Predicting 30-day postoperative mortality for emergent anterior abdominal wall hernia repairs using the American College of Surgeons National Surgical Quality Improvement Program database

Mortality after emergency versus elective groin hernia repair: a systematic review and meta-analysis

BACKGROUND

Emergency groin hernia repair is associated with increased mortality risk, but the actual risk is unknown. Therefore, this review aimed to investigate 30- and 90-day postoperative mortality in adult patients who had undergone emergency or elective groin hernia repair.

METHODS

This review was reported following PRISMA 2020 guidelines, and a protocol (CRD42021244412) was registered to PROSPERO. A systematic search was conducted in PubMed, EMBASE, and Cochrane CENTRAL in April 2021. Studies were included if they reported 30- or 90-day mortality following an emergency or elective groin hernia repair. Meta-analyses were conducted when possible, and subgroup analyses were made for bowel resection, sex, and hernia type. According to the study design, the risk of bias was assessed using either the Newcastle-Ottawa Scale or Cochrane Risk of Bias tool.

RESULTS

Thirty-seven studies with 30,740 patients receiving emergency repair and 457,253 receiving elective repair were included. The 30-day mortality ranged from 0-11.8% to 0-1.7% following emergency and elective repair, respectively. The risk of 30-day mortality following emergency repair was estimated to be 26-fold higher than after elective repair (RR = 26.0, 95% CI 21.6-31.4, I2 = 0%). A subgroup meta-analysis on bowel resection in emergency repair estimated 30-day mortality to be 7.9% (95% CI 6.5-9.3%, I2 = 6.4%). Subgroup analyses on sex and hernia type showed no differences regarding the mortality risk in elective surgery. However, femoral hernia and female sex significantly increased the risk of mortality in emergency surgery, both given by a risk ratio of 1.7.

CONCLUSION

The overall mortality after emergency groin hernia repair is 26-fold higher than after elective repair, but the increased risk is attributable mostly to female and femoral hernias.

TRIAL REGISTRATION

PROSPERO protocol (CRD42021244412).

Comparison of two fascial defect closure methods for laparoscopic incisional hernia repair

PURPOSE

Currently there is no consensus regarding the optimal surgical approach to an incisional hernia measuring less than 10 cm. Certain hernia features including defect size, intra-abdominal adhesions, and overlying scar/skin properties contribute to choosing an open versus a laparoscopic approach. This retrospective cohort study was designed to compare incisional hernia defects repaired with laparoscopic suture closure to a hybrid approach with open defect closure, both with laparoscopic intraperitoneal onlay mesh (IPOM) reinforcement.

METHODS

We identified 164 consecutive patients who underwent incisional hernia repair from two centers, North York General Hospital (NYGH) and Humber River Hospital (HRH) between 2015 and 2020. Patients were grouped by totally laparoscopic or hybrid fascial closure. Both techniques included laparoscopically placed intra-peritoneal mesh with 5 cm of overlap in all directions. Patients were analyzed by age, sex, body mass index (BMI), ASA class and hernia size. Primary outcomes included surgical site infection (SSI), other wound complications including seroma/hematoma, length of hospital stay, pain reported at follow-up appointment, and hernia recurrence.

RESULTS

Post-operative pain, surgical site infections and seromas did not differ between the totally laparoscopic and hybrid approach. The recurrence rates were 5.8% and 6.8% for the laparoscopic and hybrid group, respectively, which were not significantly different. The time to recurrence was 15 months (range 8-12) in the laparoscopic group and 7 months (range 6-36) in the hybrid group, also not significantly different. The hernia defect size and BMI were significantly higher in the hybrid group, without increased wound complications.

CONCLUSION

These results suggest that a hybrid approach to incisional ventral hernia repair with open defect closure is comparable to a totally laparoscopic closure. The hybrid technique can help facilitate fascial closure and resection of the hernia sac in patients with higher BMI and hernia defects up to 6 cm.

Associations between different measures of intra-operative tachycardia during noncardiac surgery and adverse postoperative outcomes: A retrospective cohort analysis

BACKGROUND

Intra-operative tachycardia during noncardiac surgery has been associated with adverse postoperative outcomes. However, harm thresholds for tachycardia have not been uniformly defined. The definition of intra-operative tachycardia that best correlates with adverse postoperative outcomes remains unclear.

OBJECTIVE

We aimed to identify the definition of intra-operative tachycardia during noncardiac surgery that is associated with the best predictive ability for adverse postoperative outcomes.

