Abstract
Background
Morbid obesity is associated with worse colorectal cancer (CRC) perioperative outcomes. The impact of bariatric surgery on these outcomes is unknown.
Methods
The National Inpatient Sample Database (2006–2012) was used to identify adults with prior bariatric surgery (divided into BMI ≤35 kg/m2 and BMI >35 kg/m2) or morbid obesity that underwent CRC surgery. Main outcomes were mortality, surgical complications and health care utilization.
Results
There were 1813 patients with prior bariatric surgery and 22,552 morbidly obese patients that underwent CRC surgery between 2006 and 2012. Prior bariatric surgery patients were younger, with fewer comorbidities, and had less emergency CRC surgery admissions (p < 0.05). Multivariate analyses revealed no adverse association (OR 0.54, 95 % CI = 0.16 to 1.79) between prior bariatric surgery and CRC perioperative mortality. Notably, multivariate analysis revealed that bariatric surgery patients undergoing CRC surgery had fewer accidental surgical lacerations (OR 0.38, 95 % CI = 0.15 to 0.93), shorter hospitalizations (−1.85 days, 95 % CI = 2.03 to 1.67), decreased total hospital costs (US$−5374, 95 % CI = −5935 to −4813) and lower disposition to short-term rehabilitation facilities (OR 0.65, 95 % CI = −0.43 to 0.97). Propensity score matched analysis validated these reductions in surgical complications and health care utilization in bariatric surgery patients, which were further more pronounced when bariatric surgery patients were restricted to BMI ≤35 kg/m2.
Conclusions
Analysis of national-level data demonstrates that prior bariatric surgery is associated with fewer colorectal cancer surgical complications and improved health care resource utilization compared to morbidly obese patients. These findings emphasize and extend the therapeutic effect of bariatric surgery to the colorectal cancer perioperative setting.
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References
Sturm R, Hattori A. Morbid obesity rates continue to rise rapidly in the United States. Int J Obes. 2013;37(6):889–91.
Ogden CL et al. Prevalence of childhood and adult obesity in the United States, 2011-2012. JAMA. 2014;311(8):806–14.
NIH conference. Gastrointestinal surgery for severe obesity. Consensus development conference panel. Ann Intern Med, 1991. 115(12): p. 956–961.
Buchwald H, Oien DM. Metabolic/bariatric surgery worldwide 2011. Obes Surg. 2013;23(4):427–36.
Trastulli S et al. Laparoscopic sleeve gastrectomy compared with other bariatric surgical procedures: a systematic review of randomized trials. Surg Obes Relat Dis. 2013;9(5):816–29.
Puzziferri N et al. Long-term follow-up after bariatric surgery: a systematic review. JAMA. 2014;312(9):934–42.
Yamaura K et al. Effect of low-dose milrinone on gastric intramucosal pH and systemic inflammation after hypothermic cardiopulmonary bypass. J Cardiothorac Vasc Anesth. 2001;15(2):197–203.
Vendrell J et al. Resistin, adiponectin, ghrelin, leptin, and proinflammatory cytokines: relationships in obesity. Obes Res. 2004;12(6):962–71.
Laimer M et al. Markers of chronic inflammation and obesity: a prospective study on the reversibility of this association in middle-aged women undergoing weight loss by surgical intervention. Int J Obes Relat Metab Disord. 2002;26(5):659–62.
Trakhtenbroit MA et al. Body weight, insulin resistance, and serum adipokine levels 2 years after 2 types of bariatric surgery. Am J Med. 2009;122(5):435–42.
Brethauer SA et al. Early effects of gastric bypass on endothelial function, inflammation, and cardiovascular risk in obese patients. Surg Endosc. 2011;25(8):2650–9.
Miller GD, Nicklas BJ, Fernandez A. Serial changes in inflammatory biomarkers after roux-en-Y gastric bypass surgery. Surg Obes Relat Dis. 2011;7(5):618–24.
Ben Q et al. Body mass index increases risk for colorectal adenomas based on meta-analysis. Gastroenterology. 2012;142(4):762–72.
Ma Y et al. Obesity and risk of colorectal cancer: a systematic review of prospective studies. PLoS One. 2013;8(1):e53916.
