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Algorithm helps assess surgical trade-offs of hernia repair
BOSTON – Choosing an operative approach for ventral hernia can be a matter of weighing the trade-offs between infection risk, postop quality of life, and patient and defect characteristics. A predictive algorithm has been developed to help with this decision, according to a study presented at the annual clinical congress of the American College of Surgeons.
Predictive modeling indicates that open repair might be considered, for example, in low BMI patients with large defects because of potentially fewer anticipated complications and improved quality of life, according to authors of the study. Conversely, laparoscopic repair might be considered in high BMI patients with recurrent hernias to decrease the associated risk of infection, the authors noted in a published abstract of the study.
The retrospective study was based on data on ventral hernia repairs in the International Hernia Mesh Registry that were performed between 2007 and 2017. Investigators used that data to build a predictive algorithm that took into account the impact on outcomes of BMI, hernia size, and operative approach, as well as age, sex, and diabetes status.
They identified 1,906 repairs, of which about 60% were open procedures. The mean patient age was 54.9 years, while mean BMI was 31.2 kg/m2 and the mean defect area was 44.8 cm2. Patients undergoing open procedures were significantly more likely to have infections, at 3.1% versus 0.3% for the laparoscopic approach (P less than .0001), investigators found.
A multivariate regression analysis controlling for confounding variables found that patients undergoing laparoscopic repair had an increased risk of seroma (odds ratio 1.78, confidence interval 1.05-3.03) but a decreased risk of infection (OR 0.05, CI 0.01-0.42). In addition, those undergoing laparoscopic procedures were more likely to have non-ideal quality of life at 1, 6, 12, and 24 months postoperatively, said the study’s lead author, Kathryn A. Schlosser, MD, a resident in the division of gastrointestinal and minimally invasive surgery, department of surgery, Carolinas Medical Center, Charlotte, N.C.
“These are both important factors — infection and non-ideal quality of life — and need to be part of our preoperative discussion with our patients when we start managing their expectations around the time of surgery,” Dr. Schlosser said in a podium presentation.
She and her colleagues calculated probability of infection based on the ratio of BMI to defect area. They found that, for example, the probability of postoperative infection was 21% for a diabetic 69-year-old female with a recurrent hernia who had a BMI of 39 and a defect area of 20 cm2. By contrast, infection probability was 3% in a 66-year-old female with a BMI of 37, a defect area of 1 cm2, and no diabetes, Dr. Schlosser said at the meeting.
Laparoscopic versus open procedures represented a trade-off between infection risk and quality of life in this algorithm. For patients at medium risk for infection based on BMI, defect size, and other variables, switching to a laparoscopic approach dropped the infection probability from 3%-8% down to 0.1%-0.5%, Dr. Schlosser told attendees. On the other hand, switching to a laparoscopic approach increased the risk of non-ideal quality of life, she said.
One sample patient Dr. Schlosser described had an infection risk of 7.2% with the open procedure that dropped to just 0.4% for the laparoscopic procedure; however, that switch would mean that her likelihood of non-ideal quality of life 12 months after surgery increased from 24% with the open repair to 44% with the laparoscopic repair.
Dr. Schlosser had no disclosures related to the study. Co-authors provided disclosures related to Acelity, Allergan, Intuitive, Stryker, and W.L. Gore.
SOURCE: Schlosser KA, et al. abstract SF215 presented at the American College of Surgeons Clinical Congress 2018.
BOSTON – Choosing an operative approach for ventral hernia can be a matter of weighing the trade-offs between infection risk, postop quality of life, and patient and defect characteristics. A predictive algorithm has been developed to help with this decision, according to a study presented at the annual clinical congress of the American College of Surgeons.
Predictive modeling indicates that open repair might be considered, for example, in low BMI patients with large defects because of potentially fewer anticipated complications and improved quality of life, according to authors of the study. Conversely, laparoscopic repair might be considered in high BMI patients with recurrent hernias to decrease the associated risk of infection, the authors noted in a published abstract of the study.
The retrospective study was based on data on ventral hernia repairs in the International Hernia Mesh Registry that were performed between 2007 and 2017. Investigators used that data to build a predictive algorithm that took into account the impact on outcomes of BMI, hernia size, and operative approach, as well as age, sex, and diabetes status.
They identified 1,906 repairs, of which about 60% were open procedures. The mean patient age was 54.9 years, while mean BMI was 31.2 kg/m2 and the mean defect area was 44.8 cm2. Patients undergoing open procedures were significantly more likely to have infections, at 3.1% versus 0.3% for the laparoscopic approach (P less than .0001), investigators found.
A multivariate regression analysis controlling for confounding variables found that patients undergoing laparoscopic repair had an increased risk of seroma (odds ratio 1.78, confidence interval 1.05-3.03) but a decreased risk of infection (OR 0.05, CI 0.01-0.42). In addition, those undergoing laparoscopic procedures were more likely to have non-ideal quality of life at 1, 6, 12, and 24 months postoperatively, said the study’s lead author, Kathryn A. Schlosser, MD, a resident in the division of gastrointestinal and minimally invasive surgery, department of surgery, Carolinas Medical Center, Charlotte, N.C.
“These are both important factors — infection and non-ideal quality of life — and need to be part of our preoperative discussion with our patients when we start managing their expectations around the time of surgery,” Dr. Schlosser said in a podium presentation.
She and her colleagues calculated probability of infection based on the ratio of BMI to defect area. They found that, for example, the probability of postoperative infection was 21% for a diabetic 69-year-old female with a recurrent hernia who had a BMI of 39 and a defect area of 20 cm2. By contrast, infection probability was 3% in a 66-year-old female with a BMI of 37, a defect area of 1 cm2, and no diabetes, Dr. Schlosser said at the meeting.
Laparoscopic versus open procedures represented a trade-off between infection risk and quality of life in this algorithm. For patients at medium risk for infection based on BMI, defect size, and other variables, switching to a laparoscopic approach dropped the infection probability from 3%-8% down to 0.1%-0.5%, Dr. Schlosser told attendees. On the other hand, switching to a laparoscopic approach increased the risk of non-ideal quality of life, she said.
One sample patient Dr. Schlosser described had an infection risk of 7.2% with the open procedure that dropped to just 0.4% for the laparoscopic procedure; however, that switch would mean that her likelihood of non-ideal quality of life 12 months after surgery increased from 24% with the open repair to 44% with the laparoscopic repair.
Dr. Schlosser had no disclosures related to the study. Co-authors provided disclosures related to Acelity, Allergan, Intuitive, Stryker, and W.L. Gore.
SOURCE: Schlosser KA, et al. abstract SF215 presented at the American College of Surgeons Clinical Congress 2018.
BOSTON – Choosing an operative approach for ventral hernia can be a matter of weighing the trade-offs between infection risk, postop quality of life, and patient and defect characteristics. A predictive algorithm has been developed to help with this decision, according to a study presented at the annual clinical congress of the American College of Surgeons.
Predictive modeling indicates that open repair might be considered, for example, in low BMI patients with large defects because of potentially fewer anticipated complications and improved quality of life, according to authors of the study. Conversely, laparoscopic repair might be considered in high BMI patients with recurrent hernias to decrease the associated risk of infection, the authors noted in a published abstract of the study.
The retrospective study was based on data on ventral hernia repairs in the International Hernia Mesh Registry that were performed between 2007 and 2017. Investigators used that data to build a predictive algorithm that took into account the impact on outcomes of BMI, hernia size, and operative approach, as well as age, sex, and diabetes status.
They identified 1,906 repairs, of which about 60% were open procedures. The mean patient age was 54.9 years, while mean BMI was 31.2 kg/m2 and the mean defect area was 44.8 cm2. Patients undergoing open procedures were significantly more likely to have infections, at 3.1% versus 0.3% for the laparoscopic approach (P less than .0001), investigators found.
A multivariate regression analysis controlling for confounding variables found that patients undergoing laparoscopic repair had an increased risk of seroma (odds ratio 1.78, confidence interval 1.05-3.03) but a decreased risk of infection (OR 0.05, CI 0.01-0.42). In addition, those undergoing laparoscopic procedures were more likely to have non-ideal quality of life at 1, 6, 12, and 24 months postoperatively, said the study’s lead author, Kathryn A. Schlosser, MD, a resident in the division of gastrointestinal and minimally invasive surgery, department of surgery, Carolinas Medical Center, Charlotte, N.C.
“These are both important factors — infection and non-ideal quality of life — and need to be part of our preoperative discussion with our patients when we start managing their expectations around the time of surgery,” Dr. Schlosser said in a podium presentation.
She and her colleagues calculated probability of infection based on the ratio of BMI to defect area. They found that, for example, the probability of postoperative infection was 21% for a diabetic 69-year-old female with a recurrent hernia who had a BMI of 39 and a defect area of 20 cm2. By contrast, infection probability was 3% in a 66-year-old female with a BMI of 37, a defect area of 1 cm2, and no diabetes, Dr. Schlosser said at the meeting.
Laparoscopic versus open procedures represented a trade-off between infection risk and quality of life in this algorithm. For patients at medium risk for infection based on BMI, defect size, and other variables, switching to a laparoscopic approach dropped the infection probability from 3%-8% down to 0.1%-0.5%, Dr. Schlosser told attendees. On the other hand, switching to a laparoscopic approach increased the risk of non-ideal quality of life, she said.
One sample patient Dr. Schlosser described had an infection risk of 7.2% with the open procedure that dropped to just 0.4% for the laparoscopic procedure; however, that switch would mean that her likelihood of non-ideal quality of life 12 months after surgery increased from 24% with the open repair to 44% with the laparoscopic repair.
Dr. Schlosser had no disclosures related to the study. Co-authors provided disclosures related to Acelity, Allergan, Intuitive, Stryker, and W.L. Gore.
SOURCE: Schlosser KA, et al. abstract SF215 presented at the American College of Surgeons Clinical Congress 2018.
REPORTING FROM THE ACS CLINICAL CONGRESS
Key clinical point: BMI and defect size are key factors for choosing laparoscopic or open surgery for ventral hernia repair.
Major finding: Patients undergoing open procedures were significantly more likely to have infections, at 3.1% versus 0.3% for the laparoscopic approach.
Study details: Retrospective study including 1,906 ventral hernia repairs in the International Hernia Mesh Registry conducted between 2007 and 2017.
Disclosures: Study authors provided disclosures related to Acelity, Allergan, Intuitive, Stryker, and W.L. Gore.
Source: Schlosser KA, et al. abstract SF215 presented at the American College of Surgeons Clinical Congress 2018.
Guidelines offer recommendations for hernia repair in obese patients
and combining repair techniques with bariatric surgery can improve outcomes and lower the rate of complication for select patients, according to recent guidelines released by the American Society for Metabolic and Bariatric Surgery and the American Hernia Society.
Emanuele Lo Menzo, MD, of the Bariatric and Metabolic Institute at Cleveland Clinic Florida in Weston, and his colleagues issued a statement, published in the journal Surgery for Obesity and Related Diseases, based on available evidence from scientific literature on the impact of obesity on hernia surgery and what effect treating obesity has on improving hernia repair outcomes.
The authors noted abdominal wall hernia in obese patients is “a significant and increasingly common challenge for surgeons” and cited recent data from the American College of Surgeons National Surgical Quality Improvement Program that shows 60% of ventral hernia repairs (VHR) are performed on patients with body mass indexes (BMIs) above 30 kg/m2. Overall, they noted that general surgeons perform approximately 350,000 conventional hernia repairs (CHR) and 800,000 incisional hernia (IH) repairs each year.
The literature on the impact of obesity on hernia repair outcomes and the feasibility of a combined operation to address each problem has significant gaps, leaving surgeons to decide on a correct course based on individual patient needs. The guideline offers some recommendations, and notes areas that remain understudied. First, “in patients with severe obesity and [ventral hernia] and both being amenable to laparoscopic repair, combined hernia repair and [metabolic/bariatric surgery] may be safe and associated with good short-term outcomes and low risk of infection.” But the use of synthetic mesh in these patients is not well studied and so the guideline passes on a recommendation of mesh. For those obese patients with symptomatic abdominal wall hernias (AWHs) not amenable to laparoscopy, the guideline notes that metabolic/bariatric surgery first may be the best option.
Risk of hernia in obese patients
Studies suggest there is an increased risk of primary and IH among patients with BMIs greater than 25 kg/m2, with one study finding an 18.2% complication rate after single-incision laparoscopic surgery for patients with BMIs of 40 kg/m2 or higher, compared with a 3.5% complication rate among patients at a normal body weight. Severe BMI also is a risk factor for developing surgical site infection (SSI), which can cause recurrence, the authors said. Evidence from multiple studies further supports BMI as a risk factor for hernia recurrence, and intra-abdominal pressure from obesity increases the risk of developing an AWH.
