Smoking and obesity are associated with increased readmission after elective repair of small primary ventral hernias: A nationwide database study

Cost analysis of open versus robot-assisted ventral hernia repair - a retrospective cohort study

BACKGROUND

Robot-assisted ventral hernia repair is associated with decreased length of stay and lower complication rates compared with open repair, but acquisition and maintenance of the robotic system is costly. The aim of this was study was to compare the procedure-specific cost of robot-assisted and open ventral and incisional hernia repair including cost of procedure-related readmissions and reoperations within 90 days postoperatively.

METHODS

Single-center retrospective cohort study of 100 patients undergoing robot-assisted ventral hernia. Patients were propensity-score matched 1:1 with 100 patients undergoing open repairs on age, type of hernia (primary/incisional), and horizontal defect size. The primary outcome of the study was the total cost per procedure in Euros including the cost of a robotic approach, extra ports, mesh, tackers, length of stay, length of readmission, and operative reintervention. The cost of the robot itself was not included in the cost calculation.

RESULTS

The mean length of stay was 0.3 days for patients undergoing robot-assisted ventral hernia repair, which was significantly shorter compared with 2.1 days for patients undergoing open repair, P < 0.005. The readmission rate was 4% for patients undergoing robot-assisted ventral hernia repairs and was significantly lower compared with open repairs (17%), P = 0.006. The mean total cost of all robot-assisted ventral and incisional hernia repairs was 1,094 euro compared with 1,483 euro for open repairs, P = 0.123. The total cost of a robot-assisted incisional hernia repair was significantly lower (1,134 euros) compared with open ventral hernia repair (2,169 euros), P = 0.005.

CONCLUSIONS

In a Danish cohort of patients with incisional hernia, robot-assisted incisional hernia repair was more cost-effective than an open repair due to shortened length of stay, and lower rates of readmission and reintervention within 90 days.

Risk factors associated to incisional hernia in stoma site after stoma closure: A systematic review and meta-analysis

BACKGROUND

This study aims to identify which risk factors are associated with the appearance of an incisional hernia in a stoma site after its closure. This in the sake of identifying which patients would benefit from a preventative intervention and thus start implementing a cost-effective protocol for prophylactic mesh placement in high-risk patients.

METHODS

A systematic review of PubMed, Cochrane library, and ScienceDirect was performed according to PRISMA guidelines. Studies reporting incidence, risk factors, and follow-up time for appearance of incisional hernia after stoma site closure were included. A fixed-effects and random effects models were used to calculate odds ratios' estimates and standardized mean values with their respective grouped 95% confidence interval. This to evaluate the association between possible risk factors and the appearance of incisional hernia after stoma site closure.

RESULTS

Seventeen studies totaling 2899 patients were included. Incidence proportion between included studies was of 16.76% (CI95% 12.82; 21.62). Out of the evaluated factors higher BMI (p = 0.0001), presence of parastomal hernia (p = 0.0023), colostomy (p = 0,001), and end stoma (p = 0.0405) were associated with the appearance of incisional hernia in stoma site after stoma closure, while malignant disease (p = 0.0084) and rectum anterior resection (p = 0.0011) were found to be protective factors.

CONCLUSIONS

Prophylactic mesh placement should be considered as an effective preventative intervention in high-risk patients (obese patients, patients with parastomal hernia, colostomy, and end stoma patients) with the goal of reducing incisional hernia rates in stoma site after closure while remaining cost-effective.

Distressed community index as a predictor of presentation and postoperative outcomes in ventral hernia repair

BACKGROUND

We evaluated the impact of socioeconomic status on presentation, management, and outcomes of ventral hernias.

METHODS

The Abdominal Core Health Quality Collaborative was queried for adult patients undergoing ventral hernia repair. Socioeconomic quintiles were assigned using the Distressed Community Index (DCI): prosperous (0-20), comfortable (21-40), mid-tier (41-60), at-risk (61-80), and distressed (81-100). Outcomes included presenting symptoms, urgency, operative details, 30-day outcomes, and one-year hernia recurrence rates. Multivariable regression evaluated 30-day wound complications.

RESULTS

39,494 subjects were identified; 32,471 had zip codes (82.2%).Urgent presentation (3.6% vs. 2.3%) and contaminated cases (0.83% vs. 2.06%) were more common in the distressed group compared to the prosperous group (p < 0.001). Higher DCI correlated with readmission (distressed: 4.7% vs prosperous: 2.9%,p < 0.001) and reoperation (distressed 1.8% vs prosperous: 0.92%,p < 0.001). Wound complications were independently associated with increasing DCI (p < 0.05). Clinical recurrence rates were similar at one-year (distressed: 10.4% vs prosperous: 8.6%, p = 0.54).

