A total of 130 patients were included in this study. We first analyzed the correlation between BMI and VFA, and BMI and VFA were found to have a positive correlation (r2 = 0.202, p < 0.001) (Fig. 2). Based on short-term postoperative complications, ROC curve was used to analyze, the curve AUC was 0.702, and the best cut-off value for VFA was 93 cm2 (sensitivity was 70.8%, specificity was 69.0%).
The clinicopathological characteristics of the 130 patients are summarized in Table 1. Their median age was 54 years (range, 24–80 years). There is a lack of visceral obesity standards for the Chinese population based on CT measurements. According to the ROC curve, 93 was determined to be the best cut-off value to divide patients into two groups, visceral obesity and non-visceral obesity. Patients with visceral obesity were older than those with non-visceral obesity (58.4 years old vs. 52.1 years old, p < 0.001). TFA and SFA were much higher in the visceral obesity group (294.3 ± 75.5 vs. 176.2 ± 68.7, p < 0.001; 158.9 ± 54.7 vs. 121.7 ± 52.6, p < 0.001). Patients with visceral obesity were more likely to have hypertension (35.7% vs. 13.3%, p = 0.003).
Table 1. Clinicopathological characteristics
Characteristics
|
Obesity
|
Non-obesity
|
P-value
|
N = 70
|
N = 60
|
Age ( years )
|
58.4 ± 9.4
|
52.1 ± 10.6
|
< 0.001
|
Abdominal surgery times n ( % )
|
|
|
|
≥ 2 times
|
8(11.4)
|
10(16.7)
|
0.389
|
< 2 times
|
62(88.5)
|
50(83.3)
|
Hypertension n ( % )
|
25(35.7)
|
8(13.3)
|
0.003
|
Diabetes n ( % )
|
5(7.1)
|
1(1.7)
|
0.287
|
Ascites n ( % )
|
|
|
|
≥ 1000 ml
|
20(29.4)
|
21(35.6)
|
0.457
|
< 1000 ml
|
48(70.6)
|
38(64.4)
|
ASA n ( % )
|
|
|
|
ASA1
|
33(41.7)
|
40(66.7)
|
0.080
|
ASA2
|
35(50.0)
|
19(31.7)
|
ASA3
|
2(2.9)
|
1(1.7)
|
FIGO stage n ( % )
|
|
|
|
III
|
57(81.4)
|
58(96.7)
|
0.007
|
IV
|
13(18.6)
|
2(3.3)
|
Histology n ( % )
|
|
|
|
Serous
|
65(92.9)
|
55(92.9)
|
0.800
|
Non-Serous
|
5(7.1)
|
5(7.1)
|
Neoadjuvant chemotherapy
|
|
|
|
Yes
|
39(55.7)
|
28(46.7)
|
0.303
|
No
|
31(44.3)
|
32(53.3)
|
SFA
|
158.9 ± 54.7
|
121.7 ± 52.6
|
< 0.001
|
TFA
|
294.3 ± 75.5
|
176.2 ± 68.7
|
< 0.001
|
In patients with visceral obesity, lipoprotein a (LPa) was lower (206.7 ± 225.5 vs.305.5 ± 276.9, P = 0.037), while triglycerides (TG) (1.8 ± 0.8 vs. 1.3 ± 0.6, p = 0.012) was higher. However, serum CA125 and HE4 levels were not significantly different between the two groups (Table 2).
Table 2. Preoperative serological test results
Characteristics
|
Obesity
|
Non-obesity
|
P-value
|
N = 70
|
N = 60
|
PT
|
10.9 ± 1.1
|
11.1 ± 0.8
|
0.387
|
APTT
|
26.3 ± 2.2
|
26.8 ± 2.1
|
0.524
|
D-dimer
|
1.9 ± 2.1
|
1.9 ± 2.1
|
0.842
|
ALT
|
18.6 ± 11.7
|
19.7 ± 17.3
|
0.152
|
AST
|
23.6 ± 9.4
|
23.9 ± 11.4
|
0.286
|
LDH
|
250.8 ± 146.7
|
241.5 ± 153.3
|
0.811
|
HDL
|
1.1 ± 0.3
|
1.1 ± 0.3
|
0.926
|
LDL
|
2.9 ± 0.7
|
2.9 ± 0.7
|
0.402
|
Lpa
|
206.7 ± 225.5
|
305.5 ± 276.9
|
0.037
|
TC
|
4.6 ± 0.9
|
4.6 ± 0.9
|
0.221
|
TG
|
1.8 ± 0.8
|
1.3 ± 0.6
|
0.012
|
ALB
|
38.3 ± 3.9
|
38.0 ± 3.8
|
0.766
|
CA125
|
613.8 ± 951.9
|
684.8 ± 1125.6
|
0.422
|
HE4
|
316.3 ± 344.5
|
291.3 ± 335.6
|
0.722
|
PT, Prothrombin time. APTT, activated partial thromboplastin time. ALT, alanine aminotransferase. AST, aspartate aminotransferase. LDH, lactate dehydrogenase. HDL, high-density lipoprotein. LDL, low-density lipoprotein. Lpa, Lipoprotein(a). TC, Serum total cholesterol. TG, Triglyceride. ALB, Serum Albumin. Hb, Hemoglobin. TLC, total lymphocyte count.
