Impact of obesity on postoperative 30-day outcomes in emergent open ventral hernia repairs

doi:10.1016/j.amjsurg.2016.09.007

The American Journal of Surgery

Volume 212, Issue 6, December 2016, Pages 1068-1075

https://doi.org/10.1016/j.amjsurg.2016.09.007 Get rights and content

Abstract

Background

Anecdotally, obese patients experience increased morbidity with emergent ventral hernia repair (VHR). We hypothesized obese patients are over-represented in emergent VHRs and experience increased 30-day morbidity.

Methods

American College of Surgeons National Surgical Quality Improvement Program database (2011 to 2013) was queried for patients undergoing open VHR. Patients were stratified by body mass index (BMI) categories: underweight, normal weight, overweight, and obesity classes I, II, and III; 30-day postoperative complications (surgical site infections, return to operating room, dehiscence, death) were evaluated across BMI for elective vs emergent VHR.

Results

In all, 39,822 patients were included: 7.3% emergent. Obese classes I to III represented higher percent of emergent VHRs (55.8% vs 68.9%). Complication rate doubled for emergent group (7.2% vs 14.5%), and likelihood of at least one complication increased with BMI for emergent vs normal weight–elective VHR (overweight odds ratio, 2.2; 95% confidence interval, 1.4 to 3.4; class III odds ratio, 4.0; 95% confidence interval, 2.9 to 5.5).

Conclusions

Selection bias exists with obese patients and ventral hernias. Emergent VHR have increased complications. Elective BMI cutoffs require re-evaluation.

Section snippets

Methods

The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database offers a robust blinded, risk-adjusted database evaluating 30-day postoperative outcomes, with currently 707 sites participating. NSQIP enables national benchmarking of complication rates and surgical outcomes.19, 20

An institutional review board approved the retrospective review of NSQIP data from 2011 to 2013. Patients age ≥18 undergoing open repair of initial/recurrent incisional or ventral hernias

Results

In all, 39,822 patients comprised the total data set. The data set was split randomly by year into 2 sets evenly: 1 set for model selection and estimation of parameters and the other for validation of the model. Table 1 provides baseline characteristics for elective and emergent VHR groups in estimation set. Owing to the large sample size, many of the comparisons between baseline characteristics were statistically significant but do not reflect clinical significance. Analysis of the validation

Comments

The increasing incidence of both elective and emergent VHRs demands re-evaluation of VHR management, especially in light of the increased risk of morbidity and mortality of emergent repairs.2, 3 Our data found approximately 7% of VHRs were preformed emergent. This population was associated with higher risks of 30-day postoperative surgical site complications and mortality (SSO, unadjusted OR, 2.2; 95% CI, 1.9 to 2.5; mortality unadjusted OR, 5.8; 95% CI, 3.6 to 9.2; P < .0001). Likewise,

Conclusions

Selection bias is present in obese patients with ventral hernias. These patients are over-represented in both elective and emergent VHRs. The risk of complications with emergent VHR is greater than the risk of complication with elective VHR in patients with co-morbidities of obesity, diabetes, and smoking. Given the irreversible trajectory of ventral hernias, poor patient reported QOL with conservative management and increased morbidity with emergent VHR, BMI cutoffs for elective surgery, and

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Cited by (21)

Tipping the scale in abdominal wall reconstruction: An analysis of short- and long-term outcomes by body mass index
2024, Surgery (United States)
Morbid obesity, with a body mass index 35 kg/m², is a commonly used cutoff for denying elective transversus abdominis release. Although obesity is linked to short-term wound morbidity, its effect on long-term outcomes remains unknown, calling into question if a cutoff is justified. We sought to compare 1-year recurrence rates after transversus abdominis release based on body mass index and to evaluate short- and long-term outcomes.
Patients undergoing open, clean transversus abdominis release from August 2014 to January 2022 at our institution with 1-year follow-up completed were identified. Univariate and multivariable analyses were performed to determine the association of body mass index with 90-day wound events, 1-year hernia recurrence, and hernia-specific quality of life. Covariates included body mass index, diabetes, recurrent hernia, hernia width, fascial closure, surgical site occurrence requiring procedural intervention, previous abdominal wall surgical site infection, inflammatory bowel disease, mesh weight, and mesh–to–hernia size ratio.
A total of 1,089 patients were included. Increasing body mass index was associated with surgical site infection (adjusted odds ratio = 1.59; 95% confidence interval, 1.14–1.77; P < .01) and surgical site occurrence (adjusted odds ratio = 1.42; 95% confidence interval, 1.13–1.74; P < .01) but was not associated with surgical site occurrence requiring procedural intervention. Hernia width was associated with surgical site occurrence (adjusted odds ratio = 1.4; 95% confidence interval, 1.08–1.82; P < .01) and surgical site occurrence requiring procedural intervention (adjusted odds ratio = 1.4; 95% confidence interval, 1.08–1.82; P = .01). Hernia recurrence rate at 1 year was lower for the body mass index ≥35 kg/m² group (7% vs 12%; P = .02). Hernia width (odds ratio = 1.33; 95% confidence interval, 1.02–1.74; P = .04) was associated with recurrence; body mass index was not (P = .11). Both groups experienced significant improvement in hernia-specific quality of life at 1 year.
Morbid obesity is associated with 90-day wound morbidity; however, short-term complications did not translate to higher reoperation or long-term recurrence rates. The impact of body mass index on hernia recurrence is likely overstated. An arbitrary body mass index cutoff of 35 kg/m² should not be used to deny symptomatic patients abdominal wall reconstruction.
High Body Mass Index is Associated With Increased Risk of Complications After Emergency Ventral Hernia Repair
2024, Journal of Surgical Research
Emergency general surgery is a risk factor for postoperative morbidity and mortality. Patients with obesity are at greater risk for complications following ventral hernia repair (VHR). Our study aimed to determine the association of obesity with postoperative outcomes in patients requiring emergency VHR.
Our retrospective study used the 2016-2020 National Surgical Quality Improvement Program database to identify patients undergoing emergency VHR. Patients were classified by body mass index (BMI): normal weight 18.5-24.9 kg/m², overweight 25-29.9 kg/m², obesity 30-39.9 kg/m², morbid obesity 40-49.9 kg/m², and super morbid obesity (SMO) ≥50 kg/m². The primary outcome of interest was surgical site infection (SSI).
From 2016 to 2020, a total 11,593 patients underwent emergency VHR. Patients with higher BMI had increased incidences of postoperative complications. Compared to other patients with obesity, SMO patients had higher rates of SSI (11.5% versus 5.5%, P < 0.001), prolonged ventilatory support (4.0% versus 1.5%, P < 0.001), length of stay ≥4 d (52.7% versus 42.2%, P < 0.001), reoperation (6.4% versus 3.4%, P < 0.001), and readmission (11.3% versus 7.2%, P < 0.001). Super morbid obesity (SMO) patients had increased odds of SSI (odds ratio [OR] 5.55, 95% confidence interval [CI] 3.47-8.88), prolonged ventilatory support (OR 1.92, 95% CI 1.07-3.45), and reoperation (OR 1.97, 95% CI 1.26-3.09) compared to normal weight patients.
Patients with BMI ≥50 kg/m² undergoing emergency VHR have increased overall incidences of SSIs, prolonged mechanical ventilation, reoperation, and readmission, and this remains significant when compared to other patients with obesity. This population is at significant risk for postoperative morbidity, and increased vigilance in perioperative management is imperative to ensure safe, high-quality care.