“While most authors attribute the increased risk for AWH formation in the setting of obesity to BMI alone, others have suggested that abdominal circumference and elevated visceral fat may play a more significant role,” the authors wrote.
However, Dr. Lo Menzo and his colleagues admitted the actual rate of IH is difficult to calculate because some patients may not seek treatment for minimally symptomatic hernias. Patients with higher BMIs may not be aware of or seek treatment for common symptoms of IH such as groin bulge, or when they do seek treatment, it can present with symptoms such as incarceration or strangulation, they said. Patients with higher BMIs also are more likely to be offered “watchful waiting” because of higher complication rates in this patient population, which may contribute to incarceration or strangulation symptoms in these patients, they added.
Complications and recurrence
There is no one recommended repair technique or ideal BMI for hernia repair in obese patients, the authors wrote. One study found laparoscopic VHRs had a complication rate of 1.2% and reoccurrence rate of 5.5% at mean 25-month follow-up in patients with BMIs of 38 kg/m2 or greater, while a different study with a similar design found a 3.8% reoccurrence rate at 18-month follow-up. Degree of obesity can affect complication rate: One study showed that 73% of all complications after laparoscopic VHR occurred in the group of patients with BMIs of 30 kg/m2 or greater; a different study of laparoscopic VHR had an 8.3% hernia reoccurrence rate in patients with BMIs of 40 kg/m2 or greater, compared with patients at a normal weight (2.9%), with time to hernia reoccurrence being shorter in the higher-BMI group. A study of obese patients undergoing retromuscular open repair had a wound complication rate of 16% and a reoccurrence rate of 6%, with another study of patients undergoing umbilical hernia repair showing similar rates of complication and reoccurrence.
Panniculectomy
Among patients who underwent IH repair with panniculectomy, the authors found a 40% complication rate and a 10% reoccurrence rate in patients with BMIs of 40 kg/m2 or greater who received a partial underlay mesh placement hernia repair, while a different study found an increased risk of surgical site occurrences but not SSI in patients with BMIs of 34.3 kg/m2 or greater who underwent open ventral incisional hernia repair with panniculectomy. A third study found BMIs were not linked to a 55% complication rate in patients who underwent open ventral IH repair with and without mesh.
Simultaneous surgery
The authors noted that studies have shown that performing laparoscopic hernia repair and metabolic and bariatric surgery simultaneously is safe and has good short-term results. Specifically, patients who underwent the surgery with synthetic mesh had a low rate of infection or reoccurrence. Patients who underwent simultaneous weight-loss surgery and VHR had an elevated risk of SSI but no increased rate of 30-day mortality or morbidity, according to results from a large-scale registry. However, the authors noted patients with severe obesity may not be good candidates for simultaneous metabolic and bariatric surgery [MBS] and VHR, such as in patients with “large abdominal wall defects, loss of abdominal domain, extensive intestinal adhesive disease, poor quality skin (i.e., attenuated skin, prior skin graft, or ulcerated skin), incarcerated hernias containing bowel, hernias with previous synthetic mesh, hernias with chronic infection, or patients who have already undergone MBS with altered anatomy that is still intact.”
Preop weight loss
There is mixed data on the effect of weight loss prior to VHR through interventions such as very-low-calorie diets, pharmacotherapy, intragastric balloon therapy, and MBS as a first-stage procedure prior to VHR. Many patients treating their obesity with very-low-calorie diets lose approximately 10%-20% of their initial body weight and keep the weight off for at least 18 months, while one study showed patients who underwent intragastric balloon therapy lost approximately 10% of their body weight over 6 months; however, other studies have questioned the efficacy of this therapy, compared with a structured weight loss program or bariatric surgery. The authors also noted the difficulty of coordinating VHR after weight-loss surgery, lack of support from insurers, and they cited reports that cautioned bariatric surgeons to not leave hernias untreated during MBS. There is no current evidence pharmacotherapy through Food and Drug Administration–approved weight-loss drugs prior to hernia repair yield the weight-loss results needed for these patients to improve hernia outcomes, they added.
“Ultimately, there are various appropriate treatment modalities for each patient, and surgeons must use their judgment in selecting from among the different feasible options,” Dr. Lo Menzo and his colleagues wrote in the guidelines.
The authors report no relevant conflicts of interest.
SOURCE: Lo Menzo E et al. Surg Obes Relat Dis. 2018 Jul 19. doi: 10.1016/j.soard.2018.07.005.
and combining repair techniques with bariatric surgery can improve outcomes and lower the rate of complication for select patients, according to recent guidelines released by the American Society for Metabolic and Bariatric Surgery and the American Hernia Society.
Emanuele Lo Menzo, MD, of the Bariatric and Metabolic Institute at Cleveland Clinic Florida in Weston, and his colleagues issued a statement, published in the journal Surgery for Obesity and Related Diseases, based on available evidence from scientific literature on the impact of obesity on hernia surgery and what effect treating obesity has on improving hernia repair outcomes.
The authors noted abdominal wall hernia in obese patients is “a significant and increasingly common challenge for surgeons” and cited recent data from the American College of Surgeons National Surgical Quality Improvement Program that shows 60% of ventral hernia repairs (VHR) are performed on patients with body mass indexes (BMIs) above 30 kg/m2. Overall, they noted that general surgeons perform approximately 350,000 conventional hernia repairs (CHR) and 800,000 incisional hernia (IH) repairs each year.
The literature on the impact of obesity on hernia repair outcomes and the feasibility of a combined operation to address each problem has significant gaps, leaving surgeons to decide on a correct course based on individual patient needs. The guideline offers some recommendations, and notes areas that remain understudied. First, “in patients with severe obesity and [ventral hernia] and both being amenable to laparoscopic repair, combined hernia repair and [metabolic/bariatric surgery] may be safe and associated with good short-term outcomes and low risk of infection.” But the use of synthetic mesh in these patients is not well studied and so the guideline passes on a recommendation of mesh. For those obese patients with symptomatic abdominal wall hernias (AWHs) not amenable to laparoscopy, the guideline notes that metabolic/bariatric surgery first may be the best option.
Risk of hernia in obese patients
Studies suggest there is an increased risk of primary and IH among patients with BMIs greater than 25 kg/m2, with one study finding an 18.2% complication rate after single-incision laparoscopic surgery for patients with BMIs of 40 kg/m2 or higher, compared with a 3.5% complication rate among patients at a normal body weight. Severe BMI also is a risk factor for developing surgical site infection (SSI), which can cause recurrence, the authors said. Evidence from multiple studies further supports BMI as a risk factor for hernia recurrence, and intra-abdominal pressure from obesity increases the risk of developing an AWH.
“While most authors attribute the increased risk for AWH formation in the setting of obesity to BMI alone, others have suggested that abdominal circumference and elevated visceral fat may play a more significant role,” the authors wrote.
However, Dr. Lo Menzo and his colleagues admitted the actual rate of IH is difficult to calculate because some patients may not seek treatment for minimally symptomatic hernias. Patients with higher BMIs may not be aware of or seek treatment for common symptoms of IH such as groin bulge, or when they do seek treatment, it can present with symptoms such as incarceration or strangulation, they said. Patients with higher BMIs also are more likely to be offered “watchful waiting” because of higher complication rates in this patient population, which may contribute to incarceration or strangulation symptoms in these patients, they added.
Complications and recurrence
There is no one recommended repair technique or ideal BMI for hernia repair in obese patients, the authors wrote. One study found laparoscopic VHRs had a complication rate of 1.2% and reoccurrence rate of 5.5% at mean 25-month follow-up in patients with BMIs of 38 kg/m2 or greater, while a different study with a similar design found a 3.8% reoccurrence rate at 18-month follow-up. Degree of obesity can affect complication rate: One study showed that 73% of all complications after laparoscopic VHR occurred in the group of patients with BMIs of 30 kg/m2 or greater; a different study of laparoscopic VHR had an 8.3% hernia reoccurrence rate in patients with BMIs of 40 kg/m2 or greater, compared with patients at a normal weight (2.9%), with time to hernia reoccurrence being shorter in the higher-BMI group. A study of obese patients undergoing retromuscular open repair had a wound complication rate of 16% and a reoccurrence rate of 6%, with another study of patients undergoing umbilical hernia repair showing similar rates of complication and reoccurrence.
Panniculectomy
Among patients who underwent IH repair with panniculectomy, the authors found a 40% complication rate and a 10% reoccurrence rate in patients with BMIs of 40 kg/m2 or greater who received a partial underlay mesh placement hernia repair, while a different study found an increased risk of surgical site occurrences but not SSI in patients with BMIs of 34.3 kg/m2 or greater who underwent open ventral incisional hernia repair with panniculectomy. A third study found BMIs were not linked to a 55% complication rate in patients who underwent open ventral IH repair with and without mesh.
Simultaneous surgery
The authors noted that studies have shown that performing laparoscopic hernia repair and metabolic and bariatric surgery simultaneously is safe and has good short-term results. Specifically, patients who underwent the surgery with synthetic mesh had a low rate of infection or reoccurrence. Patients who underwent simultaneous weight-loss surgery and VHR had an elevated risk of SSI but no increased rate of 30-day mortality or morbidity, according to results from a large-scale registry. However, the authors noted patients with severe obesity may not be good candidates for simultaneous metabolic and bariatric surgery [MBS] and VHR, such as in patients with “large abdominal wall defects, loss of abdominal domain, extensive intestinal adhesive disease, poor quality skin (i.e., attenuated skin, prior skin graft, or ulcerated skin), incarcerated hernias containing bowel, hernias with previous synthetic mesh, hernias with chronic infection, or patients who have already undergone MBS with altered anatomy that is still intact.”
Preop weight loss
There is mixed data on the effect of weight loss prior to VHR through interventions such as very-low-calorie diets, pharmacotherapy, intragastric balloon therapy, and MBS as a first-stage procedure prior to VHR. Many patients treating their obesity with very-low-calorie diets lose approximately 10%-20% of their initial body weight and keep the weight off for at least 18 months, while one study showed patients who underwent intragastric balloon therapy lost approximately 10% of their body weight over 6 months; however, other studies have questioned the efficacy of this therapy, compared with a structured weight loss program or bariatric surgery. The authors also noted the difficulty of coordinating VHR after weight-loss surgery, lack of support from insurers, and they cited reports that cautioned bariatric surgeons to not leave hernias untreated during MBS. There is no current evidence pharmacotherapy through Food and Drug Administration–approved weight-loss drugs prior to hernia repair yield the weight-loss results needed for these patients to improve hernia outcomes, they added.
“Ultimately, there are various appropriate treatment modalities for each patient, and surgeons must use their judgment in selecting from among the different feasible options,” Dr. Lo Menzo and his colleagues wrote in the guidelines.
The authors report no relevant conflicts of interest.
SOURCE: Lo Menzo E et al. Surg Obes Relat Dis. 2018 Jul 19. doi: 10.1016/j.soard.2018.07.005.
and combining repair techniques with bariatric surgery can improve outcomes and lower the rate of complication for select patients, according to recent guidelines released by the American Society for Metabolic and Bariatric Surgery and the American Hernia Society.
Emanuele Lo Menzo, MD, of the Bariatric and Metabolic Institute at Cleveland Clinic Florida in Weston, and his colleagues issued a statement, published in the journal Surgery for Obesity and Related Diseases, based on available evidence from scientific literature on the impact of obesity on hernia surgery and what effect treating obesity has on improving hernia repair outcomes.
The authors noted abdominal wall hernia in obese patients is “a significant and increasingly common challenge for surgeons” and cited recent data from the American College of Surgeons National Surgical Quality Improvement Program that shows 60% of ventral hernia repairs (VHR) are performed on patients with body mass indexes (BMIs) above 30 kg/m2. Overall, they noted that general surgeons perform approximately 350,000 conventional hernia repairs (CHR) and 800,000 incisional hernia (IH) repairs each year.
The literature on the impact of obesity on hernia repair outcomes and the feasibility of a combined operation to address each problem has significant gaps, leaving surgeons to decide on a correct course based on individual patient needs. The guideline offers some recommendations, and notes areas that remain understudied. First, “in patients with severe obesity and [ventral hernia] and both being amenable to laparoscopic repair, combined hernia repair and [metabolic/bariatric surgery] may be safe and associated with good short-term outcomes and low risk of infection.” But the use of synthetic mesh in these patients is not well studied and so the guideline passes on a recommendation of mesh. For those obese patients with symptomatic abdominal wall hernias (AWHs) not amenable to laparoscopy, the guideline notes that metabolic/bariatric surgery first may be the best option.
Risk of hernia in obese patients
Studies suggest there is an increased risk of primary and IH among patients with BMIs greater than 25 kg/m2, with one study finding an 18.2% complication rate after single-incision laparoscopic surgery for patients with BMIs of 40 kg/m2 or higher, compared with a 3.5% complication rate among patients at a normal body weight. Severe BMI also is a risk factor for developing surgical site infection (SSI), which can cause recurrence, the authors said. Evidence from multiple studies further supports BMI as a risk factor for hernia recurrence, and intra-abdominal pressure from obesity increases the risk of developing an AWH.
