1
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Grappolini N, Zanchetta M, Inversini D, Ietto G. Spontaneous bowel evisceration through umbilical hernia in an adult non-cirrhotic patient. BMJ Case Rep 2024; 17:e258602. [PMID: 38589238 PMCID: PMC11015293 DOI: 10.1136/bcr-2023-258602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2024] [Indexed: 04/10/2024] Open
Abstract
Few cases of spontaneous bowel evisceration (SBE) through umbilical hernias (UHs) in adult patients have been reported in the literature. Interestingly, the spontaneous rupture of the hernia sac is a rare complication usually seen in adult cirrhotic patients with persistent ascites or in patients with congenital wall defects. A man in his early 50s was admitted to our emergency department with SBE through a long-standing acquired UH. He was not clinically cirrhotic, although being HCV positive. Surgeons performed an urgent laparotomy with ileal resection, latero-lateral ileal anastomosis and direct hernioplasty without mesh. Given the rarity of this presentation, we reported it and reviewed the available literature on this subject. Elective hernioplasty is currently suggested to lower the risk of complications. Mesh placement should be preferred, but only if comorbidities and infectious risks do not contraindicate its use. In emergency situations, a direct hernia repair is preferred.
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Affiliation(s)
- Niccolo Grappolini
- General, Emergency and Transplant Surgery Department, University of Insubria, Varese, Italy
| | - Matteo Zanchetta
- General, Emergency and Transplant Surgery Department, University of Insubria, Varese, Italy
| | - Davide Inversini
- General, Emergency and Transplant Surgery Department, University of Insubria, Varese, Italy
- Department of Medicine and Innovation Technology, University of Insubria, Varese, Italy
| | - Giuseppe Ietto
- General, Emergency and Transplant Surgery Department, University of Insubria, Varese, Italy
- Department of Medicine and Innovation Technology, University of Insubria, Varese, Italy
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2
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van Steensel S, Deerenberg EB, Poelman MM. Abdominal wall closure. Br J Surg 2023; 110:1597-1600. [PMID: 37713648 DOI: 10.1093/bjs/znad294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 08/27/2023] [Indexed: 09/17/2023]
Affiliation(s)
| | - Eva B Deerenberg
- Department of General Surgery, Franciscus Gasthuis en Vlietland, Rotterdam, The Netherlands
| | - Marijn M Poelman
- Department of General Surgery, Franciscus Gasthuis en Vlietland, Rotterdam, The Netherlands
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3
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Snitkjær C, Christoffersen MW, Gluud LL, Kimer N, Helgstrand F, Jensen KK, Henriksen NA. Umbilical Hernia Repair in Patients with Cirrhosis and in Patients with Severe Comorbidities-A Nationwide Cohort Study. World J Surg 2023; 47:2733-2740. [PMID: 37202491 DOI: 10.1007/s00268-023-07047-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/24/2023] [Indexed: 05/20/2023]
Abstract
INTRODUCTION Umbilical hernia is a frequent condition in patients with cirrhosis. The aim of the study was to evaluate the risks associated with umbilical hernia repair in patients with cirrhosis in the elective and emergency setting. Secondly, to compare patients with cirrhosis with a population of patients with equally severe comorbidities but without cirrhosis. METHODS Patients with cirrhosis who underwent umbilical hernia repair from January 1, 2007, to December 31, 2018, were included from the Danish Hernia Database. A control group of patients with a similar Charlson score (≥ 3) without cirrhosis was generated using propensity score matching. The primary outcome was postoperative re-intervention within 30 days following hernia repair. Secondary outcomes were mortality within 90 days and readmission within 30 days following hernia repair. RESULTS A total of 252 patients with cirrhosis and 504 controls were included. Emergency repair in patients with cirrhosis was associated with a significantly increased rate of re-intervention (54/108 (50%) vs. 24/144 (16.7%), P < 0.001), 30-day readmission rate (50/108 (46.3%) compared with elective repair vs. 36/144 (25%) (P < 0.0001)), and 90-day mortality (18/108 (16.7%) vs. 5/144 (3.5%), P < 0.001). Patients with cirrhosis were more likely to undergo a postoperative re-intervention compared with comorbid patients without cirrhosis (OR = 2.10; 95% CI [1.45-3.03]). CONCLUSION Patients with cirrhosis and other severe comorbidity undergo emergency umbilical hernia repair frequently. Emergency repair is associated with increased risk of poor outcome. Patients with cirrhosis undergo a postoperative reintervention more frequently than patients with other severe comorbidity undergoing umbilical hernia repair.