|
Due to the large scope of cytoreductive surgery for advanced ovarian cancer, postoperative complications will increase. We found that 39% (51/130) of patients with advanced ovarian cancer had ≥ 2 postoperative complications. In addition, we analyzed the correlation between visceral obesity and postoperative complications in patients with stage III-IV disease, and the number of postoperative complications in patients with visceral obesity increased significantly (p < 0.001). Patients with visceral obese prolonged the time from surgery to adjuvant chemotherapy (p = 0.037). Patients in the visceral obese group were more likely to have postoperative fever (p = 0.023) (Table 3).
Table 3. Intra- and post-operative characteristics
|
Characteristics
|
Obesity
|
Non-obesity
|
P-value
|
N = 70
|
N = 60
|
Blood loss volume
|
971.4 ± 1101.6
|
740.0 ± 588.1
|
0.053
|
Operation time (min)
|
|
|
|
< 300
|
43(58.9)
|
30(41.1)
|
0.211
|
≥ 300
|
27(47.4)
|
30(52.6)
|
Surgical approach n(%)
|
|
|
0.387
|
Open abdomen
|
58(82.9)
|
53(88.3)
|
Laparoscopy to open abdomen
|
12(17.1)
|
7 (11.7)
|
Scope of operation n(%)
|
|
|
|
Bowel resection
|
18(25.7)
|
13(21.7)
|
0.589
|
Lymph node dissection/biopsy
|
32(45.7)
|
28(46.7)
|
0.914
|
Liver resection
|
2(2.9)
|
0(0)
|
0.545*
|
Diaphragmectomy
|
10(14.3)
|
13(21.7)
|
0.272
|
Ureteral stent implantation
|
8(11.4)
|
6(10.0)
|
0.793
|
SCS
|
|
|
|
1(low)
|
8(11.4)
|
8(13.3)
|
|
2(intermediate)
|
51(72.9)
|
42(70.0)
|
0.928
|
3(high)
|
11(15.7)
|
10(16.7)
|
|
R0/R1
|
|
|
|
R0
|
55(78.6)
|
50(83.3)
|
0.492
|
R1
|
15(21.4)
|
10(16.7)
|
CDC
|
50(71.4)
|
22(36.7)
|
< 0.001
|
CDC1
|
19(27.1)
|
2(3.3)
|
0.079
|
CDC2
|
25(35.7)
|
17(28.3)
|
0.004
|
CDC3
|
1(1.4)
|
1(1.7)
|
0.383
|
CDC4
|
5(7.1)
|
2(3.3)
|
0.343
|
Complications
|
|
|
|
Fever
|
21(30.0)
|
8(13.3)
|
0.023
|
Incision infection or bleeding
|
0(0)
|
1(1.7)
|
0.938
|
Abnormal liver function
|
11(15.7)
|
6(10.0)
|
0.335
|
Intestinal obstruction
|
2(2.9)
|
0(0)
|
0.187
|
Infection or sepsis
|
9(12.9)
|
7(11.7)
|
0.837
|
Thromboembolism
|
4(5.7)
|
2(3.3)
|
0.519
|
Blood transfusion rate
|
12(17.1)
|
10(16.7)
|
0.942
|
Intestinal fistula
|
1(1.4)
|
0(0)
|
0.353
|
Pleural effusion
|
9(12.9)
|
2(3.3)
|
0.052
|
Antibiotic using time
|
9(5.1)
|
8(3.1)
|
0.371
|
Time to chemotherapy
|
24(13.9)
|
19(7.2)
|
0.037
|
ICU admission n(%)
|
5(7.1)
|
2(3.3)
|
0.569
|
Length of hospital stay
|
18.2(7.5)
|
18.6(7.4)
|
0.758
|
*, Fisher’s exact test. CDC, Clavien–Dindo classification. SCS, surgery complexity score.
|
Postoperative treatment and rehabilitation of patients with fever were reported in Table 4. More types of antibiotics were used in patients with postoperative fever. And the using time of antibiotics and length of hospital stay prolonged significantly (p < 0.001, p < 0.001, p = 0.009) (Table 4).
