DOES OBESITY AFFECT OUTCOMES IN PATIENTS UNDERGOING POUCH EXCISION?: A COMPARATIVE ANALYSIS FROM THE AMERICAN COLLEGE OF SURGEONS NATIONAL SURGICAL QUALITY IMPROVEMENT PROGRAM
Eren Esen*1, Erman Aytac2, Tarik H. Kirat1, David M. Schwartzberg1, Feza H. Remzi1
1Surgery, NYU Langone Health, New York, NY; 2Surgery, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
BACKGROUND
Impact of obesity on the outcomes of ileal pouch excision is poorly studied. In our study, we aimed to assess the effect of obesity on short-term ileal pouch excision outcomes in a nationwide cohort.
METHODS
We included the patients who underwent pouch excision between 2005-2017 using American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) participant user files. We compared the operative outcomes between obese (BMI≥30 kg/m2) and non-obese (BMI<30 kg/m2) groups.
RESULTS
There were 507 patients. Eighty (16%) of them were obese. ASA score of the obese group were higher than non-obese group [ASA>3, n=45 (56.3%) vs n=183 (42.9%), p=0.027]. There were more patients with diabetes mellitus (DM) and hypertension (HT) in the obese group [n=21 (26.3%) vs n=48 (11.2%), p=0.015; n=9 (11.3%) vs n=19 (4.4%), p<0.001, respectively] (Table 1). Operative time was similar between two groups [mean (SD), 275(111) min vs 252 (111) min, p=0.084]. Length of hospital stay was comparable [median (interquartile range), 7 days (4-13.5 days) vs 7 days (5-11 days), p=0.942]. Deep incisional surgical site infection (SSI) was more common in obese group [n=6 (7.5%) vs n=12 (2.8%), p=0.038]. Obese patients readmitted more frequently than non-obese counterparts [n=15 (28.3%) vs n=38 (16%), p=0.035]. Other complications were comparable (Table 2). Obesity was found to be independently associated with deep incisional SSI (OR: 2.79, 95% CI: 1.02-7.67) in multivariate analyses.
CONCLUSION
Excision of a ileal pouch in obese patients can be preferred when feasible to provide better quality of life and eliminate risk of pelvic sepsis and neoplasia development in the failed ileal pouch and remnant anorectum. The decision to terminate intestinal continuity in obese patients should be calibrated by considering expected long-term benefits and increased risks of wound complications resulting readmissions.
Table 2: Comparison of the short-term outcomes between obese and non-obese groups
| Non-obese (n=427) | Obese (n=80) | P value | RR | CI | |
| Postoperative morbidity, n (%) | 116 (27.2) | 24 (30) | 0.603 | 1.1 | 0.76-1.6 |
| Superficial SSI, n (%) | 39 (9.1) | 10 (12.5) | 0.35 | 1.37 | 0.71-2.63 |
| Deep incisional SSI, n (%) | 12 (2.8) | 6 (7.5) | 0.038 | 2.67 | 1.03-6.9 |
| Organ Space SSI, n (%) | 45 (10.5) | 9 (11.3) | 0.85 | 1.07 | 0.54-2.1 |
| Wound dehiscence, n (%) | 5 (1.2) | 1 (1.3) | 0.952 | 1.07 | 0.13-9.02 |
| Pneumonia, n (%) | 9 (2.1) | 3 (3.8) | 0.375 | 1.78 | 0.49-6.43 |
| Reintubation, n (%) | 6 (1.4) | 0 | 0.286 | - | - |
| Pulmonary embolism, n (%) | 2 (0.5) | 1 (1.3) | 0.403 | 2.67 | 0.24-29.08 |
| Acute renal failure, n (%) | 3 (0.7) | 0 | 1 | - | - |
| Urinary infection, n (%) | 22 (5.2) | 2 (2.5) | 0.305 | 0.49 | 0.12-2.02 |
| CVA, n (%) | 0 | 1 (1.3) | 0.158 | - | - |
| DVT, n (%) | 5 (1.2) | 0 | 1 | - | - |
| Sepsis, n (%) | 35 (8.2) | 10 (12.6) | 0.214 | 1.53 | 0.79-2.95 |
| Septic shock, n (%) | 8 (1.9) | 1 (1.3) | 0.698 | 0.67 | 0.08-5.26 |
| Reoperation, n (%) | 25 (5.9) | 5 (6.3) | 0.891 | 1.07 | 0.42-2.71 |
| Readmission, n (%) | 38 (16) | 15 (28.3) | 0.035 | 1.77 | 1.06-2.98 |
CI: Confidence interval, SSI: Surgical site infection, CVA: Cerebrovascular attack, DVT: Deep vein thrombosis, SD: Standard deviation
Table 1: Comparison of the preoperative patient characteristics and laboratory parameters between obese and non-obese groups
| Non-obese (n=427) | Obese (n=80) | P value | |
| Age (years), mean±SD | 47±15 | 50±12 | 0.05 |
| Sex (male), n (%) | 202 (47.3) | 39 (48.8) | 0.812 |
| BMI (kg/m2), mean±SD | 23.2±3.5 | 34.6±4.1 | <0.001 |
| Smoking, n (%) | 61 (14.3) | 10 (12.5) | 0.673 |
| Co-morbidity | |||
| COPD, n (%) | 5 (1.2) | 1 (1.3) | 0.952 |
| DM, n (%) | 19 (4.4) | 9 (11.3) | 0.015 |
| HT, n (%) | 48 (11.2) | 21 (26.3) | <0.001 |
| CHF, n (%) | 3 (0.7) | 0 | 1 |
| Renal failure, n (%) | 3 (0.7) | 0 | 1 |
| Cancer, n (%) | 4 (0.9) | 0 | 1 |
| Bleeding disorder, n (%) | 14 (3.3) | 4 (5) | 0.445 |
| ASA >3, n (%) | 183 (42.9) | 45 (56.3) | 0.027 |
| Preoperative anemia, n (%) | 178 (44.4) | 25 (33.3) | 0.076 |
| Preoperative BUN/Cr >20, n (%) | 55 (15.3) | 10 (14.5) | 0.868 |
| Preoperative hypoalbuminemia, n (%) | 83 (30.1) | 7 (13) | 0.01 |
| Preoperative leukocytosis, n (%) | 45 (11.5) | 9 (12) | 0.891 |
| Preoperative thrombocytosis, n(%) | 49 (12.4) | 4 (5.3) | 0.075 |
| Preoperative high creatinine, n (%) | 40 (10.5) | 13 (17.1) | 0.101 |
| Preoperative wound infection, n (%) | 30 (7) | 5 (6.3) | 0.802 |
| Preoperative steroid use, n (%) | 87 (20.4) | 16 (20) | 0.939 |
| Preoperative weight loss (>10%), n (%) | 24 (5.6) | 1 (1.3) | 0.098 |
| Preoperative transfusion, n (%) | 4 (0.9) | 1 (1.3) | 0.578 |
COPD: Chronic obstructive pulmonary disease, DM: Diabetes mellitus, HT: Hypertension, CHF: Chronic heart failure, BUN: Blood urea nitrogen, Cr: Creatinine, ASA: American Society of Anesthesiologists score
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