title: Poor outcomes in cirrhosis-associated hernia repair: a nationwide cohort study of 32,033 patients.
abstract: Cirrhosis is a significant marker of adverse postoperative outcome. A large national database was analyzed for abdominal wall hernia repair outcomes in cirrhotic vs. non-cirrhotic patients. Data from cirrhotics and non-cirrhotics undergoing inpatient repair of abdominal wall hernias (excluding inguinal) from 1999 to 2004 were obtained from the University HealthSystem Consortium (UHC) database. Differences (P < 0.05) were determined using standard statistical methods. Inpatient hernia repair was performed in 30,836 non-cirrhotic (41.5% male) and 1,197 cirrhotic patients (62.7% male; P < 0.0001). Cirrhotics had a higher age distribution (P < 0.0001), no race differences (P = 0.64), underwent ICU admission more commonly (15.9% vs. 6%; P < 0.0001), had a longer LOS (5.4 vs. 3.7 days), and higher morbidity (16.5% vs. 13.8%; P = 0.008), and mortality (2.5% vs. 0.2%; P < 0.0001) compared to non-cirrhotics. Several comorbidities had a higher associated mortality in cirrhosis: functional impairment, congestive heart failure, renal failure, nutritional deficiencies, and peripheral vascular disease. The complications with the highest associated mortality in cirrhotics were aspiration pneumonia, pulmonary compromise, myocardial infarction, pneumonia, and metabolic derangements. Cirrhotics underwent emergent surgery more commonly than non-cirrhotics (58.9% vs. 29.5%; P < 0.0001), with longer LOS regardless of elective or emergent surgery. Although elective surgical morbidity in cirrhotics was no different from non-cirrhotics (15.6% vs. 13.5%; P = 0.18), emergent surgery morbidity was (17.3% vs. 14.5%; P = 0.04). While differences in elective surgical mortality in cirrhotics approached significance (0.6% vs. 0.1%; P = 0.06), mortality was 7-fold higher in emergencies (3.8% vs. 0.5%; P < 0.0001). Patients with cirrhosis carry a significant risk of adverse outcome after abdominal wall hernia repair compared to non-cirrhotics, particularly with emergent surgery. It may, however, be safer than previously thought. Ideally, patients with cirrhosis should undergo elective hernia repair after medical optimization.
authors.affiliation: Minimally Invasive Surgery Center Division of General Surgery, Virginia Commonwealth University Medical Center, 1200 East Broad Street, Richmond, P.O. Box 980519, VA 23298, USA. amcarbonell@vcu.edu
authors.forename: Alfredo M
authors.initials: AM
authors.lastname: Carbonell
authors.forename: Luke G
authors.initials: LG
authors.lastname: Wolfe
authors.forename: Eric J
authors.initials: EJ
authors.lastname: DeMaria
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D015331:Cohort Studies; D004630:Emergencies; D005260:Female; D006554:Hernia, Umbilical / Q000209:etiology / Q000401:mortality / Q000601:surgery*; D006555:Hernia, Ventral / Q000209:etiology / Q000401:mortality / Q000601:surgery*; D017052:Hospital Mortality; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008103:Liver Cirrhosis / Q000150:complications* / Q000401:mortality; D008297:Male; D008875:Middle Aged; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology