COLORECTAL SURGERY

Does the body mass index impact lymph node yield for colorectal
cancer resection, and does operative approach influence this: a review
of bi-national colorectal cancer audit database

Ju Yong Cheong , Christopher John Young and Christopher Byrne

Colorectal Surgery Unit, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia

Key words Abstract

colorectal cancer, lymph node number, obesity,
oncological quality of resection.
Correspondence
Dr Ju Yong Cheong, Royal Prince Alfred Hospital,
50 Missenden Rd, Camperdown
NSW 2050, Australia.
Email: juyong.cheong@gmail.com
J. Y. Cheong PhD, FRACS; C. J. Young MBBS,
FRACS; C. Byrne MBBS, FRACS.
Accepted for publication 7 September 2021.
doi: 10.1111/ans.17227
Background: Operating on an obese patient is technically more challenging. This study
aimed to determine whether there was any correlation between lymph node (LN) harvesting
and patient’s BMI, and how the operative approach influences this.
Methods: A retrospective analysis of the bi-national colorectal cancer audit (BCCA) data-
base from 2008 to 2018 was performed.
Results: In the analysis of the correlation between operative approach and number of
lymph nodes, data on 22 963 patients were analyzed. The operative approach did not lead
to a significant difference in the number of lymph nodes yielded, except for
proctocolectomy and low anterior resection where laparoscopic approach yielded greater
lymph nodes than open approach. Linear regression of BMI and number of lymph nodes
harvested for each operation based on 3986 patients showed that BMI largely does not
impact the lymph node yield. The exception was open left hemicolectomy/sigmoid cole-
ctomy and laparoscopic high anterior resection, where a unit increase in BMI led to a reduc-
tion in the number of lymph nodes harvested. However, the regression coefficient and
reduction in number of lymph nodes were low (r2 = 0.11, r2 = 0.0108 and 0.41, 0.18
lymph nodes).
Conclusion: In colorectal cancer operations, the number of lymph nodes removed is largely
not impacted by the patient’s body mass index, regardless of which operative approach is
taken.

laparoscopic and robotic resections (ROLLAR).4–7 The question

Introduction
Surgery is often more difficult in patients with intra-abdominal obe-
sity, as the planes of dissection are not as clear and the tissue is
heavier. This results in a longer operating time and a greater risk of
surgical complications, including wound infection, stoma retraction
and stoma herniation.1 In rectal cancer resection, obesity is an inde-
pendent risk factor for anastomotic leakage (16% versus 6%), and
it is recommended that drains be inserted after surgery in obese
patients.2 Obesity poses a challenge for minimally invasive colorec-
tal surgery as well, with longer operating times, higher conversion
rates, and a greater risk of cardiopulmonary complications.3
The approaches to colorectal resection can be open or minimally
invasive, which includes laparoscopic, hand-assisted and robotic
resection. Current evidence suggests that the oncological quality of
dissection is similar between laparoscopic and open rectal resec-
tions (COLOR II, ALACART, CLASSIC), and between
that arises is whether this is still correct when obesity becomes an
independent factor in the operation.
Aim of study
The World Health Organization (WHO) classifies obesity according
to the patient’s body mass index (BMI). Normal BMI is between
18.5 and 24.99, and underweight is <18.5. Overweight is defined as
a BMI of 25–29.99, Grade 1 obesity as a BMI of 30–34.99, and
Grade 2 obesity as a BMI of 35–39.99. Grade 3 obesity or morbid
obesity is defined as a BMI greater than 40 or greater than 35 with
comorbidities.8
The aim of this study was to determine one specific aspect of
oncological resection quality, lymph node harvesting. The study
aimed to determine whether an open, laparoscopic or robotic
approach was superior for lymph node harvesting, and how patient

