Impact of Metabolic Syndrome on the Morbidity and Mortality of Patients Undergoing Panniculectomy

Abstract

Background

Metabolic syndrome (MetS) is defined as the concomitant disease process of obesity and at least two of the following variables: diabetes, hypertension, hypertriglyceridemia, or reduced high-density lipoprotein. These entities are well established as risk factors for complications following surgery. Obese patients are particularly prone to the development of MetS. The authors therefore aimed at elucidating the impact of MetS on the perioperative panniculectomy outcomes.

Methods

The American College of Surgeons National Surgical Quality Improvement Program database was analyzed for all primary procedures of panniculectomy from 2010 through 2015. The cases were stratified based on the presence or absence of MetS and evaluated for demographic data, intraoperative details, and their morbidity and mortality within 30 days after surgery.

Results

A total of 7030 cases were included in this study. Patients with MetS (6.2%) were of significantly worse health, required more emergency admissions (p = 0.022), longer hospitalization (p < 0.001), and more frequently inpatient procedures (p < 0.001) compared to the control group without MetS (3.8%). Plastic surgery was the predominant specialty operating on 79.5% of all cases. Surgical (23.3 vs. 8.7%) complications, readmission (8.7 vs. 3.0%), and reoperations (6.9 vs. 3.1%) rates were all significantly higher in patients with MetS that those without (p < 0.001). One fatality occurred in each cohort (0.23 vs. 0.02%, p = 0.010).

Conclusion

Comorbidities are not uncommon in patients undergoing panniculectomy, especially in those diagnosed with MetS. Health-care providers need to be aware of the increased morbidity and mortality in this high-risk subgroup and need to consider preoperative optimization and management before proceeding with surgery.

Level of Evidence III

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Background

Metabolic syndrome (MetS) encompasses the simultaneous presence of obesity, diabetes, hypertension, and dyslipidemia. The International Diabetes Foundation (IDF) sought to unify this diagnosis and defined it as a body mass index (BMI) over 30.0 combined with at least two of the following factors: increased triglycerides, reduced high-density lipoprotein, high blood pressure, or raised blood glucose [1]. The prevalence of MetS has been on a steady rise in recent years and has reached epidemic levels approaching 40% for American adults [2]. This trend is attributed to poor nutritional choices, a sedentary lifestyle, and low physical activity in industrialized nations [3, 4].

One typical downside of this process is the development of excess skin folds and fat, especially on the trunk where an abdominal pannus forms causing substantial functional impairment [5]. Such a pannus can be classified in grades 1 through 5 depending on how far the apron extends downwards [6]. Severe degrees typically necessitate panniculectomy to alleviate symptoms and produce satisfactory cosmetic outcomes [7]. This procedure needs to be clearly discriminated from abdominoplasties that primarily address cosmetic concerns, which include the plication of the rectus muscle and typically the transposition of the umbilicus [8]. Panniculectomies, on the other hand, consist of a resection of skin and subcutaneous tissue with optional liposuction on the anterior and lateral aspects of the trunk. No flap undermining or muscle treatment is performed in these medically indicated procedures.

Multiple reports have been published on panniculectomies, yet prior scientific approaches have tended to focus more on operative details [9] or employed smaller case numbers to evaluate risks and outcomes [10,11,12,13,14].

Objective

This study aims at analyzing the impact of a combination of independent risk factors in form of MetS on the morbidity and mortality outcomes following panniculectomy using a large national multi-institutional database. The underlying hypothesis is that patients with MetS undergoing panniculectomy are at increased risk of developing complications related to surgery.

Methods

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) datasets, years 2010 through 2015, were retrospectively utilized as source in this case–control study. This validated multi-institutional program is updated continuously and on a regular basis by the participating institutions that range from community hospitals to academic centers. Patient demographics, preoperative comorbidities and medical history, intraoperative details, postoperative outcomes, morbidity, and mortality are collected for 30 days after surgical intervention. Further details on the exact data collection are described in the NSQIP participant guide [15].

Inclusion criteria were all adult patients who underwent panniculectomy at any of the NSQIP institutions documented with an American Current Procedural Terminology [16] (CPT) code 15830 (“Excision, excessive skin and subcutaneous tissue [includes lipectomy]; abdomen, infraumbilical panniculectomy”). Surgeries performed in 2009 and earlier were not part of our analysis because, during that period, the same CPT code was defined as “EXC SKIN ABD” and would not have allowed differentiation from abdominoplasty procedures. Cases recorded with a primary abdominoplasty CPT code 15847 (“Excision, excessive skin and subcutaneous tissue [includes lipectomy]; abdomen [e.g., abdominoplasty][includes umbilical transposition and fascial placation]”) were not included, either.

