Class 2/3 Obesity and Metabolic Syndrome are Associated with Higher Complications Following Endoscopic Lumbar Decompression

Class 2/3 Obesity and Metabolic Syndrome are Associated with Higher Complications Following Endoscopic Lumbar Decompression | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Class 2/3 Obesity and Metabolic Syndrome are Associated with Higher Complications Following Endoscopic Lumbar Decompression Junho Song, Tejas Subramanian, Alexander Yu, Kareem Mohamed, Ryan Hoang, and 10 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8822929/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Purpose Retrospective cohort study to evaluate the association between obesity severity and postoperative outcomes after endoscopic lumbar decompression. Methods A national surgical database was queried to identify patients undergoing endoscopic lumbar decompression between 2017–2023. Patients were stratified by BMI category (normal, overweight [25 to < 30], class I obesity [30 to < 35], class II/III obesity [≥ 35]). Metabolic syndrome was defined as BMI ≥ 30 with concurrent diabetes mellitus and hypertension. Outcomes included 30-day readmission, reoperation, and composite morbidity, including surgical site infection(SSI)/wound dehiscence, urinary tract infection (UTI), transfusion, pneumonia, or sepsis. Categorical variables were compared using chi-square or Fisher exact tests; continuous variables were analyzed using one-way ANOVA with Bonferroni correction. Results A total of 398 patients were included (normal n = 70, overweight n = 116, class I obesity n = 137, class II/III obesity n = 75). Patients with class II/III obesity had higher comorbidity burden and longer operative time compared to normal BMI. BMI ≥ 30 was not associated with differences in 30-day readmission, reoperation, or overall morbidity. In contrast, BMI ≥ 35 was associated with higher 30-day morbidity (6.7% vs 1.2%, p = 0.014), higher SSI/dehiscence (4.0% vs 0.6%, p = 0.048), higher UTI (2.7% vs 0.3%, p = 0.033) rates. Metabolic syndrome was associated with increased readmission (9.7% vs 2.7%, p = 0.037) and morbidity (9.7% vs 1.6%, p = 0.026). Conclusions Endoscopic lumbar decompression demonstrated low overall 30-day event rates across BMI strata. Class I obesity was not associated with worse short-term outcomes; however, class II/III obesity and metabolic syndrome were associated with increased morbidity, driven primarily by wound complications and UTI. endoscopic lumbar decompression endoscopic spine surgery obesity body mass index metabolic syndrome ACS-NSQIP INTRODUCTION Lumbar spinal stenosis is a leading indication for spine surgery in older adults and results from degenerative narrowing of the spinal canal with compression of neural elements, commonly driven by ligamentum flavum hypertrophy, disc herniation, and facet arthropathy [1–4]. Decompression is the preferred operative treatment for patients with persistent, function-limiting symptoms despite conservative care [5–7]. Traditional open lumbar decompression reliably relieves neural compression but requires wider exposure with muscle dissection and soft-tissue manipulation, which may contribute to blood loss, postoperative pain, and paraspinal morbidity [8, 9]. Accordingly, endoscopic lumbar decompression has gained momentum as a minimally invasive alternative intended to achieve adequate decompression through smaller incisions while limiting tissue disruption [10, 11]. Potential advantages of endoscopic approaches have been well-described, including reduced tissue trauma, blood loss, and infection rates with accelerated recovery, although comparative outcome data remain heterogeneous across techniques and study designs [12, 13]. Obesity further complicates perioperative management in spine surgery. Patients with obesity are at increased risk of perioperative morbidity, including longer operative times and higher rates of wound-related complications [12, 14]. Endoscopic techniques may mitigate some obesity-associated risks by minimizing incision size and soft-tissue disruption, and available clinical series suggest that endoscopic decompression can be performed safely in patients with obesity with meaningful symptom improvement [12, 15]. However, the evidence base remains limited, and more generalizable estimates of short-term postoperative risk, particularly in severe obesity, are still needed [10, 12]. Therefore, we performed a national database analysis to evaluate the association between obesity severity and 30-day outcomes after endoscopic lumbar decompression. Secondarily, we also evaluated the influence of metabolic syndrome on postoperative outcomes. METHODS We performed a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), which captures patient-level perioperative variables and tracks 30-day postoperative outcomes across participating hospitals [16, 17]. Because NSQIP data are de-identified, this study was considered exempt from institutional review board oversight. Patients undergoing endoscopic lumbar decompression between 2017–2023 were identified using the primary Current Procedural Terminology (CPT) code 62380, which was introduced to distinguish endoscopic lumbar decompression procedures in the year 2017 [10, 18]. We excluded cases performed in the setting of infection or malignancy and those involving concomitant fusion procedures. Patients with missing body mass index (BMI) or demographic data were excluded. BMI (kg/m²) was evaluated both categorically and using clinically relevant thresholds. Patients were stratified into four BMI groups: normal, overweight (25 to < 30), class I obesity (30 to < 35), and class II/III obesity (≥ 35). We performed threshold-based analysis of 30-day outcomes for BMI ≥ 30 and BMI ≥ 35 compared to their respective control cohorts. Metabolic syndrome was defined a priori as BMI ≥ 30 with comorbid diabetes mellitus and hypertension [19, 20]. Baseline characteristics extracted included age, sex, race, ethnicity, smoking status, diabetes mellitus, hypertension, chronic steroid use, and American Society of Anesthesiologists (ASA) class. Perioperative variables included operative time, length of hospital stay (LOS), outpatient status, discharge disposition. The primary outcomes were 30-day readmission, reoperation, and composite morbidity. Composite morbidity included surgical site infection (SSI)/wound dehiscence, urinary tract infection (UTI), bleeding requiring transfusion, pneumonia, or sepsis. Statistical Analysis Categorical variables were compared using chi-square tests or Fisher exact tests, as appropriate. Continuous variables were compared using one-way ANOVA with Bonferroni post hoc correction for pairwise comparisons. When comparing postoperative outcomes, we performed threshold analyses for BMI ≥ 30, BMI ≥ 35, and metabolic syndrome. All tests were two-sided, with statistical significance set at p < 0.05. RESULTS Patient Characteristics A total of 398 patients undergoing endoscopic lumbar decompression met inclusion criteria, including 70 (17.6%) with normal BMI, 116 (29.1%) overweight, 137 (34.4%) with class I obesity, and 75 (18.8%) with class II/III obesity. Mean age differed across BMI strata (p = 0.018), with the normal BMI group older than the overweight and class II/III obesity groups on post hoc testing. Sex distribution also differed across BMI groups (p = 0.016). There were no differences across BMI groups in Black race, Hispanic ethnicity, diabetes mellitus, smoking status, or chronic steroid use (all p > 0.05).Patients with class II/III obesity had higher comorbidity burden, with a greater proportion classified as ASA ≥ 3 (66.7% vs 30.0% in normal BMI; p = 0.001), and higher rates of hypertension (57.3% vs 34.3% in normal BMI; p = 0.002). Metabolic syndrome was present in 31 patients overall and differed by BMI category (p < 0.001), occurring only in the class I obesity (15.3%) and class II/III obesity (13.3%) groups (Table 1). Perioperative Characteristics Operative time differed across BMI groups (p = 0.048), with longer operative time among patients with class II/III obesity compared with normal BMI (110.6 ± 47.8 vs 90.4 ± 45.9 minutes; Bonferroni p = 0.049). Length of stay did not differ by BMI category (p = 0.830), and there were no significant differences in outpatient surgery rates, prolonged length of stay, or non-home discharge (all p > 0.05) (Table 2). Thirty-Day