Extending the value of the National Surgical Quality Improvement Program claims dataset to study long-term outcomes: Rate of repeat ventral hernia repair

Long-term patient-reported outcome measures (PROMs) after primary ventral or small midline incisional hernia repair

BACKGROUND

Ventral hernia repair is a common elective surgical procedure lacking strong evidence for specific operative approaches. This study aimed to evaluate the outcomes of primary suture repair or polypropylene sandwich mesh repair for ventral hernias. The main outcome measures were the rate of hernia recurrence, and evaluation of long-term complications and patient-reported outcomes.

METHODS

This retrospective cohort study evaluated patient perceived recurrence and pain in patients who had undergone a primary ventral hernia (epigastric, supraumbilical, or umbilical) repair or small (≤20 mm) midline incisional hernia repair 10 years after the procedure. Short-term follow-up occurred up to 6 weeks after the initial operation, while long-term follow-up included patients who were reviewed clinically or interviewed via telephone at or beyond 3 years after the procedure.

RESULTS

Most (75/100, 75.0%) patients had an extra-peritoneal sandwich mesh repair. Short-term follow-up showed minimal pain and normal activities for all patients (97/97, 100%). Long-term follow-up (median 12 years [IQR 11-13]) was achieved in 95.9% (93/97) of patients with only a small number reporting a slight bulge (5/93, 5.4%) and intermittent mild discomfort (8/93, 8.6%). Nine patients (9/97, 9.3%) experienced hernia recurrence, diagnosed at a median of 26 months [interquartile range, IQR, 7-58] post-operatively.

CONCLUSIONS

These findings suggest that an open sandwich mesh technique is a safe and effective method for repairing primary ventral hernias and small midline incisional hernias and is associated with favourable long-term patient-reported outcomes.

Year-Over-Year Ventral Hernia Recurrence Rates and Risk Factors

Importance

Recurrence is one of the most challenging adverse events after ventral hernia repair as it impacts quality of life, utilization of resources, and subsequent need for re-repair. Rates of recurrence range from 30% to 80% after ventral hernia repair.

Objective

To determine the contemporary ventral hernia recurrence rate over time in patients with previous hernia repair and to determine risk factors associated with recurrence.

Design, Setting, and Participants

This retrospective, population-based study used the Abdominal Core Health Quality Collaborative registry to evaluate year-over-year recurrence rates in patients with prior ventral hernia repair between January 2012 and August 2022. Patients who underwent at least 1 prior ventral hernia repair were included and categorized into 2 groups based on mesh or no-mesh use. There were 43 960 eligible patients; after exclusion criteria (patients with concurrent inguinal hernias as the primary diagnosis, nonstandard hernia procedure categories, American Society of Anesthesiologists class unassigned, or no follow-up), 29 834 patients were analyzed in the mesh group and 5599 in the no-mesh group.

Main Outcomes and Measures

Ventral hernia recurrence rates. Risk factors analyzed include age, body mass index, sex, race, insurance type, medical comorbidities, American Society of Anesthesiologists class, smoking, indication for surgery, concomitant procedure, hernia procedure type, myofascial release, fascial closure, fixation type, number of prior repairs, hernia width, hernia length, mesh width, mesh length, operative approach, prior mesh placement, prior mesh infection, mesh location, mesh type, postoperative surgical site occurrence, postoperative surgical site infection, postoperative seroma, use of drains, and reoperation.

Results

Among 29 834 patients with mesh, the mean (SD) age was 57.17 (13.36) years, and 14 331 participants (48.0%) were female. Among 5599 patients without mesh, the mean (SD) age was 51.9 (15.31) years, and 2458 participants (43.9%) were female. When comparing year-over-year hernia recurrence rates in patients with and without prior mesh repair, respectively, the Kaplan Meier analysis showed a recurrence rate of 201 cumulative events with 13 872 at risk (2.8%) vs 104 cumulative events with 1707 at risk (4.0%) at 6 months; 411 cumulative events with 4732 at risk (8.0%) vs 184 cumulative events with 427 at risk (32.6%) at 1 year; 640 cumulative events with 1518 at risk (19.7%) vs 243 cumulative events with 146 at risk (52.4%) at 2 years; 731 cumulative events with 670 at risk (29.3%) vs 258 cumulative events with 73 at risk (61.4%) at 3 years; 777 cumulative events with 337 at risk (38.5%) vs 267 cumulative events with 29 at risk (71.2%) at 4 years; and 798 cumulative events with 171 at risk (44.9%) vs 269 cumulative events with 19 at risk (73.7%) at 5 years. Higher body mass index; immunosuppressants; incisional and parastomal hernias; a robotic approach; greater hernia width; use of a biologic or resorbable synthetic mesh; and complications, such as surgical site infections and reoperation, were associated with higher odds of hernia recurrence. Conversely, greater mesh width, myofascial release, and fascial closure had lower odds of recurrence. Hernia type was the most important variable associated with recurrence.

