Predictors of 30- and 90-Day Readmissions After Complex Abdominal Wall Reconstruction With Biological Mesh: A Longitudinal Study of 232 Patients

The Modified Fragility Index and Perioperative Albumin as Predictors of Complications in Complex Abdominal Wall Reconstruction

BACKGROUND AND SIGNIFICANCE

Complex abdominal wall reconstruction (CAWR) is performed to restore the structure and function of the abdominal wall. These procedures carry the risk of complications such as delayed wound healing, skin necrosis, infection, recurrence, or even death. The 5-factor modified fragility index (5-mFI) has gained popularity as a concise method of evaluating preoperative risk across various surgical specialties. Additionally, perioperative hypoalbuminemia has been previously associated with delayed wound healing after surgery. The purpose of this study was to assess the utility of the 5-mFI in combination with perioperative albumin levels for assessing risk in complex abdominal wall reconstruction.

METHODS

This was a retrospective, single-institution chart review study of all patients who underwent CAWR by the senior author (A.L.) from 2002 to 2023. Demographics, comorbidities, details of surgery, perioperative albumin levels, ASA scores, and complications were collected for each patient. Five-factor modified fragility indices were calculated for each patient. Statistical analysis consisted of χ 2 and Fisher exact tests for categorical variables, t tests for continuous variables, and multivariate analysis.

RESULTS

Our analysis included 437 patients. The average age of our patients was 54.3 years, the average BMI was 32.1 kg/m 2 , and the average length of follow-up with the plastic surgery service was 264 days. A total of 118 (27.0%) developed complications, with the most common complications being delayed wound healing (89 patients, 20.4%) and infection (78 patients, 17.8%). Other complications included skin necrosis, fistula formation, hematoma, seroma, infection, and death. Sixty patients (13.7%) experienced recurrence of their hernias within the follow-up period. An mFI of 2 or greater was significantly associated with delayed wound healing (LR, 11.42; P = 0.0436) as well as skin necrosis (LR, 4.826; P = 0.028). The presence of an mFI of 2 or greater and perioperative hypoalbuminemia was significantly associated with development of major complications (LR, 3.221; P = 0.0457), delayed wound healing (LR, 5.999; P = 0.0143), skin necrosis (LR, 9.19; P = 0.0024), and mortality (LR, 5.287; P = 0.0215). On multivariate analysis, the presence of an mFI of 2 or greater when combined with perioperative hypoalbuminemia was found to be independently associated with mortality (LR, 1524.5; P < 0.0001).

CONCLUSIONS

We found the 5-factor mFI to be significantly associated with delayed wound healing and skin necrosis in our patient population. When an mFI of 2 or greater was present along with perioperative hypoalbuminemia, patients were significantly more likely to experience complications, issues with wound healing, and mortality. Surgeons should take these findings into account when counseling patients preoperatively.

National epidemiologic trends (2008-2018) in the United States for the incidence and expenditures associated with incisional hernia in relation to abdominal surgery

PURPOSE

It is unknown whether the trend of rising incisional hernia (IH) repair (IHR) incidence and costs until 2011 currently persists. We aimed to evaluate how the IHR procedure incidence, cost and patient risk-profile have changed over the last decade relative to all abdominal surgeries (AS).

METHODS

Repeated cross-sectional analysis of 38,512,737 patients undergoing inpatient 4AS including IHR within the 2008-2018 National Inpatient Sample. Yearly incidence (procedures/1,000,000 people [PMP]), hospital costs, surgical and patient characteristics were compared between IHR and AS using generalized linear and multinomial regression.

RESULTS

Between 2008-2018, 3.1% of AS were IHR (1,200,568/38,512,737). There was a steeper decrease in the incidence of AS (356.5 PMP/year) compared to IHR procedures (12.0 PMP/year) which resulted in the IHR burden relative to AS (2008-2018: 12,576.3 to 9,113.4 PMP; trend difference P < 0.01). National costs averaged $47.9 and 1.7 billion/year for AS and IHR, respectively. From 2008-2018, procedure costs increased significantly for AS (68.2%) and IHR (74.6%; trends P < 0.01). Open IHR downtrended (42.2%), whereas laparoscopic (511.1%) and robotic (19,301%) uptrended significantly (trends P < 0.01). For both AS and IHR, the proportion of older (65-85y), Black and Hispanic, publicly-insured, and low-income patients, with higher comorbidity burden, undergoing elective procedures at small- and medium-sized hospitals uptrended significantly (all P < 0.01).

CONCLUSION

IH persists as a healthcare burden as demonstrated by the increased proportion of IHR relative to all AS, disproportionate presence of high-risk patients that undergo these procedures, and increased costs. Targeted efforts for IH prevention have the potential of decreasing $17 M/year in costs for every 1% reduction.

Early versus delayed complex abdominal wall reconstruction with biologic mesh following damage-control surgery

BACKGROUND

Damage-control surgery for trauma and intra-abdominal catastrophe is associated with a high rate of morbidities and postoperative complications. This study aimed to compare the outcomes of patients undergoing early complex abdominal wall reconstruction (e-CAWR) in acute settings versus those undergoing delayed complex abdominal wall reconstruction (d-CAWR).

METHOD

This study was a pooled analysis derived from the retrospective and prospective database between the years 2013 and 2019. The outcomes were compared for differences in demographics, presentation, intraoperative variables, Ventral Hernia Working Grade (VHWG), US Centers for Disease Control and Prevention wound class, American Society of Anesthesiologists (ASA) scores, postoperative complications, hospital length of stay, and readmission rates. We performed Student's t test, χ2 test, and Fisher's exact test to compare variables of interest. Multivariable linear regression model was built to evaluate the association of hospital length of stay and all other variables including the timing of complex abdominal wall reconstruction (CAWR). A p value of <0.05 was considered significant.

