title: The minimally invasive approach is associated with reduced surgical site infections in obese patients undergoing proctectomy.
abstract: BACKGROUND
  While laparoscopic colorectal resection may be underused in technically challenging circumstances, the minimally invasive approach may in fact maximally benefit patients at the greatest risk of complications. Obesity and proctectomy pose particular technical challenges during laparoscopic resection and are also associated with the greatest risks of complications, especially surgical site infections (SSIs). We evaluated the role of laparoscopy in minimizing SSI in such patients.
  
  
  METHODS
  From the American College of Surgeons-National Surgical Quality Improvement Program database, outcomes for obese [body mass index (BMI) ≥ 30 kg/m(2)] and non-obese (BMI < 30 kg/m(2)) patients undergoing colectomy or proctectomy between 2006 and 2011 by the laparoscopic (laparoscopic colectomy, laparoscopic proctectomy) or open (open colectomy, open proctectomy) approaches were compared. A univariate analysis was used to determine the influence of laparoscopic surgery within each group on SSI, and a multivariate analysis evaluated the influence of laparoscopy on SSI for obese patients undergoing proctectomy.
  
  
  RESULTS
  OC patients were more likely than OP, LC, and LP, respectively, to undergo emergency operation and have an American Society of Anesthesiologists (ASA) score of 3-5. Overall SSI rates after OC, OP, LC, and LP were 15.2, 17.6, 8.6, and 10.1 %, respectively (p < 0.001), and for obese patients, the rates were 18.7, 22.3, 10.7, and 13.3 % (p < 0.001). On univariate analysis, open surgery, obesity, proctectomy, younger age, race, steroid use, diabetes, chronic obstructive pulmonary disease, prior wound infection, transfusion history, previous operation within 30 days, coronary artery or vascular disease, ASA class 3-5, tobacco use, resident involvement, male gender, albumin <3.5 g/dL, and emergent operation were associated with a higher risk of SSI. Laparoscopy reduced the risk of SSI by at least 35 % across all BMI classes and procedures, an effect that persisted on multivariate analysis even in obese patients undergoing proctectomy.
  
  
  CONCLUSIONS
  In colorectal surgery, an already high-risk outlier for SSI, obesity and proctectomy are associated with the highest risk of SSI. Despite the particular technical challenges of laparoscopy in these circumstances, the minimally invasive approach attenuates the risk of SSI in these high-risk patients and thus should be strongly considered during treatment planning.
authors.affiliation: Division of Colorectal Surgery, New York Presbyterian Hospital, Columbia University Medical Center, 177 Fort Washington Ave, 7 South Knuckle, New York, NY, 10032, USA. prteja2389@gmail.com.
authors.forename: R T
authors.initials: RT
authors.lastname: Pasam
authors.affiliation: Division of Colorectal Surgery, New York Presbyterian Hospital, Columbia University Medical Center, 177 Fort Washington Ave, 7 South Knuckle, New York, NY, 10032, USA.
authors.forename: I O
authors.initials: IO
authors.lastname: Esemuede
authors.affiliation: Division of Colorectal Surgery, New York Presbyterian Hospital, Columbia University Medical Center, 177 Fort Washington Ave, 7 South Knuckle, New York, NY, 10032, USA.
authors.forename: S A
authors.initials: SA
authors.lastname: Lee-Kong
authors.affiliation: Division of Colorectal Surgery, New York Presbyterian Hospital, Columbia University Medical Center, 177 Fort Washington Ave, 7 South Knuckle, New York, NY, 10032, USA.
authors.forename: R P
authors.initials: RP
authors.lastname: Kiran
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D015992:Body Mass Index; D003082:Colectomy / Q000009:adverse effects* / Q000379:methods; D003108:Colonic Diseases / Q000601:surgery; D005260:Female; D006801:Humans; D015994:Incidence; D010535:Laparoscopy / Q000009:adverse effects*; D008297:Male; D008875:Middle Aged; D009765:Obesity / Q000150:complications*; D011014:Pneumonia / Q000453:epidemiology; D019106:Postoperative Hemorrhage / Q000453:epidemiology; D012002:Rectal Diseases / Q000601:surgery; D012007:Rectum / Q000601:surgery*; D012307:Risk Factors; D013529:Surgical Wound Dehiscence / Q000453:epidemiology; D013530:Surgical Wound Infection / Q000453:epidemiology* / Q000209:etiology; D014481:United States / Q000453:epidemiology; D014552:Urinary Tract Infections / Q000453:epidemiology
keywords: Colectomy; Complications; Laparoscopic surgery; Obesity; Proctectomy; Surgical site infection