DESIGN

A single-centre retrospective cohort analysis.

SETTING

Secondary care hospital, Afula, Israel.

PATIENTS AND METHODS

Adults who underwent elective or nonelective noncardiac surgery during 2015 to 2019. Five intra-operative heart rate (HR) cut-off values and durations were applied with penalised logistic regression modelling for the outcome measures.

MAIN OUTCOME MEASURES

The primary outcome was all-cause 30-day mortality; the secondary outcome was myocardial ischaemia or infarction (MI) within 30 days after noncardiac surgery.

RESULTS

The derivation and validation datasets included 6490 and 4553 patients, respectively. Altogether, all-cause 30-day mortality and MI rates averaged 2.1% and 3.2%, respectively. Only two definitions of intra-operative tachycardia were significantly associated with the outcome measures: HR ≥ 100 bpm for ≥ 30 min and HR ≥ 120 bpm for ≥ 5 min. The C-statistics of the base models without tachycardia exposure for all-cause 30-day mortality and MI were 0.75 (95% confidence interval, CI, 0.74 to 0.78) and 0.73 (95% CI, 0.72 to 0.76), respectively. The addition of intra-operative tachycardia exposure to the base models significantly improved their predictive performance. The highest area under the curve (AUC) was achieved when tachycardia was defined as an intra-operative HR ≥ 100 bpm for at least 30 min: AUC 0.81 (95% CI, 0.80 to 0.84) and AUC 0.80 (95% CI, 0.79 to 0.82) for all-cause 30-day mortality and MI, respectively.

CONCLUSION

Intra-operative tachycardia, defined as an intra-operative HR ≥ 100 bpm for at least 30 min, was associated with the highest predictive power for adverse postoperative outcomes.

Emergency surgery of the abdominal wall hernias: risk factors that increase morbidity and mortality-a single-center experience

PURPOSE

Morbidity and mortality are higher in urgently operated abdominal hernia cases compared to elective surgeries. The present study aims to investigate the factors that cause increased morbidity and mortality in emergency surgical operations.

METHODS

The files of a total of 426 patients who were operated for non-reducible abdominal hernia between 2015 and 2020 were reviewed retrospectively. Patients' ages, genders, comorbidities, Charlson Comorbidity Index (CCI), ASA score, BMI, hernia types, duration of symptom, laboratory values, intestinal strangulations or necroses, whether intestinal resection was performed, whether mesh was preferred for hernia repair, and rates of morbidity and mortality were recorded. Factors affecting morbidity and mortality rates were analyzed.

RESULTS

Factors such as gender, BMI (> 30), duration of symptom (> 24 h), presence of bowel necrosis and resection, type of hernia and prolonged operation time were found to cause an increase in morbidity. In the multivariate analysis, however, gender, duration of symptom and BMI (> 30) were statistically significant factors causing increased morbidity (p = 0.009, p < 0.001, p = 0.032, respectively). Advanced age, high ASA scores, CCI and duration of symptom were determined as factors affecting the increase in mortality. In the multivariate analysis, the effect of high ASA scores and advanced age on high mortality rate was statistically significant (p < 0.023, p = 0.039, respectively).

CONCLUSIONS

The mortality rate is higher, especially in elderly patients with high comorbidity. Therefore, we argue that the cases of abdominal wall hernia should be operated under elective conditions even if they do not give any clinical findings to prevent problems in older ages.

Incisional Hernia Cannot Be Diagnosed by a Patient-Reported Diagnostic Questionnaire

BACKGROUND

Incisional hernia (IH) is one of the most frequent complications after abdominal surgery. Follow-up with regard to IH remains challenging. Physical examination and imaging to diagnose IH are time-consuming and costly, require devotion of both the physician and patient, and are often not prioritized. Therefore, a patient-reported diagnostic questionnaire for the diagnosis of IH was developed. Objective of this study was to validate this questionnaire in a consecutive sample of patients.

METHODS

All patients above 18 y of age who underwent abdominal surgery with a midline incision at least 12 mo ago were eligible for inclusion. Included patients visited the outpatient clinic where they filled out the diagnostic questionnaire and underwent physical examination. The questionnaire answers were compared with the physical examination results. The diagnostic accuracy of the entire questionnaire was assessed by multivariable logistic regression.

