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World Journal of Surgery

, Volume 39, Issue 10, pp 2376–2385 | Cite as

The Effect of Body Mass Index on Perioperative Outcomes After Major Surgery: Results from the National Surgical Quality Improvement Program (ACS-NSQIP) 2005–2011

  • Akshay Sood
  • Firas Abdollah
  • Jesse D. Sammon
  • Kaustav Majumder
  • Marianne Schmid
  • James O. Peabody
  • Mark A. Preston
  • Adam S. Kibel
  • Mani Menon
  • Quoc-Dien TrinhEmail author
Original Scientific Report

Abstract

Background

Obesity is associated with poor surgical outcomes and disparity in access-to-care. There is a lack of quality data on the effect of body mass index (BMI) on perioperative outcomes. Accordingly, we sought to determine the procedure specific, independent-effect of BMI on 30-day perioperative outcomes in patients undergoing major surgery.

Methods

Participants included individuals undergoing one of 16 major surgery (cardiovascular, orthopedic, oncologic; n = 141,802) recorded in the ACS-NSQIP (2005–2011). Outcomes evaluated included complications, blood transfusion, length-of-stay (LOS), re-intervention, readmission, and perioperative mortality. Multivariable-regression models assessed the independent-effect of BMI on outcomes.

Results

Nearly, 74  % of patients had a BMI disturbance; the majority being overweight (35.3  %) or obese (29.8  %). Morbidly obese patients constituted a small but significant proportion of the patients (5.7 %; n = 8067). In adjusted-analyses, morbidly obese patients had significantly increased odds of wound complications in 15 of the examined procedures, of renal complications after 6-procedures, of thromboembolism after 5-procedures, of pulmonary, septic and UTI complications after 2-procedures, and of cardiovascular complications after CABG. Conversely, obese/overweight patients, except for increased odds of wound complications after select procedures, had significantly decreased odds of perioperative mortality, prolonged-LOS and blood transfusion relative to normal BMI patients after 4, 8, and 9 of the examined procedures.

Conclusions

The prevalence of BMI derangements in surgical patients is high. The effect of BMI on outcomes is procedure specific. Patients with BMI between 18.5 and 40-kg/m2 at time of surgery fare equally well with regard to complications and mortality. However, morbidly obese patients are at-risk for postsurgical complications and targeted preoperative-optimization may improve outcomes and attenuate disparity in access-to-care.

Keywords

Obese Patient Coronary Artery Bypass Grafting Wound Complication Abdominal Aortic Aneurysm Repair Underweight Patient 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Notes

Acknowledgments

Quoc-Dien Trinh is supported by the Professor Walter Morris-Hale Distinguished Chair in Urologic Oncology at Brigham and Women’s Hospital; The American College of Surgeons National Surgical Quality Improvement Program and the hospitals participating in the ACS-NSQIP are the source of the data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors.

Conflict of interest

None.

Supplementary material

268_2015_3112_MOESM1_ESM.doc (210 kb)
Supplementary material 1 (DOC 210 kb)

