Julie L. Holihan

Development and Validation of a Risk Stratification Score for Ventral Incisional Hernia after Abdominal Surgery: Hernia Expectation Rates iN Intra-Abdominal Surgery (The HERNIA Project)

BACKGROUND Ventral incisional hernias (VIH) develop in up to 20% of patients after abdominal surgery. No widely applicable preoperative risk-assessment tool exists. We aimed to develop and validate a risk-assessment tool to predict VIH after abdominal surgery. STUDY DESIGN A prospective study of all patients undergoing abdominal surgery was conducted at a single institution from 2008 to 2010. Variables were defined in accordance with the National Surgical Quality Improvement Project, and VIH was determined through clinical and radiographic evaluation. A multivariate Cox proportional hazard model was built from a development cohort (2008 to 2009) to identify predictors of VIH. The HERNIAscore was created by converting the hazards ratios (HR) to points. The predictive accuracy was assessed on the validation cohort (2010) using a receiver operator characteristic curve and calculating the area under the curve (AUC). RESULTS Of 625 patients followed for a median of 41 months (range 0.3 to 64 months), 93 (13.9%) developed a VIH. The training cohort (n = 428, VIH = 70, 16.4%) identified 4 independent predictors: laparotomy (HR 4.77, 95% CI 2.61 to 8.70) or hand-assisted laparoscopy (HAL, HR 4.00, 95% CI 2.08 to 7.70), COPD (HR 2.35; 95% CI 1.44 to 3.83), and BMI ≥ 25 kg/m(2) (HR1.74; 95% CI 1.04 to 2.91). Factors that were not predictive included age, sex, American Society of Anesthesiologists (ASA) score, albumin, immunosuppression, previous surgery, and suture material or technique. The predictive score had an AUC = 0.77 (95% CI 0.68 to 0.86) using the validation cohort (n = 197, VIH = 23, 11.6%). Using the HERNIAscore: HERNIAscore = 4(∗)Laparotomy+3(∗)HAL+1(∗)COPD+1(∗) BMI ≥ 25, 3 classes stratified the risk of VIH: class I (0 to 3 points),5.2%; class II (4 to 5 points),19.6%; and class III (6 points), 55.0%. CONCLUSIONS The HERNIAscore accurately identifies patients at increased risk for VIH. Although external validation is needed, this provides a starting point to counsel patients and guide clinical decisions. Increasing the use of laparoscopy, weight-loss programs, community smoking prevention programs, and incisional reinforcement may help reduce rates of VIH.

Ventral Hernia Management: Expert Consensus Guided by Systematic Review.

Objective: To achieve consensus on the best practices in the management of ventral hernias (VH). Background: Management patterns for VH are heterogeneous, often with little supporting evidence or correlation with existing evidence. Methods: A systematic review identified the highest level of evidence available for each topic. A panel of expert hernia-surgeons was assembled. Email questionnaires, evidence review, panel discussion, and iterative voting was performed. Consensus was when all experts agreed on a management strategy. Results: Experts agreed that complications with VH repair (VHR) increase in obese patients (grade A), current smokers (grade A), and patients with glycosylated hemoglobin (HbA1C) ≥ 6.5% (grade B). Elective VHR was not recommended for patients with BMI ≥ 50 kg/m2 (grade C), current smokers (grade A), or patients with HbA1C ≥ 8.0% (grade B). Patients with BMI= 30–50 kg/m2 or HbA1C = 6.5–8.0% require individualized interventions to reduce surgical risk (grade C, grade B). Nonoperative management was considered to have a low-risk of short-term morbidity (grade C). Mesh reinforcement was recommended for repair of hernias ≥ 2 cm (grade A). There were several areas where high-quality data were limited, and no consensus could be reached, including mesh type, component separation technique, and management of complex patients. Conclusions: Although there was consensus, supported by grade A–C evidence, on patient selection, the safety of short-term nonoperative management, and mesh reinforcement, among experts; there was limited evidence and broad variability in practice patterns in all other areas of practice. The lack of strong evidence and expert consensus on these topics has identified gaps in knowledge where there is need of further evidence.

