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A Risk Model and Cost Analysis of Incisional Hernia After Elective, Abdominal Surgery Based Upon 12,373 Cases: The Case for Targeted Prophylactic Intervention.

ABSTRACT: Incisional hernia (IH) remains a common, highly morbid, and costly complication. Modest progress has been realized in surgical technique and mesh technology; however, few advances have been achieved toward understanding risk and prevention. In light of the increasing emphasis on prevention in today's health care environment and the billions in costs for surgically treated IH, greater focus on predictive risk models is needed.All patients undergoing gastrointestinal or gynecologic procedures from January 1, 2005 to June 1, 2013, within the University of Pennsylvania Health System were identified. Comorbidities and operative characteristics were assessed. The primary outcome was surgically treated IH after index procedures. Patients with prior hernia, less than 1-year follow-up, or emergency surgical procedures were excluded. Cox hazard regression modeling with bootstrapped validation, risk factor stratification, and assessment of model performance were conducted.A total of 12,373 patients with a 3.5% incidence of surgically treated IH (follow-up 32.2?±?26.6 months) were identified. The cost of surgical treatment of IH and management of associated complications exceeded $17.5 million. Notable independent risk factors for IH were ostomy reversal (HR?=?2.76), recent chemotherapy (HR?=?2.04), bariatric surgery (HR?=?1.78), smoking history (HR?=?1.74), liver disease (HR?=?1.60), and obesity (HR?=?1.96). High-risk patients (20.6%) developed IH compared with 0.5% of low-risk patients (C-statistic?=?0.78).This study demonstrates an internally validated preoperative risk model of surgically treated IH after 12,000 elective, intra-abdominal procedures to provide more individualized risk counseling and to better inform evidence-based algorithms for the role of prophylactic mesh.

SUBMITTER: Fischer JP

PROVIDER: S-EPMC4825112 | biostudies-literature | 2016 May

REPOSITORIES: biostudies-literature

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A Risk Model and Cost Analysis of Incisional Hernia After Elective, Abdominal Surgery Based Upon 12,373 Cases: The Case for Targeted Prophylactic Intervention.

Fischer John P JP Basta Marten N MN Mirzabeigi Michael N MN Bauder Andrew R AR Fox Justin P JP Drebin Jeffrey A JA Serletti Joseph M JM Kovach Stephen J SJ

Annals of surgery 20160501 5

<h4>Objectives</h4>Incisional hernia (IH) remains a common, highly morbid, and costly complication. Modest progress has been realized in surgical technique and mesh technology; however, few advances have been achieved toward understanding risk and prevention. In light of the increasing emphasis on prevention in today's health care environment and the billions in costs for surgically treated IH, greater focus on predictive risk models is needed.<h4>Methods</h4>All patients undergoing gastrointest ...[more]

PMID: 26465784

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Project description:ImportanceIncisional hernia is a frequent complication after open abdominal surgery. Prophylactic mesh implantation in the onlay or sublay position requires dissection of the abdominal wall, potentially leading to wound-associated complications.ObjectiveTo compare the incidence of incisional hernia among patients after prophylactic intraperitoneal mesh implantation with that among patients after standard abdominal closure.Design, setting, and participantsAn open-label randomized clinical trial was performed in 169 patients undergoing elective open abdominal surgery from January 1, 2011, to February 29, 2014. Follow-up examinations were performed 1 year and 3 years after surgery. The study was conducted at Bern University Hospital, Bern, Switzerland, a referral center that offers the whole spectrum of abdominal surgical interventions. Patients with 2 or more of the following risk factors were included: overweight or obesity, diagnosis of neoplastic disease, male sex, or history of previous laparotomy. Patients were randomly assigned to prophylactic intraperitoneal mesh implantation or standard abdominal closure. Data were analyzed in August 2017.InterventionsIntraperitoneal implantation of a polypropylene-polyvinylidene fluoride mesh with circumferential fixation.Main outcomes and measuresThe primary end point was the incidence of incisional hernia 3 years after surgery. Secondary end points included mesh-related complications.ResultsAfter the exclusion of 19 patients, 150 patients (81 in the control group and 69 in the mesh group; mean [SD] age, 64.2 [11.1] years; 102 [68.0%] male) were studied. The cumulative incidence of incisional hernia was significantly lower in the mesh group compared with the control group (5 of 69 [7.2%] vs 15 of 81 [18.5%], log-rank test P = .03). Abdominal pain was observed in significantly more patients in the mesh group compared with the control group at 6 weeks (34 of 52 [65%] vs 26 of 59 [44%], P = .04) but not at 12 and 36 months postoperatively. No difference in surgical site infections was observed, but time to complete wound healing of surgical site infection was significantly longer in patients with mesh implantation (median [interquartile range], 8 [6-24] weeks compared with 5 [1-9] weeks; P = .03). Trunk extension was significantly decreased after mesh implantation compared with the control group (mean [SD], 1.73 [0.97] cm vs 2.40 [1.23] cm, P = .009).Conclusions and relevanceIn patients at elevated risk for incisional hernia, prophylactic intraperitoneal mesh implantation reduces the incidence of hernia formation but with increased early postoperative pain and prolonged wound healing of surgical site infection.Trial registrationClinicalTrials.gov Identifier: NCT01203553.

