Reuters Health Information (2012-09-20): Should cirrhotic patients with umbilical hernias have surgery?
Should cirrhotic patients with umbilical hernias have surgery?
Last Updated: 2012-09-20 17:00:16 -0400 (Reuters Health)
NEW YORK (Reuters Health) - A new paper helps identify cirrhotic patients with portal hypertension who can safely undergo an umbilical hernia repair.
Elective umbilical herniorrhaphy is much safer for cirrhotic patients with portal hypertension or ascites if they are under 65, have a serum albumin greater than 3 and a model for end-stage liver disease (MELD) score of less than 15, according to a study from Providence Portland Medical Center in Oregon.
In an email to Reuters Health, lead author Dr. Sung W. Cho said, "In some patients with well-compensated liver function, umbilical hernia repair can be performed safely. Our paper identifies those with likely poor outcome and helps in the patient selection process."
The increased intra-abdominal pressure caused by ascites leads to umbilical hernias in as many as 20% of cirrhotic patients. Because of perceived poor outcomes, elective surgical repair is often denied these patients.
The study analyzed five years of data from the National Surgical Quality Improvement Project (NSQIP) and compared umbilical herniorrhaphy in 390 cirrhotic patients with ascites or esophageal varices, or both, to repairs in 22,592 non-cirrhotic patients.
Cirrhotic patients were sicker, having significantly more comorbidities such as heart disease, diabetes, lung disease, hypertension, steroid use and preoperative sepsis, and their American Society of Anesthesiology (ASA) classifications were much higher, with 90% having ASA class III or IV designations versus only 23% of controls (p<0.001).
MELD scores, calculated using serum bilirubin, international normalized ratio for prothrombin time (INR), and serum creatinine, averaged 13 for the cirrhotics and 8 for the controls (p<0.001).
The difficulty of umbilical hernia surgery in these patients is illustrated by the comparison of intraoperative bleeding. Dr. Cho confirmed that the cirrhotic group averaged 3.9 U of blood transfused during surgery while the non-cirrhotic patients needed a mean of only 0.2 U.
Cirrhotic patients had postoperative morbidity and mortality rates of 13.1% and 5.1%, respectively, compared to 3.9% and 0.1% in controls (p<0.001).
On logistic regression analysis, age greater than 65, MELD score greater than 15, preoperative sepsis and a serum albumin of less than 3 each predicted significantly higher mortality for the cirrhotic group.
Emergency surgery was performed in 37.7% of cirrhotics and 4.9% of controls (p<0.001) and was associated with significantly more frequent postoperative sepsis, failure to wean from mechanical ventilation and need to return to the operating room in cirrhotics.
Mortality rates for elective and emergency surgery in cirrhotics were not significantly different, but Dr. Cho said the study may not have been sufficiently powered for this endpoint.
On logistic regression analysis, age greater than 65, meld score greater than 15, preoperative sepsis and albumin levels of less than 3.0 each predicted significantly higher mortality for the cirrhotic group.
The authors acknowledged some limitations of the study. The database had no information on how many patients with umbilical hernias did not have surgery and were successfully observed. In addition, the specific diagnosis of cirrhosis was not recorded and the presence of that disease was inferred from the numbers of patients with esophageal varices and ascites, after excluding those with ascites from kidney disease, malignancy and congestive heart failure.
Still, the researchers believe that elective umbilical herniorrhaphy should be offered to cirrhotic patients without significant predictors of postoperative mortality.
Dr. Andrew McKay of the University of Manitoba, who has published on this subject, told Reuters Health, "This was a well done study and helps guide patient selection in this difficult problem."
He noted that the database was huge, with many more subjects than any other study design would allow. But he too cited variables that couldn't be measured in this study, such as severity of ascites or degree of portal hypertension.
Dr. Cho said, "I think the key to successful outcomes is identifying patients who are at high risk." He suggested that such patients might need referral to tertiary centers with hepatologists and transplant surgeons.
An editorial by hepatic surgeon Dr. Linda L. Wong of the University of Hawaii stated that the recommendation regarding elective surgery for cirrhotic patients was reasonable but proposed that these complex patients might be better managed by liver surgeons.
In an email interview with Reuters Health, Dr. Wong said, "One cannot think of a hernia as just a hole that needs to be patched in a patient with ascites because there are so many other comorbidities, medical issues and management strategies that come along with these patients."
In her opinion, such patients should be evaluated for a liver transplant, and if it is possible and imminent, waiting until after the transplant to fix the hernia could improve outcomes. If a transplant is not possible for some reason, such as age or comorbidities, optimization of the ascites so that the hernia will not recur after surgery should be considered. Diuretics can be better managed, or a transjugular intrahepatic portosystemic shunt (TIPS) can be place to help control the ascites.
Dr. McKay emphasized that the entire picture must be taken into account, and cirrhotic patients' condition must be optimized before elective surgery. Most of these efforts are aimed at reducing ascites or portal hypertension and may not be directly reflected by the MELD score alone.
Dr. Cho agreed that optimizing fluid status with diuretics, improving nutrition and the TIPS procedure might help. But he said, "Our paper was not designed to test this hypothesis. However, it tells us that if one decides to operate on an older patient with a high MELD score and low albumin, surgical outcome will not be good."
The paper appeared in the September 2012 issue of Archives of Surgery,
Arch Surg 2012.