Abdominal hernias in cirrhotic patients: Surgery or conservative treatment? Results of a prospective cohort study in a high volume center: Cohort study

Abstract

BackgroundSurgical treatment of abdominal hernias in cirrhotics is often delayed due to the higher morbidity and mortality associated with the underlying liver disease. Some patients are followed conservatively and only operated on when complications occur (“wait and see” approach). The aim of this study is to compare outcomes of cirrhotic patients undergoing conservative non-operative care or elective hernia repair.MethodsA prospective observational study including 246 cirrhotic patients with abdominal hernia was carried out. Patients were given the option to select their treatment: elective hernia repair or conservative non-operative care. Demographics, characteristics of underlying liver disease, type of hernia, complications and mortality were analyzed. During follow-up of patients who opted for the “wait and see” approach, emergency hernia repair was performed in case of hernia complications.ResultsElective hernia repair was performed in 57 patients and 189 patients were kept in conservative care, of which 43 (22.7%) developed complications that required emergency hernia repair. Elective surgery provided better five-years survival than conservative care (80% vs. 62%; p = 0.012). Multivariate analysis identified multiples hernias [Hazards Ratio (HR):6.7, p < 0.001] and clinical follow-up group (HR 3.62, p = 0.005) as risk factors for mortality. Among patients undergoing surgical treatment, multivariate analysis revealed MELD>11 (HR 7.8; p = 0.011) and emergency hernia repair (HR 5.35; p = 0.005) as independent risk factors for 30-day mortality.ConclusionsElective hernia repair offers an acceptable morbidity and ensures longer survival. “Wait and see” approach jeopardizes cirrhotic patients and should be avoided, given the higher incidence of emergency surgery due to hernia complications.

Cirrhosis and hernia repair in a cohort of 6352 patients in a tertiary hospital: Risk assessment and survival analysis

“…Regarding sex, the group of patient with cirrhosis had a higher prevalence of men (76%) than non-cirrhotic patient, similar to that found by Pinheiro et al [ 13 ] who only analyzed a population of patients with hernia and cirrhosis (73.9%). The BMI of patients with cirrhosis (26.2) in our study was lower than that found in the group without cirrhosis, probably due to the state of malnutrition resulting from cirrhosis.…”

“…[8] For these reasons, in addition to the supposed perioperative decompensation, the repair of hernias in the abdominal and inguinal wall in these patients is traditionally managed by a “watch and see strategy.” [5,8–12] However, this strategy can lead to worse outcomes for the patient in inadequate clinical conditions, such as in emergency cases, where an increased risk of perioperative morbidity and mortality is frequently found. [13–15]…”

The impact of compensated and decompensated cirrhosis on the postoperative outcomes of patients undergoing hernia repair: a propensity score-matched analysis of 2011–2017 US hospital database

“…The increased postoperative mortality associated with DC is in line with prior studies that stratified the preoperative populations according to escalating levels of MELD and Child-Pugh scores [4,11]. These studies showed a correlative risk in postoperative mortality with rising scores, thus reinforcing the importance of liver prognostication in these select patients with underlying cirrhosis [4,11,31,32]. Our study supports these conclusions, as it demonstrates a similar rise in risk ratios (odds ratios and adjusted odds ratios) associated with DC, although this was only evident in patients undergoing umbilical and other abdominal hernia repairs.…”

“…These studies may not be applicable to current hernia repair outcomes in cirrhotic patients since they are over a decade old [4,7–10,12]. Additionally, many of these studies are cohort-based studies with a small sample size, which further reduces their statistical power [4,8–10,12]. Therefore, in order to better clarify the current prognostic implications of cirrhosis on hernia repair outcomes, there needs to be a study approach that incorporates a large-scale database with current data on the intersection between cirrhosis and various types of hernia surgery.…”

Conservative treatment versus elective repair of umbilical hernia in patients with liver cirrhosis and ascites: results of a randomized controlled trial (CRUCIAL trial)

“…Additionally, a conservative approach can also be accompanied by severe complications; our study showed more incarceration, decompensated cirrhosis, and ultimately death for the patients in the conservative treatment group than in the intervention group. Other authors describe a nearly 23% emergency surgery rate due to complications of a hernia during conservative treatment [ 23 ].…”