Umbilical Herniorrhapy in Patients with Cirrhosis: Improved Outcomes with Elective Repair
Stephen H. Gray*1,2, Catherine C. Vick1,3, Laura a. Graham3, Kelly R. Finan1,3, Leigh a. Neumayer4,5, Mary T. Hawn1,3
1Department of Surgery, University of Alabama at Birmingham, Birmingham, AL; 2Health Services & Outcomes Research Training Program, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL; 3Deep South Center on Effectiveness, Birmingham Veterans Affairs Medical Center, Birmingham, AL; 4Department of Surgery, University of Utah, Salt Lake City, UT; 5Surgery, Salt Lake City VA Healthcare System, Salt Lake City, UT
Background: Umbilical herniorrhapy (UHR) is a commonly performed operation with low morbidity and mortality. Patients with cirrhosis frequently develop umbilical hernias; however, UHR is often reserved for hernia related complications. We performed a retrospective multi-site study to examine the effect of cirrhosis on elective and emergent UHR outcomes within the VA healthcare system.
Methods: We abstracted medical records and operative reports on patients undergoing UHR at 16 VA hospitals between 1998-2002 to ascertain: 1) primary versus recurrent hernia, 2) elective versus emergent case status, 3) indication for surgery and 4) presence of cirrhosis. Pre-operative risk variables and post-operative outcomes were obtained from matched records in the National Surgical Quality Improvement Program dataset.
Results: Of the 1421 cases reviewed, 127 (8.9%) had cirrhosis. Overall, patients with cirrhosis were more likely to have an emergent repair (25.6% vs. 4.8% p< 0.0001), concomitant bowel resection (7.9% vs. 0.5% p<0.0001), return to operating room (7.9% vs. 2.5% p=0.0006), and increased median post-operative length of stay (LOS) (4.0 days vs. 2.0 days p=0.01). There were no deaths in either group. Best-fit multivariable regression analysis of UHR found cirrhosis was not a significant predictor of postoperative complications. Significant predictors of complications were emergent case status (OR 6.1; 95% CI 3.5-10.5), diabetes (OR 2.4; 95% CI 1.4-4.2), and COPD (OR 2.1; 95% CI 1.2-3.8). However, among patients undergoing emergent repair cirrhosis (OR 3.6; 95% CI 1.1-11.7) was strongly associated with postoperative complications, other predictors of marginal statistical significance include alcohol use, diabetes, and COPD.
Conclusions: Umbilical hernia repair in patients with cirrhosis is more likely to be performed for hernia related complications, such as incarceration or obstruction. In this multi-site study, we found that elective UHR in cirrhotics is safe and associated with similar outcomes as in patients without cirrhosis. However, emergent repair of UHR in patients with cirrhosis is associated with worse outcomes. Early elective repair of umbilical hernias may improve the overall outcomes for patients with cirrhosis.
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