“While most authors attribute the increased risk for AWH formation in the setting of obesity to BMI alone, others have suggested that abdominal circumference and elevated visceral fat may play a more significant role,” the authors wrote.
However, Dr. Lo Menzo and his colleagues admitted the actual rate of IH is difficult to calculate because some patients may not seek treatment for minimally symptomatic hernias. Patients with higher BMIs may not be aware of or seek treatment for common symptoms of IH such as groin bulge, or when they do seek treatment, it can present with symptoms such as incarceration or strangulation, they said. Patients with higher BMIs also are more likely to be offered “watchful waiting” because of higher complication rates in this patient population, which may contribute to incarceration or strangulation symptoms in these patients, they added.
Complications and recurrence
There is no one recommended repair technique or ideal BMI for hernia repair in obese patients, the authors wrote. One study found laparoscopic VHRs had a complication rate of 1.2% and reoccurrence rate of 5.5% at mean 25-month follow-up in patients with BMIs of 38 kg/m2 or greater, while a different study with a similar design found a 3.8% reoccurrence rate at 18-month follow-up. Degree of obesity can affect complication rate: One study showed that 73% of all complications after laparoscopic VHR occurred in the group of patients with BMIs of 30 kg/m2 or greater; a different study of laparoscopic VHR had an 8.3% hernia reoccurrence rate in patients with BMIs of 40 kg/m2 or greater, compared with patients at a normal weight (2.9%), with time to hernia reoccurrence being shorter in the higher-BMI group. A study of obese patients undergoing retromuscular open repair had a wound complication rate of 16% and a reoccurrence rate of 6%, with another study of patients undergoing umbilical hernia repair showing similar rates of complication and reoccurrence.
Panniculectomy
Among patients who underwent IH repair with panniculectomy, the authors found a 40% complication rate and a 10% reoccurrence rate in patients with BMIs of 40 kg/m2 or greater who received a partial underlay mesh placement hernia repair, while a different study found an increased risk of surgical site occurrences but not SSI in patients with BMIs of 34.3 kg/m2 or greater who underwent open ventral incisional hernia repair with panniculectomy. A third study found BMIs were not linked to a 55% complication rate in patients who underwent open ventral IH repair with and without mesh.
Simultaneous surgery
The authors noted that studies have shown that performing laparoscopic hernia repair and metabolic and bariatric surgery simultaneously is safe and has good short-term results. Specifically, patients who underwent the surgery with synthetic mesh had a low rate of infection or reoccurrence. Patients who underwent simultaneous weight-loss surgery and VHR had an elevated risk of SSI but no increased rate of 30-day mortality or morbidity, according to results from a large-scale registry. However, the authors noted patients with severe obesity may not be good candidates for simultaneous metabolic and bariatric surgery [MBS] and VHR, such as in patients with “large abdominal wall defects, loss of abdominal domain, extensive intestinal adhesive disease, poor quality skin (i.e., attenuated skin, prior skin graft, or ulcerated skin), incarcerated hernias containing bowel, hernias with previous synthetic mesh, hernias with chronic infection, or patients who have already undergone MBS with altered anatomy that is still intact.”
Preop weight loss
There is mixed data on the effect of weight loss prior to VHR through interventions such as very-low-calorie diets, pharmacotherapy, intragastric balloon therapy, and MBS as a first-stage procedure prior to VHR. Many patients treating their obesity with very-low-calorie diets lose approximately 10%-20% of their initial body weight and keep the weight off for at least 18 months, while one study showed patients who underwent intragastric balloon therapy lost approximately 10% of their body weight over 6 months; however, other studies have questioned the efficacy of this therapy, compared with a structured weight loss program or bariatric surgery. The authors also noted the difficulty of coordinating VHR after weight-loss surgery, lack of support from insurers, and they cited reports that cautioned bariatric surgeons to not leave hernias untreated during MBS. There is no current evidence pharmacotherapy through Food and Drug Administration–approved weight-loss drugs prior to hernia repair yield the weight-loss results needed for these patients to improve hernia outcomes, they added.
“Ultimately, there are various appropriate treatment modalities for each patient, and surgeons must use their judgment in selecting from among the different feasible options,” Dr. Lo Menzo and his colleagues wrote in the guidelines.
The authors report no relevant conflicts of interest.
SOURCE: Lo Menzo E et al. Surg Obes Relat Dis. 2018 Jul 19. doi: 10.1016/j.soard.2018.07.005.
FROM SURGERY FOR OBESITY AND RELATED DISEASES
Hernia registries need uniform data collection
Hernia registries have proliferated in recent years but would contribute more to the evaluation of treatments and outcomes of hernia repair if the data quality was uniform, according to a study of one U.S.-based and six European registries.
The CORE (Comparison of Hernia Registries in Europe) project was initiated in 2015 by a group of to survey the defining characteristics of each registry and compare their features. Each registry has a unique profile of data collected, basis of participation, and financial support.
“Despite the differences in the way data are collected for each of the listed hernia registries, the data are indispensable in clinical research. As a consequence of the numerous innovations in hernia surgery (surgical procedures, meshes, fixation devices), hardly any other area of surgical study has such a high need for clinical trials and data collection, comparison and analysis. Registries play a vital role in this innovation process,” the CORE investigators wrote.
The project collected information about the Danish Hernia Database (DHDB, the Netherlands), Swedish Hernia Registry (SHR), Herniamed (Germany, Switzerland, Austria), EuraHS (Belgium), Club Hernie (CH, France), EVEREG (Spain) and the Americas Hernia Society Quality Collaborative (AHSQC, the United States). Representatives of each registry provided details of the size of database, the types of cases contained in the registry, the terms of participation, operative data collected, and registry sponsors.
The DHDB and the SHR have the longest histories (created 1992 and 1998, respectively) and contain the largest number of cases (more than 200,000). The SHR has data from more than 95% of all national inguinal cases, and about 15% of ventral and parastomal cases). The DHDB covers 90% of all inguinal cases and 80% of all ventral and other types of hernia. These two registries are publicly funded, nonprofit institutions.
The other registries are of more recent origin (2007-2015), cover a lower percentage of the hernia cases in each country, but nonetheless have accumulated a large number of cases (for example, Herniamed has data on more than 290,000 inguinal cases and almost 200,000 ventral and other types of hernias). These registries are industry funded and participation by surgical centers is voluntary.
These seven registry differ primarily in the kinds of data they collect. The DHDB collects far less data than do the others on complications and, in particular, no data on mesh complications or pain. And although each of the other registries covers a long list of complications, the lists are far from identical, according to the CORE project investigators.
Follow-up protocol also varies considerably among the registries. The CORE investigators note that the “limitation of all data analysis from registries is always selection and input bias,” and the potential of combining the data from all of the registries into one database could only be accomplished if the uniform quality and consistency in data collection were assured.
The CORE project was initiated with registry representatives and each was were responsible for the information about their registry. Conflicts are reported for each contributor on the Hernia website.
SOURCE: Kyle-Leinhase I et al. Hernia 2018;22(4):561-75.
Hernia registries have proliferated in recent years but would contribute more to the evaluation of treatments and outcomes of hernia repair if the data quality was uniform, according to a study of one U.S.-based and six European registries.
The CORE (Comparison of Hernia Registries in Europe) project was initiated in 2015 by a group of to survey the defining characteristics of each registry and compare their features. Each registry has a unique profile of data collected, basis of participation, and financial support.
“Despite the differences in the way data are collected for each of the listed hernia registries, the data are indispensable in clinical research. As a consequence of the numerous innovations in hernia surgery (surgical procedures, meshes, fixation devices), hardly any other area of surgical study has such a high need for clinical trials and data collection, comparison and analysis. Registries play a vital role in this innovation process,” the CORE investigators wrote.
The project collected information about the Danish Hernia Database (DHDB, the Netherlands), Swedish Hernia Registry (SHR), Herniamed (Germany, Switzerland, Austria), EuraHS (Belgium), Club Hernie (CH, France), EVEREG (Spain) and the Americas Hernia Society Quality Collaborative (AHSQC, the United States). Representatives of each registry provided details of the size of database, the types of cases contained in the registry, the terms of participation, operative data collected, and registry sponsors.
The DHDB and the SHR have the longest histories (created 1992 and 1998, respectively) and contain the largest number of cases (more than 200,000). The SHR has data from more than 95% of all national inguinal cases, and about 15% of ventral and parastomal cases). The DHDB covers 90% of all inguinal cases and 80% of all ventral and other types of hernia. These two registries are publicly funded, nonprofit institutions.
The other registries are of more recent origin (2007-2015), cover a lower percentage of the hernia cases in each country, but nonetheless have accumulated a large number of cases (for example, Herniamed has data on more than 290,000 inguinal cases and almost 200,000 ventral and other types of hernias). These registries are industry funded and participation by surgical centers is voluntary.
These seven registry differ primarily in the kinds of data they collect. The DHDB collects far less data than do the others on complications and, in particular, no data on mesh complications or pain. And although each of the other registries covers a long list of complications, the lists are far from identical, according to the CORE project investigators.
Follow-up protocol also varies considerably among the registries. The CORE investigators note that the “limitation of all data analysis from registries is always selection and input bias,” and the potential of combining the data from all of the registries into one database could only be accomplished if the uniform quality and consistency in data collection were assured.
The CORE project was initiated with registry representatives and each was were responsible for the information about their registry. Conflicts are reported for each contributor on the Hernia website.
SOURCE: Kyle-Leinhase I et al. Hernia 2018;22(4):561-75.
Hernia registries have proliferated in recent years but would contribute more to the evaluation of treatments and outcomes of hernia repair if the data quality was uniform, according to a study of one U.S.-based and six European registries.
The CORE (Comparison of Hernia Registries in Europe) project was initiated in 2015 by a group of to survey the defining characteristics of each registry and compare their features. Each registry has a unique profile of data collected, basis of participation, and financial support.
“Despite the differences in the way data are collected for each of the listed hernia registries, the data are indispensable in clinical research. As a consequence of the numerous innovations in hernia surgery (surgical procedures, meshes, fixation devices), hardly any other area of surgical study has such a high need for clinical trials and data collection, comparison and analysis. Registries play a vital role in this innovation process,” the CORE investigators wrote.
The project collected information about the Danish Hernia Database (DHDB, the Netherlands), Swedish Hernia Registry (SHR), Herniamed (Germany, Switzerland, Austria), EuraHS (Belgium), Club Hernie (CH, France), EVEREG (Spain) and the Americas Hernia Society Quality Collaborative (AHSQC, the United States). Representatives of each registry provided details of the size of database, the types of cases contained in the registry, the terms of participation, operative data collected, and registry sponsors.
The DHDB and the SHR have the longest histories (created 1992 and 1998, respectively) and contain the largest number of cases (more than 200,000). The SHR has data from more than 95% of all national inguinal cases, and about 15% of ventral and parastomal cases). The DHDB covers 90% of all inguinal cases and 80% of all ventral and other types of hernia. These two registries are publicly funded, nonprofit institutions.
The other registries are of more recent origin (2007-2015), cover a lower percentage of the hernia cases in each country, but nonetheless have accumulated a large number of cases (for example, Herniamed has data on more than 290,000 inguinal cases and almost 200,000 ventral and other types of hernias). These registries are industry funded and participation by surgical centers is voluntary.
These seven registry differ primarily in the kinds of data they collect. The DHDB collects far less data than do the others on complications and, in particular, no data on mesh complications or pain. And although each of the other registries covers a long list of complications, the lists are far from identical, according to the CORE project investigators.
Follow-up protocol also varies considerably among the registries. The CORE investigators note that the “limitation of all data analysis from registries is always selection and input bias,” and the potential of combining the data from all of the registries into one database could only be accomplished if the uniform quality and consistency in data collection were assured.
The CORE project was initiated with registry representatives and each was were responsible for the information about their registry. Conflicts are reported for each contributor on the Hernia website.
SOURCE: Kyle-Leinhase I et al. Hernia 2018;22(4):561-75.
FROM HERNIA
Anemia in hiatal hernia patients doubled postop complications risk
but it turns out to be associated with elevated risk of postoperative complications, according to findings published in Surgical Endoscopy.
In a retrospective study of 263 patients who underwent HHR, 27% were anemic. Anemia in these patients was associated with 2.6-fold greater odds of postoperative complications, reported Guillaume S. Chevrollier, MD, of the department of surgery at Jefferson Medical College, Philadelphia, and his coauthors.
Investigators identified 263 patients for study who underwent HHR between January 2011 and April 2017. Preoperative data included a full physical examination, chest x-ray, esophagogastroduodenoscopy, esophageal manometry, 24-hour pH study, and routine blood work.