Table 4
Postoperative treatment and rehabilitation of Patients with high fever
Characteristics
|
High fever
|
Non-high fever
|
P-value
|
N = 29
|
N = 101
|
Length of hospital stay
|
21.6(17.5)
|
17.5(6.3)
|
0.009
|
Antibiotic using time
|
11(7.3)
|
7(2.8)
|
< 0.001
|
Types of antibiotics
|
3(0.8)
|
2(0.5)
|
< 0.001
|
Time to chemotherapy
|
24.9(19.9)
|
21.5(7.4)
|
0.148
|
To investigate whether the characteristics of patients with visceral obesity have independent predictive value for the occurrence of complications, univariate and multivariate logistic regression analyses were performed. Univariate analysis showed that visceral obesity, operation time and intraoperative blood loss were significantly associated with postoperative complications. In multivariate analysis, visceral obesity (OR = 6.451, p < 0.001) and operation time (OR = 1.006, p = 0.009) were independent predictors of postoperative complications (Table 5).
Table 5
Univariate and Multivariate Logistic Regression Analysis
|
Univariate Logistic Regression Analysis
|
P-value
|
Multivariate Logistic Regression Analysis
|
P-value
|
OR(95%CI)
|
OR(95%CI)
|
Age (years)
|
1.013(0.980–1.048)
|
0.444
|
|
|
Abdominal surgery times
|
|
|
|
|
≥ 2 times
|
1
|
0.599
|
|
|
< 2 times
|
0.761 (0.275–2.107)
|
|
|
|
Hypertension
|
0.751(0.336–1.679)
|
0.486
|
|
|
Diabetes
|
0.235(0.027–2.071)
|
0.192
|
|
|
BMI
|
|
|
|
|
< 25
|
1
|
0.556
|
|
|
≥ 25
|
0.793 (0.366–1.717)
|
|
|
|
SFA
|
1.001(0.995–1.007)
|
0.680
|
|
|
TFA
|
1.005(1.001–1.009)
|
0.002
|
0.998(0.993–1.004)
|
0.556
|
VO
|
5.778(2.706–12.337)
|
< 0.001
|
4.770(2.080-10.943)
|
< 0.001
|
ALT
|
0.994(0.971–1.019)
|
0.649
|
|
|
AST
|
1.005(0.971–1.039)
|
0.787
|
|
|
LDH
|
1.001(0.998–1.003)
|
0.534
|
|
|
HDL
|
0.756(0.204–2.793)
|
0.674
|
|
|
Lpa
|
1.000(0.998–1.001)
|
0.734
|
|
|
LDL
|
1.274(0.745–2.087)
|
0.401
|
|
|
TG
|
1.164(0.721–1.879)
|
0.534
|
|
|
TC
|
1.015(0.758–1.611)
|
0.604
|
|
|
CA125
|
1.000(1.000–1.001)
|
0.258
|
|
|
HE4
|
1.001(1.000–1.002)
|
0.145
|
|
|
ALB
|
|
|
|
|
< 4
|
1
|
0.750
|
|
|
≥ 4
|
1.124(0.547–2.310)
|
|
|
|
ASA
|
|
|
|
|
ASA1
|
1
|
|
|
|
ASA2
|
2.424(0.210–27.933)
|
0.153
|
|
|
ASA3
|
4.353(0.369–51.370)
|
|
|
|
Ascites
|
0.815(0.384–1.728)
|
0.593
|
|
|
Neoadjuvant chemotherapy
|
1.301(0.650–2.604)
|
0.457
|
|
|
Blood loss volume
|
1.001(1.000–1.002)
|
0.006
|
1.000(1.000–1.001)
|
0.325
|
Operation time (min)
|
|
|
|
|
< 300
|
1
|
< 0.001
|
1.005(1.001–1.010)
|
< 0.001
|
≥ 300
|
1.006(1.003–1.009)
|
|
|
|
Surgical approach
|
1.313(0.460–3.749)
|
0.663
|
|
|
SCS
|
|
|
|
|
1(low)
|
1
|
|
|
|
2(intermediate)
|
0.234(0.059–0.994)
|
0.104
|
|
|
3(high)
|
0.348(0.118–1.028)
|
|
|
|
R0/R1
|
1.184(0.494–2.838)
|
0.705
|
|
|
FIGO stage
|
|
|
|
|
III
|
1
|
0.703
|
|
|
IV
|
1.238(0.414–3.706)
|
|
|
|
BMI, Body mass index. SFA, subcutaneous fat area. TFA, total fat area. VO, visceral obesity. HDL, high-density lipoprotein. Lpa, Lipoprotein(a). TG, Triglyceride. ALB, Serum Albumin. PNI, prognostic nutritional index.
|
The AUCs of VFA, SFA, TFA, and BMI were 0.702, 0.507, 0.609, and 0.572, respectively. Compared with SFA, TFA and BMI, VFA can better assess visceral obesity and can better predict short-term complications after ovarian cancer surgery. (Fig. 3)