A population-level analysis of abdominal wall reconstruction by component separation in the morbidly obese patient: Can it be performed safely?

Enhanced-view totally extraperitoneal repair in a morbidly obese patient with epigastric and umbilical hernias in combination with rectus diastasis: A case report

INTRODUCTION

The use of enhanced-view totally extraperitoneal (eTEP) repair for patients with ventral hernias has become more widespread due to its ability to prevent mesh-and-tacker-related complications by placing the mesh in the retrorectus space. However, the efficacy of eTEP repair in obese patients remains unknown. Herein, we report a case of a morbidly obese patient with epigastric and umbilical hernias in combination with a rectus diastasis repaired using the eTEP technique.

PRESENTATION OF CASE

A 42-year-old man with a history of spontaneously reduced incarcerated epigastric hernia two weeks previously was referred to our hospital. His body mass index (BMI) was 42.9 kg/m2. Abdominal computed tomography revealed a small epigastric hernia, an umbilical hernia, and a rectus diastasis. We performed eTEP repair. The postoperative course was uneventful, and the patient was discharged on postoperative day 3. There has been no evidence of hernia recurrence after a follow-up period of 2 years.

DISCUSSION

We consider that the eTEP technique is rarely affected by intra-abdominal fat because endoscopic manipulation is performed in the bilateral retrorectus and preperitoneal spaces. Moreover, the eTEP allows the epigastric artery perforator to be spared. Therefore, eTEP repair is considered the best surgical option for morbidly obese patients with ventral hernias in combination with rectus diastasis.

CONCLUSIONS

This case provides support for the efficacy of eTEP repair in morbidly obese patients with epigastric and umbilical hernias in combination with a rectus diastasis.

The Association Between BMI and Mortality in Surgical Patients

BACKGROUND

While obesity is commonly associated with increased morbidity and mortality, in patients with chronic diseases, it has have been associated with a better prognosis, a phenomenon known as the 'obesity paradox'.

OBJECTIVE

We investigated the relationship between mortality, length of hospital stay (LOHS), and body mass index (BMI) in patients hospitalized to general surgical wards.

METHODS

We extracted data of patients admitted to the hospital between January 2011 and December 2017. BMI was classified according to the following categories: underweight (< 18.5), normal weight (18.5-24.9), overweight (25-29.9), obesity (30-34.9) and severe obesity (≥ 35). Main outcomes were mortality at 30-day mortality and at the end-of-follow-up mortality), as well as LOHS.

RESULTS

A total of 27,639 patients (mean age 55 ± 20 years; 48% males; 19% had diabetes) were included in the study. Median LOHS was longer in patients with diabetes vs. those without diabetes (4.0 vs 3.0 days, respectively), with longest LOHS among underweight patients. A 30-day mortality was 2% of those without (371/22,297) and 3% of those with diabetes (173/5,342). In patients with diabetes, 30-day mortality risk showed a step-wise decrease with increased BMI: 10% for underweight, 6% for normal weight, 3% for overweight, 2% for obese and only 1% for severely obese patients. In patients without diabetes, 30-day mortality was found to be 6% for underweight, 3% for normal weight and 1% across the overweight and obese categories. Mortality rate at the end-of-follow-up was 9% of patients without diabetes and 18% of those with diabetes (adjusted OR = 1.3, 95% CI, 1.2-1.5). In patients with diabetes, mortality risk showed an inverse association with respect to BMI: 52% for underweight, 29% for normal weight, 17% for overweight, 14% for obesity and 7% for severely obese patients, with similar trend in patients without diabetes.

CONCLUSIONS

The results support the 'obesity paradox' in the general surgical patients as those with and without diabetes admitted to surgical wards, BMI had an inverse association with short- and long-term mortality.

Scoping Review of the National Surgical Quality Improvement Program in Plastic Surgery Research

Background

The National Surgical Quality Improvement Program (NSQIP) is a robust, high-quality surgical outcomes database that measures risk-adjusted 30-day outcomes of surgical interventions. The purpose of this scoping review is to describe how the NSQIP is being used in plastic surgery research.