© 2021 Royal Australasian College of Surgeons. ANZ J Surg 91 (2021) 2707–2713


2708
BMI affects lymph node harvesting efficacy. The evidence indi-
cates that there is no difference between laparoscopic and open
approaches in obese patients in the number of lymph nodes
harvested. Rather than following a dichotomous ‘obese’ versus
‘non-obese’ variable, we assessed BMI as a continuous variable to
see if the number of lymph nodes harvested was different. This will
help determine at what BMI one approach becomes oncologically
technically inferior (with regards to the number of lymph nodes
harvested).
Methods
A retrospective database-based study was conducted. The bi-national
colorectal cancer audit (BCCA) is a Clinical Quality Registry
established by the Colorectal Surgical Society of Australia and
New Zealand (CSSANZ). The BCCA was initiated in 2007 with
patients undergoing resection or treatment for colorectal cancer
recorded in the database. The number of entries currently stored in
the database is over 24 000 episodes. The data are used for clinical
audits of the surgical practices of Australian and New Zealand
surgeons for the purpose of quality assurance. The audit also
works towards creating a large dataset containing Australian and
New Zealand data that can be used for research and quality
improvement purposes, with the aim of advancing the knowledge
and understanding of the treatment of colorectal cancer. BCCA is a
declared Quality Assurance Activity by both the Australian and
New Zealand Health Departments and is also an Approved Activity
for the purposes of clinical professional development (CPD) for the
Royal Australasian College of Surgeons (RACS).9 Data of open
colorectal cancer resections were collected over 10 years (from
2008 to 2018), and laparoscopic, robotic, and hand-assisted
approaches were analyzed. The primary outcome of interest was
the number of lymph nodes harvested for colorectal resections
and the distal resection margin for rectal cancer. The principal
exposure was obesity as measured by BMI. The study was
reviewed and approved by the Ethics Committee of Sydney Local
Health District (X19-0062, 2019/ETH00439).
Inclusion criteria
The inclusion criteria were all patients in the BCCA undergoing
colorectal cancer resections via the open laparotomy, hand-assisted
laparoscopic, laparoscopic or robotic approaches.
Only patients above age of 18 were considered.
As operations performed as part of emergency surgery tend to be
different from elective approaches, only elective operations were
considered, and emergency operations were excluded.
Sample size calculation
To calculate the estimate of the number of patients required to
determine if there is a difference in the number of LNs harvested
between obese and non-obese patients using different approaches,
an online clinical sample size calculator was used.10 Using the liter-
ature’s proportion of colorectal cancer patients who were obese/not
obese (0.21, 0.25), the number of lymph nodes harvested, and their
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Cheong et al.
SD (6.4, 5.5), the number needed for a power of 80% with an α of
0.05 required the sample size of 513 non-obese and 108 obese
patients.11,12
Statistical analyses
Quantitative continuous variables, such as BMI and number of
lymph nodes, are summarized as the mean and 95% confidence
interval, and comparisons of means were performed using Student’s
t-test and analysis of variance (ANOVA). The correlation between
BMI and number of lymph nodes was analyzed using linear regres-
sion. All statistical analyses were performed using IBM SPSS ver-
sion 23 (New York, USA) and GraphPad Prism version 7.0
(GraphPad Software Inc., California, USA).
Result
In the 10-year period from 2008 to 2018, a total of 22 963 patients
undergoing colorectal cancer resections were registered with
BCCA. The mean age was 68.6 years, 44.8% were female and the
median ASA was 2. With regard to T staging, 13.3% of patients
were in stage T1, 17.3% were in stage T2, 49.3% were in stage T3,
and 20% were in stage T4. Moreover, 60.2% were in stage N0,
24.3% were in stage N1, 13.2% were in stage N2, 2.2% were in
stage N3, and 24.1% were in stage M1. The operations performed
are presented in the Table 1 below. There were 9406 right/extended
right hemicolectomies, 1183 left/sigmoid hemicolectomies, 1202
total/subtotal colectomies, 281 proctocolectomies, 4977 high ante-
rior resections and 5914 low/ultralow anterior resections. The oper-
ative approach included 9149 open, 11 048 laparoscopic, 1158
hybrid (laparoscopic hand-assisted), 1227 laparoscopic converted
to open, 268 robotic and 113 TaTME (Table 1).
BMI data were available for 3986 patients. The minimum BMI
was 11.03, the maximum was 50.92, and the mean BMI was 27.62
(95% of 27.48–27.79). The distribution of BMI for each of the
operations and their operative approaches is presented in Table 2
below. For right hemicolectomy/extended right hemicolectomy, the
mean BMI (30.04) of patients undergoing a laparoscopic approach
converted to an open approach was significantly higher than that of
patients undergoing other operative approaches (P = 0.0001). For
high anterior resection, the mean BMI (31.79) of patients undergo-
ing a laparoscopic approach converted to an open approach was
significantly greater than that of patients undergoing other
approaches (P = 0.0001). For low/ultralow anterior resection, the
mean BMI (29.66) of patients undergoing a laparoscopic approach
converted to an open approach was significantly higher than that of
patients undergoing other operative approaches (P = 0.005).
The mean number of lymph nodes harvested with each operative
approach is presented in Table 3. In the majority of cases, the oper-
ative approach did not lead to a significant difference in the number
of lymph nodes yielded. In proctocolectomy, the laparoscopic
approach yielded significantly more lymph nodes than the open
approach (33.51 versus 23.44, P = 0.004). In low/ultralow anterior
resection, the laparoscopic approach yielded significantly more
lymph nodes than the open approach (17.17 versus 15.89,
P = 0.0001). Additionally, the hybrid approach yielded
© 2021 Royal Australasian College of Surgeons.
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Impact of BMI on Lymph node yield 2709