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Affiliation(s)
- Christian Snitkjær
- Abdominalcenter, University of Copenhagen, Herlev Hospital, 2730, Herlev, Denmark.
| | - Mette W Christoffersen
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Lise Lotte Gluud
- Gastro Unit, Medical Division, University Hospital Hvidovre, Copenhagen, Denmark
| | - Nina Kimer
- Gastro Unit, Medical Division, University Hospital Hvidovre, Copenhagen, Denmark
| | | | - Kristian Kiim Jensen
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Nadia A Henriksen
- Abdominalcenter, University of Copenhagen, Herlev Hospital, 2730, Herlev, Denmark
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4
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Li XT, Lin MZ, Chen HD, Chen M. Incarcerated umbilical hernia in a patient with cirrhotic ascites in combination with chronic lymphocytic leukemia: a case report. J Int Med Res 2023; 51:3000605231208574. [PMID: 37933975 PMCID: PMC10631368 DOI: 10.1177/03000605231208574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 10/02/2023] [Indexed: 11/08/2023] Open
Abstract
Umbilical hernia is a common type of extra-abdominal hernia in adults. However, chronic granulocytic leukemia in combination with cirrhotic ascites and renal insufficiency is less common. The patient reported here had both indications and contraindications for emergency surgery; therefore, the treatment options were subject to debate. We report the case of a man in his 60s who had a strangulated umbilical hernia, with overlying purple-colored infected and necrotic skin. The area was painful, but his bowel movements were normal. Patients underwent comprehensive conservative management, and remote follow-ups via telephone and video conferencing for a period of 60 days, during which the incarcerated contents of the hernia eventually retracted and his pain was relieved, such that there were no longer indications for emergency surgery. In addition, his skin infection disappeared and his quality of life improved, and therefore the treatment outcomes were good. Thus, we provide evidence that not all incarcerated umbilical hernias require emergency surgery, but may respond well to conservative treatment when the contents do not include intestinal loops or other critical organs.
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Affiliation(s)
- Xiao-Tian Li
- Department of Hepatobiliary Surgery, Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Man-Zhou Lin
- Department of Hepatobiliary Surgery, Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
- Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Huan-De Chen
- Department of Hepatobiliary Surgery, Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Ming Chen
- Department of Hepatobiliary Surgery, Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
- Guangdong Medical University, Zhanjiang, Guangdong, China
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5
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Shahait A, Mesquita-Neto JWB, Weaver D, Mostafa G. Outcomes of umbilical hernia repair in cirrhotic veterans: a VASQIP study. Langenbecks Arch Surg 2023; 408:246. [PMID: 37358646 DOI: 10.1007/s00423-023-02984-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 06/14/2023] [Indexed: 06/27/2023]
Abstract
PURPOSE Umbilical hernia repair (UHR) in cirrhotics with ascites is a challenging problem associated with increased morbidity and mortality. This study examines the outcomes of UHR in veterans, comparing those undergoing elective versus emergent repair. METHODS VASQIP was queried for all UHRs during the period 2008-2015. Data collection included demographics, operative details, Model for End-stage Liver Disease (MELD) score, and postoperative outcomes. Univariate and multivariate regression analyses were performed, and a p value of ≤ 0.05 was considered significant. RESULTS A total of 383 patients were included in the analysis. Overall, mean age was 58.9, 99.0% were males, mean body mass index (BMI) was 26.7 kg/m2, 98.2% had American Society of Anesthesiologists (ASA) classification ≥ III, and 87.7% had independent functional status. More than 1/3 the patients underwent emergent UHR (37.6%). Compared with the elective UHR group, who underwent emergent repair were older, more likely to be functionally dependent, higher MELD score. Hypoalbuminemia, emergency repair and MELD score were found to be independent predictors of poor outcomes. CONCLUSION UHR in cirrhotic veterans has worse outcomes when performed emergently. Diagnosis should be followed by medical optimization and elective repair, rather than waiting for an emergent indication in > 1/3 of patients.
