ORIGINAL ARTICLES FROM THE ESA PROCEEDINGS Waist Circumference and Waist/Hip Ratio Are Better Predictive Risk Factors for Mortality and Morbidity after Colorectal Surgery Than Body Mass Index and Body Surface Area Alex H. Kartheuser, MD, PhD, MSc, ∗ Daniel F. Leonard, MD, ∗ Freddy Penninckx, MD, PhD,† Hugh M. Paterson, MD, FRCSEd, ∗ ‡ Dimitri Brandt, MD, ∗ § Christophe Remue, MD, ∗ C´ eline Bugli, PhD,¶ Eric Dozois, MD,|| Neil Mortensen, MD, PhD, ∗∗ Fr´ ed´ eric Ris, MD,†† Emmanuel Tiret, MD, PhD,‡‡ and on behalf of the Waist Circumference Study Group From the ∗ Colorectal Surgery Unit and Colorectal Tumor Board, Cliniques Uni- versitaires Saint-Luc, Brussels, Belgium; †Department of Abdominal Surgery, Gasthuisberg University Hospital, Leuven, Belgium; ‡Department of Colo- proctology, Western General Hospital, University of Edinburgh, Edinburgh, United Kingdom; §Department of Digestive Surgery, Hˆ opital St-Joseph, Gilly, Belgium; ¶Plateforme technologique de Support en M´ ethodologie et Calcul Statistique, Universit´ e Catholique de Louvain, Louvain-La-Neuve, Belgium; ||Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA; ∗∗ Department of Colorectal Surgery, Oxford University Hospitals, Oxford, United Kingdom; ††Service of Visceral Surgery, Geneva University Hospitals, Geneva, Switzerland; and ‡‡Department of General and Digestive Surgery, Hˆ opital St-Antoine, Paris, France. Waist Circumference Study Group: N. Abbes Orabi (Centre Hospitalier R´ egional de Mons, Mons, Belgium), S. Achkasov (State Research Centre of Colo- proctology, Moscow, Russia), D. Aleshin (State Research Centre of Colo- proctology, Moscow, Russia), P. Ambrosetti (Clinique G´ en´ erale Beaulieu, Geneva, Switzerland), J. Baulieux (CHU de Lyon, Hˆ opital de la Croix-Rousse, Lyon, France), D. Brandt (Hˆ opital Saint-Joseph, Gilly, Belgium), F. Bretagnol (Hˆ opital Beaujon, Clichy, France), P-Y. Bouteloup (Centre Hospitalier Priv´ e de Saint-Gr´ egoire, Saint-Gr´ egoire, France), R. Chamlou (Clinique Saint-Jean, Bruxelles, Belgium), C. Coimbra (CHU du Sart-Tilman, Li` ege, Belgium), E. Cotte (CHU de Lyon, Centre Hospitalier Lyon Sud, Pierre-B´ enite, France), G. Decker (Zithaklinik, Luxemburg, Grand Duchy of Luxemburg), A. D’Hoore (KUL UZ Gasthuisberg, Leuven, Belgium), R. Droissart (Clinique Saint-Jean, Bruxelles, Belgium), E. J. Dozois (Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA), J. Etienne (Clinique Sainte-Elisabeth, Na- mur, Belgium), J-C. Etienne (Centre Hospitalier Inter-communal de Poissy, Poissy, France), J-L. Faucheron (CHU de Grenoble–Hˆ opital A. Michallon, La Tronche, France), P. Frileux (Hˆ opital Foch, Suresnes, France), O. Gle- hen (CHU de Lyon, Centre Hospitalier Lyon Sud, Pierre-B´ enite, France), C. Jehaes (Les Cliniques Saint-Joseph, Li` ege, Belgium), A.H. Kartheuser (Clin- iques Universitaires Saint-Luc, Bruxelles, Belgium), Kayser J. (Zithaklinik, Luxemburg, Grand Duchy of Luxemburg), Konrad B. (Geneva University Hospitals, Geneva, Switzerland), Z. Krivokapic (Institute for Digestive Dis- ease, Belgrade, Serbia), Ch. Laurent (H ˆ opital Saint-Andr´ e, Bordeaux, France), P-A. Lehur (Hˆ otel Dieu CHU de Nantes, Nantes, France), D. Leonard (Clin- iques Universitaires Saint-Luc, Bruxelles, Belgium), J. Loriau (Groupe Hos- pitalier Saint-Joseph, Paris, France), J-Y. Mabrut (CHU de Lyon, Hˆ opital de la Croix-Rousse, Lyon, France), B. Majerus (Clinique Saint-Pierre, Ot- tignies, Belgium), P. Matthiessen (Department of Surgery, ¨ Orebro Univer- sity Hospital, ¨ Orebro, Sweden), Meurette G. (Hˆ otel Dieu CHU de Nantes, Nantes, France), Michot F. (CHU Charles-Nicolle, Rouen, France), B. Mon- ami (Les Cliniques Saint-Joseph, Li` ege, Belgium), N. Mortensen (John Radcliffe Hospital, Oxford, United Kingdom), B. Navez (Hˆ opital Saint- Joseph, Gilly, Belgium), Y. Panis (Hˆ opital Beaujon, Clichy, France), H. Pa- terson (Western General Hospital, Edinburgh, United Kingdom), F. Penninckx (KUL UZ Gasthuisberg, Leuven, Belgium), J. Pfeifer (University Clinic of Surgery, Graz, Austria), F. Pierard (Clinique Saint-Luc, Bouge, Belgium), M. Pocard (Hˆ opital Lariboisi` ere, Paris, France), C. Remue (Cliniques Uni- versitaires Saint-Luc, Bruxelles, Belgium), F. Ris (Geneva University Hospi- tals), Geneva, Switzerland), Ph. Rouanet (CRLC Val d’Aurelle-Paul Lamar- que, Montpellier, France), F. Rulli (University Hospital Roma, Roma, Italy), E. Rullier (Hˆ opital Saint-Andr´ e, Bordeaux, France), J-P. Saey (Centre Hos- pitalier R´ egional de Mons, Mons, Belgium), Y.A. Shelygin (State Research Centre of Coloproctology, Moscow, Russia), C. Soravia (Clinique G´ en´ erale Beaulieu Geneva, Switzerland), L. Stainier (Clinique Saint-Pierre, Ottig- nies, Belgium), N. Tinton (Hˆ opital Saint-Joseph, Gilly, Belgium), E. Tiret (Hˆ opital Saint-Antoine, Paris, France), Y. Parc (Hˆ opital Saint-Antoine, Paris, Objectives: To determine whether body fat distribution, measured by waist circumference (WC) and waist/hip ratio (WHR), is a better predictor of mor- tality and morbidity after colorectal surgery than body mass index (BMI) or body surface area (BSA). Background: Obesity measured by BMI is not a consistent risk factor for postoperative mortality and morbidity after abdominal surgery. Studies in metabolic and cardiovascular diseases have shown WC and WHR to be better outcome predictors than BMI. Methods: A prospective multicenter international study was conducted among patients undergoing elective colorectal surgery. The WHR, BMI, and BSA were derived from body weight, height, and waist and hip circumferences measured preoperatively. Uni- and multivariate analyses were performed to identify risk factors for postoperative outcomes. Results: A total of 1349 patients (754 men) from 38 centers in 11 countries were included. Increasing WHR significantly increased the risk of conversion [odds ratio (OR) = 15.7, relative risk (RR) = 4.1], intraoperative complica- tions (OR = 11.0, RR = 3.2), postoperative surgical complications (OR = 7.7, RR = 2.0), medical complications (OR = 13.2, RR = 2.5), anastomotic leak (OR = 13.7, RR = 3.3), reoperations (OR = 13.3, RR = 2.9), and death (OR = 653.1, RR = 21.8). Both BMI (OR = 39.5, RR = 1.1) and BSA (OR = 4.9, RR = 3.1) were associated with an increased risk of abdominal wound complication. In multivariate analysis, the WHR predicted intraoper- ative complications, conversion, medical complications, and reinterventions, whereas BMI was a risk factor only for abdominal wall complications; BSA did not reach significance for any outcome. Conclusions: The WHR is predictive of adverse events after elective col- orectal surgery. It should be used in routine clinical practice and in future risk-estimating systems. Keywords: body mass index, body surface area, colorectal surgery, morbi- mortality, waist/hip ratio (Ann Surg 2013;258:722–730) France), J-J. Tuech (CHU Charles-Nicolle, Rouen, France), A. Valverde (Centre Hospitalier Victor Dupouy d’Argenteuil, Argenteuil, France), J. Van de Stadt (Hˆ opital Erasme, Bruxelles, Belgium), B. Vinson-Bonnet (Centre Hospitalier Intercommunal de Poissy, Poissy, France), Y. Van Molhem (Onze-Lieve-Vrouw Ziekenhuis, Aalst, Belgium), and T. Yeung (John Radcliffe Hospital, Oxford, United Kingdom). Supported by grants from Fondation Saint-Luc, Clinique des Pathologies Tumorales du C ˆ olon et du Rectum, and Centre du Cancer, Cliniques Universitaires Saint- Luc, Brussels, Belgium. Disclosure: The authors declare no conflicts of interest. Reprints: Alex H. Kartheuser, MD, PhD, MSc, Colorectal Surgery Unit, Cliniques Universitaires Saint-Luc, Universit´ e Catholique de Louvain, 10 Avenue Hip- pocrate, B-1200 Brussels, Belgium; E-mail: alex.kartheuser@uclouvain.be. Copyright C  2013 by Lippincott Williams & Wilkins ISSN: 0003-4932/13/25805-0722 DOI: 10.1097/SLA.0b013e3182a6605a Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 722 | www.annalsofsurgery.com Annals of Surgery  Volume 258, Number 5, November 2013