Table 1 Colorectal operations performed, and operative approaches Table 2 BMI of colorectal operations and the comparison of different
operative approaches
Operations performed N
BMI mean (95%CI) Comparison of
Right/extended right hemicolectomy 9406 mean (P-value)
Open 3637
Laparoscopic 5003 Right/extended right
Hybrid 247 hemicolectomy
Laparoscopic converted to open 449 Open 27.13 (26.43–27.83) 0.0001*
Robotic 70 Laparoscopic 27.87 (27.50–28.23)
Left/sigmoid colectomy 1183 Hybrid 25.54 (24.26–26.81)
Open 488 Laparoscopic converted 30.04 (28.66–31.42)
Laparoscopic 578 Robotic 28.16 (20.94–35.38)
Hybrid 43 Left hemicolectomy/sigmoid
Laparoscopic converted to open 62 colectomy
Robotic 12 Open 26.43 (24.22–28.65) ns (0.19)
Total/subtotal colectomy 1202 Laparoscopic 28.48 (27.30–29.66)
Open 714 Hybrid 31.28 (25.45–37.11)
Laparoscopic 379 Laparoscopic converted 29.44 (25.39–33.50)
Hybrid 52 Total/subtotal colectomy
Laparoscopic converted to open 55 Open 26.28 (25.05–27.51) ns (0.25)
Robotic 2 Laparoscopic 27.19 (26.14–28.24)
Proctocolectomy 281 Hybrid 27.77 (24.52–31.02)
Open 187 Converted 29.6 (25.42–33.78)
Laparoscopic 65 Proctocolectomy
Hybrid 12 Open 24.21 (21.72–26.71) ns (0.44)
Laparoscopic converted to open 13 Laparoscopic 26.61 (24.19–29.03)
Robotic 4 Laparoscopic converted 27.03 (17.79–36.26)
High anterior resection 4977 High anterior resection
Open 1576 Open 27.73 (26.64–28.82) 0.0001*
Laparoscopic 2793 Laparoscopic 27.44 (26.98–27.90)
Hybrid 246 Hybrid 28.54 (27.11–29.98)
Laparoscopic converted to open 319 Laparoscopic converted 31.79 (29.99–33.59)
Robotic 43 Low/ultralow anterior
Low/ultralow anterior resection 5914 resection
Open 2547 Open 28.53 (27.65–29.42) 0.0058*
Laparoscopic 2230 Laparoscopic 27.21 (26.72–27.70)
Hybrid 558 Hybrid 27.35 (26.37–28.32)
Laparoscopic converted to open 329 Laparoscopic converted 29.66 (28.21–31.12)
Robotic 137 Robotic 27.06 (24.75–29.36)
TaTME 113 TaTME 28.44 (26.52–30.36)
Total 22 963
Operative approaches compared using one-way ANOVA.
*Significant difference in BMI between operative approaches noted for right
hemicolectomy, high anterior resection, ultralow anterior resection.