Conclusions and Relevance

In this study, the 5-year recurrence rate after ventral hernia repair was greater than 40% and 70% in patients with and without mesh, respectively. Rates of ventral hernia recurrence increased over time, underscoring the importance of close, long-term follow up in this population.

Is weight trajectory a better marker of wound complication risk than BMI in hernia patients with obesity?

BACKGROUND

Complex ventral hernias are frequently repaired via an open transversus abdominis release (TAR). Obesity, particularly a BMI > 40, is a strong predictor of wound morbidity following this procedure. We aimed to determine if preoperative weight loss may still be beneficial in patients with persistently elevated BMIs.

METHODS

A retrospective chart review of patients with obesity (BMI ≥ 30) who underwent open TAR at a tertiary academic medical center from January 2018 to December 2021 was completed. Demographics, medical history, operative details, and postoperative data were analyzed. Weight and BMI were recorded at three time points: > 6 months prior to initial surgical consultation, surgical consultation, and day of surgery.

RESULTS

In total, 182 patients with obesity underwent an open TAR. Twenty-seven patients (14.8%) underwent surgery with a BMI > 40; they did not have any significant differences in surgical site occurrences (SSO, 48.1% vs 32.9%, p = 0.13) or surgical site infections (SSI, 25.9% vs 23.2%, p = 0.76) compared to those with a BMI ≤ 40. The average timeframe analyzed for preoperative weight loss was 592 days. Patients who had at least a 3% weight loss (n = 49, 26.9%) had decreased rates of SSI compared to those who did not have this weight loss (12.2% vs 27.8%, p = 0.03), despite the groups having similar BMIs at the time of surgery (36.4 vs 36.0, p = 0.50). Patients who only had a 1% weight loss did not see a decrease in SSI rate compared to those who did not (20.6% vs 25.4%, p = 0.45).

CONCLUSION

Weight loss may be a better indicator of a patient's risk for wound morbidity following TAR than BMI alone, as weight loss of at least 3% resulted in fewer SSIs despite similar BMIs at time of surgery. Further research into optimal timing and amount of weight loss, as well as effects on long-term outcomes, is needed to confirm these findings.

Short-Term Outcomes Following Removal of Infected Hernia Mesh

There are limited studies regarding outcomes of replacing an infected mesh with another mesh. We reviewed short-term outcomes following infected mesh removal and whether placement of new mesh is associated with worse outcomes. Patients who underwent hernia repair with infected mesh removal were identified from 2005 to 2018 American College of Surgeons-National Surgical Quality Improvement Program database. They were divided into new mesh (Mesh+) or no mesh (Mesh-) groups. Bivariate and multivariate logistic regression analyses were used to compare morbidity between the two groups and to identify associated risk factors. Of 1660 patients, 49.3% received new mesh, with higher morbidity in the Mesh+ (35.9% vs. 30.3%; P = .016), but without higher rates of surgical site infection (SSI) (21.3% vs. 19.7%; P = .465). Mesh+ had higher rates of acute kidney injury (1.3% vs. .4%; P = .028), UTI (3.1% vs. 1.3%, P = .014), ventilator dependence (4.9% vs. 2.4%; P = .006), and longer LOS (8.6 vs. 7 days, P < .001). Multivariate logistic regression showed new mesh placement (OR: 1.41; 95% CI: 1.07-1.85; P = .014), body mass index (OR: 1.02; 95% CI: 1.00-1.03; P = .022), and smoking (OR: 1.43; 95% CI: 1.05-1.95; P = .025) as risk factors independently associated with increased morbidity. New mesh placement at time of infected mesh removal is associated with increased morbidity but not with SSI. Body mass index and smoking history continue to contribute to postoperative morbidity during subsequent operations for complications.

Leveraging a statewide quality collaborative to understand population-level hernia care

BACKGROUND

Although ventral hernia repair (VHR) is extremely common, there is profound variation in operative technique and outcomes. This study describes the results of a statewide registry capturing hernia-specific variables to understand population-level practice patterns.

METHODS

Retrospective analysis of adult patients in a new statewide hernia registry undergoing VHR in 2020.

RESULTS

919 patients underwent VHR across 57 hospitals and 279 surgeons. Hernia width was <2 cm in 233 (25%) patients, 2-5 cm in 420 (46%) patients, 5-10 cm in 171 (19%) patients, and >10 cm in 95 (10%) patients. Mesh was used in 79% of cases and varied in use from 53% of hernias <2 cm to 95% of hernias >10 cm. The most common mesh type was synthetic non-absorbable (46%), followed by synthetic absorbable mesh (37%). The incidence of complications was significantly associated with hernia width.