References

  1. 1.
    Lopez AD, Mathers CD, Ezzati M et al (2006) Global and regional burden of disease and risk factors, 2001: systematic analysis of population health data. Lancet 367:1747–1757CrossRefPubMedGoogle Scholar
  2. 2.
    Danaei G, Ding EL, Mozaffarian D et al (2009) The preventable causes of death in the United States: comparative risk assessment of dietary, lifestyle, and metabolic risk factors. PLoS Med 6:e1000058PubMedCentralCrossRefPubMedGoogle Scholar
  3. 3.
    Ogden CL, Carroll MD, Curtin LR et al (2006) Prevalence of overweight and obesity in the United States, 1999–2004. JAMA 295:1549–1555CrossRefPubMedGoogle Scholar
  4. 4.
    Hsueh WA, Buchanan TA (1994) Obesity and hypertension. Endocrinol Metab Clin N Am 23:405–427Google Scholar
  5. 5.
    Hubert HB, Feinleib M, McNamara PM et al (1983) Obesity as an independent risk factor for cardiovascular disease: a 26-year follow-up of participants in the Framingham Heart Study. Circulation 67:968–977CrossRefPubMedGoogle Scholar
  6. 6.
    Sowers MR, Karvonen-Gutierrez CA (2010) The evolving role of obesity in knee osteoarthritis. Curr Opin Rheumatol 22:533–537PubMedCentralCrossRefPubMedGoogle Scholar
  7. 7.
    Calle EE, Thun MJ (2004) Obesity and cancer. Oncogene 23:6365–6378CrossRefPubMedGoogle Scholar
  8. 8.
    Davenport DL, Xenos ES, Hosokawa P et al (2009) The influence of body mass index obesity status on vascular surgery 30-day morbidity and mortality. J Vasc Surg 49:140–147 discussion 147 CrossRefPubMedGoogle Scholar
  9. 9.
    Merkow RP, Bilimoria KY, McCarter MD et al (2009) Effect of body mass index on short-term outcomes after colectomy for cancer. J Am Coll Surg 208:53–61CrossRefPubMedGoogle Scholar
  10. 10.
    Giles KA, Wyers MC, Pomposelli FB et al (2010) The impact of body mass index on perioperative outcomes of open and endovascular abdominal aortic aneurysm repair from the National Surgical Quality Improvement Program, 2005–2007. J Vasc Surg 52:1471–1477PubMedCentralCrossRefPubMedGoogle Scholar
  11. 11.
    Mullen JT, Davenport DL, Hutter MM et al (2008) Impact of body mass index on perioperative outcomes in patients undergoing major intra-abdominal cancer surgery. Ann Surg Oncol 15:2164–2172CrossRefPubMedGoogle Scholar
  12. 12.
    Lee CT, Dunn RL, Chen BT et al (2004) Impact of body mass index on radical cystectomy. J Urol 172:1281–1285CrossRefPubMedGoogle Scholar
  13. 13.
    Fasol R, Schindler M, Schumacher B et al (1992) The influence of obesity on perioperative morbidity: retrospective study of 502 aortocoronary bypass operations. Thorac Cardiovasc Surg 40:126–129CrossRefPubMedGoogle Scholar
  14. 14.
    Prem KA, Mensheha N, McKelvey JL (1965) Operative treatment of adenocarcinoma of the endometrium in obese women. Am J Obstet Gynecol 92:16–22PubMedGoogle Scholar
  15. 15.
    Murray KF, Carithers RL Jr (2005) AASLD practice guidelines: Evaluation of the patient for liver transplantation. Hepatology 41:1407–1432CrossRefPubMedGoogle Scholar
  16. 16.
  17. 17.
    Clancy CM (2009) CMS’s hospital-acquired condition lists link hospital payment, patient safety. Am J Med Qual 24:166–168CrossRefPubMedGoogle Scholar
  18. 18.
    American College of Surgeons American College of Surgeons National Surgical Quality Improvement Project: User Guide for the 2011 Participant Use Data File (2012)Google Scholar
  19. 19.
    Henderson WG, Daley J (2009) Design and statistical methodology of the National Surgical Quality Improvement Program: why is it what it is? Am J Surg 198:S19–S27CrossRefPubMedGoogle Scholar
  20. 20.
