Complications After Esophagectomy Are Associated With Extremes of Body Mass Index

Background: Body mass index (BMI) is not routinely taken into consideration for risk stratification prior to esophagectomy. Extremes of BMI are associated with adverse surgical outcomes in a variety of surgical specialties. We assessed the relationship of BMI to outcomes after esophagectomy for cancer. Methods: Patients in the Society of Thoracic Surgeons General Thoracic Surgery Database (2009 to 2016) who underwent elective esophagectomy for cancer were selected for analysis. Open and minimally invasive approaches were included. Complications were categorized based on the Esophagectomy Complications Consensus Group recommendations. Multivariable logistic regression was used to adjust for confounding variables. Results: We evaluated 9,389 patients grouped by BMI: underweight (<18.5 kg/m ² ; 3%), normal (18.5 to 24.9 kg/m ² ; 32%), overweight (25 to 29.9 kg/m ² ; 36%), obese I (30 to 34.9 kg/m ² ; 19%), obese II (35 to 39.9 kg/m ² ; 7%), and obese III (≥40 kg/m ² ; 3%). Most patients underwent open Ivor Lewis (33%), open transhiatal (23%), or minimally invasive Ivor Lewis (22%) approaches. The operative mortality rate was 3.4%; the frequency of complications by category ranged from 4% to 28%. On multivariable analysis, overall differences were identified among BMI categories for 7 out of 9 complication types. Underweight and obese III categories were associated with increased risk. In contrast, overweight and obese I BMI were associated with decreased risk for most complication types. Conclusions: BMI is associated with postoperative complications after esophagectomy. Postoperative risk assessment and prehabilitation regimens should be adjusted accordingly when planning an esophagectomy for a patient with very low or very high BMI.