significantly more lymph nodes than the open approach (17.19 ver-
sus 15.89, P = 0.01).
In the analysis of the correlation between BMI and the number
of LNs harvested for each operation, 3986 patients were included
(Table 4). The impact of BMI on lymph node number was analyzed
using linear regression analysis. For open left hemicolectomy/
sigmoid colectomy, an increase in BMI by one unit led to a reduc-
tion in the number of lymph nodes harvested by 0.41 (r2 = 0.11,
P = 0.03) (Fig. 1). For laparoscopic high anterior resection, a unit
increase in BMI resulted in a reduction in the number of lymph
nodes harvested by 0.18 (r2 = 0.0108, P = 0.021) (Fig. 2). The
impact of obesity (BMI > 30) on the number of lymph nodes
harvested was analyzed using Student’s t-test (Table 5). Open
proctocolectomy in obese patients was also associated with signifi-
cantly fewer lymph nodes than in non-obese patients (11 versus 25,
P = 0.04). In all other operations, obesity did not influence the
number of lymph nodes harvested.
The distribution of the distal resection margin (DRM) for low
anterior resection and ultralow anterior resection for each operative
approach is presented below (Table 6). There was no statistically
significant difference in DRM between each of the operative
approaches. The impact of BMI on the distal resection margin for
each of the operative approaches for low anterior resection and
ultralow anterior resection is presented in Table 7 below. BMI had
no impact on the distal resection margin.
Discussion
Obesity is a direct risk factor for colorectal cancer development.
Obesity is associated with increased levels of growth factors such
as insulin-like growth factor-1 (IGF-1). This, along with the associ-
ated elevated level of insulin, raises the risk of oncogenesis.13 Obe-
sity is associated with up to fivefold higher levels of leptin, which
is a hormone associated with satiety. Increased levels of leptin stim-
ulate the oncological adenomatous pathway involving MAPK and
NF-kB.13 Among the adipocytes with increased volumes are mac-
rophages, which secrete proinflammatory cytokines such as TNF-a,
IL6-MCP-1 and PAI-1, leading to a low-grade chronic inflamma-
tory response. These ‘adipocytokines’ are associated with the devel-
opment of rectal dysplasia.13

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2710 Cheong et al.

Table 3 Number of lymph node harvested for colorectal operations and comparison of different operative approaches

N of Lymph nodes Difference (P-value) Difference (P-value) Difference Difference Difference

(mean, 95% CI) (P-value) (P-value) (P-value)