The selected panniculectomy cases were then stratified into two cohorts based on the presence or absence of MetS. As per the criteria of the IDF, we defined MetS as obesity (BMI > 30.0) combined with diabetes and hypertension.

Demographic and comorbidity characteristics were first calculated for each cohort. Perioperative data analysis compared the two groups for details, such as American Society of Anesthesiologists (ASA) classification, emergency procedures, inpatient status, surgical specialty, and operative time. To simplify the assessment and interpretation of our results, composite variables were created to analyze surgical complications. In each cohort, readmission, reoperation, and mortality rates were calculated. To determine statistical associations between independent risk factors and these adverse outcomes after surgery, a multivariate regression analysis was performed. This study had approval by our institutional review board, and the Declaration of Helsinki was adhered to at all times.

Statistics

Descriptive statistics were calculated for the study population. Univariate analysis was used to compare the two cohorts using the χ 2 on categorical and the t test on continuous variables. The statistical level of significance was set at 5% (p < 0.05) for all calculations. Factors with p values <0.10, in addition to clinically pertinent factors, were gathered for a multivariate logistical regression analysis in order to control for confounders and to quantify the influence of various factors on complication rates. Statistical computations were performed using SPSS version 24.0 (IBM Corp., Armonk, NY, USA).

Results

A total of 7030 patients undergoing panniculectomy between 2010 and 2015 were identified in this study. Of those, 437 patients (6.2%) met our criteria for MetS and 6593 did not (93.8%). The mean age in the MetS cohort was 57.1 ± 10.4 years and had an average BMI of 44.3 ± 13.5. Both these variables were significantly higher (p < 0.001) compared to the non-MetS control group: 45.7 ± 11.8 years and 31.0 ± 8.6, respectively. Patients with MetS had a higher proportion of men in their cohort (20.6 vs. 10.8%, p < 0.001). From a comorbidity standpoint, patients with a diagnosis of MetS were more likely to have prior steroid use, suffer from open wounds or infections, and have congestive heart failure, a respiratory history, renal disease, and bleeding disorders (p < 0.001). Diabetes and hypertension demonstrated statistical differences per methodological criteria mentioned earlier. However, smoking rates and recent weight loss within the previous 6 months before surgery occurred at similar frequencies in both cohorts (Table 1).

Table 1 Demographic variables

Furthermore, a diagnosis of MetS was related to an increased number of emergency admissions (p = 0.022) and a lower likelihood of a panniculectomy to be graded as elective (p < 0.001). These morbid patients were more likely (p < 0.001) to receive a higher ASA class: 79.9% of all MetS cases were judged as ASA class 3 or higher compared to 19.9% in the control population. Interestingly, the mean operative time was shorter in the MetS cohort by roughly 20 min (p < 0.001). Plastic surgeons constituted the predominant specialty in this report (overall: 79.5%), yet general surgeons showed a significantly larger ratio in patients with MetS (p < 0.001). On rare occasions, some cases of panniculectomy were combined with additional procedures, such as ventral hernia repair, umbilical hernia repair, or hysterectomy, but none of these findings resulted in statistically significant differences. Bariatric procedures were not among the top four most common concomitant surgeries. Postoperatively, patients were more often treated on an inpatient basis and required much longer hospitalization times (p < 0.001) if they were in the MetS cohort (Table 2).

Table 2 Operative characteristics

Surgical complications occurred in 8.7% of control and 23.3% of all MetS patients (p < 0.001) within the NSQIP’s 30-day follow-up period. These statistically and clinically significant discrepancies between the two designed cohorts were preserved even when analyzing the subitems of surgical complications, such as wound infection, wound dehiscence, and bleeding requiring transfusion (p < 0.001 for all). The wounds of patients in the MetS cohort were classified significantly higher, corresponding to contaminated or dirty wounds, than those of patients within the control group (p < 0.001). Readmission (8.7 vs. 3.0%) and reoperation rates (6.9 vs. 3.1%) were much more common for patients suffering from MetS than for those without (p < 0.001). One fatality occurred in each panniculectomy cohort leading to a significant difference (p = 0.010, Table 3).

Table 3 Morbidity and mortality

A multivariate analysis was performed for the composite variable of surgical complications (Table 4). They had a significant association with high BMI (p < 0.001), male gender (p = 0.030), smoking (p = 0.002), ASA class 3 or greater (p = 0.001), inpatient procedures (p < 0.001), and “contaminated” wounds (p = 0.035). Plastic surgery as the operative specialty was a protective factor for surgical complications (p < 0.001).

