Two-year Outcomes of Prehabilitation Among Obese Patients With Ventral Hernias

Abstract

Objective: To determine if preoperative nutritional counseling and exercise (prehabilitation) improve outcomes in obese patients seeking ventral hernia repair (VHR)? Summary Background Data: Obesity and poor fitness are associated with complications following VHR. It is unknown if preoperative prehabilitation improves outcomes of obese patients seeking VHR. Methods: This is the 2-year follow-up of a blinded randomized controlled trial from 2015 to 2017 at a safety-net academic institution. Obese patients (BMI 30-40) seeking VHR were randomized to prehabilitation versus standard counseling. Elective VHR was performed once preoperative requirements were met: 7% total body weight loss or 6 months of counseling and no weight gain. Primary outcome was percentage of hernia-free and complication-free patients at 2 years. Complications included recurrence, reoperation, and mesh complications. Primary outcome was compared using chi-square. We hypothesize that prehabilitation in obese patients with VHR results in more hernia-and complication-free patients at 2-years. Results: Of the 118 randomized patients, 108 (91.5%) completed a median (range) follow-up of 27.3 (6.2-37.4) months. Baseline BMI (meanAESD) was similar between groups (36.8 AE 2.6 vs 37.0 AE 2.6). More patients in the prehabilitation group underwent emergency surgery (5 vs 1) or dropped out of the program (3 vs 1) compared to standard counseling (13.6% vs 3.4%, P ¼ 0.094). Among patients who underwent surgery, there was no difference in major complications (10.2% vs 9.1%, P ¼ 0.438). At 2-years, there was no difference in percentage of hernia-free and complication-free patients (72.9% vs 66.1%, P ¼ 0.424, 1.14, 0.88-1.47). Conclusion: There is no difference in 2-year outcomes of obese patients seeking VHR who undergo prehabilitation versus standard care. Prehabilitation may not be warranted in obese patients undergoing elective VHR.Clinical Trial Registration: This trial was registered with clinicaltrials.gov (NCT02365194).

Robotic Versus Laparoscopic Ventral Hernia Repair

“…Many of the patients included in this trial were at high risk for recurrence given presence of co-morbidities and prior abdominal surgeries 2 . It is unclear if the recurrence rates will taper off and be similar to our other published trials at 24 to 36 months 16,17 . The 2-year and 3-year results will shed more light on the timing of recurrence and the overall rate.…”

“…As this was not our primary outcome, we are unable to conclude if this is a true finding or secondary to chance. These results should be framed in conjunction with our prior RCTs with 2-year reoperation rates following LVHR of 1%–2% 16,17 . Given our results and assuming true effect size is 50% lower (4.5% vs 0.5% reoperation rate), 476 patients would be needed for an appropriately powered study to detect a true difference.…”

“…2 It is unclear if the recurrence rates will taper off and be similar to our other published trials at 24 to 36 months. 16,17 The 2-year and 3-year results will shed more light on the timing of recurrence and the overall rate.…”

Preoperative Optimization Before Ventral Hernia Repair: A Systematic Review and Meta-analysis

“…Most of these patients might not achieve the target weight to become optimal candidates for hernia repair, which prevents them from having a better quality of life and keeps them at risk for acute incarceration and strangulation 12. In one randomized clinical trial enrolling 118 obese patients with ventral hernias, only 12 patients (20%) were able to achieve the target weight loss of 7% of total body weight even with a prehabilitation program, and only half of them were able to maintain that weight loss after 2 years 8…”

Prehabilitation and Nutrition in Hernia Surgery

“…Interestingly, a recent report of the same study with 2 years of follow-up found no difference between the two groups in the percentage of hernia-free and complication-free patients (72.9 vs. 66.1%, p ¼ 0.424). 27 Further research is warranted before these findings can be generalized to the larger VHR population; it is possible that a personalized approach, as opposed to a one-size-fits-all program, provides longer lasting results. 28 Beyond these early conclusions, the many similarities between the abdominal wall and musculoskeletal tendons provide a solid physiopathological basis to support exercise conditioning before VHR.…”