Journal of Gastrointestinal Surgery

, Volume 21, Issue 10, pp 1700–1712 | Cite as

Association Between Obesity and Wound Infection Following Colorectal Surgery: Systematic Review and Meta-Analysis

  • Usha GurunathanEmail author
  • Simone Ramsay
  • Goran Mitrić
  • Mandy Way
  • Leesa Wockner
  • Paul Myles
Review Article



The aim of this meta-analysis is to comprehensively review and quantify the excess risk of surgical site infections (SSI) in obese patients following colorectal surgery.


A systematic electronic search of the MEDLINE and EMBASE databases identified studies that investigated the association of obesity, defined by body mass index (BMI) with SSI among colorectal surgery patients.


Twelve studies were included in the final analysis. Patients with BMI ≥30 kg/m2 were at 1.5 times (pooled OR 1.51, 95% CI: 1.39, 1.63, p < 0.001) higher odds of developing SSI after colorectal surgery when compared to BMI <30 kg/m2. Subgroup analysis of the eight studies that investigated only elective procedures showed that the odds of developing SSI when BMI ≥30 kg/m2 is 1.6 times that of those with BMI <30 kg/m2 (pooled OR 1.60; 95% CI 1.34, 1.86; p < 0.001). The odds of having SSI when BMI is 25–29.9 kg/m2 are 1.2 times than those with BMI <25 kg/m2 (pooled OR 1.17; 95% CI 1.07, 1.28; p < 0.001).


Overweight and obese patients carry at least 20% and 50% higher odds of developing SSI after colorectal surgery compared to normal weight patients, respectively.


Obesity Surgical site infection Colorectal surgery 



The authors thank Ms. Megan Neumann, The Prince Charles Hospital librarian for her assistance with literature review; Dr. David Smith, for his statistical advice; and Dr. Manju Chandrasegaram, for editing the article.

Author Contributions

All the authors have provided substantial contributions to the conception and the design of the study, or the acquisition, analysis, or interpretation of the data for the work and were involved in drafting of the work or revising it critically for important intellectual content. All the authors have provided final approval of the version to be published and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Compliance with Ethical Standards