Table 4 Multivariate regression analysis of surgical complications

Discussion

From Metabolic Syndrome to Pannus Formation

According to the IDF, the presence of obesity in combination with two of the following entities is known as MetS: diabetes, hypertension, hypertriglyceridemia, low HDL cholesterol [2]. The increasing prevalence of MetS and its role as major risk factor for various health-related issues have been infamously honored with a unique identifier in the International Classification of Diseases, ICD-10: E88.81 [17]. It is well known that a diagnosis of MetS is not only related to medical complications, such as stroke or myocardial infarction [18], but it also significantly correlates with adverse perioperative outcomes [19, 20]. Obesity—defined as BMI of 30.0 or greater [21]—plays the fundamental role in the disease process of MetS. Weight loss can therefore have many positive effects on a patient’s health. Unfortunately, the process of massive weight reduction may lead to development of a pannus, colloquially often called an “apron” or “hanging abdomen” [12]. This excess abdominal fat and skin tissue is particularly prominent in patients who started off with a high BMI [10]. A pannus may lead to low quality of life, impaired sexual function, reduced genital hygiene, and a number of complications including infections (panniculitis) [5, 22], hernias [9], and lymphedema [23]. The main management of such debilitating panni is operative by means of panniculectomy that can prevent these physical sequelae and improve psychosocial well-being [24]. The authors subsequently intended to analyze the details and outcomes of panniculectomy procedures in the setting of MetS, regardless of exact operative technique [7]. The ACS NSQIP with its almost 900,000 recorded surgical cases per year (2015) was an optimal source of data herein [15].

Which Patients Undergo Panniculectomy?

Over 7000 patients have been identified that underwent panniculectomy at participating institutions in the USA. Of those, only 6.2% were diagnosed with MetS in our study, a figure much lower than what has been reported by larger population studies [2, 25]. While certain variations are within tolerance, these discrepancies can be due to differences in diagnostic criteria or rather focused history taking and patient assessment in the surgical departments. Overall, patients in the MetS cohort were significantly more morbid than those in the control group: Age and BMI were much higher. MetS patients presented more often with comorbidities of the cardiovascular, pulmonary, renal, and hematological systems. Furthermore, a worrisome 14.2% of MetS patients were admitted to the hospital with open wounds or infections compared to merely 1.8% in the control group. All these comorbidities are well described in literature and are magnified when patients meet the criteria for MetS [9, 18, 26, 27]. Similar to recent studies, women were predominant in both cohorts despite the statistical difference [28]. Interestingly, only 0.3% of non-MetS patients and 0.7% of MetS patients were admitted with a weight loss of over 10% within the 6 months prior to surgery. These figures suggest that a stable weight has been maintained for a longer period of time which is favored by most surgeons before performing panniculectomy, both clinically and in order to obtain compensation by US health insurances [22].

Operative Details

The aggravating preoperative findings appear to influence the perioperative management. Patients were more likely to be operated on as emergency cases and less likely as elective if they belonged to the MetS category. The distribution of ASA classifications highlighted the risk of performing panniculectomy on a patient with MetS [29]. Plastic surgery was predominant as shown in an earlier published article [30], but, interestingly, a patient was more likely to be operated on by a general surgeon when diagnosed with MetS (32.3 vs. 19.3%). In these 437 cases, the mean operative time was roughly 20 min shorter compared to our control group of 6593 patients. It is plausible that a patient with MetS and mean BMI 44.3 would receive bariatric surgery or an urgent intra-abdominal operation and then return to the same general surgeon [10] for the panniculectomy. The shorter operative time in MetS cases can be intentional in order to reduce perioperative complications, such as deep venous thrombosis. Also, variations in operative technique by plastic surgeons were suggested by other authors as explanation for their longer operative times [30].

To ensure integrity and validity of our data, we only utilized datasets between 2010 and 2015 when the American CPT code 15830 was specifically defined as a panniculectomy procedure. We did not include cases using the abdominoplasty CPT code 15847 [16]. For years 2009 and earlier, the code 15830 was rather inconclusive and would have failed to differentiate between panniculectomy and abdominoplasty and in our opinion should not be applied at all [30].

Although often reported by other surgeons, secondary procedures were infrequent (<3%) in our two patient cohorts and did not bias the statistical analysis [31, 32]. Nevertheless, multi-morbid patients with MetS more frequently underwent panniculectomy as inpatients and required significantly longer hospitalizations.