RESULTS

Of the 236 patients who underwent CAWR with biological mesh, 79 (33.5%) had e-CAWR. There were 45 males (57%) and 34 females (43%) in the e-CAWR group. The ASA scores of IV and V, and VHWG grades III and IV were significantly more frequent in the e-CAWR group compared with the d-CAWR one. Postoperatively, the incidence of surgical site occurrence, Clavien-Dindo complications, comprehensive complication index, unplanned reoperations, and mortality were similar between the two groups. Backward linear regression model showed that the timing of CAWR (β = -11.29, p < 0.0001), ASA (β = 3.98, p = 0.006), VHWG classification (β = 3.62, p = 0.015), drug abuse (β = 13.47, p = 0.009), and two comorbidities of cirrhosis (β = 12.34, p = 0.001) and malignancy (β = 7.91, p = 0.008) were the significant predictors of the hospital length of stay left in the model.

CONCLUSION

Early CAWR led to shorter hospital length of stay compared with d-CAWR in multivariable regression model.

LEVEL OF EVIDENCE

Therapeutic, level IV.

Risk factors, outcomes, and complications associated with combined ventral hernia and enterocutaneous fistula single-staged abdominal wall reconstruction

PURPOSE

To compare two cohorts of patients; those with isolated ventral hernias (VH) and those with VH and enterocutaneous fistulas (ECF). Risk factors for surgical complications (including recurrent ECF) and outcomes during single-stage VH with ECF surgical reconstruction were analyzed.

METHODS

A retrospective review was performed from 2008 to 2019. We compared two cohorts of patients with single-stage VH repairs: (1) ventral hernia repair alone (hernia alone), and (2) combined VH repair and ECF repair (hernia plus ECF). Inclusion criteria were patients ≥ 18 years of age with pre-operative VH either with or without an ECF, who underwent open hernia repair and ECF repair in a single-stage operation, with a minimum follow-up of 12 months. Patient risk factors, operative characteristics, outcomes and surgical-site complications were compared using univariate and multivariate analyses.

RESULTS

We included 442 patients (hernia alone = 401; hernia plus ECF = 41) with a median follow-up of 22 months (12-96). Hernia plus ECF patients were more likely to have inflammatory bowel disease (IBD)(OR 4.4, 95% CI 1.1-17.5, p = 0.037), a history of abdominal wound infections (OR 3.4, 95% CI 1.5-7.9, p = 0.004), reoperations (OR 4.9, 95% CI 1.6-15.4, p = 0.006), superficial soft tissue infections (OR 2.5, 95% CI 1.1-6.1, p = 0.044) and hematomas (OR 8.4, 95% CI 1.2-58.8, p = 0.031), compared to hernia alone patients. ECF recurrence was associated with diabetes mellitus (DM) (n = 8, 73% vs. n = 6, 20%; p = 0.003) and surgical-site complications (n = 10, 91% vs. n = 16, 53%; p = 0.048), compared to ECF resolution.

CONCLUSION

Risk factors for developing ECF were IBD and history of abdominal wound infections. Single-staged combined ECF reconstruction was associated with reoperations, soft tissue infections and hematomas. DM and surgical-site complications were associated with ECF recurrence.

Biologic Mesh in Surgery: A Comprehensive Review and Meta-Analysis of Selected Outcomes in 51 Studies and 6079 Patients

BACKGROUND

In recent decades, biologic mesh (BM) has become an important adjunct to surgical practice. Recent evidence-based clinical applications of BM include but are not limited to: reconstruction of abdominal wall defects; breast reconstruction; face, head and neck surgery; periodontal surgery; other hernia repairs (diaphragmatic, hiatal/paraesophageal, inguinal and perineal); hand surgery; and shoulder arthroplasty. Prior systematic reviews of BM in complex abdominal wall hernia repair had several shortcomings that our comprehensive review seeks to address, including exclusion of laparoscopic repair, assessment of risk of bias, use of an acceptable meta-analytic method and review of risk factors identified in multivariable regression analyses.

MATERIALS AND METHODS

We sought articles of BM for open ventral hernia repair reporting on early complications, late complications or recurrences and included minimum of 50. We used the quality in prognostic studies risk of bias assessment tool. Random effects meta-analysis was applied.

RESULTS

This comprehensive review selected 62 articles from 51 studies that included 6,079 patients. Meta-analytic pooling found that early complications are present in about 50%, surgical site occurrences (SSOs) in 37%, surgical site infections (SSIs) in 18%, reoperation in 7%, readmission in 20% and mortality in 3%. Meta-analytic estimates of late outcomes included overall complications (42%), SSOs (40%) and SSIs (22%). Specific SSOs included seroma (14%), hematoma (4%), abscess (10%), necrosis (5%), dehiscence (8%) and fistula formation (5%). Reoperation occurred in about 17%, mesh explantation in 9% and recurrence in 36%.

CONCLUSION

Estimates of nearly all outcomes from individual studies were highly heterogeneous and sensitivity analyses and meta-regressions generally failed to explain this heterogeneity. Recurrence is the only outcome for which there are consistent findings for risk factors. Bridge placement of BM is associated with higher risk of recurrence. Prior hernia repair, history of reintervention and history of mesh removal were also risk factors for increased recurrence.