Ventral Hernia Management in Obese Patients
2021, Surgical Clinics of North America
Citation Excerpt :
Emergency VHR was required in 7.4% of patients, of whom 68.9% were obese, with BMI greater than 40 kg/m2 conferring a 3-times higher risk of requiring emergent repair. Emergent VHR is less likely to utilize mesh; increases risk of SSI, return to the operating room, dehiscence, and mortality; and doubles the overall surgical complications in obese patients.64 Hernia characteristics help predict the risk of incarceration.
Postoperative outcomes of ventral hernia repair in veterans
2021, Surgery (United States)
Citation Excerpt :
Studies comparing open (OVHR) and laparoscopic VHR (LVHR) have yielded conflicting data, with no clearly defined selection criteria to determine patient suitability for either type of operation.5,6 Outcome analyses of different surgical approaches for repair, coupled by factor association with postoperative adverse events, may help individualize the operative approach for each patient.7-9 Obesity is a well-known risk factor for developing ventral/incisional hernias as well as their recurrence.3
Ventral hernia repair is a common procedure with reported 15% to 37% morbidity and 0.3% to 1.4% mortality rates. This study examines the 30-day morbidity and mortality of open and laparoscopic ventral hernia repair in veterans, along with the impact of body mass index on these outcomes.
The Veterans Affairs Surgical Quality Improvement Program was queried for all ventral hernia repairs during the period 2008 to 2015. In this retrospective analysis, we compared outcomes of open ventral hernia repair versus laparoscopic ventral hernia repair and among different body mass index classes.
A total of 19,883 patients were identified (92.6% male, mean age 59.7, 53.1% obese, and 71.6% with American Society of Anesthesiologists class ≥III). There were 95 (0.5%) mortalities, and complications occurred in 1,289 (6.5%) patients. Open ventral hernia repair was performed in 60.2%; 14.5% were recurrent, and 3.3% were performed as an emergency operation. When compared with open ventral hernia repair, the laparoscopic ventral hernia repair group had higher mean body mass index, less patients with American Society of Anesthesiologists class ≥III, fewer emergency operations, longer operative time, less complications, decreased mortality, and shorter duration of stay. Body mass index 35.00 to 49.99 was predictive of overall complications in the open ventral hernia repair group.
Ventral hernia repair can be performed in the veteran population with outcomes comparable to those in the private sector. Morbid obesity has a negative impact on ventral hernia repair outcomes that is most prominent following open surgery. Laparoscopic ventral hernia repair may offer superior outcomes when compared to open ventral hernia repair and may be considered.
Improved Understanding of Acute Incisional Hernia Incarceration: Implications for Addressing the Excess Mortality of Emergent Repair
2020, Journal of the American College of Surgeons
Citation Excerpt :
Decision-making for incisional hernia management is complex and requires assessment of both the risk of elective repair and the potential for acute incarceration. This is particularly true because patients who experience acute incarceration and require emergent operations tend to have worse outcomes.11-13 We identified contributors to increased risk of mortality and bowel resection to inform incisional hernia management.
Incisional hernia develops in up to 20% of patients undergoing abdominal operations. We sought to identify characteristics associated with poor outcomes after acute incisional hernia incarceration.
We performed a retrospective cohort study of adult patients with incisional hernias undergoing elective repair or with acute incarceration between 2010 and 2017. The primary end point was 30-day mortality. Logistic regression was used to determine adjusted odds associated with 30-day mortality. The American College of Surgeons Surgical Risk Calculator was used to estimate outcomes had these patients undergone elective repair.