Morbidity and Mortality Following Panniculectomy

In the MetS cohort, 23.3% of patients suffered from wound infection, dehiscence, or bleeding, but only 8.7% in the control population. These adverse events can potentially be traced back to preoperatively documented comorbidity “open wound/infection” presented in Table 1. Overall, the complication figures for our control group were lower than in other studies that reported striking rates of 12.6–43.0% [7, 10, 14, 23, 30]. However, complication rates for the MetS group were within the range description of prior literature. These variations can be due to the significant inconsistency of complication criteria or the 30-day follow-up limitation of this NSQIP analysis. Ultimately, our results did not only establish a statistical relationship between MetS and the increased likelihood of postoperative complications, but also demonstrated a significantly higher risk of readmission, reoperation, and suffering a fatal event after panniculectomy in patients with MetS. Reoperation rates were lower than published in previous articles (13–15%) [7, 13], which is most likely because of our limited standardized follow-up.

A multivariate regression analysis was performed to identify potential hazards that could be related to complications and subsequently offer guidance in preoperative patient selection and optimization. Adverse events were statistically associated with high BMI [33] and ASA class 3 or greater [34]. Male gender [35], smoking [36], and inpatient surgeries further correlated with unfavorable surgical outcomes. The inpatient setting showed the strongest correlation with surgical complications, yet it is more likely to be consequence than cause. High-risk patients are more likely to be admitted as inpatient in the first place. Considering their high prevalence (Tables 1, 2), an increased BMI and an ASA class of 3 or greater can be interpreted as predominant contributors to postoperative complications. On the other hand, diabetes and hypertension did not correlate with any form of complication reinforcing the entity of obesity as leading risk factor in MetS. Age was not related to adverse events after panniculectomy, either, indicating that these procedures should not be withheld from elderly patients simply based on chronological age. Instead, a physician needs to closely evaluate a patient’s medical condition before proceeding with surgery. Interestingly, plastic surgery as the primary specialty was a protective factor for complications analog to a previous retrospective study [30].

Lessons Learned

This large multi-institutional study demonstrates the typical demographic, clinical risk profiles, and the subsequent outcomes of patients undergoing panniculectomy in the USA. Furthermore, it explores the impact of MetS on the perioperative patient management and rates of various adverse events. These findings can help guide treatment before and after panniculectomy procedures. Based on the data presented here, intensified patient optimization before surgery is vital to ensure favorable outcomes after panniculectomy in multi-morbid cases diagnosed with MetS unless, of course, certain reservations necessitate emergency procedures. Medical treatment to improve glycaemia, blood pressure, general cardiovascular risk factors, as well as conservative wound management need to be carefully assessed before proceeding with the panniculectomy [37]. The importance of pre-surgical management before panniculectomies in high-risk patient cannot be overemphasized.

Study Limitations

Retrospective NSQIP databases have their limitations. The over 7000 cases of panniculectomies included in this report originate from numerous health-care institution nationwide ranging from community hospitals to academic centers, all of which remain anonymous by default. These study results might therefore not be representative of every clinical setting in the USA. Further details, such as the description of the operative technique or weight of the resected specimen, are not documented. Lastly, patients are monitored only for 30 days after surgery. Any complication, readmission, reoperation, or death beyond this time frame would therefore be reported as a new case with potentially different diagnosis and procedure codes.

Conclusion

Patients presenting for panniculectomy are inherently a challenging population. Despite the not uncommon complications in our control group, the rates of adverse events were further elevated by MetS, defined as the simultaneous presence of obesity, diabetes, and hypertension. Complications including wound infection and dehiscence are the primary concern after a panniculectomy. In patients, particularly those diagnosed with MetS, it is imperative to plan for aggressive preoperative medical and local wound optimization to ameliorate unfavorable outcomes. Undergoing panniculectomy with a plastic and reconstructive surgeon was linked to more favorable outcomes compared to other surgical specialties.

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Acknowledgment

American College of Surgeons National Surgical Quality Improvement Program and the hospitals participating in the ACS NSQIP are the source of the data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors.

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Correspondence to Dmitry Zavlin.

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None of the authors, nor their close family members, have a financial interest in any of the products, devices, or drugs mentioned in this manuscript. Furthermore, the authors declare that no commercial associations or financial disclosures exist that might pose or create a conflict of interest with information presented in this manuscript. No funding was received for the work presented in this manuscript.

Ethical Approval

The work described in this manuscript was approved by the Houston Methodist Hospital’s institutional review board (IRB, protocol number Pro00011704). The authors adhered to the Declaration of Helsinki at all times. No informed consent was obtained as the patient data from the American College of Surgeons National Surgical Quality Improvement Program are only available in a de-identified format.

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Zavlin, D., Jubbal, K.T., Balinger, C.L. et al. Impact of Metabolic Syndrome on the Morbidity and Mortality of Patients Undergoing Panniculectomy. Aesth Plast Surg 41, 1400–1407 (2017). https://doi.org/10.1007/s00266-017-0952-6

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Keywords

  • Panniculectomy
  • Metabolic syndrome
  • Obesity
  • Risk factors
  • Outcomes