Patient data were also assessed for identification of Cameron lesions, defined as either linear erosions or ulcers present at the diaphragmatic hiatus. Baseline data collected for analysis included age, sex, body mass index, Charlson Comorbidity Index, hernia type, hernia size, surgical approach, and urgency of repair.
Preoperative anemia was defined as serum hemoglobin levels less than 13 mg/dL in men and less than 12 mg/dL in women, in accordance with World Health Organization criteria. Outcomes of anemic and nonanemic patients were compared and included measures such as estimated blood loss, operative times, need for blood transfusion, intensive care unit admission, and postoperative complications. Postoperative complications were assessed for severity using the Clavien-Dindo Scale, Dr. Chevrollier and his colleagues wrote.
In total, 70 patients (27%) were anemic before their hernia repair surgery. A majority of patients (54%) were aged 65 years or older, of whom 29% were anemic. Large hernias were most common (60%), followed by moderate size (18%), giant (14%), and small (8%).
Sixty-four patients (24%) developed postoperative complications. Among anemic patients, 41% developed one or more complications, compared with just 18% of nonanemic patients (P less than .01). Anemia was associated with 2.6-fold greater odds of postoperative complications in adjusted multivariable analysis (odds ratio, 2.57; 95% confidence interval, 1.36-4.86; P less than .01), the authors reported.
“Heightened awareness for the presence and the implications of preoperative anemia in patients undergoing HHR is necessary,” the authors wrote. “Consideration for treatment of anemia prior to elective repair is likely warranted.”
No disclosures or conflicts of interest were reported.
SOURCE: Chevrollier G et al. Surg Endosc. 2018 Jul 11. doi: 10.1007/s00464-018-6328-4.
but it turns out to be associated with elevated risk of postoperative complications, according to findings published in Surgical Endoscopy.
In a retrospective study of 263 patients who underwent HHR, 27% were anemic. Anemia in these patients was associated with 2.6-fold greater odds of postoperative complications, reported Guillaume S. Chevrollier, MD, of the department of surgery at Jefferson Medical College, Philadelphia, and his coauthors.
Investigators identified 263 patients for study who underwent HHR between January 2011 and April 2017. Preoperative data included a full physical examination, chest x-ray, esophagogastroduodenoscopy, esophageal manometry, 24-hour pH study, and routine blood work.
Patient data were also assessed for identification of Cameron lesions, defined as either linear erosions or ulcers present at the diaphragmatic hiatus. Baseline data collected for analysis included age, sex, body mass index, Charlson Comorbidity Index, hernia type, hernia size, surgical approach, and urgency of repair.
Preoperative anemia was defined as serum hemoglobin levels less than 13 mg/dL in men and less than 12 mg/dL in women, in accordance with World Health Organization criteria. Outcomes of anemic and nonanemic patients were compared and included measures such as estimated blood loss, operative times, need for blood transfusion, intensive care unit admission, and postoperative complications. Postoperative complications were assessed for severity using the Clavien-Dindo Scale, Dr. Chevrollier and his colleagues wrote.
In total, 70 patients (27%) were anemic before their hernia repair surgery. A majority of patients (54%) were aged 65 years or older, of whom 29% were anemic. Large hernias were most common (60%), followed by moderate size (18%), giant (14%), and small (8%).
Sixty-four patients (24%) developed postoperative complications. Among anemic patients, 41% developed one or more complications, compared with just 18% of nonanemic patients (P less than .01). Anemia was associated with 2.6-fold greater odds of postoperative complications in adjusted multivariable analysis (odds ratio, 2.57; 95% confidence interval, 1.36-4.86; P less than .01), the authors reported.
“Heightened awareness for the presence and the implications of preoperative anemia in patients undergoing HHR is necessary,” the authors wrote. “Consideration for treatment of anemia prior to elective repair is likely warranted.”
No disclosures or conflicts of interest were reported.
SOURCE: Chevrollier G et al. Surg Endosc. 2018 Jul 11. doi: 10.1007/s00464-018-6328-4.
but it turns out to be associated with elevated risk of postoperative complications, according to findings published in Surgical Endoscopy.
In a retrospective study of 263 patients who underwent HHR, 27% were anemic. Anemia in these patients was associated with 2.6-fold greater odds of postoperative complications, reported Guillaume S. Chevrollier, MD, of the department of surgery at Jefferson Medical College, Philadelphia, and his coauthors.
Investigators identified 263 patients for study who underwent HHR between January 2011 and April 2017. Preoperative data included a full physical examination, chest x-ray, esophagogastroduodenoscopy, esophageal manometry, 24-hour pH study, and routine blood work.
Patient data were also assessed for identification of Cameron lesions, defined as either linear erosions or ulcers present at the diaphragmatic hiatus. Baseline data collected for analysis included age, sex, body mass index, Charlson Comorbidity Index, hernia type, hernia size, surgical approach, and urgency of repair.
Preoperative anemia was defined as serum hemoglobin levels less than 13 mg/dL in men and less than 12 mg/dL in women, in accordance with World Health Organization criteria. Outcomes of anemic and nonanemic patients were compared and included measures such as estimated blood loss, operative times, need for blood transfusion, intensive care unit admission, and postoperative complications. Postoperative complications were assessed for severity using the Clavien-Dindo Scale, Dr. Chevrollier and his colleagues wrote.
In total, 70 patients (27%) were anemic before their hernia repair surgery. A majority of patients (54%) were aged 65 years or older, of whom 29% were anemic. Large hernias were most common (60%), followed by moderate size (18%), giant (14%), and small (8%).
Sixty-four patients (24%) developed postoperative complications. Among anemic patients, 41% developed one or more complications, compared with just 18% of nonanemic patients (P less than .01). Anemia was associated with 2.6-fold greater odds of postoperative complications in adjusted multivariable analysis (odds ratio, 2.57; 95% confidence interval, 1.36-4.86; P less than .01), the authors reported.
“Heightened awareness for the presence and the implications of preoperative anemia in patients undergoing HHR is necessary,” the authors wrote. “Consideration for treatment of anemia prior to elective repair is likely warranted.”
No disclosures or conflicts of interest were reported.
SOURCE: Chevrollier G et al. Surg Endosc. 2018 Jul 11. doi: 10.1007/s00464-018-6328-4.
FROM SURGICAL ENDOSCOPY
Key clinical point: Anemia is common in patients undergoing hiatal hernia repair and is associated with greater risk of postoperative complications.
Major finding: Of patients in the study, 27% were anemic; anemia was associated with 2.6-fold greater odds of postoperative complications.
Study details: A retrospective analysis of 263 patients who underwent hiatal hernia repair between January 2011 and April 2017.
Disclosures: No disclosures or conflicts of interest were reported.
Source: Chevrollier G et al. Surg Endosc. 2018 Jul 11. doi: 10.1007/s00464-018-6328-4.
MIS underused for hernia repair
Surgeons in the United States have been slow to adopt according to data from more than 6,000 patients.
“The benefit of MIS over open repair is recognized for patients with bilateral or recurrent inguinal hernias, and current guidelines recommend MIS repair for these cases,” wrote Joceline V. Vu, MD, of the University of Michigan, Ann Arbor, and her colleagues.
In a study published in Surgical Endoscopy, the researchers assessed surgeons’ practice patterns for hernia repair, with a primary outcome of minimally invasive surgery (MIS) rates per individual surgeon. They reviewed data from a statewide clinical registry of 6,723 adults older than 18 years who underwent elective hernia surgery in Michigan between 2012 and 2016.
Overall, the surgeons’ use of MIS varied, but more than half (58%) of the surgeons performed no MIS for hernia repair. For those who did use MIS, it was used in 41% of bilateral hernias and 38% of recurrent hernias.
Surgeons were significantly less likely to use MIS for hernia on patients aged 65 years and older (odds ratio, 0.68, P = .003), or those who were black (OR 0.75, P = .045). MIS repair also was significantly less likely for patients with chronic obstructive pulmonary disease (OR 0.57, P less than .001) or patients in American Society of Anesthesiologists Classification under 3 (OR 0.79, P less than .001).
Of the 227 surgeons who performed MIS, 71 (31%) had MIS utilization rates of 75% or higher and were defined as high-utilization surgeons. Overall, 75% of the MIS repairs were performed by 14% of the surgeons.
The surgeons with the highest use of MIS were unevenly distributed across the state; the Ann Arbor region had the highest percentage of high MIS-use surgeons (22%), compared with the Lansing area, in which 2% of surgeons were high users of MIS.
The risk-adjusted rate of MIS for inguinal hernia repair varied significantly across six regions of the state, from 10% to 48%, and the regions with the highest rates were those with the highest percentage of high-MIS use surgeons.
“These findings suggest that a large portion of decision making to offer MIS repair may depend on surgeon differences, rather than clinical appropriateness,” the researchers said. “The likelihood that a patient receives MIS repair may thus be predetermined by the surgeon to whom they are referred,” they added.
“Whether through novel training interventions or by establishing regional referral networks to improve access to MIS repair, improvement in MIS delivery and access is needed to reduce disparity and promote evidence-based practice,” they concluded.
The findings were limited by several factors including the potential for bias because of the observational nature of the study, the potential lack of generalizability of the findings, and lack of data on the particular attributes of the hernias, the researchers said.
Dr. Vu disclosed funding from the National Institutes of Health but had no financial conflicts to disclose. One of the study coauthors disclosed a relationship with Medtronic.
SOURCE: Vu JV et al. Surg Endosc. 2018 Jul 9. doi: 10.1007/s00464-018-6322-x.
Surgeons in the United States have been slow to adopt according to data from more than 6,000 patients.
“The benefit of MIS over open repair is recognized for patients with bilateral or recurrent inguinal hernias, and current guidelines recommend MIS repair for these cases,” wrote Joceline V. Vu, MD, of the University of Michigan, Ann Arbor, and her colleagues.
In a study published in Surgical Endoscopy, the researchers assessed surgeons’ practice patterns for hernia repair, with a primary outcome of minimally invasive surgery (MIS) rates per individual surgeon. They reviewed data from a statewide clinical registry of 6,723 adults older than 18 years who underwent elective hernia surgery in Michigan between 2012 and 2016.
Overall, the surgeons’ use of MIS varied, but more than half (58%) of the surgeons performed no MIS for hernia repair. For those who did use MIS, it was used in 41% of bilateral hernias and 38% of recurrent hernias.
Surgeons were significantly less likely to use MIS for hernia on patients aged 65 years and older (odds ratio, 0.68, P = .003), or those who were black (OR 0.75, P = .045). MIS repair also was significantly less likely for patients with chronic obstructive pulmonary disease (OR 0.57, P less than .001) or patients in American Society of Anesthesiologists Classification under 3 (OR 0.79, P less than .001).
Of the 227 surgeons who performed MIS, 71 (31%) had MIS utilization rates of 75% or higher and were defined as high-utilization surgeons. Overall, 75% of the MIS repairs were performed by 14% of the surgeons.
The surgeons with the highest use of MIS were unevenly distributed across the state; the Ann Arbor region had the highest percentage of high MIS-use surgeons (22%), compared with the Lansing area, in which 2% of surgeons were high users of MIS.
The risk-adjusted rate of MIS for inguinal hernia repair varied significantly across six regions of the state, from 10% to 48%, and the regions with the highest rates were those with the highest percentage of high-MIS use surgeons.
“These findings suggest that a large portion of decision making to offer MIS repair may depend on surgeon differences, rather than clinical appropriateness,” the researchers said. “The likelihood that a patient receives MIS repair may thus be predetermined by the surgeon to whom they are referred,” they added.
“Whether through novel training interventions or by establishing regional referral networks to improve access to MIS repair, improvement in MIS delivery and access is needed to reduce disparity and promote evidence-based practice,” they concluded.
The findings were limited by several factors including the potential for bias because of the observational nature of the study, the potential lack of generalizability of the findings, and lack of data on the particular attributes of the hernias, the researchers said.
Dr. Vu disclosed funding from the National Institutes of Health but had no financial conflicts to disclose. One of the study coauthors disclosed a relationship with Medtronic.
SOURCE: Vu JV et al. Surg Endosc. 2018 Jul 9. doi: 10.1007/s00464-018-6322-x.
Surgeons in the United States have been slow to adopt according to data from more than 6,000 patients.
“The benefit of MIS over open repair is recognized for patients with bilateral or recurrent inguinal hernias, and current guidelines recommend MIS repair for these cases,” wrote Joceline V. Vu, MD, of the University of Michigan, Ann Arbor, and her colleagues.
In a study published in Surgical Endoscopy, the researchers assessed surgeons’ practice patterns for hernia repair, with a primary outcome of minimally invasive surgery (MIS) rates per individual surgeon. They reviewed data from a statewide clinical registry of 6,723 adults older than 18 years who underwent elective hernia surgery in Michigan between 2012 and 2016.