CONCLUSIONS

Inequity exists in presentation and perioperative outcomes for ventral hernia repair and efforts should be focused on increasing access to elective surgery and improving postoperative wound care.

Impact of sex on ventral hernia repair outcomes: A systematic review and meta-analysis

BACKGROUND

Given the variability in abdominal physiology and hernia presentation between sexes, better comprehension of sex-related differences in outcomes would tailor surgical approach and counseling regarding postoperative outcomes. This meta-analysis aims to appraise the effect of sex on the outcomes of ventral hernia repair.

METHODS

A literature search in PubMed, EMBASE and Cochrane selected studies comparing outcomes of ventral hernia repair between sexes. Postoperative outcomes were assessed by pooled and meta-analysis. Statistical analysis was performed using RevMan 5.4.

RESULTS

We screened 3128 studies, reviewed 133, and included 18 observational studies, which encompassed 220,799 patients following ventral hernia repair. Postoperative chronic pain was significantly higher in female (OR 1,9; 95% CI 1,64-2,2; p ​< ​0,001). There were no significant differences in complications, readmission, or recurrence rates between females and males.

CONCLUSION

Female sex is associated with a higher risk of postoperative chronic pain following ventral hernia repair.

Association of body mass index with morbidity following elective ventral hernia repair

Background

Prior work has linked body mass index (BMI) with postoperative outcomes of ventral hernia repair (VHR), though recent data characterizing this association are limited. This study used a contemporary national cohort to investigate the association between BMI and VHR outcomes.

Methods

Adults ≥ 18 years undergoing isolated, elective, primary VHR were identified using the 2016-2020 American College of Surgeons National Surgical Quality Improvement Program database. Patients were stratified by BMI. Restricted cubic splines were utilized to ascertain the BMI threshold for significantly increased morbidity. Multivariable models were developed to evaluate the association of BMI with outcomes of interest.

Results

Of ~89,924 patients, 0.5 % were considered Underweight, 12.9 % Normal Weight, 29.5 % Overweight, 29.1 % Class I, 16.6 % Class II, 9.7 % Class III, and 1.7 % Superobese. After risk adjustment, class I (Adjusted Odds Ratio [AOR] 1.22, 95 % Confidence Interval [95%CI]: 1.06-1.41), class II (AOR 1.42, 95%CI: 1.21-1.66), class III obesity (AOR 1.76, 95%CI: 1.49-2.09) and superobesity (AOR 2.25, 95 % CI: 1.71-2.95) remained associated with increased odds of overall morbidity relative to normal BMI following open, but not laparoscopic, VHR. A BMI of 32 was identified as the threshold for the most significant increase in predicted rate of morbidity. Increasing BMI was linked to a stepwise rise in operative time and postoperative length of stay.

Conclusion

BMI ≥ 32 is associated with greater morbidity following open, but not laparoscopic VHR. The relevance of BMI may be more pronounced in open VHR and must be considered for stratifying risk, improving outcomes, and optimizing care.

Key message

Body mass index (BMI) continues to be a relevant factor in morbidity and resource use for elective open ventral hernia repair (VHR). A BMI of 32 serves as the threshold for significant increase in overall complications following open VHR, though this association is not observed in operations performed laparoscopically.

Early and Late Readmission after Enhanced Recovery Thoracoscopic Lobectomy

OBJECTIVES

The purpose of this study was to describe the incidence and reasons for early (0-30 days) and late (31-90 days) readmission after enhanced recovery video-assisted thoracoscopic surgery lobectomy.

METHODS

We performed a retrospective analysis of prospectively collected consecutive VATS lobectomy data in an institutional database from January 2019 until December 2020. All reasons for readmission with complete follow-up were individually evaluated. Univariable and multivariable analyses were used to assess predictors.

RESULTS

In total 508 patients were included and median length of stay after surgery was 3 days. Early and late readmission were 77 (15%) and 54 (11%), respectively. Multiple readmissions during postoperative 0-90 days were 33 (7%). Pneumonia (19.8%) and pneumothorax (18.3%) were the dominant reasons for early readmission, and side effects to adjuvant chemotherapy (22.0%) for late readmission. In multivariable analyses, current smoking (P = 0.001), alcohol abuse (P = 0.024) and chronic obstructive pulmonary disease (P = 0.019) were predictors for early readmission, while (Clavien-Dindo I-II grade gastrointestinal complicationspredicted late readmission (P = 0.006) and multiple readmissions (P = 0.007). Early discharge (< 3 days) was not a predictor for readmission. Early readmission does not increase late readmission.