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Affiliation(s)
- Awni Shahait
- The Michael and Marian Ilitch Department of Surgery, Wayne State University School of Medicine, Detroit Medical Center, 6C, University Health Center, 4201 St. Antoine, Detroit, MI, 48201, USA.
- Department of Surgery, John D Dingell Veterans Affairs Medical Center, Detroit, MI, USA.
| | - Jose Wilson B Mesquita-Neto
- The Michael and Marian Ilitch Department of Surgery, Wayne State University School of Medicine, Detroit Medical Center, 6C, University Health Center, 4201 St. Antoine, Detroit, MI, 48201, USA
- Department of Surgery, John D Dingell Veterans Affairs Medical Center, Detroit, MI, USA
| | - Donald Weaver
- The Michael and Marian Ilitch Department of Surgery, Wayne State University School of Medicine, Detroit Medical Center, 6C, University Health Center, 4201 St. Antoine, Detroit, MI, 48201, USA
- Department of Surgery, John D Dingell Veterans Affairs Medical Center, Detroit, MI, USA
| | - Gamal Mostafa
- The Michael and Marian Ilitch Department of Surgery, Wayne State University School of Medicine, Detroit Medical Center, 6C, University Health Center, 4201 St. Antoine, Detroit, MI, 48201, USA
- Department of Surgery, John D Dingell Veterans Affairs Medical Center, Detroit, MI, USA
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Abbas N, Fallowfield J, Patch D, Stanley AJ, Mookerjee R, Tsochatzis E, Leithead JA, Hayes P, Chauhan A, Sharma V, Rajoriya N, Bach S, Faulkner T, Tripathi D. Guidance document: risk assessment of patients with cirrhosis prior to elective non-hepatic surgery. Frontline Gastroenterol 2023; 14:359-370. [PMID: 37581186 PMCID: PMC10423609 DOI: 10.1136/flgastro-2023-102381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/16/2023] Open
Abstract
As a result of the increasing incidence of cirrhosis in the UK, more patients with chronic liver disease are being considered for elective non-hepatic surgery. A historical reluctance to offer surgery to such patients stems from general perceptions of poor postoperative outcomes. While this is true for those with decompensated cirrhosis, selected patients with compensated early-stage cirrhosis can have good outcomes after careful risk assessment. Well-recognised risks include those of general anaesthesia, bleeding, infections, impaired wound healing, acute kidney injury and cardiovascular compromise. Intra-abdominal or cardiothoracic surgery are particularly high-risk interventions. Clinical assessment supplemented by blood tests, imaging, liver stiffness measurement, endoscopy and assessment of portal pressure (derived from the hepatic venous pressure gradient) can facilitate risk stratification. Traditional prognostic scoring systems including the Child-Turcotte-Pugh and Model for End-stage Liver Disease are helpful but may overestimate surgical risk. Specific prognostic scores like Mayo Risk Score, VOCAL-Penn and ADOPT-LC can add precision to risk assessment. Measures to mitigate risk include careful management of varices, nutritional optimisation and where possible addressing any ongoing aetiological drivers such as alcohol consumption. The role of portal decompression such as transjugular intrahepatic portosystemic shunting can be considered in selected high-risk patients, but further prospective study of this approach is required. It is of paramount importance that patients are discussed in a multidisciplinary forum, and that patients are carefully counselled about potential risks and benefits.