Outcomes by BMI Thresholds In BMI threshold analyses, BMI ≥ 30 was present in 212 (53.3%) patients, with 186 (46.7%) in the control group. BMI ≥ 30 was not associated with differences in 30-day readmission (2.8% vs 3.8%, p = 0.601), reoperation (0.9% vs 1.1%, p = 0.895), or composite morbidity (3.3% vs 1.1%, p = 0.136). Individual complications, including SSI/wound dehiscence and UTI, did not differ between groups (Table 3). BMI ≥ 35 was present in 75 (18.8%) patients, with 323 (81.2%) in the control group. BMI ≥ 35 was associated with higher 30-day composite morbidity (6.7% vs 1.2%, p = 0.014). This increase was driven by higher SSI/wound dehiscence (4.0% vs 0.6%, p = 0.048) and UTI (2.7% vs 0.3%, p = 0.033). Rates of readmission (5.3% vs 2.8%, p = 0.278) and reoperation (0.0% vs 1.2%, p = 0.333) did not differ between BMI ≥ 35 and controls (Table 4). Thirty-Day Outcomes by Metabolic Syndrome Metabolic syndrome was present in 31 (7.8%) patients, with 367 (92.2%) in the control group. Metabolic syndrome was associated with higher 30-day readmission (9.7% vs 2.7%, p = 0.037) and higher composite morbidity (9.7% vs 1.6%, p = 0.026). Reoperation rates did not differ (0.0% vs 1.1%, p = 0.559). Individual complications were numerically higher among patients with metabolic syndrome but did not reach statistical significance (Table 5). DISCUSSION In this cohort of patients undergoing endoscopic lumbar decompression, short-term adverse event rates were low across BMI strata. Class I obesity defined at the conventional threshold of BMI ≥ 30 was not associated with higher 30-day readmission, reoperation, or composite morbidity, whereas class II/III obesity (BMI ≥ 35) was associated with higher 30-day morbidity (6.7% vs 1.2%), driven primarily by SSI/wound dehiscence and urinary tract infection. Metabolic syndrome was additionally associated with increased 30-day readmission and morbidity, suggesting that metabolic health may further refine perioperative risk stratification beyond BMI alone. These findings align with the growing body of evidence supporting favorable perioperative safety profiles for endoscopic decompression, including large database studies demonstrating low 30-day adverse event rates and, in comparative analyses, lower overall adverse outcomes relative to non-endoscopic decompression after risk adjustment [10, 18]. At the same time, the observed “threshold effect” at BMI ≥ 35 is clinically plausible: while endoscopic techniques may mitigate obesity-associated risk by limiting incision size and soft-tissue disruption, the physiologic and technical consequences of severe obesity (thicker subcutaneous envelope, longer working distance, and higher baseline comorbidity burden) may outstrip these procedural advantages, contributing to longer operative times and higher wound complication risk in the highest BMI strata [21–23]. This interpretation is consistent with systematic review-level data suggesting that endoscopic spine surgery can maintain favorable clinical outcomes in obese patients, though operative times may be longer and symptom recurrence may be slightly increased in some endoscopic cohorts [12]. The increased incidence of UTI in severe obesity may reflect broader associations between obesity and postoperative infection risk. For example, in other lumbar surgery cohorts, obesity has been linked to increased wound complications and UTI, which may relate to altered immune function, higher prevalence of metabolic derangements, and perioperative factors such as urinary retention and catheter utilization [14]. While NSQIP does not provide granular detail regarding catheter practices or postoperative urinary retention in this cohort, the consistent directionality across procedures supports heightened attention to perioperative bladder management (e.g., minimizing indwelling catheter duration when feasible) in patients with severe obesity. Importantly, metabolic syndrome appeared to identify a subgroup at elevated short-term risk, including readmission, even when BMI ≥ 30 alone did not. Metabolic syndrome, as defined by obesity with concomitant diabetes and hypertension, may better capture systemic risk factors (insulin resistance, vascular dysfunction, and inflammatory milieu) that plausibly contribute to impaired wound healing, infection susceptibility, and medical readmissions. Although the current study was not designed to isolate mechanisms, these findings support considering metabolic health alongside BMI in preoperative counseling and optimization. From a practical standpoint, the overall low 30-day complication rates across BMI categories support that endoscopic lumbar decompression can be performed safely in many patients with obesity. However, the increased morbidity observed in class II/III obesity and metabolic syndrome groups suggests these patients may benefit from targeted mitigation strategies: (1) preoperative counseling about modestly increased short-term infection/UTI risk, (2) preoperative optimization of glycemic control and blood pressure when time permits, and (3) heightened attention to wound management and early postoperative surveillance. This study has important limitations that must be considered. NSQIP captures only short-term outcomes within 30 days and lacks key clinical granularity, including specific endoscopic technique (uniportal vs. biportal), intraoperative details, radiographic data, and patient-reported outcome measures. Additionally, although CPT 62380 enables identification of endoscopic decompression in NSQIP, coding practices may introduce misclassification: some endoscopic cases may be billed under non-endoscopic codes (e.g., 63030) due to payer recognition, which could bias case capture and limit generalizability. Finally, the sample size was limited and adverse event counts were low, particularly within the BMI ≥ 35 and metabolic syndrome strata, limiting power for less common complications and precluding robust multivariable modeling of rare outcomes. CONCLUSION In conclusion, this national database study suggests that endoscopic lumbar decompression is associated with low 30-day complication rates across BMI strata, with no detectable increase in short-term adverse outcomes at BMI ≥ 30. In contrast, severe obesity (BMI ≥ 35) and metabolic syndrome were associated with higher 30-day morbidity, driven primarily by wound complications and urinary tract infection, underscoring the value of obesity severity and metabolic risk profiling in perioperative counseling and optimization. Declarations Author Contribution Junho Song, MD contributed to all aspects of the study, including study conception and design, data acquisition, data analysis and interpretation, and manuscript drafting. Tejas Subramanian, MD; Alexander Yu, BS; Kareem S. Mohamed, BS; Ryan Hoang, BA; Timothy Hoang, BA; Austin Q. Nguyen, MD; Joshua Zhang, BS; Omri Maayan, MD; Tariq Z. Issa, MD; Nikan K. Namiri, MD; John J. Corvi, MD; Saad B. Chaudhary, MD; Andrew C. Hecht, MD; and Samuel K. Cho, MD contributed to manuscript writing, critical revision for important intellectual content, and final approval of the manuscript. All authors approved the final version and agree to be accountable for all aspects of the work. References Shahi P, Vaishnav AS, Mai E, et al. Practical answers to frequently asked questions in minimally invasive lumbar spine surgery. Spine J 2023;23:54–63. Subramanian T, Shahi P, Hirase T, et al. Outcomes of one versus two level MIS decompression with adjacent level stenosis. Global Spine J 2024;15:21925682241303104. Bovonratwet P, Kulm S, Kolin DA, et al. Identification of novel genetic markers for the risk of spinal pathologies: A genome-wide association study of 2 biobanks. J Bone Joint Surg Am 2023;105:830–8. Jung B, Han J, Song J, et al. Interventional therapy and surgical management of lumbar disc herniation in spine surgery: A narrative review. Orthop Rev (Pavia) 2023;15:88931. Bovonratwet P, Samuel AM, Mok JK, et al. Minimally invasive lumbar decompression versus minimally invasive transforaminal lumbar interbody fusion for treatment of low-grade lumbar degenerative spondylolisthesis. Spine (Phila Pa 1976) 2022;47:1505–14. Shahi P, Song J, Dalal S, et al. Improvement following minimally invasive lumbar decompression in patients 80 years or older compared with younger age groups. J Neurosurg Spine 2022;37:828–35. Song J, Samuel A, Shahi P, et