CONCLUSIONS

A population-level, hernia-specific database captured operative details for 919 patients in 1 year. There was significant variation in mesh use and outcomes based on hernia size. These nuanced data may inform higher quality clinical practice.

Effects of smoking and different BMI cutoff points on surgical site infection after elective open ventral hernia repair

PURPOSE

BMI > 40 kg/m² and smoking have been identified as risk factors for surgical site infections (SSIs) after ventral hernia repair, however, the relationship with lower BMI values has not been described. The objective of this study was to analyze the relationship between different BMI thresholds, smoking, and SSI after open ventral hernia repair.

METHODS

All patients who underwent an elective non-emergent open ventral hernia repair with mesh were extracted from the 2011 to 2016 NSQIP database. Bivariate, multivariate logistic regression, and Classification and Regression Tree (CART) analyses were used.

RESULTS

Of 55,240 patients, 2,620 (4.7%) developed SSIs (superficial: 58.5%, deep:27%, organ-space: 16%). BMI (OR: 1.035; 95% CI:1.03-1.04; p < 0.001) and smoking (OR:1.51; 95% CI:1.37-1.67; p < 0.001) were identified in logistic regression analysis as the two most modifiable risk factors independently associated with SSIs. CART analysis demonstrated that the lowest SSI rate belonged to non-smokers with BMI < 24.2 kg/m² (1.9%), and the highest SSI to smokers with BMI > 42.3 kg/m² (12%). Between these values, there was a stepwise increase in SSI rate as BMI increased, while smoking added additional risk in each group.

CONCLUSION

Following open hernia repair, the association between SSI and being overweight starts at a BMI of 24.2, a threshold lower than previously described. The risk of SSI increases in a stepwise fashion as BMI increases and is augmented by smoking. Future studies are needed to determine if SSI reduction can be achieved with a combination of smoking cessation and weight loss using these BMI thresholds.

Expectant Management of Patients with Ventral Hernias: 3 Years of Follow-up

BACKGROUND

The safety and effectiveness of expectant management (e.g., watchful waiting or initially managing non-operatively) for patients with a ventral hernia is unknown. We report our 3-year results of a prospective cohort of patients with ventral hernias who underwent expectant management.

METHODS

A hernia clinic at an academic safety-net hospital was used to recruit patients. Any patient undergoing expectant management with symptoms and high-risk comorbidities, as determined by a surgeon based on institutional criteria, would be included in the study. Patients unlikely to complete follow-up assessments were excluded from the study. Patient-reported outcomes were collected by phone and mailed surveys. A modified activities assessment scale normalized to a 1-100 scale was used to measure results. The rate of operative repair was the primary outcome, while secondary outcomes include rate of emergency room (ER) visits and both emergent and elective hernia repairs.

RESULTS

Among 128 patients initially enrolled, 84 (65.6%) completed the follow-up at a median (interquartile range) of 34.1 (31, 36.2) months. Overall, 28 (33.3%) patients visited the ER at least once because of their hernia and 31 (36.9%) patients underwent operative management. Seven patients (8.3%) required emergent operative repair. There was no significant change in quality of life for those managed non-operatively; however, substantial improvements in quality of life were observed for patients who underwent operative management.

CONCLUSIONS

Expectant management is an effective strategy for patients with ventral hernias and significant comorbid medical conditions. Since the short-term risk of needing emergency hernia repair is moderate, there could be a safe period of time for preoperative optimization and risk-reduction for patients deemed high risk.

Surgical site occurrences, not body mass index, increase the long-term risk of ventral hernia recurrence

BACKGROUND

Recurrence rates after ventral hernia repair vary widely and evidence about risk factors for recurrence are conflicting. There is little evidence for risk factors for long-term recurrence.

METHODS

Patients who underwent ventral hernia repair at our institution and were captured in the American College of Surgeons-National Surgical Quality Improvement Program database between 2002 and 2015 were included. We reviewed all demographic, procedural, and hernia-specific data.

RESULTS

Six hundred and thirty patients were included for analysis with a median follow-up of 4.9 years (inter-quartile range, 2-7.3 years). By univariate analysis, index hernia repairs were more likely to recur if defect size was ≥4 cm (P = .019), no mesh was used (P = .026), or if the repair was for a recurrent hernia (P = .001). Five-year cumulative incidence of recurrence and reoperation was 24.3% and 16.0%, respectively. Patients with a perioperative surgical site occurrence, which included superficial, deep-incisional, and organ space surgical site infections as well as wound disruption, had a 5-year cumulative incidence of recurrence of 54.9% compared with 22.6% for those without surgical site occurrence. By multivariable analysis, non-primary hernia repair (hazard ratio 1.7, 95% confidence interval 1.2-2.4, P = .005) and any postoperative surgical site occurrence (hazard ratio 1.9, 95% confidence interval 1.1-3.6, P = .02) were the only risk factors predictive of recurrence. Patient body mass index had no independent effect on recurrence.

