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DANGERS AT THE EXTREMES OF WEIGHT IN IBD SURGERY
H. Hande Aydinli*1, Michael Grieco1, Shannon Chang2, Lisa Malter2, Hasan T. Kirat1, David Hudesman2, Feza H. Remzi1
1Department of Surgery, New York University, New York, NY; 2Department of Medicine, New York University Langone Health, New York, NY
Background: There is a paucity of data on the association of body mass index (BMI) and postoperative outcomes in patients undergoing major abdominal surgery for inflammatory bowel diseases. The aim of this study was to evaluate the association between BMI and postoperative outcomes in a nationwide cohort.
Methods: A retrospective analysis of a prospectively acquired American College of Surgeons National Surgical Quality Improvement Program database was performed. Patients with IBD who underwent major colorectal surgery in the elective settings (2005-2015) were reviewed. Patients were grouped into five based on BMI (kg/m2): underweight: <18.5, normal: 18.5-24.5, overweight:25-29.9, obese:30-39.9, morbid obese (MO):>40). Demographics, preoperative characteristics and postoperative 30-day outcomes were reviewed. Groups were compared using χ2 or Fisher exact tests for categorical and Wilcoxon rank-sum test for quantitative data. Multivariate logistic regression analysis was conducted.
Results: A total of 14,852 patients were included in the analysis with a mean age of 40.9 years (50% female). Table summarizes the patient characteristics and postoperative 30-day outcomes. Fifty-three percent of the patients (N=7,906) underwent surgery for Crohn's disease and 48.5% were operated laparoscopically. More than half of the patients in the underweight group were on steroids (52.8%, p<0.01), with anemia (66.7%, p<0.01) and hypoalbuminemia (57.5%, p<0.01). An ASA class ≥3 were most common in MO (57.9%) and obese patients (39.2%)(p<0.01). Although mean operative time was shortest in underweight group (p<0.01), length of stay was longest (p<0.01). Twenty-six percent of the patients (N=3,869) were diagnosed with at least one complication (p<0.01), 41 patients died (p=0.6) within 30 days of surgery. Underweight patients were at 2.3 times more risk for blood transfusions when compared to MO (p<0.01), 1.9 times to obese (p<0.0) and 1.4 to overweight patients (p=0.01). Readmission rate was highest in underweight patients [underweight 12.3% vs. normal 9.9%, Odds ratio (OR): 1.3, Confidence interval (CI) 95%: 1.1-1.5, p=0.01]. Obese patients (30.1%) were at a higher risk for 30-day morbidity when compared to normal (23.9%) [OR: 1.2 (CI 95 %: 1.1-1.4), p<0.1] and overweight (25.8%)(OR: 1.1 (CI 95%: 1.0-1.4), p=0.03). This rate was 29.2% in underweight group. Wound disruption was 4 times more common in MO patients compared to normal (OR: 4.1 (CI 95%: 1.8-9.1), p<0.01).
Conclusion: Relative to normal weight patients, obese patients had a greater risk of both overall complications, wound disruption and longer operative times. Underweight patients were shown to have increased blood loss, length of stay and readmission. IBD surgery patients at the extremes of weight are at an increased risk for postoperative complications.
Comparison of patient characteristics and perioperative outcomes between the groups.