Overall, the surgeons’ use of MIS varied, but more than half (58%) of the surgeons performed no MIS for hernia repair. For those who did use MIS, it was used in 41% of bilateral hernias and 38% of recurrent hernias.
Surgeons were significantly less likely to use MIS for hernia on patients aged 65 years and older (odds ratio, 0.68, P = .003), or those who were black (OR 0.75, P = .045). MIS repair also was significantly less likely for patients with chronic obstructive pulmonary disease (OR 0.57, P less than .001) or patients in American Society of Anesthesiologists Classification under 3 (OR 0.79, P less than .001).
Of the 227 surgeons who performed MIS, 71 (31%) had MIS utilization rates of 75% or higher and were defined as high-utilization surgeons. Overall, 75% of the MIS repairs were performed by 14% of the surgeons.
The surgeons with the highest use of MIS were unevenly distributed across the state; the Ann Arbor region had the highest percentage of high MIS-use surgeons (22%), compared with the Lansing area, in which 2% of surgeons were high users of MIS.
The risk-adjusted rate of MIS for inguinal hernia repair varied significantly across six regions of the state, from 10% to 48%, and the regions with the highest rates were those with the highest percentage of high-MIS use surgeons.
“These findings suggest that a large portion of decision making to offer MIS repair may depend on surgeon differences, rather than clinical appropriateness,” the researchers said. “The likelihood that a patient receives MIS repair may thus be predetermined by the surgeon to whom they are referred,” they added.
“Whether through novel training interventions or by establishing regional referral networks to improve access to MIS repair, improvement in MIS delivery and access is needed to reduce disparity and promote evidence-based practice,” they concluded.
The findings were limited by several factors including the potential for bias because of the observational nature of the study, the potential lack of generalizability of the findings, and lack of data on the particular attributes of the hernias, the researchers said.
Dr. Vu disclosed funding from the National Institutes of Health but had no financial conflicts to disclose. One of the study coauthors disclosed a relationship with Medtronic.
SOURCE: Vu JV et al. Surg Endosc. 2018 Jul 9. doi: 10.1007/s00464-018-6322-x.
FROM SURGICAL ENDOSCOPY
Key clinical point: Minimally invasive surgery remains underused as a method for managing inguinal hernias.
Major finding: Overall, 75% of MIS hernia repairs were performed by 14% of the surgeons.
Study details: The data come from a retrospective cohort study of 6,723 hernia surgery patients treated between 2012 and 2016.
Disclosures: Dr. Vu disclosed funding from the National Institutes of Health but had no financial conflicts to disclose. One of the study coauthors disclosed a relationship with Medtronic.
Source: Vu JV et al. Surg Endosc. 2018 Jul 9. doi: 10.1007/s00464-018-6322-x.
Clinical trial: Robotic versus laparoscopic ventral hernia repair
The Robotic Versus Laparoscopic Ventral Hernia Repair study is an interventional trial recruiting patients undergoing elective ventral hernia repair appropriate for minimally invasive surgery.
The trial will compare outcomes of laparoscopic and robotic approaches to ventral hernia repair. compared with the laparoscopic approach, and has been endorsed by the American Hernia Society. However, this evidence is based on database and cohort studies, and more randomized, controlled trials are needed to assess the true effects of the robotic approach.
Patients will be included if they are scheduled for a ventral hernia repair that has been deemed appropriate for minimally invasive surgery. Exclusion criteria include being unlikely to survive for 2 years post surgery, being unlikely to follow up, having advanced chronic obstructive pulmonary disease or congestive heart failure, having a history of open abdomen or extensive lysis of adhesions, having ascites caused by cirrhosis or malignancy, having an active infection, and having a hernia defect size larger than 12 cm.
The primary outcome measure is total number of days spent in the hospital. Secondary outcomes include rates of surgical site infection, rates of surgical site occurrence, rates of hernia reoccurrence, patient-centered outcomes collected using HerQLes (a hernia quality of life measuring instrument), patient-centered outcomes collected using the EQ-5D questionnaire, and cost from a health care perspective.
The primary completion date is April 30, 2020, and the study completion date is April 30, 2023. About 120 people are expected to be recruited.
Find more information on the study page at Clinicaltrials.gov.
The Robotic Versus Laparoscopic Ventral Hernia Repair study is an interventional trial recruiting patients undergoing elective ventral hernia repair appropriate for minimally invasive surgery.
The trial will compare outcomes of laparoscopic and robotic approaches to ventral hernia repair. compared with the laparoscopic approach, and has been endorsed by the American Hernia Society. However, this evidence is based on database and cohort studies, and more randomized, controlled trials are needed to assess the true effects of the robotic approach.
Patients will be included if they are scheduled for a ventral hernia repair that has been deemed appropriate for minimally invasive surgery. Exclusion criteria include being unlikely to survive for 2 years post surgery, being unlikely to follow up, having advanced chronic obstructive pulmonary disease or congestive heart failure, having a history of open abdomen or extensive lysis of adhesions, having ascites caused by cirrhosis or malignancy, having an active infection, and having a hernia defect size larger than 12 cm.
The primary outcome measure is total number of days spent in the hospital. Secondary outcomes include rates of surgical site infection, rates of surgical site occurrence, rates of hernia reoccurrence, patient-centered outcomes collected using HerQLes (a hernia quality of life measuring instrument), patient-centered outcomes collected using the EQ-5D questionnaire, and cost from a health care perspective.
The primary completion date is April 30, 2020, and the study completion date is April 30, 2023. About 120 people are expected to be recruited.
Find more information on the study page at Clinicaltrials.gov.
The Robotic Versus Laparoscopic Ventral Hernia Repair study is an interventional trial recruiting patients undergoing elective ventral hernia repair appropriate for minimally invasive surgery.
The trial will compare outcomes of laparoscopic and robotic approaches to ventral hernia repair. compared with the laparoscopic approach, and has been endorsed by the American Hernia Society. However, this evidence is based on database and cohort studies, and more randomized, controlled trials are needed to assess the true effects of the robotic approach.
Patients will be included if they are scheduled for a ventral hernia repair that has been deemed appropriate for minimally invasive surgery. Exclusion criteria include being unlikely to survive for 2 years post surgery, being unlikely to follow up, having advanced chronic obstructive pulmonary disease or congestive heart failure, having a history of open abdomen or extensive lysis of adhesions, having ascites caused by cirrhosis or malignancy, having an active infection, and having a hernia defect size larger than 12 cm.
The primary outcome measure is total number of days spent in the hospital. Secondary outcomes include rates of surgical site infection, rates of surgical site occurrence, rates of hernia reoccurrence, patient-centered outcomes collected using HerQLes (a hernia quality of life measuring instrument), patient-centered outcomes collected using the EQ-5D questionnaire, and cost from a health care perspective.
The primary completion date is April 30, 2020, and the study completion date is April 30, 2023. About 120 people are expected to be recruited.
Find more information on the study page at Clinicaltrials.gov.
Accidental bowel injury occurs in 2% of hernia repairs
occurring in only about 2% of these cases, a database review has determined. But patients who experience this kind of injury have a significantly longer length of stay and are at increased risk for fistulas, sepsis, reoperations and readmissions, and even death, David M. Krpata, MD, of the Cleveland Clinic and his colleagues wrote in Surgery.
“When these events occur, the surgeon must decide whether to repair primarily or resect the bowel, proceed with definitive hernia repair with mesh, or abort the procedure and repair primarily the hernia defect,” they wrote. The lack of published studies on this injury prompted the research team to look into prevalence and outcomes in order to offer some data to guide surgical decision making.
The research team examined surgical outcomes among 5,916 patients who underwent a ventral hernia repair during 2013-2017 and were included in the Americas Hernia Society Quality Collaborative, a national hernia surgery database. The database included information from the records of 180 surgeons.
The multivariate analysis controlled for sex, race, elective case, wound status, hernia width, immunosuppressants, subcutaneous flaps, myofascial release, drains, smoking, body mass index, age, diabetes, laparoscopic surgery, mesh type, and concomitant procedure.
Among the cohort, there were 110 full-thickness bowel injuries (1.9%). Three patients also had a bladder injury. Most of the enterotomies were small-bowel injuries (85%); the rest were colon injuries. The majority of patients (64%) underwent a primary repair; 36% required bowel resection. Injuries were most common among patients with larger hernia defects, recurrent repairs, mesh or active infection, a history of abdominal wound infection, and older age.
Patients with the accidental enterotomies were less likely to get a mesh repair (85% vs. 94%). When they did, their surgeons were less likely to use a permanent synthetic barrier–coated mesh and more likely to use biologic mesh, absorbable mesh, and/or uncoated synthetic mesh. But the investigators wrote: “Further data are necessary to address specifically what is the most appropriate mesh to utilize (if any) after an inadvertent enterotomy has occurred and which compartment within the abdominal wall is safest.”
In the fully adjusted analysis, injured patients were no more likely to experience surgical site infections, but they were significantly more likely to develop an enterocutaneous fistula (4% vs. 1%), sepsis (2% vs. 1%), and to die (3% vs 1%) after a bowel injury. They also had a significantly longer length of stay (7 vs. 4 days), and more reoperations (6% vs. 3%). Major wound complication was the most common reason for reoperation (43%) and readmission (58%).
The limitations of this study mostly reflect variables not captured by the database. For example, the tenacity of adhesions and the duration of adhesiolysis are not accounted for. The investigators noted that “patients with an enterotomy likely had more tenacious adhesions, given that an operative time greater than 2 hours had a greater association with an enterotomy (91% vs. 71%).” These patients were more likely to be older and have COPD. In addition, unrecognized enterotomies were not accounted for in the data, but inclusion of those injuries would likely have meant worse outcomes.
“Although definitive hernia repair with mesh can be safely performed, surgeons should consider multiple factors, including type of mesh and location of mesh in the abdominal wall, before proceeding with definitive repair in any case of an enterotomy,” Dr. Krpata and his coauthors concluded.
The investigators reported no financial disclosures.
SOURCE: Krpata et al. Surg. 2018. doi: 10.1016/j.surg.2018.04.003
occurring in only about 2% of these cases, a database review has determined. But patients who experience this kind of injury have a significantly longer length of stay and are at increased risk for fistulas, sepsis, reoperations and readmissions, and even death, David M. Krpata, MD, of the Cleveland Clinic and his colleagues wrote in Surgery.
“When these events occur, the surgeon must decide whether to repair primarily or resect the bowel, proceed with definitive hernia repair with mesh, or abort the procedure and repair primarily the hernia defect,” they wrote. The lack of published studies on this injury prompted the research team to look into prevalence and outcomes in order to offer some data to guide surgical decision making.
The research team examined surgical outcomes among 5,916 patients who underwent a ventral hernia repair during 2013-2017 and were included in the Americas Hernia Society Quality Collaborative, a national hernia surgery database. The database included information from the records of 180 surgeons.
The multivariate analysis controlled for sex, race, elective case, wound status, hernia width, immunosuppressants, subcutaneous flaps, myofascial release, drains, smoking, body mass index, age, diabetes, laparoscopic surgery, mesh type, and concomitant procedure.
Among the cohort, there were 110 full-thickness bowel injuries (1.9%). Three patients also had a bladder injury. Most of the enterotomies were small-bowel injuries (85%); the rest were colon injuries. The majority of patients (64%) underwent a primary repair; 36% required bowel resection. Injuries were most common among patients with larger hernia defects, recurrent repairs, mesh or active infection, a history of abdominal wound infection, and older age.
Patients with the accidental enterotomies were less likely to get a mesh repair (85% vs. 94%). When they did, their surgeons were less likely to use a permanent synthetic barrier–coated mesh and more likely to use biologic mesh, absorbable mesh, and/or uncoated synthetic mesh. But the investigators wrote: “Further data are necessary to address specifically what is the most appropriate mesh to utilize (if any) after an inadvertent enterotomy has occurred and which compartment within the abdominal wall is safest.”
In the fully adjusted analysis, injured patients were no more likely to experience surgical site infections, but they were significantly more likely to develop an enterocutaneous fistula (4% vs. 1%), sepsis (2% vs. 1%), and to die (3% vs 1%) after a bowel injury. They also had a significantly longer length of stay (7 vs. 4 days), and more reoperations (6% vs. 3%). Major wound complication was the most common reason for reoperation (43%) and readmission (58%).
The limitations of this study mostly reflect variables not captured by the database. For example, the tenacity of adhesions and the duration of adhesiolysis are not accounted for. The investigators noted that “patients with an enterotomy likely had more tenacious adhesions, given that an operative time greater than 2 hours had a greater association with an enterotomy (91% vs. 71%).” These patients were more likely to be older and have COPD. In addition, unrecognized enterotomies were not accounted for in the data, but inclusion of those injuries would likely have meant worse outcomes.