CONCLUSION

1 in 4 patients undergoing an open ventral hernia repair will have a recurrence after 5 years, and this risk is doubled among patients who experience any perioperative surgical site occurrence. After controlling for patient comorbidities, including body mass index, hernia size, and mesh position, the most significant risk factor for recurrence after ventral hernia repair was a non-primary hernia and surgical site occurrence.

Comparing Reported Complication Rates in Shoulder Arthroplasty Between 2 Large Databases

Large databases are commonly used to analyze surgical outcomes. Recent studies have suggested that there are differences in complication rates between databases across certain procedures, but the reasons for these differences are not fully understood. The goal of this study was to compare complications of shoulder arthroplasty across databases as well as to interpret the causes of any differences. The authors compared complication rates for shoulder arthroplasty as reported by the Healthcare Cost and Utilization Project Nationwide Inpatient Sample (NIS) and the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) from 2006 to 2010. The authors then restricted NIS data solely to hospitals that also contributed to NSQIP to provide a more direct comparison of the patient populations. The authors identified 48,287 discharges reported in NIS and 1679 discharges reported in NSQIP for patients who underwent shoulder arthroplasty. The complication rate for shoulder arthroplasty was significantly higher in the NIS population (12.6%; 95% confidence interval, 12.0%-13.2%) than in the NSQIP population (5.60%; 95% confidence interval, 4.59%-6.81%). When NIS data were restricted solely to hospitals that also participated in NSQIP, the rate of complications remained higher, at 13.4% (95% confidence interval, 11.2%-15.8%), and the rate increased relative to the nonrestricted data. The databases compared in this study had statistically significant differences in reported complication rates for shoulder arthroplasty. This difference persisted when NIS data were restricted to hospitals that also participated in NSQIP, suggesting that differences in database design contribute to important differences in data. Orthopedic surgeons and administrators must use caution when using complication rates derived from large database studies. [Orthopedics. 2020;43(2):113-118.].

Do 30-Day Reoperation Rates Adequately Measure Quality in Orthopedic Surgery?

BACKGROUND

Unplanned reoperation rates represent an important metric in monitoring quality in orthopedic surgery. Previous studies have focused on 30-day reoperation rates, not accounting for complications that may arise beyond this time. This study aimed to understand the frequency, timing, and procedure type of orthopedic reoperations, as well as the complications leading up to these reoperations over a 1-year period.

METHODS

A single-center, retrospective cohort study reviewed all orthopedic surgeries performed within a three-year period and subsequently identified reoperations within a year following the initial case. Exclusion criteria for reoperations included those that were planned, involved a different body part, or had a different laterality from the first operation. The cases were analyzed by procedure type, timing of reoperation, and causes of reoperation.

RESULTS

Of the 10,449 orthopedic surgeries performed between 2012 and 2015, 947 (9.1%) were unplanned reoperations within 1 year. Most (775; 81.8%) unplanned reoperations occurred after 30 days. Infections/wound complications (58.2%) were the most common reason for unplanned reoperations at 1 month from the initial operation, and mechanical complications (49.5%) predominated at the 6-months-to-1-year time frame.

CONCLUSION

This study demonstrated that the current paradigm of focusing on reoperations occurring within 30 days of the initial operation captures only a fraction of unplanned reoperations. Stratification of this metric by time and precipitating complication type provides additional information that quality improvement programs may target. A 1-year unplanned reoperation rate could be used as a broad indicator of surgical quality across institutions.

Management of Reducible Ventral Hernias: Clinical Outcomes and Cost-effectiveness of Repair at Diagnosis Versus Watchful Waiting

OBJECTIVE

To compare long-term clinical and economic outcomes associated with 3 management strategies for reducible ventral hernia: repair at diagnosis (open or laparoscopic) and watchful waiting.

BACKGROUND

There is variability in ventral hernia management. Recent data suggest watchful waiting is safe; however, long-term clinical and economic outcomes for different management strategies remain unknown.

