High intra-, postoperative complication risks in patients with obesity and ulcerative colitis
Patients with obesity have an elevated risk of intra- and postoperative complications following surgical treatment for inflammatory bowel disease (IBD), according to a presentation at the recent Advances in Inflammatory Bowel Disease meeting (AIBD 2018).
The prevalence of obese patients with IBD is increasing, with research showing that 15–40 percent of patients with IBD are obese, while an additional 20–40 percent are overweight, [Nat Rev Gastroenterol Hepatol 2017;14:110-121] presented Dr Nicole Lopez from the University of California San Diego Health in La Jolla, California, US.
Obesity has implications on surgical management of ulcerative colitis which include longer operation time, increased perioperative morbidity, reduced technical ability to create an ilieal pouch-anal anastomosis (IPAA), and increased risk of conversion to open surgery or postoperative complications, said Lopez. In particular, patients with obesity who undergo laparoscopic colorectal surgery also have an elevated risk of blood loss and visceral injury as well as a shorter specimen length. [Dis Colon Rectum 2017;60:433-445]
In a study conducted among 1,175 patients who were scheduled to undergo IPAA for ulcerative colitis, 23 patients could not undergo the procedure due to obesity. The study found a higher risk of technical inability to perform the IPAA procedures among patients with elevated BMI (odds ratio, 1.26, 95 percent confidence interval, 1.17–1.34; p<0.001), with the rate of unsuccessful IPAA procedures rising with higher BMIs (2.0, 5.7, and 15.0 percent for BMI 30, 35, and 40 kg/m2, respectively; p<0.01). [Dis Colon Rectum 2016;59:1034-1038]
A separate retrospective review conducted among 103 and 75 non-obese and obese patients, respectively, with ulcerative colitis found a higher rate of complications among obese patients than non-obese ones (BMI ≥30 vs <30 kg/m2; 80 percent vs 64 percent; p=0.03), specifically pouch-related complications such as anastomotic or pouch strictures (27 percent vs 6 percent; p<0.01), inflammatory pouch complications (17 percent vs 4 percent; p<0.01), and pouch fistulas (12 percent vs 3 percent; p=0.03). [J Gastrointest Surg 2014;18:573-579]
Another retrospective study looking at long-term outcomes post-IPAA in patients with ulcerative colitis found that obese patients were less likely to undergo laparoscopic IPAA procedures than non-obese patients (47.1 percent vs 73.4 percent; p<0.0001 and 15.8 percent vs 29.4 percent; p=0.03 for stage 2 and 3 procedures, respectively), had longer operative times (288.7 vs 270.1 min; p=0.02 and 237.7 vs 200.5 min; p=0.0002, respectively), higher estimated blood loss (271.2 vs 205.6 mL; p=0.005 and 301.1 vs 186.1 mL; p<0.0001, respectively), and longer hospital stay (8.8 vs 7.6 days; p=0.03 for stage 2 procedures). [Inflamm Bowel Dis 2017;23:2142-2146]
“Obesity impacts intraoperative complexity and 30-day postoperative outcomes while long-term functional outcomes are not affected,” said Lopez.
“So all in all we can see that incisional hernias, pouch complications, anastomotic or pouch strictures, and inflammatory pouch complications are more common in obese patients, as is longer operation time, prolonged inpatient stay, wound infection, and anastomotic leak,” said Lopez.
A solution to this problem is to encourage weight loss in this group of patients with bariatric surgery as a potential method, she said.
A study from the Netherlands showed that bariatric surgery appeared to be safe and effective in patients with ulcerative colitis or Crohn’s disease. There were no deaths or major perioperative complications among the 45 patients in the study, while two major complications (gastro-enterostomy bleeding and pyelonephritis with secondary pancreatitis) occurred during follow up in two patients with Crohn’s disease. [Obes Surg 2018;28:1681-1687]
However, it is important for surgeons to anticipate reach problems in patients with obesity and subsequently adjust their techniques to gain adequate reach, said Lopez.