Conflict of Interest and Source of Funding



  1. 1.
    Gendall KA, Raniga S, Kennedy R, Frizelle FA. The impact of obesity on outcome after major colorectal surgery. Dis Colon Rectum. 2007;50:2223–37. doi: 10.1007/s10350-007-9051-0.CrossRefPubMedGoogle Scholar
  2. 2.
    Kirchhoff P, Clavien PA, Hahnloser D. Complications in colorectal surgery: risk factors and preventive strategies. Patient safety in surgery. 2010;4:5. doi: 10.1186/1754-9493-4-5.CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Tanaka S, Inoue S, Isoda F, Waseda M, Ishihara M, Yamakawa T, Sugiyama A, Takamura Y, Okuda K. Impaired immunity in obesity: suppressed but reversible lymphocyte responsiveness. Int J Obes Relat Metab Disord. 1993;17:631–6.PubMedGoogle Scholar
  4. 4.
    Anaya DA, Dellinger EP. The obese surgical patient: a susceptible host for infection. Surg Infect (Larchmt). 2006;7:473–80. doi: 10.1089/sur.2006.7.473.CrossRefPubMedGoogle Scholar
  5. 5.
    Khoury W, Stocchi L, Geisler D. Outcomes after laparoscopic intestinal resection in obese versus non-obese patients. The British journal of surgery. 2011;98:293–8. doi: 10.1002/bjs.7313.CrossRefPubMedGoogle Scholar
  6. 6.
    Hourigan JS. Impact of obesity on surgical site infection in colon and rectal surgery. Clin Colon Rectal Surg. 2011;24:283–90. doi: 10.1055/s-0031-1295691.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Kurmann A, Vorburger SA, Candinas D, Beldi G. Operation time and body mass index are significant risk factors for surgical site infection in laparoscopic sigmoid resection: a multicenter study. Surgical endoscopy. 2011;25:3531–4. doi: 10.1007/s00464-011-1753-7.CrossRefPubMedGoogle Scholar
  8. 8.
    de Lissovoy G, Fraeman K, Hutchins V, Murphy D, Song D, Vaughn BB. Surgical site infection: incidence and impact on hospital utilization and treatment costs. Am J Infect Control. 2009;37:387–97. doi: 10.1016/j.ajic.2008.12.010.CrossRefPubMedGoogle Scholar
  9. 9.
    Sparling KW, Ryckman FC, Schoettker PJ, Byczkowski TL, Helpling A, Mandel K, Panchanathan A, Kotagal UR. Financial impact of failing to prevent surgical site infections. Qual Manag Health Care. 2007;16:219–25. doi: 10.1097/01.QMH.0000281058.99929.ea.CrossRefPubMedGoogle Scholar
  10. 10.
    Smith RL, Bohl JK, McElearney ST, Friel CM, Barclay MM, Sawyer RG, Foley EF. Wound infection after elective colorectal resection. Annals of surgery. 2004;239:599–605; discussion -7.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Finkelstein EA, Khavjou OA, Thompson H, Trogdon JG, Pan L, Sherry B, Dietz W. Obesity and severe obesity forecasts through 2030. Am J Prev Med. 2012;42:563–70. doi: 10.1016/j.amepre.2011.10.026.CrossRefPubMedGoogle Scholar
  12. 12.
    Dindo D, Muller MK, Weber M, Clavien PA. Obesity in general elective surgery. Lancet. 2003;361:2032–5. doi: 10.1016/s0140-6736(03)13640-9.CrossRefPubMedGoogle Scholar
  13. 13.
    Tjeertes EE, Hoeks SS, Beks SS, Valentijn TT, Hoofwijk AA, Stolker RJ. Obesity—a risk factor for postoperative complications in general surgery? BMC Anesthesiol. 2015;15:112. doi: 10.1186/s12871-015-0096-7.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Senagore AJ, Delaney CP, Madboulay K, Brady KM, Fazio VW. Laparoscopic colectomy in obese and nonobese patients. Journal of gastrointestinal surgery: official journal of the Society for Surgery of the Alimentary Tract. 2003;7:558–61.CrossRefGoogle Scholar
  15. 15.