CONCLUSIONS

Early and late readmission are frequent despite of following enhanced recovery programs after video-assisted thoracoscopic lobectomy. Pulmonary complications and adjuvant chemotherapy are the most predominant reasons for early and late readmission.

Umbilical hernia repair in patients with cirrhosis: systematic review of mortality and complications

BACKGROUND

Umbilical hernia is a common and potential serious condition in patients with cirrhosis. This systematic review evaluated the risks associated with emergency and elective hernia repair in patients with cirrhosis.

METHODS

Systematic review of clinical trials identified through manual and electronic searches in several databases (last update November 2021). The primary random-effects meta-analyses evaluated mortality in patients with or without cirrhosis or following emergency versus elective repair. The quality of the evidence was assessed using GRADE and Newcastle Ottawa Scale.

RESULTS

Thirteen prospective and 10 retrospective studies including a total of 3229 patients were included. The evidence was graded as very low quality for all outcomes (mortality and postoperative complications within 90 days). In total 191 patients (6%) died after undergoing umbilical hernia repair. Patients with cirrhosis were more than eight times as likely to die after surgery compared with patients without cirrhosis [OR = 8.50, 95% CI (1.91-37.86)] corresponding to 69 more deaths/1000 patients. Among patients with cirrhosis, mortality was higher after emergency versus elective repair [OR = 2.67, 95% CI (1.87-3.97)] corresponding to 52 more deaths/1000 patients. Postoperative complications were more common in patients with cirrhosis compared with patients without cirrhosis.

CONCLUSION

Patients with cirrhosis undergoing emergency umbilical hernia repair have a considerably increased risk of death and severe complications. Accordingly, additional evidence is needed to evaluate methods that would allow elective umbilical hernia repair in patients with cirrhosis.

Association of socioeconomic status with 30- and 90-day readmission following open and laparoscopic hernia repair: a nationwide readmissions database analysis

BACKGROUND

Socioeconomic disparities have been associated with outcomes in many medical conditions. The association of socioeconomic status (SES) with readmissions after ventral and inguinal hernia repair has not been well studied on a national level. This study aims to evaluate the association of SES with readmission as a significant outcome in patients undergoing ventral and inguinal hernia repair.

METHODS

A retrospective cohort study was performed evaluating patients undergoing ventral hernia and inguinal hernia repair with 1:1 propensity score matching using the Nationwide Readmissions Database (2016-2017). Both 30- and 90-day readmissions were examined. After matching, a multivariate logistic regression analysis was performed using confounding variables including hospital setting, comorbidities, urgency of repair, sociodemographic status, and payer. Likelihood of readmission was reported in odds ratio form.

RESULTS

Readmission rates were 11.56% (24,323 out of 210,381) and 17.94% (30,893 out of 172,210) for 30- and 90-day readmissions, respectively. Patients with Medicaid and in the lower income quartile were more likely to present in an emergent fashion for hernia repair. After matching, a multivariate logistic regression analysis showed socioeconomic status (OR 1.250 and 1.229) was a statistically significant independent predictor of readmission at 30 and 90 days, respectively. Inversely, factors associated with the least likely chance of readmission were a laparoscopic approach (OR 0.646 and 0.641), elective admission (OR 0.824 and 0.779), and care in a teaching hospital (OR 0.784 and 0.798).

CONCLUSION

SES is an independent predictor of readmission at 30 and 90 days following open and laparoscopic ventral and inguinal hernia repair. Patients with a lower socioeconomic status were more likely to undergo hernia repair in the emergent setting. Efforts toward mitigating SES disparities by potentially promoting MIS techniques, enhancing access to elective cases, and systematic approaches to perioperative care for this disadvantaged population can potentially enhance overall hernia outcomes.

Smoking, Obesity, and the Elective Operation

Smoking and obesity are commonly encountered problems in the elective, perioperative setting. This article reviews the risks posed by smoking and diabetes and explores way to mitigate such risks. Other means of perioperative optimization are also discussed in an effort to describe perioperative strategies that can improve patient outcomes.

Impact of Excess Body Weight on Postsurgical Complications

BACKGROUND

Obesity is considered a risk factor for postoperative complications as it can limit exposure to the operation field, thereby significantly prolonging surgery time. Obesity-associated comorbidities, such as low-grade systemic inflammation, impaired functional status, and type 2 diabetes, are independent risk factors for impaired anastomotic wound healing and nonsurgical site infections. If obesity itself is an independent risk factor for surgical complications remains controversial, but the reason for this is largely unexplored.

