A commentary on “Moderate and severe exacerbations have a significant impact on health related quality of life, utility, and lung function in patients with chronic obstructive pulmonary disease: A meta-analysis” (Int J Surg 2020; 78:28-35)

Several studies have suggested an association between visceral obesity and adverse perioperative outcomes in pancreatic surgery. However, no study has reported the impact of visceral obesity on robotic pancreatic surgery. This study aimed to assess the impact of preoperative visceral obesity on clinically relevant postoperative pancreatic fistula (CR-POPF) in pancreatic ductal adenocarcinoma (PDAC) patients following robotic distal pancreatectomy (RDP) or open distal pancreatectomy (ODP).A retrospective analysis was performed on all patients who consecutively underwent RDP or ODP for PDAC. The visceral adipose tissue was measured on preoperative computed tomography (CT) images at the L3 vertebra level. A 1:1 propensity score matching method was used in the visceral obesity group and the nonvisceral obesity group to minimize the bias between RDP and ODP.Between December 2011 and December 2018, a total of 445 patients were included. Visceral obesity (n = 219) was found to be associated with higher estimated blood loss (p = 0.033), a higher CR-POPF rate (p = 0.001), delayed drain removal (p = 0.005) and a longer length of stay (p = 0.033). In multivariable analysis, visceral obesity was an independent risk factor for CR-POPF (OR: 1.69; 95% CI 1.07–2.67, p = 0.024). Among patients without visceral obesity, the incidence of CR-POPF was lower among RDP than among ODP patients (11.27% vs. 23.87%, p = 0.028), and the difference remained after propensity score matching (9.52% vs. 26.98%, p = 0.011). However, there was no significant difference in the CR-POPF rate between RDP and ODP for visceral obesity patients.In nonvisceral obesity patients, RDP had better perioperative outcomes than ODP, with a significantly lower CR-POPF rate. However, in visceral obesity patients, RDP showed equivalent CR-POPF rate when compared to ODP.