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Affiliation(s)
- Nadir Abbas
- The Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Jonathan Fallowfield
- Centre for Inflammation Research, The University of Edinburgh The Queen's Medical Research Institute, Edinburgh, UK
| | - David Patch
- Hepatology and Liver Transplantation, Royal Free Hampstead NHS Trust, London, UK
| | - Adrian J Stanley
- Gastroenterology Department, Glasgow Royal Infirmary, Glasgow, UK
| | - Raj Mookerjee
- Institute for Liver and Digestive Health, University College London, London, UK
| | | | - Joanna A Leithead
- Department of Gastroenterology, Forth Valley Royal Hospital, Larbert, UK
- Hepatology, Forth Valley Royal Hospital, Larbert, UK
| | - Peter Hayes
- The Liver Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Abhishek Chauhan
- The Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Vikram Sharma
- GI and Liver Unit, Royal London Hospital, London, UK
| | - Neil Rajoriya
- The Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Simon Bach
- Academic Department of Surgery, University Hospitals NHS Foundation Trust, Birmingham, UK
| | - Thomas Faulkner
- Department of Anaesthetics, University Hospitals NHS Foundation Trust, Birmingham, UK
| | - Dhiraj Tripathi
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
- The Liver Unit, University Hospitals NHS Foundation Trust, Birmingham, UK
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7
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Seppey R, Benjamin A, Lambrakis P. A novel approach to managing ruptured umbilical hernias in cirrhosis. ANZ J Surg 2022; 92:2524-2528. [DOI: 10.1111/ans.17936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 06/15/2022] [Accepted: 07/14/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Romain Seppey
- Trauma and Acute Care Surgery Unit Liverpool Hospital Sydney New South Wales Australia
| | - Aditya Benjamin
- Trauma and Acute Care Surgery Unit Liverpool Hospital Sydney New South Wales Australia
| | - Paul Lambrakis
- Trauma and Acute Care Surgery Unit Liverpool Hospital Sydney New South Wales Australia
- School of Medicine University of New South Wales Sydney New South Wales Australia
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8
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Bronswijk M, Jaekers J, Vanella G, Struyve M, Miserez M, van der Merwe S. Umbilical hernia repair in patients with cirrhosis: who, when and how to treat. Hernia 2022; 26:1447-1457. [PMID: 35507128 DOI: 10.1007/s10029-022-02617-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 04/09/2022] [Indexed: 11/21/2022]
Abstract
PURPOSE Hernia management in patients with cirrhosis is a challenging problem, where indication, timing and type of surgery have been a subject of debate. Given the high risk of morbidity and mortality following surgery, together with increased risk of recurrence, a wait and see approach was often advocated in the past. METHODS The purpose of this review was to provide an overview of crucial elements in the treatment of patients with cirrhosis and umbilical hernia. RESULTS Perioperative ascites control is regarded as the major factor in timing of hernia repair and is considered the most important factor governing outcome. This can be accomplished by either medical treatment, ascites drainage prior to surgery or reduction of portal hypertension by means of a transjugular intrahepatic portosystemic shunt (TIPS). The high incidence of perioperative complications and inferior outcomes of emergency surgery strongly favor elective surgery, instead of a "wait and see" approach, allowing for adequate patient selection, scheduled timing of elective surgery and dedicated perioperative care. The Child-Pugh-Turcotte and MELD score remain strong prognostic parameters and furthermore aid in identifying patients who fulfill criteria for liver transplantation. Such patients should be evaluated for early listing as potential candidates for transplantation and simultaneous hernia repair, especially in case of umbilical vein recanalization and uncontrolled refractory preoperative ascites. Considering surgical techniques, low-quality evidence suggests mesh implantation might reduce hernia recurrence without dramatically increasing morbidity, at least in elective circumstances. CONCLUSION Preventing emergency surgery and optimizing perioperative care are crucial factors in reducing morbidity and mortality in patients with umbilical hernia and cirrhosis.
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Affiliation(s)
- M Bronswijk
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Herestraat 49, 3000, Leuven, Belgium.,Department of Gastroenterology and Hepatology, Imelda Hospital, Bonheiden, Belgium.,Imelda GI Clinical Research Center, Bonheiden, Belgium
| | - J Jaekers
- Department of Abdominal Surgery, University Hospitals Leuven, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - G Vanella
- Pancreatobiliary Endoscopy and Endosonography Division, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - M Struyve
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Herestraat 49, 3000, Leuven, Belgium.,Department of Gastroenterology and Hepatology, Ziekenhuis Oost Limburg, Genk, Belgium
| | - M Miserez
- Department of Abdominal Surgery, University Hospitals Leuven, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - S van der Merwe
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Herestraat 49, 3000, Leuven, Belgium. .,Laboratory of Hepatology, CHROMETA Department, KU Leuven, Herestraat 49, 3000, Leuven, Belgium.