Right/extended right
hemicolectomy
*
Open 19.23 (18.91–19.56) (reference)
Laparoscopic 19.37 (18.91–19.82) 0.13 (P = 0.99) *
(reference)
Hybrid 21.01 (19.76–22.27) 1.78 (P = 0.27) 1.64 (P = 0.34) *
(reference)
Laparoscopic converted 18.42 (17.64–19.20) 0.81 (P = 0.75) 0.94 (P = 0.62) 2.59 (P = 0.11) *
(reference)
to open
Robotic 20.21 (18.31–22.11) 0.98 (P = 0.97) 0.84 (P = 0.98) 0.79 (P = 0.99) 1.79 (P = 0.84)
Left hemicolectomy/sigmoid
colectomy
*
Open 15.45 (14.64–16.25) (reference)
Laparoscopic 15.0 (14.29–15.71) 0.44 (P = 0.92) *
(reference)
Hybrid 17.12 (14.41–19.82) 1.67 (P = 0.72) 2.11 (P = 0.48) *
(reference)
Laparoscopic converted 14.73 (13.32–16.13) 0.71 (P = 0.96) 0.27 (P = 0.99) 2.39 (P = 0.59) *
(reference)
to open
Robotic 17.92 (13.91–21.92) 2.47 (P = 0.84) 2.91 (P = 0.74) 0.80 (P = 0.99) 3.19 (P = 0.74)
Total/subtotal colectomy
*
Open 24.83 (23.61–26.05) (reference)
Laparoscopic 27.14 (25.14–29.13) 2.30 (P = 0.23) *
(reference)
Hybrid 25.17 (22.07–28.28) 0.34 (P = 0.99) 1.96 (P = 0.93) *
(reference)
Laparoscopic converted 21.05 (18.16–23.95) 3.77 (P = 0.49) 6.08 (P = 0.09) 4.11 (P = 0.71)
to open
Proctocolectomy
*
Open 23.44 (20.57–26.3) (reference)
Laparoscopic 33.51 (28.42–38.59) 10.07 (P = 0.004)# *
(reference)
Hybrid 26.42 (15.31–37.52) 2.978 (P = 0.98) 7.09 (P = 0.79) *
(reference)
Laparoscopic converted 27.08 (14.28–39.87) 3.638 (P = 0.96) 6.43 (P = 0.83) 0.66 (P = 0.99)
to open
High anterior resection
*
Open 17.94 (17.44–18.45) (reference)
Laparoscopic 17.34 (17.01–7.67) 0.605 (P = 0.23) *
(reference)
Hybrid 18.63 (17.53–19.73) 0.685 (P = 0.82) 1.29 (P = 0.22) *
(reference)
Laparoscopic converted 17.24 (16.25–18.23) 0.706 (P = 0.72) 0.10 (P = 0.99) 1.39 (P = 0.39) *
(reference)
to open
Robotic 17.65 (15.53–19.77) 0.293 (P = 0.99) 0.31 (P = 0.99) 0.97 (P = 0.96) 0.41 (P = 0.99)
Low/ultralow anterior
resection
*
Open 15.89 (15.57–16.22) (reference)
Laparoscopic 17.17 (16.81–17.52) 1.27 (P = 0.0001)# *
(reference)
Hybrid 17.19 (16.41–17.97) 1.29 (P = 0.01)# 0.02 (P = 0.99) *
(reference)
Laparoscopic converted 16.26 (15.40–17.11) 0.36 (P = 0.99) 0.91 (P = 0.52) 0.93 (P = 0.68) *
(reference)
to open
Robotic 15.70 (14.50–16.90) 0.19 (P = 0.99) 1.46 (P = 0.43) 1.49 (P = 0.51) 0.55 (P = 0.99) *
(reference)
TaTME 16.17 (14.70–17.65) 0.28 (P = 0.99) 0.99 (P = 0.90) 1.01 (P = 0.92) 0.08 (P = 0.99) 0.47 (P = 0.99)

*(reference) indicates the reference for which other values are compared to calculate relative risk.
#
highlights the statistically significant points.

Obesity is not only a direct risk factor for colorectal cancer but
also poses significant operative challenges and affects postoperative
outcomes. Operating on an obese patient is technically more chal-
lenging, and in patients with intra-abdominal obesity (as opposed
to abdominal wall obesity), the planes of dissection may not be as
clear as those in non-obese patients. A survey of 177 colorectal sur-
geons in Canada found that colorectal surgeries on obese patients
were more difficult, had longer operative times, and had an
increased risk of post-surgical complications, including wound
infection, stoma retractions and stoma herniations.1 A study com-
paring colorectal operations in 158 obese patients with 426 non-
obese patients found that the effect of obesity on wound infection
for right hemicolectomy was non-significant. However, for left
hemicolectomy, the rate of intra-abdominal collections/abscess was
significantly higher in obese patients (2% versus 10%), such that
the author recommended drain insertion for obese patients. For rec-
tal resections, obese patients had far greater risks of wound infec-
tion and anastomotic leakage (16% versus 6%). The paper
suggested defunctioning obese patients who undergo rectal resec-
tions.2 A case-matched study that compared 62 obese patients with
118 non-obese patients undergoing laparoscopic colorectal surgery
found that obesity was associated with increased operating times
(268 versus 232 min) and conversion rates (32% versus 14%). The
cardiopulmonary complication rate was also significantly higher in
the obese group (44% versus 24%).3 However, studies have shown
that obesity is not associated with worse oncological resection, with
no significant difference in the number of lymph nodes harvested and
the rate of positive margins.11,14 A retrospective analysis based on

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Impact of BMI on Lymph node yield 2711

Table 4 Correlation between BMI and number of LN harvested for colo-

rectal cancer resections using various operative approaches

Goodness of fit Significance
(R squared) (P-value)