    Pikarsky AJ, Saida Y, Yamaguchi T, Martinez S, Chen W, Weiss EG, Nogueras JJ, Wexner SD. Is obesity a high-risk factor for laparoscopic colorectal surgery? Surgical endoscopy. 2002;16:855–8. doi: 10.1007/s004640080069.CrossRefPubMedGoogle Scholar
  16. 16.
    Wick EC, Hirose K, Shore AD, Clark JM, Gearhart SL, Efron J, Makary MA. Surgical site infections and cost in obese patients undergoing colorectal surgery. Archives Of Surgery. (Chicago, Ill: 1960) 2011;146:1068–72. doi: 10.1001/archsurg.2011.117.CrossRefPubMedGoogle Scholar
  17. 17.
    Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG. CDC definitions of nosocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infections. Am J Infect Control. 1992;20:271–4.CrossRefPubMedGoogle Scholar
  18. 18.
    The Cochrane Collaboration. In: Tool to Assess Risk of Bias in Cohort Studies. to Assess Risk of Bias in Cohort Studies.pdf Accessed 2015.
  19. 19.
    Obesity: preventing and managing the global epidemic. Report of a WHO consultation. World Health Organ Tech Rep Ser. 2000;894:i-xii, 1–253.Google Scholar
  20. 20.
    Higgins JP, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med. 2002;21:1539–58. doi: 10.1002/sim.1186.CrossRefPubMedGoogle Scholar
  21. 21.
    Anannamcharoen S, Vachirasrisirikul S, Boonya-Assadorn C. Incisional surgical site infection in colorectal surgery patients. Journal of the Medical Association of Thailand = Chotmaihet thangphaet. 2012;95:42–7.PubMedGoogle Scholar
  22. 22.
    Gervaz P, Bandiera-Clerc C, Buchs NC, Eisenring MC, Troillet N, Perneger T, Harbarth S. Scoring system to predict the risk of surgical-site infection after colorectal resection. The British journal of surgery. 2012;99:589–95. doi: 10.1002/bjs.8656.CrossRefPubMedGoogle Scholar
  23. 23.
    Lawson EH, Hall BL, Ko CY. Risk factors for superficial vs deep/organ-space surgical site infections: implications for quality improvement initiatives. JAMA Surg. 2013;148:849–58. doi: 10.1001/jamasurg.2013.2925.CrossRefPubMedGoogle Scholar
  24. 24.
    Pasam RT, Esemuede IO, Lee-Kong SA, Kiran RP. The minimally invasive approach is associated with reduced surgical site infections in obese patients undergoing proctectomy. Techniques in Coloproctology. 2015;19:733–43.CrossRefPubMedGoogle Scholar
  25. 25.
    Hibbert D, Abduljabbar AS, Alhomoud SJ, Ashari LH, Alsanea N. Risk Factors for Abdominal Incision Infection after Colorectal Surgery in a Saudi Arabian Population: The Method of Surveillance Matters. Surg Infect (Larchmt). 2015;16:254–62. doi: 10.1089/sur.2013.208.CrossRefPubMedGoogle Scholar
  26. 26.
    Itani KM, Jensen EH, Finn TS, Tomassini JE, Abramson MA. Effect of body mass index and ertapenem versus cefotetan prophylaxis on surgical site infection in elective colorectal surgery. Surg Infect (Larchmt). 2008;9:131–7. doi: 10.1089/sur.2007.034.CrossRefPubMedGoogle Scholar
  27. 27.
    Kiran RP, Murray ACA, Chiuzan C, Estrada D, Forde K. Combined preoperative mechanical bowel preparation with oral antibiotics significantly reduces surgical site infection, anastomotic leak, and ileus after colorectal surgery. Annals of surgery. 2015;262:416–23.CrossRefPubMedGoogle Scholar
  28. 28.
    Merkow RP, Bilimoria KY, McCarter MD, Bentrem DJ. Effect of body mass index on short-term outcomes after colectomy for cancer. Journal of the American College of Surgeons. 2009;208:53–61. doi: 10.1016/j.jamcollsurg.2008.08.032.CrossRefPubMedGoogle Scholar
  29. 29.
    Watanabe A, Kohnoe S, Shimabukuro R, Yamanaka T, Iso Y, Baba H, Higashi H, Orita H, Emi Y, Takahashi I, Korenaga D, Maehara Y. Risk factors associated with surgical site infection in upper and lower gastrointestinal surgery. Surg Today. 2008;38:404–12. doi: 10.1007/s00595-007-3637-y.CrossRefPubMedGoogle Scholar