“Although definitive hernia repair with mesh can be safely performed, surgeons should consider multiple factors, including type of mesh and location of mesh in the abdominal wall, before proceeding with definitive repair in any case of an enterotomy,” Dr. Krpata and his coauthors concluded.
The investigators reported no financial disclosures.
SOURCE: Krpata et al. Surg. 2018. doi: 10.1016/j.surg.2018.04.003
occurring in only about 2% of these cases, a database review has determined. But patients who experience this kind of injury have a significantly longer length of stay and are at increased risk for fistulas, sepsis, reoperations and readmissions, and even death, David M. Krpata, MD, of the Cleveland Clinic and his colleagues wrote in Surgery.
“When these events occur, the surgeon must decide whether to repair primarily or resect the bowel, proceed with definitive hernia repair with mesh, or abort the procedure and repair primarily the hernia defect,” they wrote. The lack of published studies on this injury prompted the research team to look into prevalence and outcomes in order to offer some data to guide surgical decision making.
The research team examined surgical outcomes among 5,916 patients who underwent a ventral hernia repair during 2013-2017 and were included in the Americas Hernia Society Quality Collaborative, a national hernia surgery database. The database included information from the records of 180 surgeons.
The multivariate analysis controlled for sex, race, elective case, wound status, hernia width, immunosuppressants, subcutaneous flaps, myofascial release, drains, smoking, body mass index, age, diabetes, laparoscopic surgery, mesh type, and concomitant procedure.
Among the cohort, there were 110 full-thickness bowel injuries (1.9%). Three patients also had a bladder injury. Most of the enterotomies were small-bowel injuries (85%); the rest were colon injuries. The majority of patients (64%) underwent a primary repair; 36% required bowel resection. Injuries were most common among patients with larger hernia defects, recurrent repairs, mesh or active infection, a history of abdominal wound infection, and older age.
Patients with the accidental enterotomies were less likely to get a mesh repair (85% vs. 94%). When they did, their surgeons were less likely to use a permanent synthetic barrier–coated mesh and more likely to use biologic mesh, absorbable mesh, and/or uncoated synthetic mesh. But the investigators wrote: “Further data are necessary to address specifically what is the most appropriate mesh to utilize (if any) after an inadvertent enterotomy has occurred and which compartment within the abdominal wall is safest.”
In the fully adjusted analysis, injured patients were no more likely to experience surgical site infections, but they were significantly more likely to develop an enterocutaneous fistula (4% vs. 1%), sepsis (2% vs. 1%), and to die (3% vs 1%) after a bowel injury. They also had a significantly longer length of stay (7 vs. 4 days), and more reoperations (6% vs. 3%). Major wound complication was the most common reason for reoperation (43%) and readmission (58%).
The limitations of this study mostly reflect variables not captured by the database. For example, the tenacity of adhesions and the duration of adhesiolysis are not accounted for. The investigators noted that “patients with an enterotomy likely had more tenacious adhesions, given that an operative time greater than 2 hours had a greater association with an enterotomy (91% vs. 71%).” These patients were more likely to be older and have COPD. In addition, unrecognized enterotomies were not accounted for in the data, but inclusion of those injuries would likely have meant worse outcomes.
“Although definitive hernia repair with mesh can be safely performed, surgeons should consider multiple factors, including type of mesh and location of mesh in the abdominal wall, before proceeding with definitive repair in any case of an enterotomy,” Dr. Krpata and his coauthors concluded.
The investigators reported no financial disclosures.
SOURCE: Krpata et al. Surg. 2018. doi: 10.1016/j.surg.2018.04.003
FROM SURGERY
Key clinical point: Accidental bowel injuries during ventral hernia increase risk for longer hospital stays, fistula, sepsis, and readmissions.
Major finding: The overall rate of accidental enterotomy during ventral hernia repair was 2%.
Study details: The database review included 5,916 hernia repair patients.
Disclosures: None of the authors reported any financial disclosures.
Source: Krpata D et al. Surg 2018; doi.org/10.1016/j.surg.2018.04.003
Magnetic LES augmentation for Barrett’s regression debated
SEATTLE –
The study caught the attention of audience members – and raised a few eyebrows – at the 2018 World Congress of Endoscopic Surgery, where its results were presented, because the regression rate with the current standard operation for medically refractory gastroesophageal reflux – Nissen fundoplication – is only about 40%.
Lead investigator Evan Alicuben, MD, a general surgery resident at the university, cautioned that “longer-term follow-up is required to make a meaningful comparison with results following fundoplication.”
Fundoplication has been studied for decades, whereas the new study is likely the very first to look at the rates of Barrett’s regression after magnetic augmentation, and the 70% regression rate was based on postop endoscopies a median of 1.2 years after the procedure, not after the 5, 10, or even more years typically seen in fundoplication studies.
Magnetic sphincter augmentation (LINX Reflux Management System) was approved by the Food and Drug Administration in 2012 for reflux that persists despite maximum drug therapy. Patients have a band of magnetic titanium beads surgically placed around their LES; the band opens to let food pass, but tightens again to bolster the LES and prevent reflux.
The approach is gaining popularity. “We now know that it’s effective at controlling reflux symptoms, taking patients off proton pump inhibitors, and curing esophagitis,” at least in the short term. “One of the issues with [fundoplication] is that it may not last forever; the wrap comes undone or it slips. This device may give longer lasting” protection, Dr. Alicuben said.
“The main criticism is that it’s relatively new; people are still questioning it. The optimist in me wants to say that this is the answer we’ve been looking for; the pessimist [says] we need to wait to see what longer-term data show,” he said.
Barrett’s esophagus was confirmed by endoscopy in all 67 subjects before the magnets were placed, and each had at least one postop endoscopy.
At baseline, 29 had ultrashort-segment disease, which means there was no visible Barrett’s, but did have columnar epithelium with goblet cells on pathology. Thirty patients had short-segment disease, with up to 3 cm of visible involvement confirmed by pathology, while eight had long-segment disease, with involvement extending 3 cm or more.
Of the 67 patients, 48 had no evidence of Barrett’s after the procedure, for an overall regression rate of 71.6%. The regression rate was 82.8% in the ultrashort group (24/29); 73.3% in the short segment group (22/30); and 25% in the long segment group (2/8). Long-segment disease is notorious for persisting despite treatment; both patients had 3-cm lesions.
Among the 34 patients with two or more postop endoscopies, the regression rate was 73.5% (25).
There’s a lot of debate about whether ultrashort-segment disease is truly Barrett’s and whether it carries the same risk of malignant transformation, as one surgeon in the audience noted pointedly, worrying that including ultrashort patients oversold the results.
Dr. Alicuben countered that the regression rate remained strong even when ultrashort patients were excluded: 63% (24/38). “This is every bit as good if not better than the results of fundoplication,” another surgeon in the audience said.
The subjects were aged about 60 years, on average, with more men than women. Most had hiatal hernias, often measuring 3 cm or more. The mean body mass index was 27.3 kg/m2, but BMI ranged as high as 44.3.
Mean operative time was 66 minutes, and there were no major complications. None of the patients progressed to dysplasia or carcinoma. Median DeMeester scores fell from 35.3 to 9.2 after the operation in the 47 patients who had postop pH testing.
Surgeons have worried about esophageal erosion with the LINX system. A recent paper by Dr. Alicuben and his colleagues found 29 cases among almost 10,000 patients, which makes for an erosion rate of 0.3% at a median of about 2 years (J Gastrointest Surg. 2018 Apr 17. doi: 10.1007/s11605-018-3775-0).
About 500 LINX systems have been placed at the University of Southern California. Procedures in the study were performed between 2012 and late 2017.
Dr. Alicuben had no disclosures. Two investigators, including senior author John Lipham, MD, are paid consultants for Torax Medical, the maker of the LINX system, and Johnson & Johnson, which owns Torax through a subsidiary. There was no company funding for the review.
The World Congress of Endoscopic Surgery is hosted by the Society of American Gastrointestinal and Endoscopic Surgeons and the Canadian Association of General Surgeons
SOURCE: Alicuben E et al. WCE 2018, Abstract S095.
The enthusiasm and reservation surrounding the presented results supporting relatively high rates of regression of Barrett’s esophagus in patients undergoing LES magnetic sphincter augmentation are both well founded. Barrett’s regression, which has been observed to occur spontaneously as well as following antireflux interventions, is always a rich topic for debate. The reported rate of regression in this study being higher than that of complete fundoplication (Nissen fundoplication) is perplexing. The premise for the development of magnetic sphincter augmentation at a focal site was based on the theory that complete fundoplication is supraphysiologic, resulting in desired resolution of regurgitation with unwanted sequelae of dysphagia and bloat in a substantial number of patients. The development of magnetic sphincter augmentation was inspired by the concept that it would provide very reproducible control of regurgitation nearing that of complete fundoplication in a permanent fashion and do so at a focal point (< 1 cm) at the level of the lower esophageal sphincter, minimizing dysphagia and bloat. Since the design is one to replicate appropriate physiology without over treating the targeted reflux disease, theoretically any regression of Barrett’s esophagus should likewise approach but not exceed that of complete fundoplication.
I anticipate further studies will add to this rich debate. Any reservations about the results of this study should not overshadow the inherent advantages of magnetic sphincter augmentation. Its implantation is fairly straightforward to teach to surgeons who have a practice focused on antireflux surgery and due to the limited dissection/tissue mobilization required, most patients can return home a few hours after surgery and immediately resume a diet of solid foods.
Dr. Alicuban and colleagues discuss the small but real concern of erosion, however, another point of inherent concern is the binary function of the device. It is either implanted or not, there is no ability beyond endoscopic dilation to treat relative outflow obstruction and no means to convert the device to a “partial wrap.”
As we forge ahead with increasingly creative ways to address reflux disease the lessons we learn will contribute to the development of better medical, endoscopic and minimally invasive surgical technologies and the robust, civil debate seen here is something we can all enthusiastically anticipate.
Kevin M. Reavis, MD, FACS, is with the Division of Gastrointestinal and Minimally Invasive Surgery The Oregon Clinic; associate professor, Oregon Health & Science University, Portland, and President, Oregon Medical Society.
The enthusiasm and reservation surrounding the presented results supporting relatively high rates of regression of Barrett’s esophagus in patients undergoing LES magnetic sphincter augmentation are both well founded. Barrett’s regression, which has been observed to occur spontaneously as well as following antireflux interventions, is always a rich topic for debate. The reported rate of regression in this study being higher than that of complete fundoplication (Nissen fundoplication) is perplexing. The premise for the development of magnetic sphincter augmentation at a focal site was based on the theory that complete fundoplication is supraphysiologic, resulting in desired resolution of regurgitation with unwanted sequelae of dysphagia and bloat in a substantial number of patients. The development of magnetic sphincter augmentation was inspired by the concept that it would provide very reproducible control of regurgitation nearing that of complete fundoplication in a permanent fashion and do so at a focal point (< 1 cm) at the level of the lower esophageal sphincter, minimizing dysphagia and bloat. Since the design is one to replicate appropriate physiology without over treating the targeted reflux disease, theoretically any regression of Barrett’s esophagus should likewise approach but not exceed that of complete fundoplication.
I anticipate further studies will add to this rich debate. Any reservations about the results of this study should not overshadow the inherent advantages of magnetic sphincter augmentation. Its implantation is fairly straightforward to teach to surgeons who have a practice focused on antireflux surgery and due to the limited dissection/tissue mobilization required, most patients can return home a few hours after surgery and immediately resume a diet of solid foods.
Dr. Alicuban and colleagues discuss the small but real concern of erosion, however, another point of inherent concern is the binary function of the device. It is either implanted or not, there is no ability beyond endoscopic dilation to treat relative outflow obstruction and no means to convert the device to a “partial wrap.”
As we forge ahead with increasingly creative ways to address reflux disease the lessons we learn will contribute to the development of better medical, endoscopic and minimally invasive surgical technologies and the robust, civil debate seen here is something we can all enthusiastically anticipate.
Kevin M. Reavis, MD, FACS, is with the Division of Gastrointestinal and Minimally Invasive Surgery The Oregon Clinic; associate professor, Oregon Health & Science University, Portland, and President, Oregon Medical Society.
The enthusiasm and reservation surrounding the presented results supporting relatively high rates of regression of Barrett’s esophagus in patients undergoing LES magnetic sphincter augmentation are both well founded. Barrett’s regression, which has been observed to occur spontaneously as well as following antireflux interventions, is always a rich topic for debate. The reported rate of regression in this study being higher than that of complete fundoplication (Nissen fundoplication) is perplexing. The premise for the development of magnetic sphincter augmentation at a focal site was based on the theory that complete fundoplication is supraphysiologic, resulting in desired resolution of regurgitation with unwanted sequelae of dysphagia and bloat in a substantial number of patients. The development of magnetic sphincter augmentation was inspired by the concept that it would provide very reproducible control of regurgitation nearing that of complete fundoplication in a permanent fashion and do so at a focal point (< 1 cm) at the level of the lower esophageal sphincter, minimizing dysphagia and bloat. Since the design is one to replicate appropriate physiology without over treating the targeted reflux disease, theoretically any regression of Barrett’s esophagus should likewise approach but not exceed that of complete fundoplication.