al. The impact of preoperative sagittal imbalance on long-term postoperative outcomes following minimally invasive laminectomy. HSS J 2024;20:222–9. Shinn D, Mok JK, Vaishnav AS, et al. Recovery kinetics after commonly performed minimally invasive spine surgery procedures. Spine (Phila Pa 1976) 2022;47:1489–96. Song J, Araghi K, Dupont MM, et al. Association between muscle health and patient-reported outcomes after lumbar microdiscectomy: early results. Spine J 2022;22:1677–86. Chiu RG, Patel S, Zhu A, et al. Endoscopic versus open laminectomy for lumbar spinal stenosis: An international, multi-institutional analysis of outcomes and adverse events. Global Spine J 2020;10:720–8. Kpegeol CK, Jain VS, Ansari D, et al. Surgical site infection rates in open versus endoscopic lumbar spinal decompression surgery: A retrospective cohort study. World Neurosurg X 2024;22:100347. Liawrungrueang W, Cholamjiak W, Sarasombath P, et al. Endoscopic spine surgery for obesity-related surgical challenges: a systematic review and meta-analysis of current evidence. Asian Spine J 2025;19:292–310. Kwon B, Moon A. Advances in endoscopic lumbar spine surgery: a comprehensive review of the techniques used for the treatment of lumbar disc herniations and spinal stenosis and lumbar spinal fusion. Spine J . Epub ahead of print June 25, 2025. DOI: 10.1016/j.spinee.2025.06.004. Safaee MM, Tenorio A, Osorio JA, et al. The impact of obesity on perioperative complications in patients undergoing anterior lumbar interbody fusion. J Neurosurg Spine 2020;33:332–41. Bae JS, Lee S-H. Transforaminal full-endoscopic lumbar discectomy in obese patients. Int J Spine Surg 2016;10:18. Katz AD, Galina J, Song J, et al. Impact of navigation on 30-day outcomes for adult spinal deformity surgery. Global Spine J 2023;13:1728–36. Amen TB, Song J, Mai E, et al. Unplanned readmissions following ambulatory spine surgery: assessing common reasons and risk factors. Spine J 2023;23:1848–57. Ward AJ, Ezeonu S, Raman T, et al. Comparison of endoscopic and non-endoscopic lumbar decompression outcomes using ACS-NSQIP database 2017–2022. J Spine Surg 2025;11:234–41. Shahi P, Subramanian T, Araghi K, et al. Class 2/3 obesity leads to worse outcomes following minimally invasive transforaminal lumbar interbody fusion. Spine J 2025;25:1985–96. Zhao E, Shinn DJ, Basilious M, et al. Impact of metabolic syndrome on early postoperative outcomes after cervical disk replacement: A propensity-matched analysis. Clin Spine Surg 2024;37:E185–91. Kurapatti M, Yu A, Ahmed H, et al. Comparison of the biportal endoscopic versus tubular approach for the treatment of lumbar degenerative disease: A systematic review and meta-analysis. Global Spine J 2025;21925682251356220. Mohamed KS, Yu A, Alasadi Y, et al. Statistical fragility of endoscopic lumbar decompression outcomes: A systematic review of randomized controlled trials. Global Spine J 2025;21925682251383882. Yu A, Kurapatti M, Hoang R, et al. Biportal endoscopic versus conventional open spine surgery for lumbar degenerative disease: a systematic review and meta‑analysis. Asian Spine J 2025;19:809–21. Tables Table 1. Comparison of Patient Characteristics Between BMI Groups Normal Overweight Class 1 Obesity Class 2/3 Obesity p -value Bonferroni Total N 70 116 137 75 Mean age (years) 61.1 ± 17.3 53.7 ± 16.1 54.9 ± 17.3 53.6 ± 15.8 0.018 2 vs. 1: 0.022 4 vs. 1: 0.045 Female sex 36 (51.4%) 38 (32.8%) 63 (46.0%) 40 (53.3%) 0.016 Black race 5 (7.1%) 6 (5.2%) 6 (4.4%) 5 (6.7%) 0.823 Hispanic ethnicity 2 (2.9%) 8 (6.9%) 10 (7.3%) 6 (8.0%) 0.579 ASA ≥ 3 21 (30.0%) 37 (31.9%) 53 (38.7%) 50 (66.7%) 0.001 Metabolic syndrome 0 (0.0%) 0 (0.0%) 21 (15.3%) 10 (13.3%) < 0.001 Diabetes mellitus 10 (14.3%) 17 (14.7%) 24 (17.5%) 12 (16.0%) 0.91 Hypertension 24 (34.3%) 35 (30.2%) 52 (38.0%) 43 (57.3%) 0.002 Smoker 11 (15.7%) 20 (17.2%) 17 (12.4%) 13 (17.3%) 0.690 Chronic steroid use 5 (7.1%) 2 (1.7%) 3 (2.2%) 3 (4.0%) 0.184 Bold indicates statistical significance ( p < 0.05). Class 1 obesity: BMI 30 to < 35. Class 2/3 obesity: BMI ≥ 35. ASA, American Society of Anesthesiologists. Table 2. Comparison of Perioperative Characteristics Between Groups Normal Overweight Class 1 Obesity Class 2/3 Obesity p -value Bonferroni Operative time (min) 90.4 ± 45.9 97.1 ± 52.2 93.1 ± 48.2 110.6 ± 47.8 0.048 4 vs. 1: 0.049 4 vs. 3: 0.079 Length of stay (days) 0.8 ± 1.6 0.8 ± 1.7 1.0 ± 2.0 0.9 ± 1.9 0.830 Outpatient surgery 49 (70.0%) 78 (67.2%) 95 (69.3%) 48 (64.0%) 0.845 Prolonged LOS 13 (18.6%) 19 (16.4%) 30 (21.9%) 14 (18.7%) 0.736 Non-home discharge 1 (1.4%) 1 (0.9%) 3 (2.2%) 2 (2.7%) 0.780 Bold indicates statistical significance ( p < 0.05). Class 1 obesity: BMI 30 to < 35. Class 2/3 obesity: BMI ≥ 35. LOS, length of stay. Table 3. Impact of BMI ≥ 30 on 30-Day Outcomes Control BMI ≥ 30 p -value Total N 186 212 Readmission 7 (3.8%) 6 (2.8%) 0.601 Reoperation 2 (1.1%) 2 (0.9%) 0.895 Morbidity 2 (1.1%) 7 (3.3%) 0.136 Individual Complications SSI/Dehiscence 1 (0.5%) 4 (1.9%) 0.228 Urinary tract infection 1 (0.5%) 2 (0.9%) 0.641 Bleeding transfusion 1 (0.5%) 0 (0.0%) 0.467 Pneumonia 0 (0.0%) 1 (0.5%) 0.533 Sepsis 0 (0.0%) 1 (0.5%) 0.533 SSI, surgical site infection. Table 4. Impact of BMI ≥ 35 on 30-Day Outcomes Control BMI ≥ 35 p -value Total N 323 75 Readmission 9 (2.8%) 4 (5.3%) 0.278 Reoperation 4 (1.2%) 0 (0.0%) 0.333 Morbidity 4 (1.2%) 5 (6.7%) 0.014 Individual Complications SSI/Dehiscence 2 (0.6%) 3 (4.0%) 0.048 Urinary tract infection 1 (0.3%) 2 (2.7%) 0.033 Bleeding transfusion 1 (0.3%) 0 (0.0%) 0.692 Pneumonia 1 (0.3%) 0 (0.0%) 0.692 Sepsis 0 (0.0%) 1 (1.3%) 0.067 Bold indicates statistical significance. SSI, surgical site infection. Table 5. Impact of Metabolic Syndrome on 30-Day Outcomes Control Metabolic Syndrome p -value Total N 367 31 Readmission 10 (2.7%) 3 (9.7%) 0.037 Reoperation 4 (1.1%) 0 (0.0%) 0.559 Morbidity 6 (1.6%) 3 (9.7%) 0.026 Individual Complications SSI/Dehiscence 4 (1.1%) 1 (3.2%) 0.305 Urinary tract infection 2 (0.5%) 1 (3.2%) 0.216 Bleeding transfusion 1 (0.3%) 0 (0.0%) 0.771 Pneumonia 0 (0.0%) 1 (3.2%) 0.078 Sepsis 0 (0.0%) 1 (3.2%) 0.078 Bold indicates statistical significance. SSI, surgical site infection. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 03 May, 2026 Reviewers agreed at journal 28 Apr, 2026 Reviewers agreed at journal 28 Apr, 2026 Reviewers invited by journal 28 Apr, 2026 Editor assigned by journal 13 Feb, 2026 Submission checks completed at journal 13 Feb, 2026 First submitted to journal 08 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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15:29:52","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":310107,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8822929/v1/41f1e7a1-d448-4f16-8425-3ac1b25c26ae.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Class 2/3 Obesity and Metabolic Syndrome are Associated with Higher Complications Following Endoscopic Lumbar Decompression","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eLumbar spinal stenosis is a leading indication for spine surgery in older adults and results from degenerative narrowing of the spinal canal with compression of neural elements, commonly driven by ligamentum flavum hypertrophy, disc herniation, and facet arthropathy [1\u0026ndash;4]. Decompression is the preferred operative treatment for patients with persistent, function-limiting symptoms despite conservative care [5\u0026ndash;7].\u003c/p\u003e \u003cp\u003eTraditional open lumbar decompression reliably relieves neural compression but requires wider exposure with muscle dissection and soft-tissue manipulation, which may contribute to blood loss, postoperative pain, and paraspinal morbidity [8, 9]. Accordingly, endoscopic lumbar decompression has gained momentum as a minimally invasive alternative intended to achieve adequate decompression through smaller incisions while limiting tissue disruption [10, 11].\u003c/p\u003e \u003cp\u003ePotential advantages of endoscopic approaches have been well-described, including reduced tissue trauma, blood loss, and infection rates with accelerated recovery, although comparative outcome data remain heterogeneous across techniques and study designs [12, 13]. Obesity further complicates perioperative management in spine surgery. Patients with obesity are at increased risk of perioperative morbidity, including longer operative times and higher rates of wound-related complications [12, 14]. Endoscopic techniques may mitigate some obesity-associated risks by minimizing incision size and soft-tissue disruption, and available clinical series suggest that endoscopic decompression can be performed safely in patients with obesity with meaningful symptom improvement [12, 15]. However, the evidence base remains limited, and more generalizable estimates of short-term postoperative risk, particularly in severe obesity, are still needed [10, 12].