  30. 30.
    Falagas ME, Kompoti M. Obesity and infection. Lancet Infect Dis. 2006;6:438–46. doi: 10.1016/S1473-3099(06)70523-0.CrossRefPubMedGoogle Scholar
  31. 31.
    Hopf HW, Hunt TK, West JM, Blomquist P, Goodson WH, 3rd, Jensen JA, Jonsson K, Paty PB, Rabkin JM, Upton RA, von Smitten K, Whitney JD. Wound tissue oxygen tension predicts the risk of wound infection in surgical patients. Arch Surg. 1997;132:997–1004; discussion 5.CrossRefPubMedGoogle Scholar
  32. 32.
    Pierpont YN, Dinh TP, Salas RE, Johnson EL, Wright TG, Robson MC, Payne WG. Obesity and surgical wound healing: a current review. ISRN Obes. 2014;2014:638936. doi: 10.1155/2014/638936.PubMedPubMedCentralGoogle Scholar
  33. 33.
    Huang DD, Wang SL, Zhuang CL, Zheng BS, Lu JX, Chen FF, Zhou CJ, Shen X, Yu Z. Sarcopenia, as defined by low muscle mass, strength and physical performance, predicts complications after surgery for colorectal cancer. Colorectal Dis. 2015;17:O256–64. doi: 10.1111/codi.13067.CrossRefPubMedGoogle Scholar
  34. 34.
    Toma O, Suntrup P, Stefanescu A, London A, Mutch M, Kharasch E. Pharmacokinetics and tissue penetration of cefoxitin in obesity: implications for risk of surgical site infection. Anesthesia and analgesia. 2011;113:730–7. doi: 10.1213/ANE.0b013e31821fff74.CrossRefPubMedGoogle Scholar
  35. 35.
    Janson B, Thursky K. Dosing of antibiotics in obesity. Curr Opin Infect Dis. 2012;25:634–49. doi: 10.1097/QCO.0b013e328359a4c1.CrossRefPubMedGoogle Scholar
  36. 36.
    Itatsu K, Sugawara G, Kaneoka Y, Kato T, Takeuchi E, Kanai M, Hasegawa H, Arai T, Yokoyama Y, Nagino M. Risk factors for incisional surgical site infections in elective surgery for colorectal cancer: focus on intraoperative meticulous wound management. Surg Today. 2014;44:1242–52. doi: 10.1007/s00595-013-0677-3.CrossRefPubMedGoogle Scholar
  37. 37.
    Balentine CJ, Robinson CN, Marshall CR, Wilks J, Buitrago W, Haderxhanaj K, Sansgiry S, Petersen NJ, Bansal V, Albo D, Berger DH. Waist circumference predicts increased complications in rectal cancer surgery. J Gastrointest Surg. 2010;14:1669–79. doi: 10.1007/s11605-010-1343-3.CrossRefPubMedGoogle Scholar
  38. 38.
    Kang J, Baek SE, Kim T, Hur H, Min BS, Lim JS, Kim NK, Lee KY. Impact of fat obesity on laparoscopic total mesorectal excision: more reliable indicator than body mass index. International journal of colorectal disease. 2012;27:497–505. doi: 10.1007/s00384-011-1333-2.CrossRefPubMedGoogle Scholar
  39. 39.
    Sakai T, Maekawa T, Mikami K, Kuramochi H, Noda S. Visceral fat volume and surgical outcomes of colorectal resection. Int Surg. 2009;94:370–2.PubMedGoogle Scholar
  40. 40.
    Tsujinaka S, Konishi F, Kawamura YJ, Saito M, Tajima N, Tanaka O, Lefor AT. Visceral obesity predicts surgical outcomes after laparoscopic colectomy for sigmoid colon cancer. Dis Colon rectum. 2008;51:1757–65; discussion 65-7. doi: 10.1007/s10350-008-9395-0.
  41. 41.
    Akiyoshi T, Ueno M, Fukunaga Y, Nagayama S, Fujimoto Y, Konishi T, Kuroyanagi H, Yamaguchi T. Effect of body mass index on short-term outcomes of patients undergoing laparoscopic resection for colorectal cancer: a single institution experience in Japan. Surgical laparoscopy, endoscopy & percutaneous techniques. 2011;21:409–14. doi: 10.1097/SLE.0b013e31822e5fdc.CrossRefGoogle Scholar
  42. 42.