Right/extended right 0.001369 0.195

hemicolectomy
Open 0.000025 0.943
Laparoscopic 0.002209 0.167
Hybrid 0.0081 0.5
Laparoscopic converted 0.002025 0.734
Left hemicolectomy/sigmoid 0.020164 0.078
colectomy
Open 0.116964 0.031*
Laparoscopic 0.001521 0.697
Laparoscopic converted 0.264196 0.072
Total/subtotal colectomy 0.002 0.57
Open 0.000173 0.91
Laparoscopic 0.018 0.24
Converted 0.028 0.74
Proctocolectomy 0.01055 0.5959 Fig 2. Linear regression of BMI with number of lymph nodes for laparo-
Open 0.045369 0.381 scopic high anterior resection.
Laparoscopic 0.3721 0.198
High anterior resection 0.01115 0.0046
Open 0.033856 0.065
Laparoscopic 0.010816 0.021*
deep wound dehiscence (OR 1.17, 95% CI: 1.01–1.35) and wound
Hybrid 0.015876 0.274 infection (OR 1.07, 95% CI: 1.00–1.14).12 Obesity is also associated
Laparoscopic converted 0.000361 0.9 with worse postoperative outcomes. In a population-based study on
Low/ultralow anterior resection 0.00013 0.78
Open 0.0015 0.603
71 084 patients who underwent surgery for colorectal cancer, obesity
Laparoscopic 0.00067 0.86
Hybrid 0.02 0.19 Table 5 Impact of obesity of number of lymph nodes
Laparoscopic converted 0.04 0.16
Robotic 0.2095 0.06 Number of lymph nodes
TaTME 0.07245 0.16 Not obese Obese Significance
(BMI < 30) (BMI > 30) (P-value)

Right hemicolectomy,
extended right
hemicolectomy
1464 patients who underwent laparoscopic surgery found obese Open 20.5 20.37 ns (0.91)
patients (BMI > 30) were far more likely to have conversion to open Laparoscopic 20.67 19.94 ns (0.27)
surgery, with conversion rates of 10.9% versus 7.1%. Obesity was Hybrid 22.74 24.31 ns (0.54)
Laparoscopic 18.06 17.59 ns (0.82)
also associated with a greater risk of postoperative complications, converted
with higher rates of anastomotic leakage (OR 1.06, 95% CI: 1.01– Left hemicolectomy,
1.12), superficial wound dehiscence (OR 1.16, 95% CI: 1.09–1.24), sigmoid colectomy
Open 16.71 11.56 ns (0.11)
Laparoscopic 16.16 14.94 ns (0.53)
Laparoscopic 17.3 13.14 ns (0.20)
converted
High anterior
resection
Open 19.51 17.39 ns (0.30)
Laparoscopic 18.55 17.35 ns (0.20)
Hybrid 21.12 21.25 ns (0.95)
Laparoscopic 17.63 18.25 ns (0.80)
converted
LAR, ULAR
Open 16.15 16.79 ns (0.57)
Laparoscopic 17.61 17.69 ns (0.94)
Hybrid 19.67 18.2 ns (0.51)
Laparoscopic 17.74 14.65 ns (0.14)
converted
Robotic 16.83 19.75 ns (0.43)
TaTME 14.5 18.2 ns (0.17)
Total colectomy,
subtotal colectomy
Open 25.7 23.07 ns (0.49)
Laparoscopic 28.4 26.2 ns (0.58)
Proctocolectomy
Open 25 11 *Significant (0.04)
Fig 1. Linear regression of BMI with number of lymph nodes for open left
hemi/sigmoid colectomy.

© 2021 Royal Australasian College of Surgeons.

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2712 Cheong et al.