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9
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Snitkjær C, Jensen KK, Henriksen NA, Werge MP, Kimer N, Gluud LL, Christoffersen MW. Umbilical hernia repair in patients with cirrhosis: systematic review of mortality and complications. Hernia 2022; 26:1435-1445. [PMID: 35412192 DOI: 10.1007/s10029-022-02598-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 03/06/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Umbilical hernia is a common and potential serious condition in patients with cirrhosis. This systematic review evaluated the risks associated with emergency and elective hernia repair in patients with cirrhosis. METHODS Systematic review of clinical trials identified through manual and electronic searches in several databases (last update November 2021). The primary random-effects meta-analyses evaluated mortality in patients with or without cirrhosis or following emergency versus elective repair. The quality of the evidence was assessed using GRADE and Newcastle Ottawa Scale. RESULTS Thirteen prospective and 10 retrospective studies including a total of 3229 patients were included. The evidence was graded as very low quality for all outcomes (mortality and postoperative complications within 90 days). In total 191 patients (6%) died after undergoing umbilical hernia repair. Patients with cirrhosis were more than eight times as likely to die after surgery compared with patients without cirrhosis [OR = 8.50, 95% CI (1.91-37.86)] corresponding to 69 more deaths/1000 patients. Among patients with cirrhosis, mortality was higher after emergency versus elective repair [OR = 2.67, 95% CI (1.87-3.97)] corresponding to 52 more deaths/1000 patients. Postoperative complications were more common in patients with cirrhosis compared with patients without cirrhosis. CONCLUSION Patients with cirrhosis undergoing emergency umbilical hernia repair have a considerably increased risk of death and severe complications. Accordingly, additional evidence is needed to evaluate methods that would allow elective umbilical hernia repair in patients with cirrhosis.
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Affiliation(s)
- C Snitkjær
- Gastro Unit, Hvidovre Hospital, University of Copenhagen, Copenhagen University Hospital Hvidovre, 2650, Hvidovre, Denmark.
| | - K K Jensen
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - N A Henriksen
- Abdominal Center, Herlev Hospital, University of Copenhagen, Copenhagen, Denmark
| | - M P Werge
- Gastro Unit, Hvidovre Hospital, University of Copenhagen, Copenhagen University Hospital Hvidovre, 2650, Hvidovre, Denmark
| | - N Kimer
- Gastro Unit, Hvidovre Hospital, University of Copenhagen, Copenhagen University Hospital Hvidovre, 2650, Hvidovre, Denmark
| | - L L Gluud
- Gastro Unit, Hvidovre Hospital, University of Copenhagen, Copenhagen University Hospital Hvidovre, 2650, Hvidovre, Denmark
| | - M W Christoffersen
- Gastro Unit, Hvidovre Hospital, University of Copenhagen, Copenhagen University Hospital Hvidovre, 2650, Hvidovre, Denmark
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10
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Albeladi AM, Odeh AM, AlAli AH, Alkhars AM, Buhlaigah AM, Alghadeer HA, Almosbeh MJ, AlAbbad MT, AlGhadeer MS. Spontaneous Umbilical Hernia Rupture Associated With Omentum Evisceration in a Patient With Advanced Hepatic Cirrhosis and Refractory Ascites. Cureus 2021; 13:e16042. [PMID: 34336523 PMCID: PMC8321416 DOI: 10.7759/cureus.16042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/29/2021] [Indexed: 11/05/2022] Open
Abstract
Flood syndrome is a spontaneous rupture of an umbilical hernia. It has a high mortality and morbidity and presents many challenges in medical versus surgical management. We present a case of a 23-year-old Yamani woman with complicated umbilical hernia, newly diagnosed hepatitis B infection, and decompensated liver cirrhosis with ascites (Child-Pugh grade B). The patient was undergoing multiple abdominal ascitic tapping that eventually ruptured with an omentum evisceration, causing Flood syndrome. An urgent umbilical hernioplasty with mesh in a sublay technique was conducted.