    Miyamoto Y, Ishii T, Tashiro J, Satoh T, Watanabe M, Baba H, Yamaguchi S. Effects of obesity on the outcome of laparoscopic surgery for colorectal cancer. Surg Today. 2014;44:1293–9. doi: 10.1007/s00595-013-0718-y.CrossRefPubMedGoogle Scholar
  43. 43.
    Consultation WHOE. Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. Lancet. 2004;363:157–63. doi: 10.1016/S0140-6736(03)15268-3.CrossRefGoogle Scholar
  44. 44.
    Shabanzadeh DM, Sorensen LT. Laparoscopic surgery compared with open surgery decreases surgical site infection in obese patients: a systematic review and meta-analysis. Annals of surgery. 2012;256:934–45. doi: 10.1097/SLA.0b013e318269a46b.CrossRefPubMedGoogle Scholar
  45. 45.
    Crombe T, Bot J, Messager M, Roger V, Mariette C, Piessen G. Malignancy is a risk factor for postoperative infectious complications after elective colorectal resection. International journal of colorectal disease. 2016;31:885–94. doi: 10.1007/s00384-016-2521-x.CrossRefPubMedGoogle Scholar
  46. 46.
    Lewis CE, McTigue KM, Burke LE, Poirier P, Eckel RH, Howard BV, Allison DB, Kumanyika S, Pi-Sunyer FX. Mortality, health outcomes, and body mass index in the overweight range: a science advisory from the American Heart Association. Circulation. 2009;119:3263–71. doi: 10.1161/CIRCULATIONAHA.109.192574.CrossRefPubMedGoogle Scholar
  47. 47.
    Limon E, Shaw E, Badia JM, Piriz M, Escofet R, Gudiol F, Pujol M, Program VI, Reipi. Post-discharge surgical site infections after uncomplicated elective colorectal surgery: impact and risk factors. The experience of the VINCat Program. J Hosp Infect. 2014;86:127–32. doi: 10.1016/j.jhin.2013.11.004.CrossRefPubMedGoogle Scholar
  48. 48.
    Blumetti J, Luu M, Sarosi G, Hartless K, McFarlin J, Parker B, Dineen S, Huerta S, Asolati M, Varela E, Anthony T. Surgical site infections after colorectal surgery: do risk factors vary depending on the type of infection considered? Surgery. 2007;142:704–11. doi: 10.1016/j.surg.2007.05.012.CrossRefPubMedGoogle Scholar
  49. 49.
    Tuech JJ, Regenet N, Hennekinne S, Pessaux P, Bergamaschi R, Arnaud JP. Laparoscopic colectomy for sigmoid diverticulitis in obese and nonobese patients: a prospective comparative study. Surgical endoscopy. 2001;15:1427–30. doi: 10.1007/s00464-001-9023-8.CrossRefPubMedGoogle Scholar
  50. 50.
    Bege T, Lelong B, Francon D, Turrini O, Guiramand J, Delpero JR. Impact of obesity on short-term results of laparoscopic rectal cancer resection. Surgical endoscopy. 2009;23:1460–4. doi: 10.1007/s00464-008-0266-5.CrossRefPubMedGoogle Scholar
  51. 51.
    Singh A, Muthukumarasamy G, Pawa N, Riaz AA, Hendricks JB, Motson RW. Laparoscopic colorectal cancer surgery in obese patients. Colorectal Dis. 2011;13:878–83. doi: 10.1111/j.1463-1318.2010.02348.x.CrossRefPubMedGoogle Scholar
  52. 52.
    van Vugt JL, Cakir H, Kornmann VN, Doodeman HJ, Stoot JH, Boerma D, Houdijk AP, Hulsewe KW. The new Body Mass Index as a predictor of postoperative complications in elective colorectal cancer surgery. Clin Nutr. 2015;34:700–4. doi: 10.1016/j.clnu.2014.08.006.CrossRefPubMedGoogle Scholar

Copyright information

© The Society for Surgery of the Alimentary Tract 2017

Authors and Affiliations

  1. 1.Department of Anaesthesia and Perfusion Services & Department of SurgeryThe Prince Charles Hospital & University of QueenslandBrisbaneAustralia
  2. 2.Statistics Unit QIMR Berghofer Medical Research InstituteBrisbaneAustralia
  3. 3.Department of Anaesthesia and Perioperative MedicineAlfred Hospital & Monash UniversityMelbourneAustralia

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