Table 6 Comparison of distal resection margin (DRM) of various opera- CLASSIC). Therefore, in our study, it would be difficult to attribute
tive approaches for low anterior resection and ultralow anterior resection differences in lymph node yield to operative approaches.
DRM Mean (95% CI) Comparison The linear regression showed that BMI largely does not impact
of mean (P-value) the operative approach’s oncological quality (lymph node yield).
Low anterior resection For open left hemicolectomy/sigmoid colectomy and for laparo-
Open 27.35 (19.90–34.80) 0.7556 scopic high anterior resection, the increase in BMI led to a reduc-
Laparoscopic 29.41 (25.57–33.26) tion in the number of lymph nodes harvested. However, the
Hybrid 33.83 (19.45–48.22)
Laparoscopic converted 25.50 (11.48–39.52) regression coefficient was low, and the reduction in the number of
Ultralow anterior resection lymph nodes was also low; therefore, it is difficult to reach mean-
Open 28.38 (23.44–33.33) 0.1831 ingful clinical significance. It is also uncertain why only these oper-
Laparoscopic 25.29 (22.66–27.93)
Hybrid 24.93 (18.89–30.98) ative approaches showed this relationship. To further assess the
Laparoscopic converted 26.89 (16.89–36.89) impact of BMI on oncological quality, the distal resection margin
Robotic 26.57 (13.2–39.93) was analyzed with linear regression, which showed no correlation
TaTME 17.08 (12.15–22.01)
between BMI and the distal resection margin in any of the operative
approaches. Another key indicator of the oncological quality of dis-
section is the assessment of the TME dissection itself. This has not
(BMI > 30) was associated with higher readmission rates and pro- been assessed due to limitations of the information available on the
longed hospitalization.15 BCCA database.
The mean BMI of the patients in our study was 27.62 (over- Despite being an extensive database, the entry of BMI into the
weight). For right/extended right hemicolectomy, high anterior re- database has been incomplete. It must be noted that despite there
section and low/ultralow anterior resection, the BMI was being 22 963 cases, only 3986 had recorded BMI. Despite only a
significantly higher for laparoscopic-converted-to-open approach fraction of cases having BMI information available, this number
than for other operative approaches. This may reflect the technical was still far greater than the number required for sample size
challenges associated with laparoscopic approach in higher BMI calculation.
patients. However, it is uncertain why other operations did not This study is a nonrandomized, retrospective study; therefore, it
show the same relationship of higher BMI and laparoscopic- is subject to associated bias. One obvious bias is selection and
converted to open approach. reporting bias, as it falls upon the involved surgeons to accurately
The lymph node yield did not vary greatly between operative input the data into the database. This may explain why only a frac-
approaches for each of the operations. In proctocolectomy and tion of the patients had BMI data. With regard to possible con-
low/ultralow anterior resection, the laparoscopic approach led to a founders, these were not examined, as it was apparent that BMI
greater lymph node yield than the open approach; however, why does not impact the number of lymph nodes even in univariate
these operative approaches showed greater lymph node yield is analysis.
uncertain. In previous laparoscopic versus open rectal cancer re- The lack of correlation between lymph node yield and BMI may
section trials, there was no difference in oncological quality between be that the lymph node number is not a reflection of technical
open and laparoscopic approaches (COLOR II, ALACART, expertise (in this case the surgeon’s expertise) but rather a reflection
of patient factors (patient variability in number of lymph nodes pre-
sent), and may also reflect variability in analysis by pathologist.
Table 7 Correlation of distal resection margin (DRM) of various operative
approaches with body mass index (BMI)

R value Goodness of Significance

fit (R squared) (P-value) Conclusion
Low anterior resection 0.053 0.002758 0.5624 In colorectal cancer operations, the number of lymph nodes
Open 0.032 0.001 0.987 removed is largely not impacted by the patient’s body mass index,
Laparoscopic 0.034 0.001131 0.7599
regardless of which operative approach is taken.
Hybrid 0.402 0.162 0.1945
Ultralow anterior resection 0.028 0.0008087 0.6128
Open 0.103 0.01051 0.388
Laparoscopic 0.108 0.01169 0.179
Hybrid 0.154 0.02362 0.3569 Conflict of interest
Laparoscopic converted 0.323 0.1043 0.1913
Robotic 0.055 0.003019 0.8883 The authors declare no potential conflict of interest.
TaTME 0.030 0.0008826 0.8879
LAR and ULAR combined 0.034 0.001148 0.4768
Open 0.087 0.007556 0.4074
Laparoscopic 0.083 0.006877 0.1995
Hybrid 0.084 0.007086 0.9537 Author contributions
Laparoscopic converted 0.331 0.1098 0.1659
Robotic 0.019 0.0003755 0.9499 Christopher Young: Conceptualization; supervision; writing –
TaTME 0.017 0.0002729 0.9348 review and editing. Chris BYRNE: Conceptualization; supervi-
sion; writing – review and editing.

© 2021 Royal Australasian College of Surgeons.

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Impact of BMI on Lymph node yield 2713

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