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Morbidity and Outcomes of Colorectal Surgery in the Underweight Population: Results From the American College of Surgeons National Surgical Quality Improvement Program (Acsnsqip) Database
Rebecca Rhee*, Hiromichi Miyagaki, Xiaohong Yan, M. C. Shantha Kumara H, Linda Njoh, Vesna Cekic, Richard L. Whelan
Surgery, St Luke's Roosevelt Hospital, New York, NY

PURPOSE: Whereas, the impact of morbid obesity on colorectal resection (CR) outcomes has been studied, there is limited data concerning CR outcomes in the underweight population (BMI <18.5). This study's goal was to assess the underweight population (UN) that comes to CR and CR-related morbidity.
METHODS: The ACS NSQIP database was queried from 2005-2010 for the CR codes. Patients (pts) who, preoperatively (preop), were ventilator dependent, ASA 5, hypotensive, had SIRS, sepsis, and emergent surgery were excluded. Pts were divided into 3 BMI groups: UN, BMI<18.5; Normal/Obese (NO), BMI ≥18.5 to ≤40; and morbidly obese (MO), BMI >40. Demographic parameters were assessed as well as surgical indications, comorbidities, preop laboratory data, and complications (including surgical site infections (SSI), transfusions, reoperation, etc). The statistical methods used were two sample for population proportions for categorical variables and Wilcoxon rank sum tests for continuous variables.
RESULTS: A total of 73,516 CR pts were identified; the breakdown as per BMI was UN, 2,180, 3%; NO, 67,732, 92%; MO, 3,604, 4.9%. In the UN group there is a significantly higher proportion of colitis/enteritis pts (UN 20.4%, NO 9%, MO 5.2%) and obstruction/volvulus pts (UN 8.3%, NO 3.3%, MO 2.5%) as well as a much lower proportion of diverticulitis cases (UN 8.4%, NO 21.1%, MO 23.4%). The percent of UN cancer pts (44%) was modestly but significantly lower than the NO (47%) or MO (47.6%) groups yet the UN group had more disseminated cases. More UN pts reported weight loss (21.6%) than in the NO (4.7%) or MO (1.7%) groups. Also, more UN pts (13.6%) were on steroids (vs NO, 6.1%; MO, 4.5%, p<0.05). Finally, the UN group had a significantly lower mean albumin level and hematocrit. Significantly fewer UN CR's were done using laparoscopic (LAP) methods than in the other groups (UN 34%, NO 45%, MO 39%). There were also more total colectomies and Hartman's procedures in UN group (p<0.05). There were significantly more complications in the underweight group (UN)(20.4%) than in the NO group (15.6%), yet, there was no difference between the UN and MO groups (20.1%). The UN group's rate of transfusions, sepsis, and reoperations were higher than noted in the NO group. Of note, there were significantly fewer superficial surgical site wound infections in the UN vs the other 2 groups (UN 5.6%, NO 8.1%, MO 16%).
CONCLUSIONS: The complication rate was notably higher in the UN group which may be related to the higher incidence of colitis and obstruction cases and the greater percentage of pts with weight loss and steroid use all of which are associated with high complication rates. Diverticulitis is rare in UN pts. For unclear reasons laparoscopic methods were used less often in the UN group.

UN (n=2180)NO (n=67732)MO (n=3604)UN vs. NO P valueUN vs. MO P value
GenderMale/ Female700/ 148033712/ 340201334/ 2270<.00010.00016
AgeMedian(range)62(16-90)63(19-90)58(16-90)0.0034<.0001
Indication
Malignant Neoplasm9603180517160.00710.0083
Benign Neoplasm1698494497<.0001<.0001
Diverticular Disease18314283843<.0001<.0001
Colitis/enteritis4446092187<.0001<.0001
Obstruction/voluvulus180220890<.0001<.0001
Rectal Prolapse6886110<.0001<.0001
Perforation/ hemorrhage1325421n.s.n.s.
Other Benign Disease1633735240
Comorbidities
Current smoker63011950569<.0001<.0001
Steroid intake2974134161<.0001<.0001
Weight loss in last 6 mo470320663<.0001<.0001
Disseminated cancer124254893n.s.<.0001
Preoperative data
Hematocrit (Mean±SD)35.8 ±5.338.3 ±5.438.1±5.3<.0001n.s.
Albumin (Mean±SD)3.5 ±0.83.8 ±0.63.7 ±0.6<.0001<.0001

UN; underweight group (BMI <18.5), NO; Normal/Obese(BMI ≥18.5 to ≤40), MO; morbidly obese(BMI >40), n.s.; not significant


UN (n=2180)NO (n=67732)MO (n=3604)UN vs. NO P valueUN vs. MO P value
Surgical Procedure
Laparoscopic Surgery742306821409<0.0001<0.0001
Abdominoperinial Resection21187n.s.n.s.
Coloproctectomy23158912420.0020<0.0001
Hartmann Procedure951877106<0.00010.0044
Partial colectomy1197442142472n.s.n.s.
Partial colectomy with removal of terminal ileum43611217595<0.00010.0008
Total colectomy2194415182<0.0001<0.0001
Complications
Major complication44510539723<.0001n.s.
Re-operation1563521227<.0001n.s.
Superficial SSI1215464578<.0001<.0001
Bleeding/Transfusions81154595<.00010.0203
Sepsis11626391950.0008n.s.
Septic Shock451026810.0394n.s.

UN; underweight group (BMI <18.5), NO; Normal/Obese(BMI ≥18.5 to ≤40), MO; morbidly obese(BMI >40), n.s.; not significant, SSI; surgical site infections


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