METHODS

We built a state-transition microsimulation model to forecast outcomes for individuals with reducible ventral hernia, simulating a cohort of 1 million individuals for each strategy. We derived cohort characteristics (mean age 58 years, 63% female), hospital costs, and perioperative mortality from the Nationwide Inpatient Sample (2003-2011), and additional probabilities, costs, and utilities from the literature. Outcomes included prevalence of any repair, emergent repair, and recurrence; lifetime costs; quality-adjusted life years (QALYs); and incremental cost-effectiveness ratios. We performed stochastic and probabilistic sensitivity analyses to identify parameter thresholds that affect optimal management, using a willingness-to-pay threshold of $50,000/QALY.

RESULTS

With watchful waiting, 39% ultimately required repair (14% emergent) and 24% recurred. Seventy per cent recurred with repair at diagnosis. Laparoscopic repair at diagnosis was cost-effective compared with open repair at diagnosis (incremental cost-effectiveness ratio $27,700/QALY). The choice of operative strategy (open vs laparoscopic) was sensitive to cost and postoperative quality of life. When perioperative mortality exceeded 5.2% or yearly recurrence exceeded 19.2%, watchful waiting became preferred.

CONCLUSIONS

Ventral hernia repair at diagnosis is very cost-effective. The choice between open and laparoscopic repair depends on surgical costs and postoperative quality of life. In patients with high risk of perioperative mortality or recurrence, watchful waiting is preferred.

The Impact of Surgical Approach on Late Recurrence in Incisional Hernia Repair

Background and Objectives:

We conducted a retrospective, observational study to compare real-world recurrence rates for different surgical approaches after incisional hernia mesh repair.

Methods:

Two large US insurance claims databases, Truven Commercial Claims (CCAE) and Medicare Supplemental (MDCR), were evaluated for the period from 2009 to 2015. The first incisional hernia repair with mesh for patients 21 years or older was identified (INDEX). One-year continuous enrollment before INDEX was required. Mesh and approach (OPEN, laparoscopic [LAP], and conversion [CONV]) were identified with the use of CPT-4/ICD-9 codes. Recurrence was defined as a second incisional hernia repair 31 days or longer after INDEX. Kaplan-Meier (KM) estimates and Cox models were used to analyze the effect of approach on recurrence.

Results:

A total of 68,560 patients were identified for CCAE (78.7%) and MDCR (21.3%) with a mean (SD) age of 55.3 (12.8) years. The majority of procedures were OPEN (80.1%) followed by LAP (16.3%) and CONV (3.6%). OPEN had fewer female patients 53.7% compared with LAP (62.1%) and CONV (62.2%). CONV represented more inpatient (51.9%) procedures compared with LAP (41.0%) and OPEN (27.3%). Starting at 2 years post-INDEX, LAP (5.1%, 95% confidence interval [CI] 4.5%–5.6%) had lower KM estimates compared with OPEN (5.9%, 95% CI 5.7%–6.2%]); after 3 years, LAP (6.8%, 95% CI 6.2%–7.5%]) had lower estimates than both OPEN (7.9%, 95% CI 7.6%–8.3%) and CONV (9.3%, 95% CI 7.6%–11.0%). After controlling for confounders, the risk was lower for LAP compared with OPEN (hazard ratio 0.839, 95% CI 0.752–0.936) and CONV (hazard ratio 0.808, 95% CI 0.746–0.875), while OPEN and CONV were not significantly different from each other.

Conclusion:

Successful laparoscopic surgery incisional hernia mesh repair was associated with decreased risk of recurrence compared with OPEN and CONV.

Delineating the burden of chronic post-operative pain in patients undergoing open repair of complex ventral hernias

BACKGROUND

After open complex ventral hernia repair (cVHR), chronic pain has a significant impact on quality of life and processes of care.

METHODS

Records of 177 patients undergoing cVHR were reviewed in order to characterize the burden of managing postoperative pain in the first post-operative year following open cVHR.

RESULTS

In this cohort, 91 patients initiated at least one unsolicited complaint of pain, though phone call (37), unscheduled clinic visit (45) or evaluation in the emergency room (9); among these an actionable diagnosis was found in 38 (41.8%). Among 41 patients who initiated additional unsolicited complaints of pain, an actionable diagnosis was found in only 3 patients. Risk factors for such complaints included pre-operative pain and the use of synthetic mesh.

CONCLUSIONS

Even in the absence of an actionable diagnosis, significant resources are utilized in evaluation and management of unsolicited complaints of pain in the first year after cVHR.

Closure methods for laparotomy incisions for preventing incisional hernias and other wound complications

BACKGROUND

Surgeons who perform laparotomy have a number of decisions to make regarding abdominal closure. Material and size of potential suture types varies widely. In addition, surgeons can choose to close the incision in anatomic layers or mass ('en masse'), as well as using either a continuous or interrupted suturing technique, of which there are different styles of each. There is ongoing debate as to which suturing techniques and suture materials are best for achieving definitive wound closure while minimising the risk of short- and long-term complications.