I anticipate further studies will add to this rich debate. Any reservations about the results of this study should not overshadow the inherent advantages of magnetic sphincter augmentation. Its implantation is fairly straightforward to teach to surgeons who have a practice focused on antireflux surgery and due to the limited dissection/tissue mobilization required, most patients can return home a few hours after surgery and immediately resume a diet of solid foods.
Dr. Alicuban and colleagues discuss the small but real concern of erosion, however, another point of inherent concern is the binary function of the device. It is either implanted or not, there is no ability beyond endoscopic dilation to treat relative outflow obstruction and no means to convert the device to a “partial wrap.”
As we forge ahead with increasingly creative ways to address reflux disease the lessons we learn will contribute to the development of better medical, endoscopic and minimally invasive surgical technologies and the robust, civil debate seen here is something we can all enthusiastically anticipate.
Kevin M. Reavis, MD, FACS, is with the Division of Gastrointestinal and Minimally Invasive Surgery The Oregon Clinic; associate professor, Oregon Health & Science University, Portland, and President, Oregon Medical Society.
SEATTLE –
The study caught the attention of audience members – and raised a few eyebrows – at the 2018 World Congress of Endoscopic Surgery, where its results were presented, because the regression rate with the current standard operation for medically refractory gastroesophageal reflux – Nissen fundoplication – is only about 40%.
Lead investigator Evan Alicuben, MD, a general surgery resident at the university, cautioned that “longer-term follow-up is required to make a meaningful comparison with results following fundoplication.”
Fundoplication has been studied for decades, whereas the new study is likely the very first to look at the rates of Barrett’s regression after magnetic augmentation, and the 70% regression rate was based on postop endoscopies a median of 1.2 years after the procedure, not after the 5, 10, or even more years typically seen in fundoplication studies.
Magnetic sphincter augmentation (LINX Reflux Management System) was approved by the Food and Drug Administration in 2012 for reflux that persists despite maximum drug therapy. Patients have a band of magnetic titanium beads surgically placed around their LES; the band opens to let food pass, but tightens again to bolster the LES and prevent reflux.
The approach is gaining popularity. “We now know that it’s effective at controlling reflux symptoms, taking patients off proton pump inhibitors, and curing esophagitis,” at least in the short term. “One of the issues with [fundoplication] is that it may not last forever; the wrap comes undone or it slips. This device may give longer lasting” protection, Dr. Alicuben said.
“The main criticism is that it’s relatively new; people are still questioning it. The optimist in me wants to say that this is the answer we’ve been looking for; the pessimist [says] we need to wait to see what longer-term data show,” he said.
Barrett’s esophagus was confirmed by endoscopy in all 67 subjects before the magnets were placed, and each had at least one postop endoscopy.
At baseline, 29 had ultrashort-segment disease, which means there was no visible Barrett’s, but did have columnar epithelium with goblet cells on pathology. Thirty patients had short-segment disease, with up to 3 cm of visible involvement confirmed by pathology, while eight had long-segment disease, with involvement extending 3 cm or more.
Of the 67 patients, 48 had no evidence of Barrett’s after the procedure, for an overall regression rate of 71.6%. The regression rate was 82.8% in the ultrashort group (24/29); 73.3% in the short segment group (22/30); and 25% in the long segment group (2/8). Long-segment disease is notorious for persisting despite treatment; both patients had 3-cm lesions.
Among the 34 patients with two or more postop endoscopies, the regression rate was 73.5% (25).
There’s a lot of debate about whether ultrashort-segment disease is truly Barrett’s and whether it carries the same risk of malignant transformation, as one surgeon in the audience noted pointedly, worrying that including ultrashort patients oversold the results.
Dr. Alicuben countered that the regression rate remained strong even when ultrashort patients were excluded: 63% (24/38). “This is every bit as good if not better than the results of fundoplication,” another surgeon in the audience said.
The subjects were aged about 60 years, on average, with more men than women. Most had hiatal hernias, often measuring 3 cm or more. The mean body mass index was 27.3 kg/m2, but BMI ranged as high as 44.3.
Mean operative time was 66 minutes, and there were no major complications. None of the patients progressed to dysplasia or carcinoma. Median DeMeester scores fell from 35.3 to 9.2 after the operation in the 47 patients who had postop pH testing.
Surgeons have worried about esophageal erosion with the LINX system. A recent paper by Dr. Alicuben and his colleagues found 29 cases among almost 10,000 patients, which makes for an erosion rate of 0.3% at a median of about 2 years (J Gastrointest Surg. 2018 Apr 17. doi: 10.1007/s11605-018-3775-0).
About 500 LINX systems have been placed at the University of Southern California. Procedures in the study were performed between 2012 and late 2017.
Dr. Alicuben had no disclosures. Two investigators, including senior author John Lipham, MD, are paid consultants for Torax Medical, the maker of the LINX system, and Johnson & Johnson, which owns Torax through a subsidiary. There was no company funding for the review.
The World Congress of Endoscopic Surgery is hosted by the Society of American Gastrointestinal and Endoscopic Surgeons and the Canadian Association of General Surgeons
SOURCE: Alicuben E et al. WCE 2018, Abstract S095.
SEATTLE –
The study caught the attention of audience members – and raised a few eyebrows – at the 2018 World Congress of Endoscopic Surgery, where its results were presented, because the regression rate with the current standard operation for medically refractory gastroesophageal reflux – Nissen fundoplication – is only about 40%.
Lead investigator Evan Alicuben, MD, a general surgery resident at the university, cautioned that “longer-term follow-up is required to make a meaningful comparison with results following fundoplication.”
Fundoplication has been studied for decades, whereas the new study is likely the very first to look at the rates of Barrett’s regression after magnetic augmentation, and the 70% regression rate was based on postop endoscopies a median of 1.2 years after the procedure, not after the 5, 10, or even more years typically seen in fundoplication studies.
Magnetic sphincter augmentation (LINX Reflux Management System) was approved by the Food and Drug Administration in 2012 for reflux that persists despite maximum drug therapy. Patients have a band of magnetic titanium beads surgically placed around their LES; the band opens to let food pass, but tightens again to bolster the LES and prevent reflux.
The approach is gaining popularity. “We now know that it’s effective at controlling reflux symptoms, taking patients off proton pump inhibitors, and curing esophagitis,” at least in the short term. “One of the issues with [fundoplication] is that it may not last forever; the wrap comes undone or it slips. This device may give longer lasting” protection, Dr. Alicuben said.
“The main criticism is that it’s relatively new; people are still questioning it. The optimist in me wants to say that this is the answer we’ve been looking for; the pessimist [says] we need to wait to see what longer-term data show,” he said.
Barrett’s esophagus was confirmed by endoscopy in all 67 subjects before the magnets were placed, and each had at least one postop endoscopy.
At baseline, 29 had ultrashort-segment disease, which means there was no visible Barrett’s, but did have columnar epithelium with goblet cells on pathology. Thirty patients had short-segment disease, with up to 3 cm of visible involvement confirmed by pathology, while eight had long-segment disease, with involvement extending 3 cm or more.
Of the 67 patients, 48 had no evidence of Barrett’s after the procedure, for an overall regression rate of 71.6%. The regression rate was 82.8% in the ultrashort group (24/29); 73.3% in the short segment group (22/30); and 25% in the long segment group (2/8). Long-segment disease is notorious for persisting despite treatment; both patients had 3-cm lesions.
Among the 34 patients with two or more postop endoscopies, the regression rate was 73.5% (25).
There’s a lot of debate about whether ultrashort-segment disease is truly Barrett’s and whether it carries the same risk of malignant transformation, as one surgeon in the audience noted pointedly, worrying that including ultrashort patients oversold the results.
Dr. Alicuben countered that the regression rate remained strong even when ultrashort patients were excluded: 63% (24/38). “This is every bit as good if not better than the results of fundoplication,” another surgeon in the audience said.
The subjects were aged about 60 years, on average, with more men than women. Most had hiatal hernias, often measuring 3 cm or more. The mean body mass index was 27.3 kg/m2, but BMI ranged as high as 44.3.
Mean operative time was 66 minutes, and there were no major complications. None of the patients progressed to dysplasia or carcinoma. Median DeMeester scores fell from 35.3 to 9.2 after the operation in the 47 patients who had postop pH testing.
Surgeons have worried about esophageal erosion with the LINX system. A recent paper by Dr. Alicuben and his colleagues found 29 cases among almost 10,000 patients, which makes for an erosion rate of 0.3% at a median of about 2 years (J Gastrointest Surg. 2018 Apr 17. doi: 10.1007/s11605-018-3775-0).
About 500 LINX systems have been placed at the University of Southern California. Procedures in the study were performed between 2012 and late 2017.
Dr. Alicuben had no disclosures. Two investigators, including senior author John Lipham, MD, are paid consultants for Torax Medical, the maker of the LINX system, and Johnson & Johnson, which owns Torax through a subsidiary. There was no company funding for the review.
The World Congress of Endoscopic Surgery is hosted by the Society of American Gastrointestinal and Endoscopic Surgeons and the Canadian Association of General Surgeons
SOURCE: Alicuben E et al. WCE 2018, Abstract S095.
REPORTING FROM WCE 2018
Key clinical point: Magnetic lower esophageal sphincter augmentation might offer an easier and more effective fix for gastroesophageal reflux than the current standard, Nissen fundoplication.
Major finding: The overall regression rate of Barrett’s esophagus topped 70%.
Study details: Review of 67 patients
Disclosures: There was no industry funding, and the presenter had no disclosures. Two authors are consultants for Torax Medical, the company that makes the device.
Source: Alicuben E et al. WCE 2018, Abstract S095
Opioids still overprescribed for postop pain management
Most patients use far less opioids than they are prescribed after hernia and other abdominal surgery, resulting in substantial waste and potential diversion, a prospective cohort study has found.
In an evaluation of 176 narcotic-naive patients who underwent surgery in a over the 14-day postdischarge study period was 30 morphine milligram equivalents (MME) but the median prescription was 150 MME, reported Wen Hui Tan, MD, and her research team at Washington University, St. Louis. The report was published in the Journal of the American College of Surgeons.
Overall, 76.7% of patients reported being satisfied or very satisfied with their postoperative pain management. Some patients (n = 31, 17.6%) reported not filling their prescription or not taking any of their prescribed opioid pain medications at all.
Sixty-nine percent of the surgeries were laparoscopic. A variety of abdominal procedures were represented, including hiatal hernia repair, inguinal hernia repair, and cholecystectomy. The median age was 60 years. Of postoperative pain prescriptions, 67% were for hydrocodone-acetaminophen and most of the remainder were for oxycodone-acetaminophen or oxycodone alone. The median prescription was for the equivalent of 20 5-mg oxycodone pills, while the median consumption in the first 7 postoperative days was 3.7 pills. Only 4.5% of patients received a refill.
The findings are consistent with numerous studies of different types of operations showing that patients often don’t use all of the opioid medications they are prescribed for pain control after surgery.
“Now that opioid pain medications can no longer be refilled with a pharmacy via telephone, overprescription may also be partially driven by a desire to prevent future inconvenience and workload of office staff from patients requesting refills. However, the rising numbers of opioid-related unintentional deaths over the last decade point to the fact that overprescription has serious potential consequences,” the researchers wrote.
They reported having no potential conflicts of interest.
SOURCE: Tan et al. J Am Coll Surg 2018 May 7. doi: 10.1016/j.jamcollsurg.2018.04.032.
Most patients use far less opioids than they are prescribed after hernia and other abdominal surgery, resulting in substantial waste and potential diversion, a prospective cohort study has found.
In an evaluation of 176 narcotic-naive patients who underwent surgery in a over the 14-day postdischarge study period was 30 morphine milligram equivalents (MME) but the median prescription was 150 MME, reported Wen Hui Tan, MD, and her research team at Washington University, St. Louis. The report was published in the Journal of the American College of Surgeons.
Overall, 76.7% of patients reported being satisfied or very satisfied with their postoperative pain management. Some patients (n = 31, 17.6%) reported not filling their prescription or not taking any of their prescribed opioid pain medications at all.
Sixty-nine percent of the surgeries were laparoscopic. A variety of abdominal procedures were represented, including hiatal hernia repair, inguinal hernia repair, and cholecystectomy. The median age was 60 years. Of postoperative pain prescriptions, 67% were for hydrocodone-acetaminophen and most of the remainder were for oxycodone-acetaminophen or oxycodone alone. The median prescription was for the equivalent of 20 5-mg oxycodone pills, while the median consumption in the first 7 postoperative days was 3.7 pills. Only 4.5% of patients received a refill.
