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Influence of Body Mass Index (BMI) on Outcomes After Colorectal Surgery: Underweight More a Problem Than Obesity?
Iyare Esemuede*, Steven Lee-Kong, Daniel L. Feingold, Pokala Kiran
Colorectal surgery, New York Presbyterian Columbia University Medical Center, New York, NY
Background: While obesity is recognized as a risk factor for adverse outcomes, the impact of a low BMI has not been well characterized. In fact, patients who are underweight are often excluded from studies evaluating the influence of weight on outcomes.
Methods: The National Surgical Quality Improvement Program (NSQIP) database was queried for colorectal operations from 2006-2011. Patients were divided into 4 groups: obese (OB; BMI>30), overweight (OW; BMI=25-29.9), normal weight (NW; BMI=18.5-24.9) and underweight (UW; BMI<18.5). Complications and 30-day mortality were compared between the 4 groups.
Results: Of 27,616 patients, the mean age was 61.8 years, 13,542 (49%) were male, and the mean albumin for each group was >3.9 g/dl. OB patients had higher rates of acute renal failure (0.9%, p=0.001), overall wound infection (17.1%, p<0.001), and wound dehiscence (2.4%, p<0.001) than the other groups (table 1). UW patients (when compared to NW, OW, and OB) were more likely to have pneumonia (p=0.002), failure to wean from the ventilator (p<0.001), prolonged length of stay (p<0.001), and increased 30-day mortality (3.1%; p<0.001). Reintubation and cardiac arrest were particularly high in the UW group (p<0.02). Overall wound infection rates were generally lower in UW patients (9.1%) than the other groups (p<0.001). Organ space infections were similar among the 4 groups (p=0.579). Myocardial infarction (MI), cerebrovascular accident (CVA), and postoperative bleeding rates were also similar (p=0.091, 0.833, and 0.976, respectively).
Conclusion: Although UW patients have a lower risk for SSI than patients who have normal weight, are overweight, or obese, they are surprisingly at significantly greater risk for several major general complications and mortality. These findings suggest the need for a focus on preoperative optimization and counseling for underweight patients that are at least on par with current practice for the overweight and obese. Demographics and Outcomes | Characteristic | BMI< 18.5 Underweight N=767 (2.8%) | BMI=18.5-24.9 Normal weight N=8333 (30.2%) | BMI=25 - 29.9 Overweight N=9535 (34.6%) | BMI≥30 Obese N=8949 (32.4%) | p-value | | Age (mean±SD) | 59.4±19.6 | 61.2±16.7 | 62.1±14.2 | 59.8±13.2 | <0.001 | | Gender (female) | 525 (68.4%) | 4793 (57.5%) | 4152 (43.5%) | 4590 (51.3%) | <0.001 | | ASA3-5 | 408 (53.2%) | 3481 (41.8%) | 4000 (42.0%) | 4693 (52.4%) | <0.001 | | Emergency Operation | 136 (17.7%) | 954 (11.4%) | 988 (10.4%) | 892 (10.0%) | <0.001 | | Operative Time (mean±SD) | 150.4±90.6 | 159.3±87.8 | 170.2±88.1 | 181.3±93.9 | <0.001 | | Medical Complications | | Pneumonia | 36 (4.7%) | 215 (2.6%) | 251 (2.6%) | 215 (2.4%) | 0.002 | | Reintubation | 27 (3.5%) | 155 (1.9%) | 203 (2.1%) | 207 (2.3%) | 0.01 | | Failure to wean | 39 (5.1%) | 211 (2.5%) | 250 (2.6%) | 306 (3.4%) | <0.001 | | Pulmonary embolism | 4 (0.5%) | 40 (0.5%) | 64 (0.7%) | 70 (0.8%) | 0.09 | | Renal failure | 4 (0.5%) | 42 (0.5%) | 51 (0.5%) | 84 (0.9%) | 0.001 | | Urinary tract infection | 36 (4.7%) | 281 (3.4%) | 294 (3.1%) | 336 (3.8%) | 0.018 | | Myocardial infarction | 1 (0.1%) | 47 (0.6%) | 46 (0.5%) | 31 (0.4%) | 0.09 | | Cerebrovascular accident | 1 (0.1%) | 23 (0.3%) | 29 (0.3%) | 24 (0.3%) | 0.83 | | Surgical Complications | | Dehiscence | 12 (1.6%) | 87 (1.0%) | 131 (1.4%) | 210 (2.3%) | <0.001 | | Superficial SSI | 40 (5.2%) | 532 (6.4%) | 771 (8.1%) | 1027 (11.5%) | <0.001 | | Deep SSI | 8 (1.0%) | 105 (1.3%) | 137 (1.4%) | 188 (2.1%) | <0.001 | | Organ Space SSI | 30 (3.9%) | 344 (4.1%) | 370 (3.9%) | 383 (4.3%) | 0.58 | | Overall Surgical Site Infection | 71 (9.3%) | 930 (11.2%) | 1216 (12.8%) | 1526 (17.1%) | <0.001 | | Postop Bleeding | 5 (0.7%) | 44 (0.5%) | 52 (0.6%) | 49 (0.6%) | 0.98 | | Return to OR | 57 (7.4%) | 484 (5.8%) | 581 (6.1%) | 601 (6.7%) | 0.04 | | Length of stay (mean±SD) | 9.3±9.0 | 7.7±7.5 | 7.63±7.2 | 7.9±7.9 | <0.001 | | 30 day mortality | 24 (3.1%) | 151 (1.8%) | 120 (1.3%) | 99 (1.1%) | <0.001 |
OR=operating room; SSI=surgical site infection
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