The effect of obesity on perioperative morbidity in oblique lumbar interbody fusion

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>Obese patients have been shown to have longer operative times and more complications from surgery. However, for obese patients undergoing minimally invasive surgery, these differences may not be as significant. In the lateral position, it is thought that obesity is less of an issue because gravity pulls the visceral fat away from the spine; however, this observation is primarily anecdotal and based on expert opinion. The authors performed oblique lumbar interbody fusion (OLIF) and they report on the perioperative morbidity in obese and nonobese patients.</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>The authors conducted a retrospective review of patients who underwent OLIF performed by 3 spine surgeons and 1 vascular surgeon at the University of California, San Francisco, from 2013 to 2018. Data collected included demographic variables; approach-related factors such as operative time, blood loss, and expected temporary approach-related sequelae; and overall complications. Patients were categorized according to their body mass index (BMI). Obesity was defined as a BMI ≥ 30 kg/m<jats:sup>2</jats:sup>, and severe obesity was defined as a BMI ≥ 35 kg/m<jats:sup>2</jats:sup>.</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>There were 238 patients (95 males and 143 females). There were no significant differences between the obese and nonobese groups in terms of sex, levels fused, or smoking status. For the entire cohort, there was no difference in operative time, blood loss, or complications when comparing obese and nonobese patients. However, a subset analysis of the 77 multilevel OLIFs that included L5–S1 demonstrated that the operative times for the nonobese group was 223.55 ± 57.93 minutes, whereas it was 273.75 ± 90.07 minutes for the obese group (p = 0.004). In this subset, the expected approach-related sequela rate was 13.2% for the nonobese group, whereas it was 33.3% for the obese group (p = 0.039). However, the two groups had similar blood loss (p = 0.476) and complication rates (p = 0.876).</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>Obesity and morbid obesity generally do not increase the operative time, blood loss, approach-related sequelae, or complications following OLIF. However, obese patients who undergo multilevel OLIF that includes the L5–S1 level do have longer operative times or a higher rate of expected approach-related sequelae. Obesity should not be considered a contraindication to multilevel OLIF, but patients should be informed of potentially increased morbidity if the L5–S1 level is to be included.</jats:p></jats:sec>

Obesity and Spine Surgery: A Qualitative Review About Outcomes and Complications. Is It Time for New Perspectives on Future Researches?

“…While outcomes are reported to be satisfactory and often comparable among obese and nonobese patients treated with surgery when needed, peri-operative complications rate seems to be higher in most of the analyzed papers with few exceptions ( Table 3 ). 60 , 62 , 63 , 65 , 66 , 70 , 73 , 77 , 78 , 80 , 82 , 86 , 88 , 90 , 92 - 94 , 97 , 101 , 102 , 105 , 107 , 109 - 112 , 114 , 116 , 118 , 123 , 125 , 126 , 129 , 131 , 133 , 135 , 139 - 141 , 146 - 148 , 151 - 153 , 166 -...…”

“…However, while obesity did not result to affect surgical outcomes in lumbar stenosis, it was found to be associated with higher risks for infection, re-operation rate and lower improvement in SF-36 physical score, when surgery was performed for degenerative spondylolisthesis 142 ; less improvement in Oswestry Disability Index (ODI) scale and SF-36 physical score was similarly reported for inter-vertebral disc herniation from the Trial. 138 121 Retrospective study 16 Safaee MM et al, 2020 70 Retrospective study 81 Cao J et al, 2015 122 Meta-analysis 17 Siccoli A et al, 2020 71 Retrospective study 82 De la Garza Ramos et al, 2015 32 Retrospective study 19 Xi Z et al, 2020 73 Retrospective study 83 Giannadakis C et al, 2015 123 Prospective study 24 Goyal Additionally, McGuire et al reported a sub-group analysis from the SPORT trial highlighting higher rate of wound infections and longer operative time for class II and III obese patients (highly obese) compared to class I obese patients. Moreover, although highly obese patients reported worst outcomes compared with class I obeses, especially when surgery was performed for disc herniation, surgical treatment resulted able to provide better outcomes when compared with nonsurgical treatment.…”

Nuances of oblique lumbar interbody fusion at L5-S1: Three case reports

“…Complication rates in OLIF/ATP approaches have been reported between 7.2% and 48.3% in different studies[ 4 , 21 - 23 ]. The incidence of certain complications may be higher when L5-S1 is included in the OLIF/ATP procedure[ 7 , 13 , 23 ]. This is especially true for vascular injuries, which can be catastrophic and potentially fatal.…”

“…Our previously published series did not show any differences in incidence of vascular injuries between the three approaches to L5-S1[ 13 ]. Approach-related complications like ileus, ipsilateral groin pain, anterior thigh numbness or pain, incisional hernia, or pseudohernia have also been reported with the OLIF/ATP approach[ 4 , 7 , 12 , 23 ]. Subsidence may be seen more often with the OLIF approach compared to other anterior approaches for interbody fusion, according to Woods et al [ 7 ].…”

The anterior-to-psoas approach for interbody fusion at the L5–S1 segment: clinical and radiological outcomes

“…36 On the other hand, Xi et al demonstrated that obesity generally does not increase the operative time, blood loss, approach-related sequelae, or complications following OLIF. 37 ATP is theoretically supposed to reduce the necessity for a wide retroperitoneal dissection, superior hypogastric plexus injuries, and retraction of iliac vessels. The patient is always placed in the right lateral decubitus position, and a small incision in front of the anterior-superior iliac crest allows the surgeon to easily access the retroperitoneal space, medial to the psoas tendon.…”