of the impact of pre-transplant or concurrent bariatric surgery are important topics for future study, particularly with the rise of steatotic liver disease as an indication for liver transplantation. Finally, our study was limited to recipients who were initially evaluated for transplant in the outpatient setting; our findings might not be generalizable to patients who are sick enough pre-transplant to require hospitalization and inpatient transplant evaluation.
5 |. CONCLUSION
In conclusion, we found that obesity was associated with longer hospital LOS and higher likelihood of wound dehiscence and venous thrombosis among LT recipients. However, it was not significantly associated with other post-transplant outcomes, including wound infection or mortality. These findings underscore that recipients with obesity, even those with classes 2–3 obesity, have overall excellent post-LT outcomes. Therefore, while LT recipients with obesity should be monitored closely for potential obesity-related complications, concerns about BMI-related complications should not prevent transplantation.
Supplementary Material
ACKNOWLEDGMENTS
This work was supported by grant numbers R01AG059183 (Lai), P30DK026743 (Lai, Shui), K24AG080021 (Lai), and F32AG067642 (Ruck). The analyses described here are the responsibility of the authors alone and do not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products or organizations imply endorsement by the U.S. Government. AMS is part of the Biostatistics Core that is supported by the UCSF Liver Center P30 DK026743. The authors of this manuscript have no conflicts of interest to disclose as described by Clinical Transplantation.
We acknowledge participation in the Transplant Peer Review Network and complied with the journal’s author guidelines and policies.
Funding information
National Institute on Aging; National Institute of Diabetes and Digestive and Kidney Diseases
Footnotes
CONFLICT OF INTEREST STATEMENT
The authors declare no conflicts of interest.
SUPPORTING INFORMATION
Additional supporting information can be found online in the Supporting Information section at the end of this article.
DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.
REFERENCES
- 1.Ogilvie WA, Shakir Z, Whinery LD, et al. Effect of obesity on outcomes after breast reconstruction surgery, an analysis of national surgical quality improvement program. JPRAS. 2022;75(12):4496–4512. [DOI] [PubMed] [Google Scholar]
- 2.Bigarella LG, Ballardin AC, Couto LS, et al. The impact of obesity on plastic surgery outcomes: a systematic review and meta-analysis. Aesth Surg J. 2022;42(7):795–807. [DOI] [PubMed] [Google Scholar]
- 3.Kassahun WT, Mehdorn M, Babel J. The impact of obesity on surgical outcomes in patients undergoing emergency laparotomy for high-risk abdominal emergencies. BMC Surg. 2022;22(1):15. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Yoon P, Rajasekar G, Nuño M, Raskin E, Lyo V. Severe obesity contributes to worse outcomes after elective colectomy for chronic diverticular disease. J Gastrointest Surg. 2022;26(7):1472–1481. [DOI] [PubMed] [Google Scholar]
- 5.Tsekrekos A, Lovece A, Chrysikos D, et al. Impact of obesity on the outcomes after gastrectomy for gastric cancer: a meta-analysis. Asian J Surg. 2022;45(1):15–26. [DOI] [PubMed] [Google Scholar]
- 6.Barone M, Viggiani MT, Avolio AW, Iannone A, Rendina M, Di Leo A. Obesity as predictor of postoperative outcomes in liver transplant candidates: review of the literature and future perspectives. Digestive and liver disease: official journal of the Italian Society of Gastroenterology and the Italian Association for the Study of the. Liver. 2017;49(9):957–966. [DOI] [PubMed] [Google Scholar]
- 7.Martin P, DiMartini A, Feng S, Brown R Jr, Fallon M. Evaluation for liver transplantation in adults: 2013 practice guideline by the American Association for the study of liver diseases and the american society of transplantation. Hepatology. 2014;59(3):1144–1165. [DOI] [PubMed] [Google Scholar]
- 8.Newsome PN, Allison ME, Andrews PA, et al. Guidelines for liver transplantation for patients with non-alcoholic steatohepatitis. Gut. 2012;61(4):484–500. [DOI] [PubMed] [Google Scholar]
- 9.Halegoua-De Marzio DL, Wong SY, Fenkel JM, Doria C, Sass DA. Listing practices for morbidly obese patients at liver transplantation centers in the United States. Exp Clin Transplant. 2016;14(6): 646–649. [DOI] [PubMed] [Google Scholar]
- 10.Schaeffer DF, Yoshida EM, Buczkowski AK, et al. Surgical morbidity in severely obese liver transplant recipients—a single Canadian Centre Experience. Ann Hepatol. 2009;8(1):38–40. [PubMed] [Google Scholar]
- 11.Hakeem AR, Cockbain AJ, Raza SS, et al. Increased morbidity in overweight and obese liver transplant recipients: a single-center experience of 1325 patients from the United Kingdom. Liver Transpl. 2013;19(5):551–562. [DOI] [PubMed] [Google Scholar]