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Affiliation(s)
| | - Ahmad M Odeh
- Laparoscopic Surgery, Prince Saud Bin Jalawi Hospital, Al-Ahsa, SAU
| | - Aminah H AlAli
- General Surgery, Prince Saud Bin Jalawi Hospital, Al-Ahsa, SAU
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11
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Spring A, Saran JS, McCarthy S, McCluskey SA. Anesthesia for the Patient with Severe Liver Failure. Adv Anesth 2020; 38:251-267. [PMID: 34106838 DOI: 10.1016/j.aan.2020.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The incidence of liver failure continues to increase, and it is associated with increased perioperative morbidity and mortality. Liver failure is associated with multiorgan dysfunction, including central nervous, cardiac, respiratory, gastrointestinal, renal, and hematological systems. Preoperative identification, optimization, and tailored anesthetic management are essential for optimum outcomes in patients with liver disease undergoing surgery. The coagulopathy of liver failure is a balanced coagulopathy better assessed by thromboelastography than conventional testing, and it is not directly associated with bleeding risk.
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Affiliation(s)
- Aidan Spring
- Abdominal Organ Transplantation Anesthesia Fellowship Program, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, 3 Eaton North, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada
| | - Jagroop S Saran
- Abdominal Organ Transplantation Anesthesia Fellowship Program, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, 3 Eaton North, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada
| | - Sinead McCarthy
- Abdominal Organ Transplantation Anesthesia Fellowship Program, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, 3 Eaton North, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada
| | - Stuart A McCluskey
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, 3 Eaton North, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada.
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12
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Conservative treatment versus elective repair of umbilical hernia in patients with liver cirrhosis and ascites: results of a randomized controlled trial (CRUCIAL trial). Langenbecks Arch Surg 2020; 406:219-225. [PMID: 33237442 PMCID: PMC7870599 DOI: 10.1007/s00423-020-02033-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Accepted: 11/15/2020] [Indexed: 11/08/2022]
Abstract
Purpose To establish optimal management of patients with an umbilical hernia complicated by liver cirrhosis and ascites. Methods Patients with an umbilical hernia and liver cirrhosis and ascites were randomly assigned to receive either elective repair or conservative treatment. The primary endpoint was overall morbidity related to the umbilical hernia or its treatment after 24 months of follow-up. Secondary endpoints included the severity of these hernia-related complications, quality of life, and cumulative hernia recurrence rate. Results Thirty-four patients were included in the study. Sixteen patients were randomly assigned to elective repair and 18 to conservative treatment. After 24 months, 8 patients (50%) assigned to elective repair compared to 14 patients (77.8%) assigned to conservative treatment had a complication related to the umbilical hernia or its repair. A recurrent hernia was reported in 16.7% of patients who underwent repair. For the secondary endpoint, quality of life through the physical (PCS) and mental component score (MCS) showed no significant differences between groups at 12 months of follow-up (mean difference PCS 11.95, 95% CI − 0.87 to 24.77; MCS 10.04, 95% CI − 2.78 to 22.86). Conclusion This trial could not show a relevant difference in overall morbidity after 24 months of follow-up in favor of elective umbilical hernia repair, because of the limited number of patients included. However, elective repair of umbilical hernia in patients with liver cirrhosis and ascites appears feasible, nudging its implementation into daily practice further, particularly for patients experiencing complaints. Trial registration Clinicaltrials.gov, NCT01421550, on 23 August 2011.
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13
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Yang S, Wu B, Wang Y, Yang L, Luo W, Lei W, Zhou Z. Repair of a medium-sized ventral hernia with the UltraPro Hernia System. Surg Today 2020; 51:1068-1073. [PMID: 33156422 DOI: 10.1007/s00595-020-02172-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 08/25/2020] [Indexed: 02/05/2023]
Abstract
Mesh repairs are widely accepted as a suitable option for ventral hernia repair. Among the various devices and surgical approaches used for ventral hernia repair, the UltraPro Hernia System (UHS) is considered an effective method of open repair for patients with medium ventral hernia defects between 3 and 5 cm in diameter. However, few clinical studies on this system have been reported. We describe a simple and safe UHS mesh technique for open ventral hernia repair, which was performed successfully under local anesthesia in 23 patients with medium ventral hernia defects. Minor postoperative complications included seroma (n = 3) and a superficial infection (n = 1). There was no incidence of recurrence in 12 months of follow-up. Our results show that the UHS is simple and easily reproducible for medium ventral hernia defects between 3 and 5 cm in diameter.