Larsson SC, Wolk A. Obesity and colon and rectal cancer risk: a meta-analysis of prospective studies. Am J Clin Nutr. 2007;86(3):556–65.
Okabayashi K et al. Body mass index category as a risk factor for colorectal adenomas: a systematic review and meta-analysis. Am J Gastroenterol. 2012;107(8):1175–85 quiz 1186.
Colorectal Cancer 2011 Report Food, nutrition, physical activity, and the prevention of colorectal cancer. [cited June 2 2016]. Available: http://www.aicr.org/continuous-update-project/reports/Colorectal-Cancer-2011-Report.pdf.
Hussan H, et al. (2015) Morbid obesity is associated with increased mortality, surgical complications, and incremental health care utilization in the peri-operative period of colorectal cancer surgery. World J Surg
Nguyen NT et al. Accelerated growth of bariatric surgery with the introduction of minimally invasive surgery. Arch Surg. 2005;140(12):1198–202 discussion 1203.
Ostlund MP, Lu Y, Lagergren J. Risk of obesity-related cancer after obesity surgery in a population-based cohort study. Ann Surg. 2010;252(6):972–6.
Derogar M et al. Increased risk of colorectal cancer after obesity surgery. Ann Surg. 2013;258(6):983–8.
Kant P et al. Rectal epithelial cell mitosis and expression of macrophage migration inhibitory factor are increased 3 years after roux-en-Y gastric bypass (RYGB) for morbid obesity: implications for long-term neoplastic risk following RYGB. Gut. 2011;60(7):893–901.
[September 11, H.C.-t.-C.R.C.F.U.A., Agency for Healthcare Research and Quality. Healthcare Cost and Utilization Project (HCUP) Rockville, MD: Agency for Healthcare Research and Quality; 2001–2011.
Agency for Healthcare Research and Quality (2016) Healthcare Cost and Utilization Project (HCUP) https://www.hcup-us.ahrq.gov/nisoverview.jsp . Last accessed on January 26
Kalanithi PA, Arrigo R, Boakye M. Morbid obesity increases cost and complication rates in spinal arthrodesis. Spine (Phila Pa 1976). 2012;37(11):982–8.
Shamji MF et al. Impact of body habitus on perioperative morbidity associated with fusion of the thoracolumbar and lumbar spine. Neurosurgery. 2009;65(3):490–8 discussion 498.
Krishna SG, et al. (2016) Effects of bariatric surgery on outcomes of patients with acute pancreatitis. Clin Gastroenterol Hepatol
Drolet S et al. Morbidity and mortality following colorectal surgery in patients with end-stage renal failure: a population-based study. Dis Colon rectum. 2010;53(11):1508–16.
Kang CY et al. Outcomes of laparoscopic colorectal surgery: data from the Nationwide Inpatient Sample 2009. Am J Surg. 2012;204(6):952–7.
Elixhauser A et al. Comorbidity measures for use with administrative data. Med Care. 1998;36(1):8–27.
Finkler SA. The distinction between cost and charges. Ann Intern Med. 1982;96(1):102–9.
Agency for Healthcare Research and Quality (2016) Healthcare Cost and Utilization Project (HCUP): https://www.hcup-us.ahrq.gov/reports/statbriefs/sb204-Most-Expensive-Hospital-Conditions.jsp . Last accessed on August 9
Agency for Healthcare Research and Quality (2016) Healthcare Cost and Utilization Project (HCUP): https://www.hcup-us.ahrq.gov/db/state/costtocharge.jsp . Last accessed on August 9
Broderick RC et al. Increasing the value of healthcare: improving mortality while reducing cost in bariatric surgery. Obes Surg. 2015;25(12):2231–8.
Mason RJ, Moroney JR, Berne TV. The cost of obesity for nonbariatric inpatient operative procedures in the United States: national cost estimates obese versus nonobese patients. Ann Surg. 2013;258(4):541–51 discussion 551-3.
Brian Moore P, Katharine Levit BA, Anne Elixhauser (2012) PhD., Healthcare Cost and Utilization Project (HCUP) Statistical briefs [Internet]. Costs for hospital stays in the United States, Statistical Brief #181
Haider AH et al. Incremental cost of emergency versus elective surgery. Ann Surg. 2015;262(2):260–6.