OBJECTIVES

The objectives of this review were to identify the best available suture techniques and suture materials for closure of the fascia following laparotomy incisions, by assessing the following comparisons: absorbable versus non-absorbable sutures; mass versus layered closure; continuous versus interrupted closure techniques; monofilament versus multifilament sutures; and slow absorbable versus fast absorbable sutures. Our objective was not to determine the single best combination of suture material and techniques, but to compare the individual components of abdominal closure.

SEARCH METHODS

On 8 February 2017 we searched CENTRAL, MEDLINE, Embase, two trials registries, and Science Citation Index. There were no limitations based on language or date of publication. We searched the reference lists of all included studies to identify trials that our searches may have missed.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared suture materials or closure techniques, or both, for fascial closure of laparotomy incisions. We excluded trials that compared only types of skin closures, peritoneal closures or use of retention sutures.

DATA COLLECTION AND ANALYSIS

We abstracted data and assessed the risk of bias for each trial. We calculated a summary risk ratio (RR) for the outcomes assessed in the review, all of which were dichotomous. We used random-effects modelling, based on the heterogeneity seen throughout the studies and analyses. We completed subgroup analysis planned a priori for each outcome, excluding studies where interventions being compared differed by more than one component, making it impossible to determine which variable impacted on the outcome, or the possibility of a synergistic effect. We completed sensitivity analysis, excluding trials with at least one trait with high risk of bias. We assessed the quality of evidence using the GRADEpro guidelines.

MAIN RESULTS

Fifty-five RCTs with a total of 19,174 participants met the inclusion criteria and were included in the meta-analysis. Included studies were heterogeneous in the type of sutures used, methods of closure and patient population. Many of the included studies reported multiple comparisons.For our primary outcome, the proportion of participants who developed incisional hernia at one year or more of follow-up, we did not find evidence that suture absorption (absorbable versus non-absorbable sutures, RR 1.07, 95% CI 0.86 to 1.32, moderate-quality evidence; or slow versus fast absorbable sutures, RR 0.81, 95% CI 0.63 to 1.06, moderate-quality evidence), closure method (mass versus layered, RR 1.92, 95% CI 0.58 to 6.35, very low-quality evidence) or closure technique (continuous versus interrupted, RR 1.01, 95% CI 0.76 to 1.35, moderate-quality evidence) resulted in a difference in the risk of incisional hernia. We did, however, find evidence to suggest that monofilament sutures reduced the risk of incisional hernia when compared with multifilament sutures (RR 0.76, 95% CI 0.59 to 0.98, I2 = 30%, moderate-quality evidence).For our secondary outcomes, we found that none of the interventions reduced the risk of wound infection, whether based on suture absorption (absorbable versus non-absorbable sutures, RR 0.99, 95% CI 0.84 to 1.17, moderate-quality evidence; or slow versus fast absorbable sutures, RR 1.16, 95% CI 0.85 to 1.57, moderate-quality evidence), closure method (mass versus layered, RR 0.93, 95% CI 0.67 to 1.30, low-quality evidence) or closure technique (continuous versus interrupted, RR 1.13, 95% CI 0.96 to 1.34, moderate-quality evidence).Similarily, none of the interventions reduced the risk of wound dehiscence whether based on suture absorption (absorbable versus non-absorbable sutures, RR 0.78, 95% CI 0.55 to 1.10, moderate-quality evidence; or slow versus fast absorbable sutures, RR 1.55, 95% CI 0.92 to 2.61, moderate-quality evidence), closure method (mass versus layered, RR 0.69, 95% CI 0.31 to 1.52, moderate-quality evidence) or closure technique (continuous versus interrupted, RR 1.21, 95% CI 0.90 to 1.64, moderate-quality evidence).Absorbable sutures, compared with non-absorbable sutures (RR 0.49, 95% CI 0.26 to 0.94, low-quality evidence) reduced the risk of sinus or fistula tract formation. None of the other comparisons showed a difference (slow versus fast absorbable sutures, RR 0.88, 95% CI 0.05 to 16.05, very low-quality evidence; mass versus layered, RR 0.49, 95% CI 0.15 to 1.62, low-quality evidence; continuous versus interrupted, RR 1.51, 95% CI 0.64 to 3.61, very low-quality evidence).