SUMMARY

A MEDLINE literature search was performed using the terms: "obesity," "excess body weight," and "surgical complications." Out of 65,493 articles 432 meta-analyses were screened, of which 25 meta-analyses were on the subject. The vast majority of complex oncologic procedures in the field of visceral surgery have shown higher complication rates in obese patients. Meta-analyses from the last 10 to 15 years with high numbers of patients enrolled consistently have shown longer operation times, higher blood loss, longer hospital stay for colorectal procedures, oncologic upper gastrointestinal (GI) procedures, and pancreatic surgery. Interestingly, these negative effects seem not to affect the overall survival in oncologic patients, especially in esophageal resections. A selection bias in oncologic upper GI patients may have influenced the results with higher BMI in upper GI cancer to be a predictor for better nutritional and performance status.

KEY MESSAGES

Contrary to bariatric surgery, only limited evidence indicated that site and type of surgery, the approach to the abdominal cavity (laparoscopic vs. open), institutional factors, and the type of perioperative care such as ERAS protocols may play a role in determining postsurgical complications in obese patients. The initial question remains therefore partially unanswered. Large nationwide register-based studies are necessary to better understand which aspects of obesity and its related comorbidities define it as a risk factor for surgical complications.

Open versus laparoscopic umbilical and epigastric hernia repair: nationwide data on short- and long-term outcomes

BACKGROUND

It is unclear whether an open or laparoscopic approach results in the best outcomes for repair of umbilical and epigastric hernias. The aim of the study was to evaluate the rates of 90-day readmission and reoperation for complication, together with rate of operation for recurrence after either open or laparoscopic mesh repair for primary umbilical or epigastric hernias with defect widths above 1 cm.

METHODS

A merge of data between the Danish Hernia Database and the National Patient Registry provided data from 2007 to 2018 on perioperative information, 90-day readmission, 90-day reoperation for complication, and long-term operation for hernia recurrence.

RESULTS

A total of 6855 patients were included, of whom 4106 (59.9%) and 2749 (40.1%) patients had an open or laparoscopic repair, respectively. There were significantly more patients readmitted with a superficial surgical site infection 2.5% (102/4106) after open repair compared with laparoscopic repair (0.5% (15/2749), P < 0.001. The 90-day reoperation rate for complications was significantly higher for open repairs 5.0% (205/4106) compared with laparoscopic repairs 2.7% (75/2749), P < 0.001. The incidence of a reoperation for a severe condition was significantly increased after laparoscopic repair 1.5% (41/2749) compared with open repair 0.8% (34/4106), P = 0.010. The 4-year cumulative incidence of operation for hernia recurrence was 3.5% after open and 4.2% after laparoscopic repairs, P = 0.302.

CONCLUSIONS

Recurrence rates were comparable between open and laparoscopic repair of umbilical and epigastric hernias. Open repair was associated with a significantly higher rate of readmission and reoperation due to surgical site infection, whereas the rate of reoperation due to a severe complication was significantly higher after laparoscopic repair.

Management of ventral hernia in patients with BMI > 30 Kg/m2: outcomes based on an institutional algorithm

INTRODUCTION

Management of ventral hernia in obese is a complex problem. The methods of weight loss, alternatives if the patient cannot undergo bariatric surgery, timing, and type of hernia surgery lacks clarity and are dependent on resources and expertise. There is a need for algorithms based on local population and expertise. In this paper, we present the outcomes of our institutional algorithm.

METHODS

It was a retrospective analysis of prospectively collected data. Patients with body mass index (BMI) > 30Kg/m² were included to undergo surgery as per algorithm taking into account (a) presentation (symptomatic vs asymptomatic), (b) hernia characteristics (defect width, site, reducibility), and (c) obesity characteristics (BMI, subcutaneous fat, android vs gynecoid). Data on age, BMI, comorbidities, tobacco consumption, hernia width, location, contents, previous surgery, intraoperative parameters (the type of surgery, mesh, drain, fixation), and outcomes (seroma, hematoma, infection, recurrence) were collected.

RESULTS

A total of 50 patients underwent treatment as per the algorithm. Mean BMI was 36.6 ± 7.3 kg/m². The mean follow-up was 17.6 ± 7.2 months. The mean defect width was 4.8 ± 2.9 cm. There were two (4%) recurrences in patients who underwent an anatomical repair under emergency conditions. None of the patients who underwent an elective repair had a recurrence. Total surgical site occurrence was 12% and surgical site occurrence requiring procedural intervention was 8%. There was one (2%) mortality on postoperative day 7 due to myocardial infarction.

CONCLUSION

The algorithm has shown encouraging results in the short-to-medium term. Long-term evaluation with a higher number of patients is needed to confirm its usefulness.