What is the target body mass index for elective Hartmann reversal? A National Surgical Quality Improvement Program...

Obesity is associated with adverse outcomes after Hartmann reversal, but there are no procedure-specific, evidence-based body mass index (BMI) targets for elective reversal. We identified data-driven BMI thresholds associated with 30-day morbidity.

A retrospective cohort study of adults undergoing elective Hartmann reversal in the American College of Surgeons National Surgical Quality Improvement Program database (2015-2023) was conducted using Current Procedural Terminology codes 44626 and 44227. Stratum-specific likelihood ratio analysis identified risk-distinct BMI strata for any 30-day complication. Multivariable regression evaluated the association of these strata with any complication, serious complication, any surgical site infection, and mortality, adjusting for demographics, comorbidities, operative time, and operative approach.

A total of 16,027 patients met the inclusion criteria. Stratum-specific likelihood ratio analysis identified 3 risk-distinct BMI strata: 18.5 to 33.9 kg/m² (n = 12,885), 34.0 to 49.9 kg/m² (n = 3021), and ≥50.0 kg/m² (n = 121). In adjusted analyzes, patients with a BMI of 34.0 to 49.9 had a 38% increase in the odds of any postoperative complication (odds ratio [OR], 1.38; 95% CI, 1.23-1.54; P <.001), whereas those with a BMI ≥ 50.0 had more than double the odds (OR, 2.54; 95% CI, 1.69-3.81; P <.001). A similar gradient was observed for serious complications (OR, 1.31 and 2.73, respectively; both P <.001) and for any surgical site infection (OR, 1.51; P <.001 and OR, 2.10; P =.002). Mortality was rare.

Stratum-specific likelihood ratio analysis identified data-driven BMI thresholds that stratify postoperative morbidity after Hartmann reversal. These thresholds could serve as evidence-based weight-loss targets for surgeons and patients to aim for during preoperative optimization.