AUTHORS' CONCLUSIONS

Based on this moderate-quality body of evidence, monofilament sutures may reduce the risk of incisional hernia. Absorbable sutures may also reduce the risk of sinus or fistula tract formation, but this finding is based on low-quality evidence.We had serious concerns about the design or reporting of several of the 55 included trials. The comparator arms in many trials differed by more than one component, making it impossible to attribute differences between groups to any one component. In addition, the patient population included in many of the studies was very heterogeneous. Trials included both emergency and elective cases, different types of disease pathology (e.g. colon surgery, hepatobiliary surgery, etc.) or different types of incisions (e.g. midline, paramedian, subcostal).Consequently, larger, high-quality trials to further address this clinical challenge are warranted. Future studies should ensure that proper randomisation and allocation techniques are performed, wound assessors are blinded, and that the duration of follow-up is adequate. It is important that only one type of intervention is compared between groups. In addition, a homogeneous patient population would allow for a more accurate assessment of the interventions.

The Impact of Body Mass Index on Abdominal Wall Reconstruction Outcomes: A Comparative Study

BACKGROUND

Obesity and higher body mass index may be associated with higher rates of wound healing complications and hernia recurrence rates following complex abdominal wall reconstruction. The authors hypothesized that higher body mass indexes result in higher rates of postoperative wound healing complications but similar rates of hernia recurrence in abdominal wall reconstruction patients.

METHODS

The authors included 511 consecutive patients who underwent abdominal wall reconstruction with underlay mesh. Patients were divided into three groups on the basis of preoperative body mass index: less than 30 kg/m (nonobese), 30 to 34.9 kg/m (class I obesity), and 35 kg/m or greater (class II/III obesity). The authors compared postoperative outcomes among these groups.

RESULTS

Class I and class II/III obesity patients had higher surgical-site occurrence rates than nonobese patients (26.4 percent versus 14.9 percent, p = 0.006; and 36.8 percent versus 14.9 percent, p < 0.001, respectively) and higher overall complication rates (37.9 percent versus 24.7 percent, p = 0.007; and 43.4 percent versus 24.7 percent, p < 0.001, respectively). Similarly, obese patients had significantly higher skin dehiscence (19.3 percent versus 7.2 percent, p < 0.001; and 26.5 percent versus 7.2 percent, p < 0.001, respectively) and fat necrosis rates (10.0 percent versus 2.1 percent, p = 0.001; and 11.8 percent versus 2.1 percent, p < 0.001, respectively) than nonobese patients. Obesity class II/III patients had higher infection and seroma rates than nonobese patients (9.6 percent versus 4.3 percent, p = 0.041; and 8.1 percent versus 2.1 percent, p = 0.006, respectively). However, class I and class II/III obesity patients experienced hernia recurrence rates (11.4 percent versus 7.7 percent, p = 0.204; and 10.3 percent versus 7.7 percent, p = 0.381, respectively) and freedom from hernia recurrence (overall log-rank, p = 0.41) similar to those of nonobese patients.

CONCLUSION

Hernia recurrence rates do not appear to be affected by obesity on long-term follow-up in abdominal wall reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

Ventral Hernia Management: Expert Consensus Guided by Systematic Review

OBJECTIVE

To achieve consensus on the best practices in the management of ventral hernias (VH).

BACKGROUND

Management patterns for VH are heterogeneous, often with little supporting evidence or correlation with existing evidence.

METHODS

A systematic review identified the highest level of evidence available for each topic. A panel of expert hernia-surgeons was assembled. Email questionnaires, evidence review, panel discussion, and iterative voting was performed. Consensus was when all experts agreed on a management strategy.

RESULTS

Experts agreed that complications with VH repair (VHR) increase in obese patients (grade A), current smokers (grade A), and patients with glycosylated hemoglobin (HbA1C) ≥ 6.5% (grade B). Elective VHR was not recommended for patients with BMI ≥ 50 kg/m (grade C), current smokers (grade A), or patients with HbA1C ≥ 8.0% (grade B). Patients with BMI= 30-50 kg/m or HbA1C = 6.5-8.0% require individualized interventions to reduce surgical risk (grade C, grade B). Nonoperative management was considered to have a low-risk of short-term morbidity (grade C). Mesh reinforcement was recommended for repair of hernias ≥ 2 cm (grade A). There were several areas where high-quality data were limited, and no consensus could be reached, including mesh type, component separation technique, and management of complex patients.

CONCLUSIONS

Although there was consensus, supported by grade A-C evidence, on patient selection, the safety of short-term nonoperative management, and mesh reinforcement, among experts; there was limited evidence and broad variability in practice patterns in all other areas of practice. The lack of strong evidence and expert consensus on these topics has identified gaps in knowledge where there is need of further evidence.

Development of a Clinically Actionable Incisional Hernia Risk Model after Colectomy Using the Healthcare Cost and Utilization Project

BACKGROUND

Incisional hernia remains a persistent and burdensome complication after colectomy. Through individualized risk-assessment and prediction models, we aimed to improve preoperative risk counseling for patients undergoing colectomy; identify modifiable preoperative risk factors; and encourage the use of evidence-based risk-prediction instruments in the clinical setting.

