(29) Rethinking Risk in Glossectomy: Obesity and Overweight Status Linked to Fewer Complications and Shorter Hospital Stays

Abstract:
Statement of the Problem: The existence of an obesity paradox in postoperative morbidity and mortality has generated controversy across medical fields. Traditional thinking, as confirmed by multiple studies, has asserted that obesity is a significant surgical comorbidity that may increase operation time, worsen wound healing due to chronic inflammation, poor angiogenesis, tissue hypoxia, and higher rates of infection.¹ In contrast, the obesity paradox postulates that an elevated BMI (body mass index) may promote improved survival compared to normal or low BMIs. Data concerning pathogenic and trauma-related maxillofacial surgical procedures indicates the possibility of an obesity paradox, but this has not been explored in the setting of glossectomy in the setting of malignancy.² This study aims to investigate whether higher BMI correlates with superior perioperative outcomes in glossectomy.
Materials and

Methods: This retrospective multi-institutional cohort study used the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to identify patients who underwent partial or complete glossectomy for malignant or pre-malignant lesions from 2006 to 2022. Excluding patients without reported height and weight, as well as elective and emergent procedures, this cohort consisted of 6,816 participants. Patient BMI, age, sex, race, inpatient status, and the presence of comorbidities (hypertension, diabetes, smoking status, weight loss, steroid use, chronic obstructive pulmonary disorder, and metastasis) were gathered.
Methods of Data Analysis: The primary independent variable was BMI. Patients were stratified into underweight ( < 18.5), normal weight (18.5–25.0), overweight (25.0-30.0), and obese (>30.0) categories. Univariate analyses were conducted to calculate differences with respect to median operative time, median length of stay, 30-day readmissions, as well as the presence of complications (infectious, respiratory, post-operative transfusions, or wound dehiscence). Multivariable analyses were conducted to analyze variables related to either length of stay or complications. Statistical significance was defined as P < 0.05. All analyses were performed using Stata version 18.5 (Statacorp, LLC, College Station, TX, USA).

Results: This study cohort was comprised of 30.8% obese patients (n = 2,096), 31.2% overweight (n = 2,126), 34.1% normal weight (n = 2,321), and 4.0% underweight (n = 273). Underweight patients had the longest median operative time (393 minutes, P < .001), compared with normal BMI (77 minutes), obese (125.5 minutes, P < .001), and overweight (165.5 minutes, P = .005) patients. On univariate analysis, obese patients had the shortest median length of stay (1 day, P < .001), followed by overweight (2 days, P < .001), normal BMI (4 days), and underweight (8 days, P < .001) patients. Obese patients presented with the lowest rate of perioperative complications (11.7%, P < .001), while underweight patients were found to have the highest rate of perioperative complications (35.9%, P < .001), compared with normal weight patients (21.6%). Multivariate analysis confirmed that obese patients hava a statistically significant shorter hospital stay (β -1.6 days, 95% CI -1.5 to -0.5, P < .001), and underweight patients having a longer hospital stay (β +1.7 days, 95% CI -1.5 to -0.5, P < .001) compared to normal weight patients. Additionally, underweight patients were found to have an increased risk of perioperative
complications (β +12.2%, 95% CI +7.7 to +1.7, P < .001) compared with normal weight patients.

Conclusions: This study highlights the presence of an obesity paradox in glossectomy, with obesity associated with shorter hospital stays and fewer complications. In contrast, underweight status correlated with worse perioperative outcomes. These findings suggest that higher BMI may have a protective role in glossectomy for malignancy, while underweight status significantly worsens perioperative performance.

1. Pierpont YN, et al. Obesity and surgical wound healing: A current review. ISRN Obes. 2014;2014:638936
2. Hakim SG, et al. Impact of body mass index, gender, and smoking on thickness of free soft tissue flaps used for orofacial reconstruction. Journal of Cranio-Maxillofacial Surgery. 2015;43(8):1325-9.
Table 1. Patient and Hospital Characteristics Stratified by BMI.Table 2. Multivariate-adjusted factors associated with hospital length of stay.Table 3. Multivariate-adjusted factors associated with perioperative complications.