Adverse Events after Ventral Hernia Repair: The Vicious Cycle of Complications

BACKGROUND Ventral hernia repairs are one of the most common procedures performed by the general surgeon. They are also among the most complex procedures performed. We hypothesized that with each surgical failure, subsequent ventral hernia repair becomes more complicated and morbid. STUDY DESIGN We assessed a multicenter database of patients who underwent an elective ventral hernia repair from 2000 to 2012 with at least 6 months of follow-up and elective repairs. Patients were evaluated by the number of previous ventral hernia repairs they had: primary ventral hernia repair (PVHR), first time incisional hernia repair (IHR1), second time incisional hernia repair (IHR2), or third time or greater incisional hernia repair (IHR3). The main outcomes measured were abdominal reoperation, operative duration, surgical site infection (SSI), and hernia recurrence. Complications were assessed and compared between the 4 groups. Time to recurrence was estimated using the Kaplan-Meier curve method by study cohort (PVHR, IHR1, IHR2, IHR3). RESULTS A total of 794 patients were assessed; of these, 481 (60.6%) had PVHR, 207 (26.1%) had IHR1, 78 (9.8%) had IHR2, and 28 (3.5%) had IHR3. Patients with multiple repairs were more likely to undergo subsequent reoperation, have a longer operative duration, develop SSI, and have a recurrence. At 140 months of follow-up, 37% of primary ventral hernias and 64% of incisional hernias have recurred. The highest recurrence rates are seen in IHR3, with 73% recurring. CONCLUSIONS Previous ventral hernia repair increases the complication profile of repair, creating a vicious cycle of repair, complications, reoperation, and re-repair. Furthermore, long-term outcomes for ventral hernia repair are poor. Future studies should focus on hernia prevention and improving long-term outcomes after hernia repair.

Original scientific articleAdverse Events after Ventral Hernia Repair: The Vicious Cycle of Complications

BACKGROUND Ventral hernia repairs are one of the most common procedures performed by the general surgeon. They are also among the most complex procedures performed. We hypothesized that with each surgical failure, subsequent ventral hernia repair becomes more complicated and morbid. STUDY DESIGN We assessed a multicenter database of patients who underwent an elective ventral hernia repair from 2000 to 2012 with at least 6 months of follow-up and elective repairs. Patients were evaluated by the number of previous ventral hernia repairs they had: primary ventral hernia repair (PVHR), first time incisional hernia repair (IHR1), second time incisional hernia repair (IHR2), or third time or greater incisional hernia repair (IHR3). The main outcomes measured were abdominal reoperation, operative duration, surgical site infection (SSI), and hernia recurrence. Complications were assessed and compared between the 4 groups. Time to recurrence was estimated using the Kaplan-Meier curve method by study cohort (PVHR, IHR1, IHR2, IHR3). RESULTS A total of 794 patients were assessed; of these, 481 (60.6%) had PVHR, 207 (26.1%) had IHR1, 78 (9.8%) had IHR2, and 28 (3.5%) had IHR3. Patients with multiple repairs were more likely to undergo subsequent reoperation, have a longer operative duration, develop SSI, and have a recurrence. At 140 months of follow-up, 37% of primary ventral hernias and 64% of incisional hernias have recurred. The highest recurrence rates are seen in IHR3, with 73% recurring. CONCLUSIONS Previous ventral hernia repair increases the complication profile of repair, creating a vicious cycle of repair, complications, reoperation, and re-repair. Furthermore, long-term outcomes for ventral hernia repair are poor. Future studies should focus on hernia prevention and improving long-term outcomes after hernia repair.