    Shiloach M, Frencher SK Jr, Steeger JE et al (2010) Toward robust information: data quality and inter-rater reliability in the American College of Surgeons National Surgical Quality Improvement Program. J Am Coll Surg 210:6–16CrossRefPubMedGoogle Scholar
  21. 21.
    Cohen ME, Ko CY, Bilimoria KY et al (2013) Optimizing ACS NSQIP modeling for evaluation of surgical quality and risk: patient risk adjustment, procedure mix adjustment, shrinkage adjustment, and surgical focus. J Am Coll Surg 217:336–346CrossRefPubMedGoogle Scholar
  22. 22.
    Ravi P, Sood A, Schmid M et al (2015) Racial disparities in perioperative outcomes of major procedures: results from the National Surgical Quality Improvement Program. Ann Surg. (Epub ahead of print)Google Scholar
  23. 23.
    Bhojani N, Gandaglia G, Sood A et al (2014) Morbidity and mortality after benign prostatic hyperplasia surgery: data from the American College of Surgeons National Surgical Quality Improvement Program. J Endourol 28(7):831–840CrossRefPubMedGoogle Scholar
  24. 24.
    Lidor AO, Moran-Atkin E, Stem M et al (2014) Hospital-acquired conditions after bariatric surgery: we can predict, but can we prevent? Surg Endosc 28(12):3285–3292CrossRefPubMedGoogle Scholar
  25. 25.
    Segev DL, Simpkins CE, Thompson RE et al (2008) Obesity impacts access to kidney transplantation. JASN 19:349–355PubMedCentralCrossRefPubMedGoogle Scholar
  26. 26.
    Cho H, Yoshikawa T, Oba MS et al (2014) Matched pair analysis to examine the effects of a planned preoperative exercise program in early gastric cancer patients with metabolic syndrome to reduce operative risk: the Adjuvant Exercise for General Elective Surgery (AEGES) study group. Ann Surg Oncol 21:2044–2050CrossRefPubMedGoogle Scholar
  27. 27.
    Martin LF, Tan TL, Holmes PA et al (1995) Can morbidly obese patients safely lose weight preoperatively? Am J Surg 169:245–253CrossRefPubMedGoogle Scholar
  28. 28.
    Wick EC, Hirose K, Shore AD et al (2011) Surgical site infections and cost in obese patients undergoing colorectal surgery. Arch Surg 146:1068–1072CrossRefPubMedGoogle Scholar
  29. 29.
    Mason LB, Garcia AG (1984) Hospital costs of surgical complications. Arch Surg 119:1065–1066CrossRefPubMedGoogle Scholar
  30. 30.
    Valentijn TM, Galal W, Tjeertes EK et al (2013) The obesity paradox in the surgical population. Surgeon 11:169–176CrossRefPubMedGoogle Scholar
  31. 31.
    Mohamed-Ali V, Goodrick S, Bulmer K et al (1999) Production of soluble tumor necrosis factor receptors by human subcutaneous adipose tissue in vivo. Am J Physiol 277:E971–E975PubMedGoogle Scholar
  32. 32.
    Gallagher D, Visser M, Sepulveda D et al (1996) How useful is body mass index for comparison of body fatness across age, sex, and ethnic groups? Am J Epidemiol 143:228–239CrossRefPubMedGoogle Scholar
  33. 33.
    Welborn TA, Dhaliwal SS (2007) Preferred clinical measures of central obesity for predicting mortality. Eur J Clin Nutr 61:1373–1379CrossRefPubMedGoogle Scholar
  34. 34.
    Anderson AD, McNaught CE, MacFie J et al (2003) Randomized clinical trial of multimodal optimization and standard perioperative surgical care. Br J Surg 90:1497–1504CrossRefPubMedGoogle Scholar
  35. 35.
    Trinh QD, Sammon J, Sun M et al (2012) Perioperative outcomes of robot-assisted radical prostatectomy compared with open radical prostatectomy: results from the nationwide inpatient sample. Eur Urol 61:679–685CrossRefPubMedGoogle Scholar
  36. 36.
    Gandaglia G, Ghani KR, Sood A et al (2014) Effect of minimally invasive surgery on the risk for surgical site infections: results from the National Surgical Quality Improvement Program (NSQIP) Database. JAMA Surg 149:1039–1044CrossRefPubMedGoogle Scholar