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Affiliation(s)
- Shiwei Yang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Bing Wu
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Yong Wang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China.
| | - Lie Yang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China.
| | - Wenqin Luo
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Wenzhang Lei
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Zongguang Zhou
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China
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14
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Shimamura Y, Nishi S. Umbilical hernia in a patient with liver cirrhosis. J Gen Fam Med 2020; 22:59-60. [PMID: 33457162 PMCID: PMC7796786 DOI: 10.1002/jgf2.385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 07/23/2020] [Accepted: 09/17/2020] [Indexed: 11/22/2022] Open
Affiliation(s)
| | - Satoshi Nishi
- Department of Surgery Teine Keijinkai Medical Center Sapporo Japan
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15
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Hill CE, Olson KA, Roward S, Yan D, Cardenas T, Teixeira P, Coopwood BT, Trust M, Aydelotte J, Ali S, Brown C. Fix it while you can … Mortality after umbilical hernia repair in cirrhotic patients. Am J Surg 2020; 220:1402-1404. [PMID: 32988606 DOI: 10.1016/j.amjsurg.2020.08.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 07/08/2020] [Accepted: 08/19/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND We hypothesize that patients with compensated cirrhosis undergoing elective UHR have an improved mortality compared to those undergoing emergent UHR. METHOD The NIS was queried for patients undergoing UHR by CPT code, and ICD-10 codes were used to define separate patient categories of non-cirrhosis (NC), compensated cirrhosis (CC) and decompensated cirrhosis (DC). RESULTS A total of 32,526 patients underwent UHR, 97% no cirrhosis, 1.1% compensated cirrhosis, 1.7% decompensated cirrhosis. On logistic regression, cirrhosis was found to be independently associated with mortality (OR 2.841, CI 2.14-3.77). On subset analysis of only cirrhosis patients, elective repair was found to be protective from mortality (OR 0.361, CI 0.15-0.87, p = 0.02). CONCLUSIONS In this retrospective review, cirrhosis as well as emergent UHR in cirrhotic patients were independently associated with mortality. More specifically, electively (rather than emergently) repairing an umbilical hernia in cirrhotic patients was independently associated with a 64% reduction in mortality.
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Affiliation(s)
- Charles E Hill
- Dept of Surgery and Perioperative Care, Dell Seton Medical Center at Univ of Texas at Austin, 1500 Red River St Suite G, Austin, Tx, 78701, USA.
| | - Kristofor A Olson
- Dept of Surgery and Perioperative Care, Dell Seton Medical Center at Univ of Texas at Austin, 1500 Red River St Suite G, Austin, Tx, 78701, USA
| | - Simin Roward
- Dept of Surgery and Perioperative Care, Dell Seton Medical Center at Univ of Texas at Austin, 1500 Red River St Suite G, Austin, Tx, 78701, USA
| | - Derek Yan
- Dept of Surgery and Perioperative Care, Dell Seton Medical Center at Univ of Texas at Austin, 1500 Red River St Suite G, Austin, Tx, 78701, USA
| | - Tatiana Cardenas
- Dept of Surgery and Perioperative Care, Dell Seton Medical Center at Univ of Texas at Austin, 1500 Red River St Suite G, Austin, Tx, 78701, USA
| | - Pedro Teixeira
- Dept of Surgery and Perioperative Care, Dell Seton Medical Center at Univ of Texas at Austin, 1500 Red River St Suite G, Austin, Tx, 78701, USA
| | - Ben T Coopwood
- Dept of Surgery and Perioperative Care, Dell Seton Medical Center at Univ of Texas at Austin, 1500 Red River St Suite G, Austin, Tx, 78701, USA
| | - Marc Trust
- Dept of Surgery and Perioperative Care, Dell Seton Medical Center at Univ of Texas at Austin, 1500 Red River St Suite G, Austin, Tx, 78701, USA
| | - Jayson Aydelotte
- Dept of Surgery and Perioperative Care, Dell Seton Medical Center at Univ of Texas at Austin, 1500 Red River St Suite G, Austin, Tx, 78701, USA
| | - Sadia Ali
- Dept of Surgery and Perioperative Care, Dell Seton Medical Center at Univ of Texas at Austin, 1500 Red River St Suite G, Austin, Tx, 78701, USA
| | - Carlos Brown
- Dept of Surgery and Perioperative Care, Dell Seton Medical Center at Univ of Texas at Austin, 1500 Red River St Suite G, Austin, Tx, 78701, USA