Preoperative Glycosylated Hemoglobin and Postoperative Glucose Together Predict Major Complications after Abdominal Surgery

BACKGROUND Glycosylated hemoglobin (HbA1c) is diagnostic of and a measure of the quality of control of diabetes mellitus. Both HbA1c and perioperative hyperglycemia have been targeted as modifiable risk factors for postoperative complications. The HbA1c percent cutoff that best predicts major complications has not been defined. STUDY DESIGN A prospective study of all abdominal operations from a single institution from 2007 to 2010 was performed. All patients with HbA1c within 3 months before surgery were included. The primary end point was major complication, using the Clavien-Dindo complication system, within 30 days of surgery. Stepwise, multivariate analysis was performed including clinically relevant variables chosen a priori. RESULTS Among 438 patients who had a measured HbA1c, 96 (21.9%) experienced a major complication. On multivariate analysis, HbA1c ≥ 6.5% (odds ratio = 1.95; 95% CI, 1.17-3.24; p = 0.01) was found to be the most significant predictor of major complications. Glyosylated hemoglobin and glucose were strongly correlated (correlation coefficient 0.414, p < 0.01). Predicted probabilities demonstrated that both HbA1c and glucose together contributed to major complications; and HbA1c impacted the ability to achieve optimal perioperative glucose control. Patients with a BMI >30 kg/m(2), history of coronary artery disease, and nonwhite race were more likely to have a HbA1c ≥ 6.5%. CONCLUSIONS Elevated HbA1c ≥ 6.5% and perioperative hyperglycemia were associated with an increased rate of major complications after abdominal surgery. Elevated peak postoperative glucose levels were correlated with elevated HbA1c and were independently associated with major complications. More liberal HbA1c testing should be considered in high-risk patients before elective surgery. Safe, feasible, and effective strategies to reduce both HbA1c and perioperative hyperglycemia need to be developed to optimize patient outcomes.

Facilitators and barriers of implementing enhanced recovery in colorectal surgery at a safety net hospital: A provider and patient perspective.

BACKGROUND Enhanced Recovery After Surgery (ERAS) pathways are known to decrease complications and duration of stay in colorectal surgery patients. However, it is unclear whether an ERAS pathway would be feasible and effective at a safety-net hospital. The aim of this study was to identify local barriers and facilitators before the adoption of an ERAS pathway for patients undergoing colorectal operations at a safety-net hospital. METHODS Semistructured interviews were conducted to assess the perceived barriers and facilitators before ERAS adoption. Stratified purposive sampling was used. Interviews were audiotaped, transcribed verbatim, and analyzed using content analysis. Analytic and investigator triangulation were used to establish credibility. RESULTS Interviewees included 8 anesthesiologists, 5 surgeons, 6 nurses, and 18 patients. Facilitators identified across the different medical professions were (1) feasibility and alignment with current practice, (2) standardization of care, (3) smallness of community, (4) good teamwork and communication, and (5) caring for patients. The barriers were (1) difficulty in adapting to change, (2) lack of coordination between different departments, (3) special needs of a highly comorbid and socioeconomically disadvantaged patient population, (4) limited resources, and (5) rotating residents. Facilitators identified by the patients were (1) welcoming a speedy recovery, (2) being well-cared for and satisfied with treatment, (3) adequate social support, (4) welcoming early mobilization, and (5) effective pain management. The barriers were (1) lack of quiet and private space, (2) need for more patient education and counseling, and (3) unforeseen complications. CONCLUSION Although limited hospital resources are perceived as a barrier to ERAS implementation at a safety-net hospital, there is strong support for such pathways and multiple factors were identified that may facilitate change. Inclusion of patient perspectives is critical to identifying challenges and facilitators to implementing ERAS changes focused on optimizing patient perioperative health and outcomes.