RESULTS

In total, 241 patients visited the outpatient clinic prospectively. 54 (22%) patients were diagnosed with IH during physical examination. The area under the receiver operating characteristic curve of the diagnostic questionnaire was 0.82. Sensitivity and specificity were respectively 81.5% and 77.5%. The positive and negative predictive values were 51.2% and 94%, respectively. Ten (19%) patients with IH were missed by the questionnaire.

CONCLUSIONS

The patient-reported diagnostic questionnaire as currently proposed cannot be used to diagnose IH. However, given the high negative predictive value, the questionnaire might be used to rule out an IH. Long-term follow-up for the diagnosis of IH should be performed by clinical examination.

Risk Factors for Incarceration in Patients with Primary Abdominal Wall and Incisional Hernias: A Prospective Study in 4472 Patients

BACKGROUND

Incarceration of primary and incisional hernias often results in emergency surgery. The objective of this study was to evaluate the relation of defect size and location with incarceration. Secondary objectives comprised identification of additional patient factors associated with an incarcerated hernia.

METHODS

A registry-based prospective study was performed of all consecutive patients undergoing hernia surgery between September 2011 and February 2016. Multivariate logistic regression was performed to identify risk factors for incarceration.

RESULTS

In total, 83 (3.5%) of 2352 primary hernias and 79 (3.7%) of 2120 incisional hernias had a non-reducible incarceration. For primary hernias, a defect width of 3-4 cm compared to defects of 0-1 cm was significantly associated with an incarcerated hernia (OR 2.85, 95% CI 1.57-5.18, p = 0.0006). For incisional hernias, a defect width of 3-4 cm compared to defects of 0-2 cm was significantly associated with an incarceration (OR 2.14, 95% CI 1.07-4.31, p = 0.0324). For primary hernias, defects in the peri- and infra-umbilical region portrayed a significantly increased odds for incarceration as compared to supra-umbilical defects (OR 1.98, 95% CI 1.02-3.85, p = 0.043). Additionally, in primary hernias age, BMI, and constipation were associated with incarceration. In incisional hernias age, BMI, female sex, diabetes mellitus and ASA classification were associated with incarceration.

CONCLUSION

For primary and incisional hernias, mainly defects of 3-4 cm were associated with incarceration. For primary hernias, mainly defects located in the peri- and infra-umbilical region were associated with incarceration. Based on patient and hernia characteristics, patients with increased odds for incarceration may be selected and these patients may benefit from elective surgical treatment.

Risk factors for surgical opportunity in patients with femoral hernia: A retrospective cohort study

Femoral hernias are extremely easily incarcerated and are recommended for early surgery. In the past, there were a number of definitely diagnosed femoral hernia patients who were not able to undergo elective surgery in a timely fashion, and then, they were obliged to undergo emergency surgery or even to lose the opportunity for surgery. The relevant epidemic factors of femoral hernia were thoroughly investigated in the clinic; however, the impact of these factors on surgical opportunity has not been widely reported. The purpose of this study is to preliminarily evaluate the risk factors affecting the femoral hernia patients' surgical opportunities.One hundred forty-two consecutive patients who were treated for femoral hernia with COD (course of disease) >1 month were analyzed. Depending on the surgical opportunity, the patients were divided into 2 groups: elective surgery and emergency surgery. A retrospective cohort study was performed in the 2 groups. Univariate and multivariate logistic regression analysis was used to assess the risk factors influencing the timing of femoral hernia surgery.Of the 163 patients with femoral hernia in our center between 2013 and 2017, 142 had COD > 1 month, including 66 elective and 76 emergency surgeries. Univariate logistic analyses revealed that age, COD, COPD (chronic obstructive pulmonary disease), cirrhosis, and hypertension were risk factors associated with surgical opportunity for femoral hernia; their corresponding odds ratios (ORs) and P values were (OR 9.931; P = .003), (OR 1.024; P = .000), (OR 14.769; P = .000), (OR 1.093; P = .000), and (OR 3.346; P = .007), respectively. On multivariate logistic regression analysis, age, COD, COPD, and cirrhosis were independent risk factors associated with the surgical opportunity of patients with femoral hernia; the corresponding ORs and P values were (OR 1.055; P = .026), (OR 1.022; P = .002), (OR 8.688; P = .009), and (OR 11.761; P = .005), respectively.The independent risk factors of patients with femoral hernia surgical opportunity were age, COD, and the comorbidities COPD and cirrhosis. Active treatment of comorbidities in elderly patients with femoral hernia, as well as timely hospitalization, may reduce the frequency of emergency surgery for femoral hernia.