\u003c/p\u003e \u003cp\u003eTherefore, we performed a national database analysis to evaluate the association between obesity severity and 30-day outcomes after endoscopic lumbar decompression. Secondarily, we also evaluated the influence of metabolic syndrome on postoperative outcomes.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003e We performed a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), which captures patient-level perioperative variables and tracks 30-day postoperative outcomes across participating hospitals [16, 17]. Because NSQIP data are de-identified, this study was considered exempt from institutional review board oversight.\u003c/p\u003e \u003cp\u003ePatients undergoing endoscopic lumbar decompression between 2017\u0026ndash;2023 were identified using the primary Current Procedural Terminology (CPT) code 62380, which was introduced to distinguish endoscopic lumbar decompression procedures in the year 2017 [10, 18]. We excluded cases performed in the setting of infection or malignancy and those involving concomitant fusion procedures. Patients with missing body mass index (BMI) or demographic data were excluded.\u003c/p\u003e \u003cp\u003eBMI (kg/m\u0026sup2;) was evaluated both categorically and using clinically relevant thresholds. Patients were stratified into four BMI groups: normal, overweight (25 to \u0026lt;\u0026thinsp;30), class I obesity (30 to \u0026lt;\u0026thinsp;35), and class II/III obesity (\u0026ge;\u0026thinsp;35). We performed threshold-based analysis of 30-day outcomes for BMI\u0026thinsp;\u0026ge;\u0026thinsp;30 and BMI\u0026thinsp;\u0026ge;\u0026thinsp;35 compared to their respective control cohorts. Metabolic syndrome was defined a priori as BMI\u0026thinsp;\u0026ge;\u0026thinsp;30 with comorbid diabetes mellitus and hypertension [19, 20].\u003c/p\u003e \u003cp\u003eBaseline characteristics extracted included age, sex, race, ethnicity, smoking status, diabetes mellitus, hypertension, chronic steroid use, and American Society of Anesthesiologists (ASA) class. Perioperative variables included operative time, length of hospital stay (LOS), outpatient status, discharge disposition. The primary outcomes were 30-day readmission, reoperation, and composite morbidity. Composite morbidity included surgical site infection (SSI)/wound dehiscence, urinary tract infection (UTI), bleeding requiring transfusion, pneumonia, or sepsis.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eCategorical variables were compared using chi-square tests or Fisher exact tests, as appropriate. Continuous variables were compared using one-way ANOVA with Bonferroni post hoc correction for pairwise comparisons. When comparing postoperative outcomes, we performed threshold analyses for BMI\u0026thinsp;\u0026ge;\u0026thinsp;30, BMI\u0026thinsp;\u0026ge;\u0026thinsp;35, and metabolic syndrome. All tests were two-sided, with statistical significance set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003ePatient Characteristics\u003c/h2\u003e \u003cp\u003eA total of 398 patients undergoing endoscopic lumbar decompression met inclusion criteria, including 70 (17.6%) with normal BMI, 116 (29.1%) overweight, 137 (34.4%) with class I obesity, and 75 (18.8%) with class II/III obesity. Mean age differed across BMI strata (p\u0026thinsp;=\u0026thinsp;0.018), with the normal BMI group older than the overweight and class II/III obesity groups on post hoc testing. Sex distribution also differed across BMI groups (p\u0026thinsp;=\u0026thinsp;0.016). There were no differences across BMI groups in Black race, Hispanic ethnicity, diabetes mellitus, smoking status, or chronic steroid use (all p\u0026thinsp;\u0026gt;\u0026thinsp;0.05).Patients with class II/III obesity had higher comorbidity burden, with a greater proportion classified as ASA\u0026thinsp;\u0026ge;\u0026thinsp;3 (66.7% vs 30.0% in normal BMI; p\u0026thinsp;=\u0026thinsp;0.001), and higher rates of hypertension (57.3% vs 34.3% in normal BMI; p\u0026thinsp;=\u0026thinsp;0.002). Metabolic syndrome was present in 31 patients overall and differed by BMI category (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), occurring only in the class I obesity (15.3%) and class II/III obesity (13.3%) groups (Table\u0026nbsp;1).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePerioperative Characteristics\u003c/h3\u003e\n\u003cp\u003eOperative time differed across BMI groups (p\u0026thinsp;=\u0026thinsp;0.048), with longer operative time among patients with class II/III obesity compared with normal BMI (110.6\u0026thinsp;\u0026plusmn;\u0026thinsp;47.8 vs 90.4\u0026thinsp;\u0026plusmn;\u0026thinsp;45.9 minutes; Bonferroni p\u0026thinsp;=\u0026thinsp;0.049). Length of stay did not differ by BMI category (p\u0026thinsp;=\u0026thinsp;0.830), and there were no significant differences in outpatient surgery rates, prolonged length of stay, or non-home discharge (all p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Table\u0026nbsp;2).\u003c/p\u003e\n\u003ch3\u003eThirty-Day Outcomes by BMI Thresholds\u003c/h3\u003e\n\u003cp\u003eIn BMI threshold analyses, BMI\u0026thinsp;\u0026ge;\u0026thinsp;30 was present in 212 (53.3%) patients, with 186 (46.7%) in the control group. BMI\u0026thinsp;\u0026ge;\u0026thinsp;30 was not associated with differences in 30-day readmission (2.8% vs 3.8%, p\u0026thinsp;=\u0026thinsp;0.601), reoperation (0.9% vs 1.1%, p\u0026thinsp;=\u0026thinsp;0.895), or composite morbidity (3.3% vs 1.1%, p\u0026thinsp;=\u0026thinsp;0.136). Individual complications, including SSI/wound dehiscence and UTI, did not differ between groups (Table\u0026nbsp;3).\u003c/p\u003e \u003cp\u003eBMI\u0026thinsp;\u0026ge;\u0026thinsp;35 was present in 75 (18.8%) patients, with 323 (81.2%) in the control group. BMI\u0026thinsp;\u0026ge;\u0026thinsp;35 was associated with higher 30-day composite morbidity (6.7% vs 1.2%, p\u0026thinsp;=\u0026thinsp;0.014). This increase was driven by higher SSI/wound dehiscence (4.0% vs 0.6%, p\u0026thinsp;=\u0026thinsp;0.048) and UTI (2.7% vs 0.3%, p\u0026thinsp;=\u0026thinsp;0.033). Rates of readmission (5.3% vs 2.8%, p\u0026thinsp;=\u0026thinsp;0.278) and reoperation (0.0% vs 1.2%, p\u0026thinsp;=\u0026thinsp;0.333) did not differ between BMI\u0026thinsp;\u0026ge;\u0026thinsp;35 and controls (Table\u0026nbsp;4).\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eThirty-Day Outcomes by Metabolic Syndrome\u003c/h2\u003e \u003cp\u003eMetabolic syndrome was present in 31 (7.8%) patients, with 367 (92.2%) in the control group. Metabolic syndrome was associated with higher 30-day readmission (9.7% vs 2.7%, p\u0026thinsp;=\u0026thinsp;0.037) and higher composite morbidity (9.7% vs 1.6%, p\u0026thinsp;=\u0026thinsp;0.026). Reoperation rates did not differ (0.0% vs 1.1%, p\u0026thinsp;=\u0026thinsp;0.559). Individual complications were numerically higher among patients with metabolic syndrome but did not reach statistical significance (Table\u0026nbsp;5).\u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eIn this cohort of patients undergoing endoscopic lumbar decompression, short-term adverse event rates were low across BMI strata. Class I obesity defined at the conventional threshold of BMI\u0026thinsp;\u0026ge;\u0026thinsp;30 was not associated with higher 30-day readmission, reoperation, or composite morbidity, whereas class II/III obesity (BMI\u0026thinsp;\u0026ge;\u0026thinsp;35) was associated with higher 30-day morbidity (6.7% vs 1.2%), driven primarily by SSI/wound dehiscence and urinary tract infection. Metabolic syndrome was additionally associated with increased 30-day readmission and morbidity, suggesting that metabolic health may further refine perioperative risk stratification beyond BMI alone.