Suture, synthetic, or biologic in contaminated ventral hernia repair

BACKGROUND Data are lacking to support the choice between suture, synthetic mesh, or biologic matrix in contaminated ventral hernia repair (VHR). We hypothesize that in contaminated VHR, suture repair is associated with the lowest rate of surgical site infection (SSI). METHODS A multicenter database of all open VHR performed at from 2010-2011 was reviewed. All patients with follow-up of 1 mo and longer were included. The primary outcome was SSI as defined by the Centers for Disease Control and Prevention. The secondary outcome was hernia recurrence (assessed clinically or radiographically). Multivariate analysis (stepwise regression for SSI and Cox proportional hazard model for recurrence) was performed. RESULTS A total of 761 VHR were reviewed for a median (range) follow-up of 15 (1-50) mo: there were 291(38%) suture, 303 (40%) low-density and/or mid-density synthetic mesh, and 167(22%) biologic matrix repair. On univariate analysis, there were differences in the three groups including ethnicity, ASA, body mass index, institution, diabetes, primary versus incisional hernia, wound class, hernia size, prior VHR, fascial release, skin flaps, and acute repair. The unadjusted outcomes for SSI (15.1%; 17.8%; 21.0%; P = 0.280) and recurrence (17.8%; 13.5%; 21.5%; P = 0.074) were not statistically different between groups. On multivariate analysis, biologic matrix was associated with a nonsignificant reduction in both SSI and recurrences, whereas synthetic mesh associated with fewer recurrences compared to suture (hazard ratio = 0.60; P = 0.015) and nonsignificant increase in SSI. CONCLUSIONS Interval estimates favored biologic matrix repair in contaminated VHR; however, these results were not statistically significant. In the absence of higher level evidence, surgeons should carefully balance risk, cost, and benefits in managing contaminated ventral hernia repair.

Ventral hernia: Patient selection, treatment, and management ☆

Ventral hernias are among the most common pathologic conditions seen by clinicians, with an estimated one fourth of all individuals being born with, developing, or acquiring a ventral hernia in their lifetime. Repair of ventral hernias is among the 5 most common procedures performed by a general surgeon, and it is estimated that in the United States more than

Sublay versus underlay in open ventral hernia repair

3.4 billion will be spent this year on the surgical management of ventral hernias. These repairs are fraught with complications including surgical site infections (SSIs), wound complications, and hernia recurrences. Despite the increasing use of advanced surgical techniques, availability of modern prosthetic materials, and increasing understanding of ventral hernias, the long-term outcome for ventral hernia repair remains poor, with a 10-year failure rate (recurrence) of 30% in the simplest ventral hernia defects and more than 70% in more complex ventral hernias. One of the main reasons for persistently poor outcomes despite the advances made is the increasingly comorbid patient population. Within Westernized nations, obesity is a growing epidemic. In the United States, 66% of adults are overweight or obese. Patients with hernias typically have an even higher BMI, and

Use of Computed Tomography in Diagnosing Ventral Hernia Recurrence: A Blinded, Prospective, Multispecialty Evaluation

BACKGROUND The ideal location for mesh placement in open ventral hernia repair (OVHR) remains under debate. Current trends lean toward underlay or sublay repair. We hypothesize that in patients undergoing OVHR, sublay versus underlay placement of mesh results in fewer surgical site infections (SSIs) and recurrences. MATERIALS AND METHODS A multi-institution database of all OVHRs performed from 2010 to 2011 was accessed. Patients with mesh placed in the sublay or underlay position and at least 1 mo of follow-up were included. Primary outcome was SSI. Secondary outcome was hernia recurrence. Multivariate analysis was performed using logistic regression for SSI and Cox regression for recurrence. Subgroup analysis of elective, midline ventral incisional hernias was also performed. RESULTS Of 447 patients, 139 (31.1%) had a sublay repair. The unadjusted analysis showed no difference in SSI and lower recurrence using sublay compared with underlay. On multivariate analysis, there was no difference in SSI using sublay compared with underlay (odds ratio 1.5, 95% confidence interval [CI] 0.8-2.8). Recurrence was less common with sublay (hazard ratio 0.4, 95% CI 0.2-0.8). On subgroup analysis of elective, midline incisional hernias only (n = 247), there were more SSIs with sublay compared with underlay repair (28.0% versus 15.1%, P = 0.018); however, there was no difference in major SSI (sublay 9.3% versus underlay 5.8%, P = 0.315). There were fewer recurrences using sublay repair compared with underlay repair (10.7% versus 25.0%, P = 0.010). CONCLUSIONS In this multi-center, risk-adjusted study, sublay repair was associated with fewer recurrences than underlay repair and no difference in SSI. Randomized controlled trials are warranted to validate these findings.