Fix it while you can … Mortality after umbilical hernia repair in cirrhotic patients

Hill, Charles E.; Olson, Kristofor A.; Roward, Simin; Yan, Derek; Cardenas, Tatiana; Teixeira, Pedro G.; Coopwood, Ben; Trust, Marc D.; Aydelotte, Jayson; Ali, Sádia; Brown, Carlos

doi:10.1016/j.amjsurg.2020.08.022

Cited by 9 publications

(5 citation statements)

References 24 publications

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“…In a systematic review and meta-analysis, the proportion of emergency umbilical hernia repair in patients with cirrhosis was found to be 43% in a total of 3,229 patients with cirrhosis [16]. Furthermore, in some studies, the mortality rate was 15%, and the morbidity rate was at least 80% following emergency umbilical hernia repair in patients with cirrhosis, respectively [17][18][19][20]. According to the latest guidelines published by European Hernia Society (EHS) in 2019, elective umbilical hernia repair should be offered to patients with cirrhosis and with a MELD-score above 15 preceded by preoperative optimization of liver function.…”

Section: Discussionmentioning

confidence: 99%

“…Although elective repair can be safely performed in patients with low MELD scores (\ 15), surgeons remain reluctant to offer elective repair to this patient group [6,7], due to fear of complications and mortality. On the other hand, emergency repair may be associated with increased risk for postoperative morbidity compared with elective surgery [8][9][10][11][12].…”

Section: Introductionmentioning

confidence: 99%

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Umbilical Hernia Repair in Patients with Cirrhosis and in Patients with Severe Comorbidities—A Nationwide Cohort Study

et al. 2023

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Introduction Umbilical hernia is a frequent condition in patients with cirrhosis. The aim of the study was to evaluate the risks associated with umbilical hernia repair in patients with cirrhosis in the elective and emergency setting. Secondly, to compare patients with cirrhosis with a population of patients with equally severe comorbidities but without cirrhosis. Methods Patients with cirrhosis who underwent umbilical hernia repair from January 1, 2007, to December 31, 2018, were included from the Danish Hernia Database. A control group of patients with a similar Charlson score (C 3) without cirrhosis was generated using propensity score matching. The primary outcome was postoperative reintervention within 30 days following hernia repair. Secondary outcomes were mortality within 90 days and readmission within 30 days following hernia repair. Results A total of 252 patients with cirrhosis and 504 controls were included. Emergency repair in patients with cirrhosis was associated with a significantly increased rate of re-intervention (54/108 (50%) vs. 24/144 (16.7%), P \ 0.001), 30-day readmission rate (50/108 (46.3%) compared with elective repair vs. 36/144 (25%) (P \ 0.0001)), and 90-day mortality (18/108 (16.7%) vs. 5/144 (3.5%), P \ 0.001). Patients with cirrhosis were more likely to undergo a postoperative re-intervention compared with comorbid patients without cirrhosis (OR = 2.10; 95% ). Conclusion Patients with cirrhosis and other severe comorbidity undergo emergency umbilical hernia repair frequently. Emergency repair is associated with increased risk of poor outcome. Patients with cirrhosis undergo a postoperative reintervention more frequently than patients with other severe comorbidity undergoing umbilical hernia repair.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Umbilical Hernia Repair in Patients with Cirrhosis and in Patients with Severe Comorbidities—A Nationwide Cohort Study

et al. 2023

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“…In 2007, Nilsson et al found that women face greater mortality after groin hernia repair than men due to the increased risk of emergency procedure [ 14 ] although the dissimilarity in this finding may be due to the difference in the type of hernia. Interestingly, 23.6% of the adult men and 14.6% of the elderly men included in this study had liver disease as a comorbidity, compared to only 9.6% of adult females and 7% of the elderly females ( Table 2 ), and liver disease has previously been shown to be a major predictor of mortality in UH patients [ 15 , 16 ].…”

Section: Discussionmentioning

confidence: 91%

“…Additionally, the literature shows that an incarcerated or strangulated hernia is a risk factor for obstruction or gangrene, respectively, while it is also a typical indication for emergent hernia repair [ 4 , 26 , 27 , 28 ]. Prior studies found that emergent repair of hernia is associated with increased morbidity, mortality, and HLOS [ 3 , 12 , 16 , 29 , 30 , 31 ]. This highlights the need for early intervention and surveillance to prevent such complications requiring emergency surgery [ 26 , 32 ].…”

Section: Discussionmentioning

confidence: 99%

Chances of Mortality Are 3.5-Times Greater in Elderly Patients with Umbilical Hernia Than in Adult Patients: An Analysis of 21,242 Patients