\u003c/p\u003e \u003cp\u003eThese findings align with the growing body of evidence supporting favorable perioperative safety profiles for endoscopic decompression, including large database studies demonstrating low 30-day adverse event rates and, in comparative analyses, lower overall adverse outcomes relative to non-endoscopic decompression after risk adjustment [10, 18]. At the same time, the observed \u0026ldquo;threshold effect\u0026rdquo; at BMI\u0026thinsp;\u0026ge;\u0026thinsp;35 is clinically plausible: while endoscopic techniques may mitigate obesity-associated risk by limiting incision size and soft-tissue disruption, the physiologic and technical consequences of severe obesity (thicker subcutaneous envelope, longer working distance, and higher baseline comorbidity burden) may outstrip these procedural advantages, contributing to longer operative times and higher wound complication risk in the highest BMI strata [21\u0026ndash;23]. This interpretation is consistent with systematic review-level data suggesting that endoscopic spine surgery can maintain favorable clinical outcomes in obese patients, though operative times may be longer and symptom recurrence may be slightly increased in some endoscopic cohorts [12].\u003c/p\u003e \u003cp\u003eThe increased incidence of UTI in severe obesity may reflect broader associations between obesity and postoperative infection risk. For example, in other lumbar surgery cohorts, obesity has been linked to increased wound complications and UTI, which may relate to altered immune function, higher prevalence of metabolic derangements, and perioperative factors such as urinary retention and catheter utilization [14]. While NSQIP does not provide granular detail regarding catheter practices or postoperative urinary retention in this cohort, the consistent directionality across procedures supports heightened attention to perioperative bladder management (e.g., minimizing indwelling catheter duration when feasible) in patients with severe obesity.\u003c/p\u003e \u003cp\u003eImportantly, metabolic syndrome appeared to identify a subgroup at elevated short-term risk, including readmission, even when BMI\u0026thinsp;\u0026ge;\u0026thinsp;30 alone did not. Metabolic syndrome, as defined by obesity with concomitant diabetes and hypertension, may better capture systemic risk factors (insulin resistance, vascular dysfunction, and inflammatory milieu) that plausibly contribute to impaired wound healing, infection susceptibility, and medical readmissions. Although the current study was not designed to isolate mechanisms, these findings support considering metabolic health alongside BMI in preoperative counseling and optimization.\u003c/p\u003e \u003cp\u003eFrom a practical standpoint, the overall low 30-day complication rates across BMI categories support that endoscopic lumbar decompression can be performed safely in many patients with obesity. However, the increased morbidity observed in class II/III obesity and metabolic syndrome groups suggests these patients may benefit from targeted mitigation strategies: (1) preoperative counseling about modestly increased short-term infection/UTI risk, (2) preoperative optimization of glycemic control and blood pressure when time permits, and (3) heightened attention to wound management and early postoperative surveillance.\u003c/p\u003e \u003cp\u003eThis study has important limitations that must be considered. NSQIP captures only short-term outcomes within 30 days and lacks key clinical granularity, including specific endoscopic technique (uniportal vs. biportal), intraoperative details, radiographic data, and patient-reported outcome measures. Additionally, although CPT 62380 enables identification of endoscopic decompression in NSQIP, coding practices may introduce misclassification: some endoscopic cases may be billed under non-endoscopic codes (e.g., 63030) due to payer recognition, which could bias case capture and limit generalizability. Finally, the sample size was limited and adverse event counts were low, particularly within the BMI\u0026thinsp;\u0026ge;\u0026thinsp;35 and metabolic syndrome strata, limiting power for less common complications and precluding robust multivariable modeling of rare outcomes.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eIn conclusion, this national database study suggests that endoscopic lumbar decompression is associated with low 30-day complication rates across BMI strata, with no detectable increase in short-term adverse outcomes at BMI\u0026thinsp;\u0026ge;\u0026thinsp;30. In contrast, severe obesity (BMI\u0026thinsp;\u0026ge;\u0026thinsp;35) and metabolic syndrome were associated with higher 30-day morbidity, driven primarily by wound complications and urinary tract infection, underscoring the value of obesity severity and metabolic risk profiling in perioperative counseling and optimization.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eJunho Song, MD contributed to all aspects of the study, including study conception and design, data acquisition, data analysis and interpretation, and manuscript drafting. Tejas Subramanian, MD; Alexander Yu, BS; Kareem S. Mohamed, BS; Ryan Hoang, BA; Timothy Hoang, BA; Austin Q. Nguyen, MD; Joshua Zhang, BS; Omri Maayan, MD; Tariq Z. Issa, MD; Nikan K. Namiri, MD; John J. Corvi, MD; Saad B. Chaudhary, MD; Andrew C. Hecht, MD; and Samuel K. Cho, MD contributed to manuscript writing, critical revision for important intellectual content, and final approval of the manuscript. All authors approved the final version and agree to be accountable for all aspects of the work.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e Shahi P, Vaishnav AS, Mai E, et al. Practical answers to frequently asked questions in minimally invasive lumbar spine surgery. \u003cem\u003eSpine J\u003c/em\u003e 2023;23:54\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Subramanian T, Shahi P, Hirase T, et al. Outcomes of one versus two level MIS decompression with adjacent level stenosis. \u003cem\u003eGlobal Spine J\u003c/em\u003e 2024;15:21925682241303104.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Bovonratwet P, Kulm S, Kolin DA, et al. Identification of novel genetic markers for the risk of spinal pathologies: A genome-wide association study of 2 biobanks. \u003cem\u003eJ Bone Joint Surg Am\u003c/em\u003e 2023;105:830\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Jung B, Han J, Song J, et al. Interventional therapy and surgical management of lumbar disc herniation in spine surgery: A narrative review. \u003cem\u003eOrthop Rev (Pavia)\u003c/em\u003e 2023;15:88931.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Bovonratwet P, Samuel AM, Mok JK, et al. Minimally invasive lumbar decompression versus minimally invasive transforaminal lumbar interbody fusion for treatment of low-grade lumbar degenerative spondylolisthesis. \u003cem\u003eSpine (Phila Pa 1976)\u003c/em\u003e 2022;47:1505\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Shahi P, Song J, Dalal S, et al. Improvement following minimally invasive lumbar decompression in patients 80 years or older compared with younger age groups. \u003cem\u003eJ Neurosurg Spine\u003c/em\u003e 2022;37:828\u0026ndash;35.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Song J, Samuel A, Shahi P, et al. The impact of preoperative sagittal imbalance on long-term postoperative outcomes following minimally invasive laminectomy. \u003cem\u003eHSS J\u003c/em\u003e 2024;20:222\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Shinn D, Mok JK, Vaishnav AS, et al. Recovery kinetics after commonly performed minimally invasive spine surgery procedures. \u003cem\u003eSpine (Phila Pa 1976)\u003c/em\u003e 2022;47:1489\u0026ndash;96.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Song J, Araghi K, Dupont MM, et al. Association between muscle health and patient-reported outcomes after lumbar microdiscectomy: early results. \u003cem\u003eSpine J\u003c/em\u003e 2022;22:1677\u0026ndash;86.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Chiu RG, Patel S, Zhu A, et al. Endoscopic versus open laminectomy for lumbar spinal stenosis: An international, multi-institutional analysis of outcomes and adverse events. \u003cem\u003eGlobal Spine J\u003c/em\u003e 2020;10:720\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Kpegeol CK, Jain VS, Ansari D, et al. Surgical site infection rates in open versus endoscopic lumbar spinal decompression surgery: A retrospective cohort study. \u003cem\u003eWorld Neurosurg X\u003c/em\u003e 2024;22:100347.