STUDY DESIGN

A retrospective review of the Healthcare Cost and Utilization Project data was conducted for all patients undergoing either open or laparoscopic colectomy as identified through the state inpatient databases of California, Florida, and New York in 2009. Incidence of incisional hernia repair was collected from both the state inpatient databases and the state ambulatory surgery and services databases in the 3 states between index surgery and 2011. Hernia risk was calculated with multivariable hierarchical logistic regression modeling and validated using bootstrapping techniques. Exclusion criteria included concurrent hernia, metastasis, mortality, and age younger than 18 years. Inflation-adjusted expenditure estimates were calculated.

RESULTS

Overall, 30,741 patients underwent colectomy, one-third of these procedures performed laparoscopically. Incisional hernia repair was performed in 2,563 patients (8.3%) (27-month follow-up). Fourteen significant risk factors were identified, including open surgery (odds ratio = 1.49; p < 0.0001), obesity (odds ratio = 1.49; p < 0.0001), and alcohol abuse (odds ratio = 1.39; p = 0.010). Extreme-risk patients experienced the highest incidence of incisional hernia (19.8%) vs low-risk patients (3.9%) (C-statistic = 0.67).

CONCLUSIONS

We present a clinically actionable model of incisional hernia using all-payer claims after colectomy. The data presented can structure preoperative risk counseling, identify modifiable patient-specific risk factors, and advance the field of risk prediction using claims data.

Pancreas fistula risk prediction: implications for hospital costs and payments

BACKGROUND

As payment models evolve, disease-specific risk stratification may impact patient selection and financial outcomes. This study sought to determine whether a validated clinical risk score for post-operative pancreatic fistula (POPF) could predict hospital costs, payments, and profit margins.

METHODS

A multi-institutional cohort of 1193 patients undergoing pancreaticoduodenectomy (PD) were matched to an independent hospital where cost, in US$, and payment data existed. An analytic model detailed POPF risk and post-operative sequelae, and their relationship with hospital cost and payment.

RESULTS

Per-patient hospital cost for negligible-risk patients was $37,855. Low-, moderate-, and high- risk patients had incrementally higher hospital costs of $38,125 ($270; 0.7% above negligible-risk), $41,128 ($3273; +8.6%), and $41,983 ($3858; +10.9%), respectively. Similarly, hospital payment for negligible-risk patients was $42,685/patient, with incrementally higher payments for low-risk ($43,265; +1.4%), moderate-risk ($45,439; +6.5%) and high-risk ($46,564; +9.1%) patients. The lowest 30-day readmission rates - with highest net profit - were found for negligible/low-risk patients (10.5%/11.1%), respectively, compared with readmission rates of moderate/high-risk patients (15%/15.7%).

CONCLUSION

Financial outcomes following PD can be predicted using the FRS. Such prediction may help hospitals and payers plan for resource allocation and payment matched to patient risk, while providing a benchmark for quality improvement initiatives.

A risk model and cost analysis of post-operative incisional hernia following 2,145 open hysterectomies-Defining indications and opportunities for risk reduction

BACKGROUND

Incisional hernia (IH) is a complication following open abdominal hysterectomy. This study addresses the incidence and health care cost of IH repair after open hysterectomy, and identify perioperative risk factors to create predictive risk models.

METHODS

We conduct a retrospective review of patients who underwent open hysterectomy between 2005 and 2013 at the University of Pennsylvania. The primary outcome was post-hysterectomy IH. Univariate/multivariate cox proportional hazard analyses identified perioperative risk factors. We performed cox hazard regression modeling with bootstrapped validation, risk stratification, and assessment of model performance.

RESULTS

2145 patients underwent open hysterectomy during the study period. 76 patients developed IH, and all underwent repair. 31.3% underwent reoperation, generating higher costs ($71,559 vs. $23,313, p < 0.001). 8 risk factors were included in the model, the strongest being presence of a vertical incision (HR = 3.73 [2.01-6.92]). Extreme-risk patients experienced the highest incidence of IH (22%) vs. low-risk patients (0.8%) [C-statistic = 0.82].

CONCLUSIONS

We identify perioperative risk factors for IH and provide a risk prediction instrument to accurately stratify patients in effort to offer risk reductive techniques.

SUMMARY

Open hysterectomies account for a magnitude of surgical procedures worldwide. This study presents an internally validated risk model of IH in patients undergoing open hysterectomy after a review of 2145 cases. With an increasing emphasis on prevention in healthcare, we create a risk model to improve outcomes after open hysterectomies in effort to identify high-risk patients, facilitate preoperative risk counseling, and implement evidence-based strategies to improve outcomes.