Project description:BackgroundBased on a recent meta-analysis, a continuous suture technique with a suture to wound length ratio of at least 4:1, using a slowly absorbable monofilament suture material, is recommended for primary median laparotomy closure. Incisional hernia, which develops in 9 to 20% of patients, remains the major complication of abdominal wall closure. Current clinical data indicate that the incidence of incisional hernias increases by 60% between the first and the third year after median laparotomy, implicating that a follow-up period of 1 year postoperatively is too short with regard to this common complication. Trauma to the abdominal wall can be reduced by improvements in suture technique as well as suture material. Several factors, such as stitch length, suture tension, elasticity, and tensile strength of the suture material are discussed and currently under investigation. A Swedish randomized controlled trial showed a significant reduction in the incisional hernia rate by shortening the stitch length. However, a non-elastic thread was used and follow-up ended after 12 months. Therefore, we designed a multicenter, international, double-blinded, randomized trial to analyze the influence of stitch length, using an elastic, extra-long term absorbable monofilament suture, on the long term clinical outcome of abdominal wall closure.MethodsIn total, 468 patients undergoing an elective, median laparotomy will be randomly allocated to either the short stitch or the long stitch suture technique for abdominal wall closure in a 1:1 ratio. Centers located in Germany and Austria will participate. The primary endpoint measure is the incisional hernia rate 1 year postoperatively, as verified by ultrasound. The frequency of short term and long term complications as well as costs, length of hospital stay and patients' quality of life (EQ-5D-5 L) will be considered as secondary parameters. Following hospital discharge, patients will be examined after 30 days and 1, 3, and 5 years after surgery.DiscussionThis study will provide further evidence on whether a short stitch suture technique in combination with an elastic, extra-long term absorbable monofilament suture can prevent incisional hernias in the long term, compared with the long stitch suture technique.Trial registrationNCT01965249 .

Project description:BackgroundRecent genetic studies identified common mutations between diverticular disease and connective tissue disorders, some of which are associated with abdominal wall hernias. Scarce data exists, however, shedding light on the potential clinical implications of this shared etiology, particularly in the era of laparoscopic surgery.MethodsThe New York Statewide Planning and Research Cooperative System database was used to identify adult patients undergoing elective sigmoid and left hemicolectomy (open or laparoscopic) from January 1, 2010, to December 31, 2016, for diverticulitis or descending/sigmoid colon cancer. The incidences of incisional hernia diagnosis and repair were compared using competing risks regression models, clustered by surgeon and adjusted for a host of demographic/clinical variables. Subsequent abdominal surgery and death were considered competing risks.ResultsAmong 8279 patients included in the study cohort, 6811 (82.2%) underwent colectomy for diverticulitis and 1468 (17.8%) for colon cancer. The overall 5-year risk of incisional hernia was 3.5% among patients with colon cancer, regardless of colectomy route, which was significantly lower than that among diverticulitis patients after both open (10.7%; p < 0.001) and laparoscopic (7.2%; p = 0.007) colectomies. Multivariable analyses demonstrated that patients with diverticulitis experienced a two-fold increase in the risk for hernia diagnosis (aHR 1.8; p < 0.001) and repair (aHR 2.1; p < 0.001), and these findings persisted after stratification by colectomy route.ConclusionsPatients undergoing elective colectomy for diverticulitis, including via laparoscopic approach, experience higher rates of incisional hernia compared with patients undergoing similar resections for colon cancer. When performing resections for diverticulitis, surgeons should strongly consider adherence to evidence-based guidelines for fascial closure to prevent this important complication.

Dataset Information

A Risk Model and Cost Analysis of Incisional Hernia After Elective, Abdominal Surgery Based Upon 12,373 Cases: The Case for Targeted Prophylactic Intervention.

Publications

A Risk Model and Cost Analysis of Incisional Hernia After Elective, Abdominal Surgery Based Upon 12,373 Cases: The Case for Targeted Prophylactic Intervention.

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