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Liawrungrueang W, Cholamjiak W, Sarasombath P, et al. Endoscopic spine surgery for obesity-related surgical challenges: a systematic review and meta-analysis of current evidence. \u003cem\u003eAsian Spine J\u003c/em\u003e 2025;19:292\u0026ndash;310.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Kwon B, Moon A. Advances in endoscopic lumbar spine surgery: a comprehensive review of the techniques used for the treatment of lumbar disc herniations and spinal stenosis and lumbar spinal fusion. \u003cem\u003eSpine J\u003c/em\u003e. Epub ahead of print June 25, 2025. DOI: 10.1016/j.spinee.2025.06.004.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Safaee MM, Tenorio A, Osorio JA, et al. The impact of obesity on perioperative complications in patients undergoing anterior lumbar interbody fusion. \u003cem\u003eJ Neurosurg Spine\u003c/em\u003e 2020;33:332\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Bae JS, Lee S-H. Transforaminal full-endoscopic lumbar discectomy in obese patients. \u003cem\u003eInt J Spine Surg\u003c/em\u003e 2016;10:18.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Katz AD, Galina J, Song J, et al. Impact of navigation on 30-day outcomes for adult spinal deformity surgery. \u003cem\u003eGlobal Spine J\u003c/em\u003e 2023;13:1728\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Amen TB, Song J, Mai E, et al. Unplanned readmissions following ambulatory spine surgery: assessing common reasons and risk factors. \u003cem\u003eSpine J\u003c/em\u003e 2023;23:1848\u0026ndash;57.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Ward AJ, Ezeonu S, Raman T, et al. Comparison of endoscopic and non-endoscopic lumbar decompression outcomes using ACS-NSQIP database 2017\u0026ndash;2022. \u003cem\u003eJ Spine Surg\u003c/em\u003e 2025;11:234\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Shahi P, Subramanian T, Araghi K, et al. Class 2/3 obesity leads to worse outcomes following minimally invasive transforaminal lumbar interbody fusion. \u003cem\u003eSpine J\u003c/em\u003e 2025;25:1985\u0026ndash;96.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Zhao E, Shinn DJ, Basilious M, et al. Impact of metabolic syndrome on early postoperative outcomes after cervical disk replacement: A propensity-matched analysis. \u003cem\u003eClin Spine Surg\u003c/em\u003e 2024;37:E185\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Kurapatti M, Yu A, Ahmed H, et al. Comparison of the biportal endoscopic versus tubular approach for the treatment of lumbar degenerative disease: A systematic review and meta-analysis. \u003cem\u003eGlobal Spine J\u003c/em\u003e 2025;21925682251356220.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Mohamed KS, Yu A, Alasadi Y, et al. Statistical fragility of endoscopic lumbar decompression outcomes: A systematic review of randomized controlled trials. \u003cem\u003eGlobal Spine J\u003c/em\u003e 2025;21925682251383882.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Yu A, Kurapatti M, Hoang R, et al. Biportal endoscopic versus conventional open spine surgery for lumbar degenerative disease: a systematic review and meta‑analysis. \u003cem\u003eAsian Spine J\u003c/em\u003e 2025;19:809\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003cdiv\u003eTable 1. Comparison of Patient Characteristics Between BMI Groups\u003c/div\u003e\n \u003ctable id=\"Taba\" border=\"1\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003eNormal\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003eOverweight\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003eClass 1 Obesity\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003eClass 2/3 Obesity\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"BoldItalic\"\u003ep\u003c/span\u003e\u003cspan class=\"Bold\"\u003e-value\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003eBonferroni\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eTotal \u003cspan class=\"Italic\"\u003eN\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e70\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e116\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e137\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e75\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eMean age (years)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e61.1\u0026thinsp;\u0026plusmn;\u0026thinsp;17.3\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e53.7\u0026thinsp;\u0026plusmn;\u0026thinsp;16.1\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e54.9 \u0026plusmn;\u0026nbsp;17.3\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e53.6\u0026thinsp;\u0026plusmn;\u0026thinsp;15.8\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003e0.018\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e2 vs. 1: \u003cspan class=\"Bold\"\u003e0.022\u003c/span\u003e\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003e4 vs. 1: \u003cspan class=\"Bold\"\u003e0.045\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eFemale sex\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e36 (51.4%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e38 (32.8%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e63 (46.0%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e40 (53.3%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003e0.016\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eBlack race\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e5 (7.1%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e6 (5.2%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e6 (4.4%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e5 (6.7%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.823\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eHispanic ethnicity\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e2 (2.9%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e8 (6.9%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e10 (7.3%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e6 (8.0%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.579\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eASA\u0026thinsp;\u0026ge;\u0026thinsp;3\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e21 (30.0%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e37 (31.9%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e53 (38.7%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e50 (66.7%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003e0.001\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eMetabolic syndrome\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0 (0.0%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0 (0.0%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e21 (15.3%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e10 (13.3%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003e\u0026lt;\u0026thinsp;0.001\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eDiabetes mellitus\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e10 (14.3%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e17 (14.7%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e24 (17.5%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e12 (16.0%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.91\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eHypertension\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e24 (34.3%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e35 (30.2%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e52 (38.0%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e43 (57.3%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003e0.002\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eSmoker\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e11 (15.7%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e20 (17.2%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e17 (12.4%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e13 (17.3%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.690\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eChronic steroid use\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e5 (7.1%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e2 (1.7%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e3 (2.2%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e3 (4.0%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.184\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\"\u003eBold indicates statistical significance (\u003cspan class=\"Italic\"\u003ep\u003c/span\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Class 1 obesity: BMI 30 to \u0026lt;\u0026thinsp;35. Class 2/3 obesity: BMI\u0026thinsp;\u0026ge;\u0026thinsp;35. ASA, American Society of Anesthesiologists.