Methods

A comprehensive electronic literature search was completed in PubMed, Embase, MEDLINE, and CINAHL. Two reviewers independently reviewed articles to determine their relevance using predefined inclusion criteria. Articles were included if they utilized NSQIP data to conduct research in a domain of plastic surgery or analyzed surgical procedures completed by plastic surgeons. Extracted information included the domain of plastic surgery, country of origin, journal, and year of publication.

Results

A total of 106 articles met the inclusion criteria. The most common domain of plastic surgery was breast reconstruction representing 35% of the articles. Of the 106 articles, 95% were published within the last 5 years. The Plastic and Reconstructive Surgery journal published most of the (59%) NSQIP-related articles. All of the studies were retrospective. Of note, there were no articles on burns and only one study on trauma as the domain of plastic surgery.

Conclusion

This scoping review describes how NSQIP data are being used to analyze plastic surgery interventions and outcomes in order to guide quality improvement in 106 articles. It demonstrates the utility of NSQIP in the literature, however also identifies some limitations of the program as it applies to plastic surgery.

Complex Ventral Hernia Repair in the Class III Morbidly Obese Patient

INTRODUCTION

Patients undergoing complex ventral hernia repair (VHR) often present with significant medical comorbidities, the most prevalent of which is obesity. Although recent advancements in abdominal wall reconstruction techniques have provided the general hernia patient population with markedly improved recurrence and postoperative complication rates, many patients have been precluded from these procedures owing to excessive body mass index (BMI). In this study, we investigate the viability of complex ventral hernia repair with epigastric artery perforator sparing skin incisions, component separation, and wide-spanning retrorectus mesh reinforcement for patients with BMI of greater than or equal to 40 kg/m(2) (class III obesity).

METHODS

A single surgeon retrospective review of our prospectively maintained database was performed. We restricted this data to class III morbidly obese patients undergoing open VHR with component muscle separation and wide-spanning mesh reinforcement.

RESULTS

Between 2010 and 2017, 131 patients met the inclusion criteria for our study. The mean patient BMI was 46.7 kg/m(2). Operative wounds were categorized according to the National Healthcare Safety Network Wound Class Definitions. There was no statistically significant association between wound class and postoperative complication rates. After our implementation of epigastric artery perforator sparing skin incisions in 2013, significantly less wound breakdown was observed (26.3%) as opposed to before (49.0%) (P < 0.01). Furthermore, significantly less cases required return to the operating room after this technique was implemented (31.3%) as compared with before (60.8%) (P < 0.001). Postoperatively, 28 patients developed an infection requiring antibiotic treatment (21.4%), and the overall hernia recurrence rate was 5.3%. Three patients expired.

CONCLUSIONS

Complex VHR with abdominal wall reconstruction may be a viable option for class III morbidly obese patients. Preliminary data suggest that implementation of epigastric artery perforator sparing skin incisions may reduce the risk of postoperative wound complications, and we have demonstrated hernia recurrence and wound complications comparable with those seen in the general population.

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.

Abdominal wall reconstruction in the obese: an assessment of complications from the National Surgical Quality Improvement Program datasets

BACKGROUND

This study utilizes the American College of Surgeons National Surgical Quality Improvement Program database to better understand the impact of obesity on perioperative surgical morbidity in abdominal wall reconstruction (AWR).

METHODS

We reviewed the 2005 to 2010 American College of Surgeons National Surgical Quality Improvement Program databases, identifying cases of AWR and examining early complications in the context of obesity (body mass index > 30, World Health Organization classes 1 to 3).

RESULTS

Of 1,695 patients undergoing AWR, 1,078 (63.2%) patients were obese (mean body mass index = 37.6 kg/m(2)). Major surgical complications (15.3% vs 10.1%, P = .003), wound complications (12.5% vs 8.1%, P = .006), medical complications (16.2% vs 11.2%, P = .005) and return to the operating room (9.1% vs 5.4%, P = .006) were significantly increased, while renal complications (1.9% vs .8%, P = .09) neared significance. On logistic regression, obesity only directly led to a significantly increased odds of having a renal complication (odds ratio = 4.4, P = .04). Complications were still noted to increase with World Health Organization classification, including a concerning incidence of venous thromboembolism.

CONCLUSIONS

Although the incidence of complications increased with obesity, obesity itself does not appear to increase the odds of perioperative morbidity. Specific care should be given to VTE prophylaxis and to preventing renal complications.