title: Abdominal wall hernia in cirrhotic patients: emergency surgery results in higher morbidity and mortality.
abstract: BACKGROUND
  Patients with cirrhosis have a high incidence of abdominal wall hernias and carry an elevated perioperative morbidity and mortality. The optimal surgical management strategy as well as timing of abdominal hernia repair remains controversial.
  
  
  METHODS
  A cohort study of 67 cirrhotic patients who underwent hernia repair during the period of January 1998-December 2009 at the University Hospital of Sao Paulo were included. After meeting study criteria, a total of 56 patients who underwent 61 surgeries were included in the final analysis. Patient characteristics, morbidity (Clavien score), mortality, Child-Turcotte-Pugh score, MELD score, use of prosthetic material, and elective or emergency surgery have been analysed with regards to morbidity and 30-day mortality.
  
  
  RESULTS
  The median MELD score of the patient population was 14 (range: 6 to 24). Emergency surgery was performed in 34 patients because of ruptured hernia (n = 13), incarceration (n = 10), strangulation (n = 4), and skin necrosis or ulceration (n = 7). Elective surgery was performed in 27 cases. After a multivariable analysis, emergency surgery (OR 7.31; p 0.017) and Child-Pugh C (OR 4.54; p 0.037) were risk factors for major complications. Moreover, emergency surgery was a unique independent risk factor for 30-day mortality (OR 10.83; p 0.028).
  
  
  CONCLUSIONS
  Higher morbidity and mortality are associated with emergency surgery in advanced cirrhotic patients. Therefore, using cirrhosis as a contraindication for hernia repair in all patients may be reconsidered in the future, especially after controlling ascites and in those patients with hernias that are becoming symptomatic or show signs of possible skin necrosis and rupture. Future prospective randomized studies are needed to confirm this surgical strategy.
authors.affiliation: Digestive Organs Transplant Unit, Department of Gastroenterology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil. wellington@usp.br.
authors.forename: Wellington
authors.initials: W
authors.lastname: Andraus
authors.affiliation: Digestive Organs Transplant Unit, Department of Gastroenterology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil.
authors.forename: Rafael Soares
authors.initials: RS
authors.lastname: Pinheiro
authors.affiliation: Department of Hepatic Surgery and Liver Transplantation, Azienda Universitario-ospedaliera Pisana, Pisa, Italy.
authors.forename: Quirino
authors.initials: Q
authors.lastname: Lai
authors.affiliation: Digestive Organs Transplant Unit, Department of Gastroenterology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil.
authors.forename: Luciana B P
authors.initials: LBP
authors.lastname: Haddad
authors.affiliation: Digestive Organs Transplant Unit, Department of Gastroenterology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil.
authors.forename: Lucas S
authors.initials: LS
authors.lastname: Nacif
authors.affiliation: Digestive Organs Transplant Unit, Department of Gastroenterology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil.
authors.forename: Luiz Augusto C
authors.initials: LAC
authors.lastname: D'Albuquerque
authors.affiliation: Starzl Unit of Abdominal Transplantation, University Hospital of Saint Luc, Université Catholique of Louvain, Brussels, Belgium.
authors.forename: Jan
authors.initials: J
authors.lastname: Lerut
mesh_terms: D000328:Adult; D000368:Aged; D000075202:Contraindications; D017558:Elective Surgical Procedures / Q000401:mortality; D004630:Emergencies; D005260:Female; D005500:Follow-Up Studies; D046449:Hernia, Abdominal / Q000150:complications / Q000401:mortality / Q000601:surgery*; D059685:Herniorrhaphy / Q000401:mortality; D006801:Humans; D008103:Liver Cirrhosis / Q000150:complications*; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D011183:Postoperative Complications / Q000453:epidemiology / Q000209:etiology; D012189:Retrospective Studies; D012307:Risk Factors; D016896:Treatment Outcome