\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv\u003eTable 2. Comparison of Perioperative Characteristics Between Groups\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Tabb\" border=\"1\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003eNormal\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003eOverweight\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003eClass 1 Obesity\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003eClass 2/3 Obesity\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"BoldItalic\"\u003ep\u003c/span\u003e\u003cspan class=\"Bold\"\u003e-value\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003eBonferroni\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eOperative time (min)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e90.4\u0026thinsp;\u0026plusmn;\u0026thinsp;45.9\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e97.1\u0026thinsp;\u0026plusmn;\u0026thinsp;52.2\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e93.1\u0026thinsp;\u0026plusmn;\u0026thinsp;48.2\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e110.6\u0026thinsp;\u0026plusmn;\u0026thinsp;47.8\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003e0.048\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e4 vs. 1: \u003cspan class=\"Bold\"\u003e0.049\u003c/span\u003e\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003e4 vs. 3: 0.079\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eLength of stay (days)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.0\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.9\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.830\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eOutpatient surgery\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e49 (70.0%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e78 (67.2%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e95 (69.3%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e48 (64.0%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.845\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eProlonged LOS\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e13 (18.6%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e19 (16.4%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e30 (21.9%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e14 (18.7%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.736\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eNon-home discharge\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1 (1.4%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1 (0.9%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e3 (2.2%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e2 (2.7%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.780\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\"\u003eBold indicates statistical significance (\u003cspan class=\"Italic\"\u003ep\u003c/span\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Class 1 obesity: BMI 30 to \u0026lt;\u0026thinsp;35. Class 2/3 obesity: BMI\u0026thinsp;\u0026ge;\u0026thinsp;35. LOS, length of stay.\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cdiv\u003eTable 3. Impact of BMI\u0026thinsp;\u0026ge;\u0026thinsp;30 on 30-Day Outcomes\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Tabc\" border=\"1\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003eControl\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003eBMI\u0026thinsp;\u0026ge;\u0026thinsp;30\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"BoldItalic\"\u003ep\u003c/span\u003e\u003cspan class=\"Bold\"\u003e-value\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003eTotal\u003c/span\u003e \u003cspan class=\"BoldItalic\"\u003eN\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e186\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e212\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003eReadmission\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e7 (3.8%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e6 (2.8%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.601\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003eReoperation\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e2 (1.1%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e2 (0.9%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.895\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003eMorbidity\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e2 (1.1%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e7 (3.3%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.136\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003eIndividual Complications\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eSSI/Dehiscence\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1 (0.5%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e4 (1.9%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.228\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eUrinary tract infection\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1 (0.5%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e2 (0.9%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.641\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eBleeding transfusion\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1 (0.5%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0 (0.0%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.467\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003ePneumonia\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0 (0.0%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1 (0.5%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.533\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eSepsis\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0 (0.0%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1 (0.5%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.533\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003eSSI, surgical site infection.\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv\u003eTable 4. Impact of BMI\u0026thinsp;\u0026ge;\u0026thinsp;35 on 30-Day Outcomes\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tabd\" border=\"1\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003eControl\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003eBMI\u0026thinsp;\u0026ge;\u0026thinsp;35\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"BoldItalic\"\u003ep\u003c/span\u003e\u003cspan class=\"Bold\"\u003e-value\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003eTotal\u003c/span\u003e \u003cspan class=\"BoldItalic\"\u003eN\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e323\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e75\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003eReadmission\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e9 (2.8%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e4 (5.3%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.278\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003eReoperation\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e4 (1.2%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0 (0.0%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.333\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003eMorbidity\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e4 (1.2%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e5 (6.7%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003e0.014\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003eIndividual Complications\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eSSI/Dehiscence\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e2 (0.6%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e3 (4.0%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003e0.048\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eUrinary tract infection\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1 (0.3%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e2 (2.7%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003e0.033\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eBleeding transfusion\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1 (0.3%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0 (0.0%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.692\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003ePneumonia\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1 (0.3%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0 (0.0%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.692\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eSepsis\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0 (0.0%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1 (1.3%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.067\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eBold indicates statistical significance. SSI, surgical site infection.\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv\u003eTable 5. Impact of Metabolic Syndrome on 30-Day Outcomes\u003c/div\u003e\n\u003ctable id=\"Tabe\" border=\"1\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003eControl\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003eMetabolic Syndrome\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"BoldItalic\"\u003ep\u003c/span\u003e\u003cspan class=\"Bold\"\u003e-value\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003eTotal\u003c/span\u003e \u003cspan class=\"BoldItalic\"\u003eN\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e367\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e31\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003eReadmission\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e10 (2.7%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e3 (9.7%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003e0.037\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003eReoperation\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e4 (1.1%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0 (0.0%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.559\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003eMorbidity\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e6 (1.6%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e3 (9.7%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003e0.026\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003eIndividual Complications\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eSSI/Dehiscence\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e4 (1.1%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1 (3.2%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.305\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eUrinary tract infection\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e2 (0.5%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1 (3.2%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.216\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eBleeding transfusion\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1 (0.3%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0 (0.0%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.771\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003ePneumonia\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0 (0.0%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1 (3.2%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.078\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eSepsis\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0 (0.0%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1 (3.2%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.078\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eBold indicates statistical significance. SSI, surgical site infection.\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-spine-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"esjo","sideBox":"Learn more about [European Spine Journal](http://link.springer.com/journal/586)","snPcode":"586","submissionUrl":"https://submission.springernature.com/new-submission/586/3","title":"European Spine Journal","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"endoscopic lumbar decompression, endoscopic spine surgery, obesity, body mass index, metabolic syndrome, ACS-NSQIP","lastPublishedDoi":"10.21203/rs.3.rs-8822929/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8822929/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eRetrospective cohort study to evaluate the association between obesity severity and postoperative outcomes after endoscopic lumbar decompression.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA national surgical database was queried to identify patients undergoing endoscopic lumbar decompression between 2017\u0026ndash;2023. Patients were stratified by BMI category (normal, overweight [25 to \u0026lt;\u0026thinsp;30], class I obesity [30 to \u0026lt;\u0026thinsp;35], class II/III obesity [\u0026ge;\u0026thinsp;35]). Metabolic syndrome was defined as BMI\u0026thinsp;\u0026ge;\u0026thinsp;30 with concurrent diabetes mellitus and hypertension. Outcomes included 30-day readmission, reoperation, and composite morbidity, including surgical site infection(SSI)/wound dehiscence, urinary tract infection (UTI), transfusion, pneumonia, or sepsis. Categorical variables were compared using chi-square or Fisher exact tests; continuous variables were analyzed using one-way ANOVA with Bonferroni correction.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 398 patients were included (normal n\u0026thinsp;=\u0026thinsp;70, overweight n\u0026thinsp;=\u0026thinsp;116, class I obesity n\u0026thinsp;=\u0026thinsp;137, class II/III obesity n\u0026thinsp;=\u0026thinsp;75). Patients with class II/III obesity had higher comorbidity burden and longer operative time compared to normal BMI. BMI\u0026thinsp;\u0026ge;\u0026thinsp;30 was not associated with differences in 30-day readmission, reoperation, or overall morbidity. In contrast, BMI\u0026thinsp;\u0026ge;\u0026thinsp;35 was associated with higher 30-day morbidity (6.7% vs 1.2%, p\u0026thinsp;=\u0026thinsp;0.014), higher SSI/dehiscence (4.0% vs 0.6%, p\u0026thinsp;=\u0026thinsp;0.048), higher UTI (2.7% vs 0.3%, p\u0026thinsp;=\u0026thinsp;0.033) rates. Metabolic syndrome was associated with increased readmission (9.7% vs 2.7%, p\u0026thinsp;=\u0026thinsp;0.037) and morbidity (9.7% vs 1.6%, p\u0026thinsp;=\u0026thinsp;0.026).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eEndoscopic lumbar decompression demonstrated low overall 30-day event rates across BMI strata. Class I obesity was not associated with worse short-term outcomes; however, class II/III obesity and metabolic syndrome were associated with increased morbidity, driven primarily by wound complications and UTI.\u003c/p\u003e","manuscriptTitle":"Class 2/3 Obesity and Metabolic Syndrome are Associated with Higher Complications Following Endoscopic Lumbar Decompression","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-07 13:35:39","doi":"10.21203/rs.3.rs-8822929/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-04T00:34:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"54990134061665377346868969545807946815","date":"2026-04-28T18:17:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"88095649883035575603479196962171124668","date":"2026-04-28T18:04:32+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-28T17:50:58+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-14T03:19:44+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-14T03:19:25+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Spine Journal","date":"2026-02-08T15:58:17+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-spine-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"esjo","sideBox":"Learn more about [European Spine Journal](http://link.springer.com/journal/586)","snPcode":"586","submissionUrl":"https://submission.springernature.com/new-submission/586/3","title":"European Spine Journal","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"eca2399f-e3e0-4f77-a39a-cb95d1f78186","owner":[],"postedDate":"May 7th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-04T00:34:09+00:00","index":16,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-07T13:35:40+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-07 13:35:39","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8822929","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8822929","identity":"rs-8822929","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}