The findings are consistent with numerous studies of different types of operations showing that patients often don’t use all of the opioid medications they are prescribed for pain control after surgery.
“Now that opioid pain medications can no longer be refilled with a pharmacy via telephone, overprescription may also be partially driven by a desire to prevent future inconvenience and workload of office staff from patients requesting refills. However, the rising numbers of opioid-related unintentional deaths over the last decade point to the fact that overprescription has serious potential consequences,” the researchers wrote.
They reported having no potential conflicts of interest.
SOURCE: Tan et al. J Am Coll Surg 2018 May 7. doi: 10.1016/j.jamcollsurg.2018.04.032.
Most patients use far less opioids than they are prescribed after hernia and other abdominal surgery, resulting in substantial waste and potential diversion, a prospective cohort study has found.
In an evaluation of 176 narcotic-naive patients who underwent surgery in a over the 14-day postdischarge study period was 30 morphine milligram equivalents (MME) but the median prescription was 150 MME, reported Wen Hui Tan, MD, and her research team at Washington University, St. Louis. The report was published in the Journal of the American College of Surgeons.
Overall, 76.7% of patients reported being satisfied or very satisfied with their postoperative pain management. Some patients (n = 31, 17.6%) reported not filling their prescription or not taking any of their prescribed opioid pain medications at all.
Sixty-nine percent of the surgeries were laparoscopic. A variety of abdominal procedures were represented, including hiatal hernia repair, inguinal hernia repair, and cholecystectomy. The median age was 60 years. Of postoperative pain prescriptions, 67% were for hydrocodone-acetaminophen and most of the remainder were for oxycodone-acetaminophen or oxycodone alone. The median prescription was for the equivalent of 20 5-mg oxycodone pills, while the median consumption in the first 7 postoperative days was 3.7 pills. Only 4.5% of patients received a refill.
The findings are consistent with numerous studies of different types of operations showing that patients often don’t use all of the opioid medications they are prescribed for pain control after surgery.
“Now that opioid pain medications can no longer be refilled with a pharmacy via telephone, overprescription may also be partially driven by a desire to prevent future inconvenience and workload of office staff from patients requesting refills. However, the rising numbers of opioid-related unintentional deaths over the last decade point to the fact that overprescription has serious potential consequences,” the researchers wrote.
They reported having no potential conflicts of interest.
SOURCE: Tan et al. J Am Coll Surg 2018 May 7. doi: 10.1016/j.jamcollsurg.2018.04.032.
FROM THE JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS
Key clinical point: For postoperative recovery, a survey showed that far more opioids are prescribed than are consumed.
Major finding: On average, surgical patients went home with opioid prescriptions of 150 MME but took a median of 30 MME.
Study details: Prospective cohort study.
Disclosures: The authors report no potential conflicts of interest.
Source: Tan et al. J Am Coll Surg 2018 May 7. doi: 10.1016/j.jamcollsurg.2018.04.032.
Sarcopenia had minor impact on hernia repair SSIs
according to findings from a prospective, single-institution study.
Steve R. Siegal, MD, and his colleagues at the Oregon Health & Science University, Portland, wrote in Hernia that risk factors for postoperative complications after hernia repair established in the literature include uncontrolled diabetes, active tobacco use, prior hernia repair, active infection, and obesity. Sarcopenia occurs in many physiological or pathological states, not only in the elderly but also in cases of immunosuppression, cirrhosis, trauma, prolonged immobility, and malignancy. Many opportunities exist for sarcopenia and hernia surgery to coincide but the role of sarcopenia in hernia repair outcomes has not been much studied.
The investigators began with the hypothesis that sarcopenia in hernia patients would lead to worse postoperative outcomes given the large metabolic requirement for postoperative healing of hernia defects and abdominal wall reconstruction.
The study involved 135 patients who underwent ventral hernia repair, 27% of whom had sarcopenia. The literature-based definition of sarcopenia was a muscle index cutoff of less than 52.4 cm2/m2 for men and less than 38.5 cm2/m2 for women. The investigators noted that the index cutoff was validated in oncology patients. Patients underwent a preoperative CT scan to assess muscle mass. The study group included patients with ventral hernia repair with or without mesh, component separation/abdominal wall reconstruction, and a hernia defect of 2 cm or larger.
With data on variables including gender, diabetes status, body mass index (BMI), chronic obstructive pulmonary disease (COPD), wound class, alcohol abuse status, and prior wound infections, the investigators created a multivariate model to look at primary outcomes of surgical site infection (SSI), surgical site occurrences (wound complications, other infections) and hernia recurrence. Secondary outcomes included length of hospital stay, morbidities, and other postoperative complications.
Patients with sarcopenia were more likely to have lower BMI (median 29.6 kg/m2 vs. 36.6 kg/m2), to be slightly older (median 63.1 vs. 59.2 years), and to have a history of immunosuppression (29.7% vs. 11.2%). The differences for the other variables (diabetes, tobacco use, COPD) were not significant.
The surprising finding was that sarcopenia was not significantly correlated with SSIs (P = 0.140), other complications (P = 0.113), or recurrence (P = 0.895) after ventral hernia repair. In-hospital morbidities and length of hospital stay did not differ significantly between the sarcopenic and nonsarcopenic patients. But sarcopenia combined with other factors did have an impact on outcomes. After adjustment for BMI and diabetes and critical care status, muscle mass as a continuous variable “was notable for a 1.44 increased odds [95% confidence interval, 1.00-2.07; P = 0.049] of inpatient morbidity with every decrease of 10 cm2/m2 of muscle index,” Dr. Siegal and his associates wrote.
The nonsignificant results of this study may be explained by the markedly lower BMI in the sarcopenic group, which could have been protective against worse outcomes, the investigators noted. However, they concluded, “Sarcopenia may still be a factor in adverse perioperative outcomes, but the established muscle index cutoff value may be inappropriately applied to benign patients, such as our ventral hernia cohort results in this study.”
The investigators declared no conflicts of interest and received no outside funding for this study.
SOURCE: Siegal SR et al. Hernia. 2018 May 11. doi: 10.1007/s10029-018-1770-8.
according to findings from a prospective, single-institution study.
Steve R. Siegal, MD, and his colleagues at the Oregon Health & Science University, Portland, wrote in Hernia that risk factors for postoperative complications after hernia repair established in the literature include uncontrolled diabetes, active tobacco use, prior hernia repair, active infection, and obesity. Sarcopenia occurs in many physiological or pathological states, not only in the elderly but also in cases of immunosuppression, cirrhosis, trauma, prolonged immobility, and malignancy. Many opportunities exist for sarcopenia and hernia surgery to coincide but the role of sarcopenia in hernia repair outcomes has not been much studied.
The investigators began with the hypothesis that sarcopenia in hernia patients would lead to worse postoperative outcomes given the large metabolic requirement for postoperative healing of hernia defects and abdominal wall reconstruction.
The study involved 135 patients who underwent ventral hernia repair, 27% of whom had sarcopenia. The literature-based definition of sarcopenia was a muscle index cutoff of less than 52.4 cm2/m2 for men and less than 38.5 cm2/m2 for women. The investigators noted that the index cutoff was validated in oncology patients. Patients underwent a preoperative CT scan to assess muscle mass. The study group included patients with ventral hernia repair with or without mesh, component separation/abdominal wall reconstruction, and a hernia defect of 2 cm or larger.
With data on variables including gender, diabetes status, body mass index (BMI), chronic obstructive pulmonary disease (COPD), wound class, alcohol abuse status, and prior wound infections, the investigators created a multivariate model to look at primary outcomes of surgical site infection (SSI), surgical site occurrences (wound complications, other infections) and hernia recurrence. Secondary outcomes included length of hospital stay, morbidities, and other postoperative complications.
Patients with sarcopenia were more likely to have lower BMI (median 29.6 kg/m2 vs. 36.6 kg/m2), to be slightly older (median 63.1 vs. 59.2 years), and to have a history of immunosuppression (29.7% vs. 11.2%). The differences for the other variables (diabetes, tobacco use, COPD) were not significant.
The surprising finding was that sarcopenia was not significantly correlated with SSIs (P = 0.140), other complications (P = 0.113), or recurrence (P = 0.895) after ventral hernia repair. In-hospital morbidities and length of hospital stay did not differ significantly between the sarcopenic and nonsarcopenic patients. But sarcopenia combined with other factors did have an impact on outcomes. After adjustment for BMI and diabetes and critical care status, muscle mass as a continuous variable “was notable for a 1.44 increased odds [95% confidence interval, 1.00-2.07; P = 0.049] of inpatient morbidity with every decrease of 10 cm2/m2 of muscle index,” Dr. Siegal and his associates wrote.
The nonsignificant results of this study may be explained by the markedly lower BMI in the sarcopenic group, which could have been protective against worse outcomes, the investigators noted. However, they concluded, “Sarcopenia may still be a factor in adverse perioperative outcomes, but the established muscle index cutoff value may be inappropriately applied to benign patients, such as our ventral hernia cohort results in this study.”
The investigators declared no conflicts of interest and received no outside funding for this study.
SOURCE: Siegal SR et al. Hernia. 2018 May 11. doi: 10.1007/s10029-018-1770-8.
according to findings from a prospective, single-institution study.
Steve R. Siegal, MD, and his colleagues at the Oregon Health & Science University, Portland, wrote in Hernia that risk factors for postoperative complications after hernia repair established in the literature include uncontrolled diabetes, active tobacco use, prior hernia repair, active infection, and obesity. Sarcopenia occurs in many physiological or pathological states, not only in the elderly but also in cases of immunosuppression, cirrhosis, trauma, prolonged immobility, and malignancy. Many opportunities exist for sarcopenia and hernia surgery to coincide but the role of sarcopenia in hernia repair outcomes has not been much studied.
The investigators began with the hypothesis that sarcopenia in hernia patients would lead to worse postoperative outcomes given the large metabolic requirement for postoperative healing of hernia defects and abdominal wall reconstruction.
The study involved 135 patients who underwent ventral hernia repair, 27% of whom had sarcopenia. The literature-based definition of sarcopenia was a muscle index cutoff of less than 52.4 cm2/m2 for men and less than 38.5 cm2/m2 for women. The investigators noted that the index cutoff was validated in oncology patients. Patients underwent a preoperative CT scan to assess muscle mass. The study group included patients with ventral hernia repair with or without mesh, component separation/abdominal wall reconstruction, and a hernia defect of 2 cm or larger.
With data on variables including gender, diabetes status, body mass index (BMI), chronic obstructive pulmonary disease (COPD), wound class, alcohol abuse status, and prior wound infections, the investigators created a multivariate model to look at primary outcomes of surgical site infection (SSI), surgical site occurrences (wound complications, other infections) and hernia recurrence. Secondary outcomes included length of hospital stay, morbidities, and other postoperative complications.
Patients with sarcopenia were more likely to have lower BMI (median 29.6 kg/m2 vs. 36.6 kg/m2), to be slightly older (median 63.1 vs. 59.2 years), and to have a history of immunosuppression (29.7% vs. 11.2%). The differences for the other variables (diabetes, tobacco use, COPD) were not significant.
The surprising finding was that sarcopenia was not significantly correlated with SSIs (P = 0.140), other complications (P = 0.113), or recurrence (P = 0.895) after ventral hernia repair. In-hospital morbidities and length of hospital stay did not differ significantly between the sarcopenic and nonsarcopenic patients. But sarcopenia combined with other factors did have an impact on outcomes. After adjustment for BMI and diabetes and critical care status, muscle mass as a continuous variable “was notable for a 1.44 increased odds [95% confidence interval, 1.00-2.07; P = 0.049] of inpatient morbidity with every decrease of 10 cm2/m2 of muscle index,” Dr. Siegal and his associates wrote.
The nonsignificant results of this study may be explained by the markedly lower BMI in the sarcopenic group, which could have been protective against worse outcomes, the investigators noted. However, they concluded, “Sarcopenia may still be a factor in adverse perioperative outcomes, but the established muscle index cutoff value may be inappropriately applied to benign patients, such as our ventral hernia cohort results in this study.”
The investigators declared no conflicts of interest and received no outside funding for this study.
SOURCE: Siegal SR et al. Hernia. 2018 May 11. doi: 10.1007/s10029-018-1770-8.
FROM HERNIA
Key clinical point: Sarcopenia was not correlated with surgical site infections, other complications, or recurrence after ventral hernia repair.
Major finding: After adjustment for body mass index and diabetes and critical care status, muscle mass as a continuous variable was notable for a 1.44 increased odds of inpatient morbidity.
Study details: A prospective, single-institution study of 135 patients who had ventral hernia repair, 27% of whom were sarcopenic.
Disclosures: The investigators declared no conflicts of interest and received no outside funding for this study.
Source: Siegal SR et al. Hernia. 2018 May 11. doi: 10.1007/s10029-018-1770-8.