| | Total N=14852 | Underweight
N: 1072 (7.2) | Normal
N: 6605 (44.4) | Overweight
N: 4276 (28.7) | Obese
N: 2561 (17.4) | Morbid obese
N: 338 (2.3) | p- value | | Age ¥ | 40.9 ± 15.0 | 34.5± 14.6 | 38.7± 15.2 | 43.7± 14.7 | 44.5± 13.7 | 43.2± 12.4 | <0.01 | | Diagnosis - Crohn | 7906 (53.2) | 722 (67.4) | 3718 (56.3) | 2033 (47.6) | 1231 (48.1) | 202 (59.8) | <0.01 | | Ulcerative colitis | 6946 (46.8) | 350 (32.6) | 2887 (43.7) | 2243 (52.4) | 1330 (51.9) | 136 (40.2) | | | Diabetes Mellitus | 612 (4.1) | 12 (1.1) | 130 (1.9) | 177 (4.1) | 236 (9.2) | 57 (16.8) | <0.01 | | Hypertension | 2326 (15.6) | 54 (5.0) | 584 (8.8) | 797 (18.6) | 768 (29.9) | 123 (36.3) | <0.01 | | Smoking | 2614 (17.6) | 231 (21.5) | 1172 (17.7) | 733 (17.1) | 424 (16.5) | 54 (15.9) | <0.01 | | Steroid use | 6719 (45.2) | 566 (52.8) | 3023 (45.7) | 1840 (43.0) | 1150 (44.9) | 140 (41.4) | <0.01 | | Weight loss | 1187 (7.9) | 272 (25.3) | 631 (9.5) | 196 (4.5) | 85 (3.3) | 3 (0.8) | <0.01 | | Hypoalbuminemia | 3562 (34.4) | 502 (57.5) | 1753 (37.1) | 791 (28.0) | 448 (26.2) | 68 (30.3) | <0.01 | | Anemia | 6256 (44.5) | 691 (66.7) | 3054 (48.6) | 1528 (38.2) | 861 (35.6) | 122 (38.4) | <0.01 | | Procedure, Ileocolic resection | 5336 (35.9) | 501 (46.7) | 2505 (37.9) | 1349 (31.6) | 840 (32.8) | 141 (41.7) | <0.01 | | Ileal pouch anal anastomotis | 5093 (34.2) | 199 (18.5) | 2096 (31.7) | 1749 (40.9) | 967 (37.7) | 82 (24.3) | | | Partial colectomy | 2119 (14.2) | 169 (15.7) | 1008 (15.2) | 570 (13.4) | 320 (12.6) | 52 (15.3) | | | Total abdominal colectomy | 1774 (11.9) | 163 (15.2) | 779 (11.9) | 453 (10.6) | 334 (13.0) | 45 (13.4) | | | Low anterior resection | 420 (2.8) | 29 (2.7) | 166 (2.5) | 126 (2.9) | 86 (3.3) | 13 (3.8) | | | Hartmann procedure | 110 (0.7) | 11 (1) | 51 (0.7) | 29 (0.6) | 14 (0.6) | 5 (1.5) | | | Wound class 3-4 | 3924 (26.4) | 365 (34.0) | 1793 (27.1) | 1031 (24.1) | 649 (25.3) | 86 (25.4) | <0.01 | | ASA class 3-4 | 4492 (30.2) | 346 (32.2) | 1719 (26.0) | 1226 (28.6) | 1005 (39.2) | 196 (57.9) | <0.01 | | Operative time, minutes ¥ | 200± 97 | 174± 88 | 189± 91 | 209± 99 | 219± 103 | 228± 103 | <0.01 | | Length of stay, days ¥ | 7.9± 7.7 | 9.5± 8 | 7.8± 8 | 7.7± 6 | 7.9± 6 | 8.4± 8 | <0.01 | | Morbidity | 3869 (26.0) | 313 (29.2) | 1579 (23.9) | 1103 (25.8) | 771 (30.1) | 103 (30.4) | <0.01 | | Mortality | 41 (0.2) | 4 (0.3) | 15 (0.2) | 11 (0.2) | 10 (0.3) | 1 (0.3) | 0.6 | | Superficial SSI | 992 (6.8) | 50 (4.6) | 344 (5.2) | 315 (7.3) | 245 (9.5) | 38 (11.2) | <0.01 | | Deep SSI | 248 (1.6) | 19 (1.7) | 91 (1.3) | 76 (1.7) | 53 (2.0) | 9 (2.6) | 0.08 | | Organ-space SSI | 1016 (6.8) | 92 (8.5) | 427 (6.4) | 283 (6.6) | 196 (7.6) | 18 (5.3) | 0.02 | | Wound disruption | 146 (0.9) | 9 (0.8) | 57 (0.8) | 37 (0.8) | 32 (1.2) | 11 (3.2) | <0.01 | | Transfusion | 883 (5.9) | 105 (9.7) | 408 (6.1) | 219 (5.1) | 138 (5.3) | 13 (3.8) | <0.01 | | Reoperation | 868 (5.8) | 79 (7.3) | 396 (6) | 222 (5.1) | 149 (5.8) | 22 (6.5) | 0.08 | | Readmission | 1605 (10.8) | 132 (12.3) | 657 (9.9) | 476 (11.1) | 301 (11.7) | 39 (11.5) | 0.03 |
Values are expressed as absolute numbers (percentages) unless indicated otherwise. ¥-Values are expressed as mean ± standard deviation. ASA: American Society of Anesthesiologists, SSI: Surgical site infection
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