  37. 37.
    Pai MP, Bearden DT (2007) Antimicrobial dosing considerations in obese adult patients. Pharmacotherapy 27:1081–1091CrossRefPubMedGoogle Scholar
  38. 38.
    Peled N, Abinader EG, Pillar G et al (1999) Nocturnal ischemic events in patients with obstructive sleep apnea syndrome and ischemic heart disease: effects of continuous positive air pressure treatment. J Am Coll Cardiol 34:1744–1749CrossRefPubMedGoogle Scholar
  39. 39.
    Rennotte MT, Baele P, Aubert G et al (1995) Nasal continuous positive airway pressure in the perioperative management of patients with obstructive sleep apnea submitted to surgery. Chest 107:367–374CrossRefPubMedGoogle Scholar
  40. 40.
    Fisher JE (2011) Chapter 96—Peroperative management of the obese. In: Fischer’s mastery of surgery, vols 1 & 2, 6th edn. Lippincott Williams & WilkinsGoogle Scholar
  41. 41.
    Morley JE, Thomas DR, Wilson MM (2006) Cachexia: pathophysiology and clinical relevance. Am J Clin Nutr 83:735–743PubMedGoogle Scholar
  42. 42.
    Lassen K, Soop M, Nygren J et al (2009) Consensus review of optimal perioperative care in colorectal surgery: enhanced Recovery After Surgery (ERAS) Group recommendations. Arch Surg 144:961–969CrossRefPubMedGoogle Scholar
  43. 43.
    Maniar HS, Bell JM, Moon MR et al (2014) Prospective evaluation of patients readmitted after cardiac surgery: analysis of outcomes and identification of risk factors. J Thorac Cardio Vasc Surg 147:1013–1018CrossRefGoogle Scholar
  44. 44.
    Sammon J, Trinh VQ, Ravi P et al (2013) Health care-associated infections after major cancer surgery: temporal trends, patterns of care, and effect on mortality. Cancer 119:2317–2324CrossRefPubMedGoogle Scholar
  45. 45.
    Trinh QD, Schmitges J, Sun M et al (2012) Morbidity and mortality of radical prostatectomy differs by insurance status. Cancer 118:1803–1810CrossRefPubMedGoogle Scholar
  46. 46.
    Pierorazio PM, Hyams ES, Lin BM et al (2012) Laparoscopic radical nephrectomy for large renal masses: critical assessment of perioperative and oncologic outcomes of stage T2a and T2b tumors. Urology 79:570–575CrossRefPubMedGoogle Scholar
  47. 47.
    Trinh QD, Sun M, Kim SP et al (2014) The impact of hospital volume, residency, and fellowship training on perioperative outcomes after radical prostatectomy. Urol Oncol 32:29 e13–29 e20CrossRefPubMedGoogle Scholar
  48. 48.
    Trinh QD, Bjartell A, Freedland SJ et al (2013) A systematic review of the volume-outcome relationship for radical prostatectomy. Eur Urol 64:786–798PubMedCentralCrossRefPubMedGoogle Scholar
  49. 49.
    Robinson WR, Furberg H, Banack HR (2014) Selection bias: a missing factor in the obesity paradox debate. Obesity (Silver Spring) 22:625CrossRefGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2015

Authors and Affiliations

  • Akshay Sood
    • 1
    • 3
  • Firas Abdollah
    • 1
  • Jesse D. Sammon
    • 1
  • Kaustav Majumder
    • 2
  • Marianne Schmid
    • 3
  • James O. Peabody
    • 1
  • Mark A. Preston
    • 3
  • Adam S. Kibel
    • 3
  • Mani Menon
    • 1
  • Quoc-Dien Trinh
    • 3
    Email author
  1. 1.Center for Outcomes Research, Analytics and Evaluation (VCORE), Vattikuti Urology InstituteHenry Ford Health SystemDetroitUSA
  2. 2.Department of SurgeryUniversity of MinnesotaMinneapolisUSA
  3. 3.Division of Urologic Surgery, Center for Surgery and Public Health, Brigham and Women’s HospitalHarvard Medical SchoolBostonUSA

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