Patel

Smiley

Feingold

et al. 2022

IJERPH

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The goal of this study was to identify risk factors that are associated with mortality in adult and elderly patients who were hospitalized for umbilical hernia. A total of 14,752 adult patients (ages 18–64 years) and 6490 elderly patients (ages 65+), who were admitted emergently for umbilical hernia, were included in this retrospective cohort study. The data were gathered from the National Inpatient Sample (NIS) 2005–2014 database. Predictors of mortality were identified via a multivariable logistic regression, in patients who underwent surgery and those who did not for adult and elderly age groups. The mean (SD) ages for adult males and females were 48.95 (9.61) and 46.59 (11.35) years, respectively. The mean (SD) ages for elderly males and females were 73.62 (6.83) and 77.31 (7.98) years, respectively. The overall mortality was low (113 or 0.8%) in the adult group and in the elderly group (179 or 2.8%). In adult patients who underwent operation, age (OR = 1.066, 95% CI: 1.040–1.093, p < 0.001) and gangrene (OR = 5.635, 95% CI: 2.288–13.874, p < 0.001) were the main risk factors associated with mortality. Within the same population, female sex was found to be a protective factor (OR = 0.547, 95% CI: 0.351–0.854, p = 0.008). Of the total adult sample, 43% used private insurance, while only 18% of patients in the deceased population used private insurance. Conversely, within the entire adult population, only about 48% of patients used Medicare, Medicaid, or self-pay, while these patients made up 75% of the deceased group. In the elderly surgical group, the main risk factors significantly associated with mortality were frailty (OR = 1.284, 95% CI: 1.105–1.491, p = 0.001), gangrene (OR = 13.914, 95% CI: 5.074–38.154, p < 0.001), and age (OR = 1.034, 95% CI: 1.011–1.057, p = 0.003). In the adult non-operation group, hospital length of stay (HLOS) was a significant risk factor associated with mortality (OR = 1.077, 95% CI: 1.004–1.155, p = 0.038). In the elderly non-operation group, obstruction was the main risk factor (OR = 4.534, 95% CI: 1.387–14.819, p = 0.012). Elderly patients experienced a 3.5-fold higher mortality than adult patients who were emergently admitted with umbilical hernia. Increasing age was a significant risk factor of mortality within all patient populations. In the adult surgical group, gangrene, Medicare, Medicaid, and self-pay were significant risk factors of mortality and female sex was a significant protective factor. In the adult non-surgical group, HLOS was the main risk factor of mortality. In the elderly population, frailty and gangrene were the main risk factors of mortality within the surgical group, and obstruction was the main risk factor for the non-surgical group.

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“…The overall emergency repair rate in this study is higher than reported in contemporary studies [6,16,22,24] and a meta-analysis [25] where the pooled emergency repair rate was around 43%. While the rate of elective repair increased in the post-2014 cohort, it highlights the opportunity to improve outcomes for this patient group by identifying patients with cirrhosis and an umbilical hernia before symptoms develop, repairing electively and potentially avoiding the associated morbidity of emergency repair [24,26]. Given the overall complication and mortality rate in patients with cirrhosis and MELD <15 without ascites is comparable to patients without cirrhosis [25], one strategy would be to consider screening and repair of umbilical hernias in this patient group, mirroring the primary prevention approach employed in varices management [27,28].…”

Section: Discussionmentioning

confidence: 99%

Risk factors for decompensation and death following umbilical hernia repair in patients with end-stage liver disease

Malik

Varghese

Pandanaboyana

et al. 2022

European Journal of Gastroenterology &Amp; Hepatology

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Introduction Symptomatic umbilical hernias are a common cause of morbidity and mortality in patients with cirrhosis and end-stage liver disease (ESLD). This study set out to characterise the factors predicting outcome following repair of symptomatic umbilical hernias in ESLD at a single institution. Methods A retrospective review was performed of all patients with ESLD who underwent repair of a symptomatic umbilical hernia between 1998 and 2020. Overall survival was predicted using the Kaplan–Meier method. Logistic regression was used to determine predictors of decompensation and 30-day, 90-day and 1-year mortality. Results One-hundred-and-eight patients with ESLD underwent umbilical hernia repair (emergency n = 78, 72.2%). Transjugular shunting was performed in 29 patients (26.9%). Decompensation occurred in 44 patients (40.7%) and was predicted by emergency surgery (OR, 13.29; P = 0.001). Length of stay was shorter in elective patients compared to emergency patients (3-days vs. 7-days; P = 0.003). Thirty-day, 90-day and 1-year survival was 95.2, 93.2 and 85.4%, respectively. Model for ESLD score >15 predicted 90-day mortality (OR, 18.48; P = 0.030) and hyponatraemia predicted 1-year mortality (OR, 5.31; P = 0.047). Transjugular shunting predicted survival at 1 year (OR, 0.15; P = 0.038). Conclusions Repair of symptomatic umbilical hernias in patients with ESLD can be undertaken with acceptable outcomes in a specialist centre, however, this remains a high-risk intervention. Patients undergoing emergency repair are more likely to decompensate postoperatively, develop wound-related problems and have a longer length of stay. Transjugular shunting may confer a benefit to survival, but further prospective trials are warranted.

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Fix it while you can … Mortality after umbilical hernia repair in cirrhotic patients

Cited by 9 publications

References 24 publications

Umbilical Hernia Repair in Patients with Cirrhosis and in Patients with Severe Comorbidities—A Nationwide Cohort Study

Umbilical Hernia Repair in Patients with Cirrhosis and in Patients with Severe Comorbidities—A Nationwide Cohort Study

Chances of Mortality Are 3.5-Times Greater in Elderly Patients with Umbilical Hernia Than in Adult Patients: An Analysis of 21,242 Patients

Risk factors for decompensation and death following umbilical hernia repair in patients with end-stage liver disease

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