- 12.Perez-Protto SE, Quintini C, Reynolds LF, et al. Comparable graft and patient survival in lean and obese liver transplant recipients. Liver Transpl. 2013;19(8):907–915. [DOI] [PubMed] [Google Scholar]
- 13.Conzen KD, Vachharajani N, Collins KM, et al. Morbid obesity in liver transplant recipients adversely affects longterm graft and patient survival in a single-institution analysis. HPB. 2015;17(3):251–257. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Alvarez J, Mei X, Daily M, et al. Tipping the scales: liver transplant outcomes of the super obese. J Gastrointest Surg. 2016;20(9):1628–1635. [DOI] [PubMed] [Google Scholar]
- 15.Pelletier SJ, Maraschio MA, Schaubel DE, et al. Survival benefit of kidney and liver transplantation for obese patients on the waiting list. Clin Transpl. 2003:77–88. [PubMed] [Google Scholar]
- 16.Leonard J, Heimbach JK, Malinchoc M, Watt K, Charlton M. The impact of obesity on long-term outcomes in liver transplant recipients-results of the NIDDK liver transplant database. Am J Transplant. 2008;8(3):667–672. [DOI] [PubMed] [Google Scholar]
- 17.Bambha KM, Dodge JL, Gralla J, Sprague D, Biggins SW. Low, rather than high, body mass index confers increased risk for post-liver transplant death and graft loss: risk modulated by model for end-stage liver disease. Liver Transpl. 2015;21(10):1286–1294. [DOI] [PubMed] [Google Scholar]
- 18.Saab S, Lalezari D, Pruthi P, Alper T, Tong MJ. The impact of obesity on patient survival in liver transplant recipients: a meta-analysis. Liver international: official journal of the International Association for the Study of the. Liver. 2015;35(1):164–170. [DOI] [PubMed] [Google Scholar]
- 19.Lai JC, Shui AM, Duarte-Rojo A, et al. Frailty, mortality, and health care utilization after liver transplantation: from the Multicenter Functional Assessment in Liver Transplantation (FrAILT) Study. Hepatology. 2022;75(6):1471–1479. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Prevention CfDCa. Defining Adult Overweight & Obesity. 2022. Dec 8 2022]; Available from: https://www.cdc.gov/obesity/basics/adult-defining.html#:~:text=If%20your%20BMI%20is%20less,falls%20within%20the%20obesity%20range
- 21.Organization WH. Obesity and overweight. 2022. Dec 8 2022]; Available from: https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight
- 22.Wong A, Naidu S, Lancashire RP, Chua TC. The impact of obesity on outcomes in patients undergoing emergency cholecystectomy for acute cholecystitis. ANZ J Surg. 2022;92(5):1091–1096. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.O’Connell RM, O’Neill M, ÓR MG, ÓS CB, O’Sullivan AW. Sarcopaenia, obesity, sarcopaenic obesity and outcomes following hepatic resection for colorectal liver metastases: a systematic review and meta-analysis. HPB. 2022;24(11):1844–1853. [DOI] [PubMed] [Google Scholar]
- 24.Cybulsky M, Murji A, Sunderji Z, Shapiro J, Elliott C, Shirreff L. Assessing the impact of obesity on surgical quality outcomes among patients undergoing hysterectomy for benign, non-urgent indications. Eur J Obstetr Gynecol Reprod Biol. 2022;274:243–250. [DOI] [PubMed] [Google Scholar]
- 25.Gioco R, Sanfilippo C, Veroux P, et al. Abdominal wall complications after kidney transplantation: a clinical review. Clin Transplant. 2021;35(12):e14506. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Sandy-Hodgetts K, Carville K, Leslie GD. Determining risk factors for surgical wound dehiscence: a literature review. Int Wound J. 2015;12(3):265–275. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Ayres-de-Campos D. Obesity and the challenges of caesarean delivery: prevention and management of wound complications. Best practice & research. Clin Obstetr Gynaecol. 2015;29(3):406–414. [DOI] [PubMed] [Google Scholar]
- 28.Gendall KA, Raniga S, Kennedy R, Frizelle FA. The impact of obesity on outcome after major colorectal surgery. Dis Colon Rectum. 2007;50(12):2223–2237. [DOI] [PubMed] [Google Scholar]
- 29.Lowe JR. Skin integrity in critically ill obese patients. Crit Care Nurs Clin North Am. 2009;21(3):311–322. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Arthurs ZM, Cuadrado D, Sohn V, et al. Post-bariatric panniculectomy: pre-panniculectomy body mass index impacts the complication profile. Am J Surg. 2007;193(5):567–570. discussion 570. [DOI] [PubMed] [Google Scholar]
- 31.Rosen RD, Manna B. Wound Dehiscence. In. StatPearls. Treasure Island (FL): StatPearls Publishing Copyright © 2022. StatPearls Publishing LLC.; 2022. [Google Scholar]
- 32.Wilson JA, Clark JJ. Obesity: impediment to postsurgical wound healing. Adv Skin Wound Care. 2004;17(8):426–435. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.