A total of 483 patients experienced acute incarceration; 30-day mortality was 9.52%. Increasing age (adjusted odds ratio 1.05; 95% CI, 1.02 to 1.08) and bowel resection (adjusted odds ratio 3.18; 95% CI, 1.45 to 6.95) were associated with mortality. Among those with acute incarceration, 231 patients (47.9%) had no documentation of an earlier surgical evaluation and 252 (52.2%) had been evaluated but had not undergone elective repair. Among patients 80 years and older, 30-day mortality after emergent repair was high (22.9%) compared with estimated 30-day mortality for elective repair (0.73%), based on the American College of Surgeons Surgical Risk Calculator. Estimated mortality was comparable with observed elective repair mortality (0.82%) in an age-matched cohort. Similar mortality trends were noted for patients younger than 60 years and aged 60 to 79 years.
Comparison of predicted elective repair and observed emergent repair mortality in patients with acute incarceration suggests that acceptable outcomes could have been achieved with elective repair. Almost one-half of acute incarceration patients had no earlier surgical evaluation, therefore, targeted interventions to address surgical referral can potentially result in fewer incarceration-related deaths.
“Closed-Incision Negative-Pressure Therapy Efficacy in Abdominal Wall Reconstruction in High-Risk Patients: A Meta-Analysis”
2019, Journal of Surgical Research
Citation Excerpt :
Obesity as defined by the National Center for Chronic Disease Prevention and Health Promotion is body mass index (BMI) ≥30 kg/m2. It is a known risk factor for surgical site infections (SSIs) and wound complications, particularly in ventral hernia repair1-6 and abdominal-based breast reconstruction.7-13 Closed-incision negativepressure therapy (ciNPT) has been used anecdotally in high-risk patients to prevent surgical site infection (SSI) and wound complications.14,15
Obesity is a known risk factor for surgical complications. Closed-incision negative-pressure therapy (ciNPT) has been used anecdotally in high-risk patients to prevent wound complications and infection. This meta-analysis aims to evaluate the efficacy of ciNPT in reducing the incidence of wound complications and infection in abdominal wall reconstruction.
A literature search using the PubMed/MEDLINE databases (2006-2016) was conducted to identify publications comparing ciNPT to standard incisional care for abdominal wall reconstruction. Outcomes of interest included surgical site infection, wound dehiscence, seroma, hematoma, reoperation, and readmission. Overall rates and associations were pooled. A fixed and random effects model was used upon meta-analysis. Publication bias was assessed using funnel plots.
A total of 11 studies met inclusion criteria. There were 1723 patients included, 681 in the ciNPT group, and 1042 in the standard incisional care group. The majority of patients were obese, diabetic, and had a recent history of smoking. On meta-analysis, the risk of surgical site infection decreased by 51% (relative risk: 0.51, 95% confidence interval [0.41-0.63]). The risk of wound dehiscence decreased by 51% (relative risk: 0.51, 95% confidence interval [0.34-0.76]). There was no significant decreased risk observed with ciNPT use for the outcomes of seroma, hematoma, reoperation, and readmission.
The use of ciNPT reduced the incidence of infection and wound dehiscence in patients with varying risk factors undergoing abdominal wall reconstruction. Future prospective randomized clinical trials are still needed to determine the efficacy of ciNPT in plastic surgery.

View all citing articles on Scopus

: There were no relevant financial relationships or any sources of support in the form of grants, equipment, or drugs.

: The authors declare no conflicts of interest.

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Southwestern Surgical CongressImpact of obesity on postoperative 30-day outcomes in emergent open ventral hernia repairs

Abstract

Background

Methods

Results

Conclusions

Section snippets

Methods

Results

Comments

Conclusions

Am J Surg

Surgery

Surgery

Am J Surg

J Am Coll Surg

Am J Surg

J Surg Res

Outcomes of emergent incisional hernia repair

Am Surg

Trends in emergent hernia repair in the United States

JAMA Surg

Outcomes after emergency versus elective ventral hernia repair: a prospective national study

World J Surg

Risk of death after emergency repair of abdominal wall hernias. Still waiting for improvement

Langenbecks Arch Surg

Emergency incisional hernia repair: a difficult problem waiting for a solution

Ann Surg Innov Res

Watchful waiting vs repair of inguinal hernia in minimally symptomatic. A randomized clinical trial

JAMA

Southwestern Surgical Congress
Impact of obesity on postoperative 30-day outcomes in emergent open ventral hernia repairs