Skala K et al. Risk factors for mortality-morbidity after emergency-urgent colorectal surgery. Int J Color Dis. 2009;24(3):311–6.
Bergstralh EJ, Kosanke J (1995) Computerized matching of cases to controls. Technical report No. 56. Department of Health Science Research Mayo Clinic, Rochester, MN
Henkel DS et al. Trends in bariatric surgery for morbid obesity in Wisconsin: a 6-year follow-up. Wmj. 2010;109(1):21–7.
Padwal RS. Characteristics of patients undergoing bariatric surgery in Canada. Obes Res. 2005;13(12):2052–4.
Lansdorp-Vogelaar I et al. Individualizing colonoscopy screening by sex and race. Gastrointest Endosc. 2009;70(1):96–108 108.e1-24.
Lieberman DA et al. Race, ethnicity, and sex affect risk for polyps >9 mm in average-risk individuals. Gastroenterology. 2014;147(2):351–8 quiz e14-5.
Sainsbury A et al. Increased colorectal epithelial cell proliferation and crypt fission associated with obesity and roux-en-Y gastric bypass. Cancer Epidemiol Biomark Prev. 2008;17(6):1401–10.
Christou NV et al. Surgery decreases long-term mortality, morbidity, and health care use in morbidly obese patients. Ann Surg. 2004;240(3):416–23 discussion 423-4.
Adams TD et al. Cancer incidence and mortality after gastric bypass surgery. Obesity (Silver Spring). 2009;17(4):796–802.
Adams TD et al. Long-term mortality after gastric bypass surgery. N Engl J Med. 2007;357(8):753–61.
Sjostrom L et al. Effects of bariatric surgery on cancer incidence in obese patients in Sweden (Swedish Obese Subjects Study): a prospective, controlled intervention trial. Lancet Oncol. 2009;10(7):653–62.
Masoomi H et al. Predictive factors of in-hospital mortality in colon and rectal surgery. J Am Coll Surg. 2012;215(2):255–61.
Merkow RP et al. Effect of body mass index on short-term outcomes after colectomy for cancer. J Am Coll Surg. 2009;208(1):53–61.
Zhou Y et al. Outcome of laparoscopic colorectal surgery in obese and nonobese patients: a meta-analysis. Surg Endosc. 2012;26(3):783–9.
Cook CH et al. Survival of critically ill surgical patients discharged to extended care facilities. J Am Coll Surg. 1999;189(5):437–41.
Greenblatt DY et al. Readmission after colectomy for cancer predicts one-year mortality. Ann Surg. 2010;251(4):659–69.
Legner VJ et al. The significance of discharge to skilled care after abdominopelvic surgery in older adults. Ann Surg. 2009;249(2):250–5.
Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: executive summary. Expert Panel on the Identification, Evaluation, and Treatment of Overweight in Adults. Am J Clin Nutr, 1998. 68(4): p. 899–917.
Romero-Corral A et al. Accuracy of body mass index in diagnosing obesity in the adult general population. Int J Obes. 2008;32(6):959–66.
Karelis AD. Metabolically healthy but obese individuals. Lancet. 2008;372(9646):1281–3.
Pi-Sunyer X. The medical risks of obesity. Postgrad Med. 2009;121(6):21–33.
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Author Contributions
Dr. Hussan was involved in the conception, design, interpretation of data, and the drafting and critical revision of the manuscript. Dr. Porter was involved in the study design, performed the acquisition and the statistical analysis of the data, and provided critical revision of the manuscript. The above authors had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Drs. Stanich, Gray, Krishna, Conwell, and Clinton were involved in the design, interpretation of data, and critical revision of the manuscript. All gave final approval of the submitted manuscript and take responsibility for the integrity of the work.
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Hussan, H., Stanich, P.P., Gray, D.M. et al. Prior Bariatric Surgery Is Linked to Improved Colorectal Cancer Surgery Outcomes and Costs: A Propensity-Matched Analysis. OBES SURG 27, 1047–1055 (2017). https://doi.org/10.1007/s11695-016-2421-8
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DOI: https://doi.org/10.1007/s11695-016-2421-8