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16
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Sheikh MM, Siraj B, Fatima F, Ehsan H, Shahid MH. Flood Syndrome: A Rare and Fatal Complication of Umbilical Hernia in Liver Cirrhosis. Cureus 2020; 12:e9915. [PMID: 32968577 PMCID: PMC7505645 DOI: 10.7759/cureus.9915] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Flood syndrome, first reported in 1961 by Frank B Flood, refers to spontaneous umbilical hernia rupture followed by a sudden rush of ascitic fluid. It is a rare sequela in the setting of refractory ascites and liver cirrhosis. Clues to impending rupture include color changes, ulceration, or necrosis over the umbilical hernia that warrants urgent surgical intervention. In this report, we present a unique case of Flood syndrome in a patient with decompensated cirrhosis and umbilical hernia. The patient underwent urgent umbilical herniorrhaphy without mesh; even though adequate postoperative management of ascites was performed, the patient still developed other comorbidities.
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Affiliation(s)
| | - Bakhtawer Siraj
- Internal Medicine, Einstein Medical Center Philadelphia, Philadelphia, USA
| | - Faraeha Fatima
- Internal Medicine, King Edward Medical University, Lahore, PAK
| | - Hamid Ehsan
- Internal Medicine, MedStar Union Memorial Hospital, Baltimore, USA.,Biomedical Sciences, Georgetown University, Washington, D.C., USA
| | - Muhammad Hassaan Shahid
- Pulmonary and Critical Care Medicine, The University of Tennessee Health Science Center, Memphis, USA
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17
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Combined treatment of refractory ascites with an alfapump® plus hernia repair in the same surgical session: A retrospective, multicentre, European pilot study in cirrhotic patients. J Visc Surg 2020; 158:27-37. [PMID: 32553558 DOI: 10.1016/j.jviscsurg.2020.06.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
INTRODUCTION The treatment of symptomatic hernia in cirrhotic patients with refractory ascites is critical but challenging. The objective of this study was to assess the feasibility and safety of the implantation of alfapump® combined with concomitant hernia repair in cirrhotic patients with refractory ascites. METHODS Using data from six European centres, we retrospectively compared patients treated with alfapump® system implantation and concomitant hernia repair [the combined treatment group (CT group, n=12)] or with intermittent paracentesis hernia repair [the standard treatment group (ST group, n=26)]. Some patients of the ST group had hernia repair in an elective setting (STel group) and others in emergency (STem group). The endpoints were requirement of peritoneal drainage, the rate of infectious complications, the in-hospital mortality, the length of stay, paracentesis-free survival. RESULTS Postoperatively, none of the patients in the CT group and 21 patients (80%) in the ST group underwent peritoneal drainage for the evacuation of ascites fluid (P<0.0001). The overall incidence of infectious complications was not different between groups but there were fewer infections in the CT group than in the STem group (33% vs. 81%; P=0.01). There was no difference for in-hospital mortality. The length of stay was shorter in the CT group (P=0.03). Paracentesis-free survival was significantly better (P=0.0003) in the CT group than in the ST group. CONCLUSION Implantation of alfapump combined with concomitant hernia repair seems feasible and safe in cirrhotic patients; however, larger and randomized study are required.
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18
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Spring A, Saran JS, McCarthy S, McCluskey SA. Anesthesia for the Patient with Severe Liver Failure. Anesthesiol Clin 2020; 38:35-50. [PMID: 32008656 DOI: 10.1016/j.anclin.2019.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The incidence of liver failure continues to increase, and it is associated with increased perioperative morbidity and mortality. Liver failure is associated with multiorgan dysfunction, including central nervous, cardiac, respiratory, gastrointestinal, renal, and hematological systems. Preoperative identification, optimization, and tailored anesthetic management are essential for optimum outcomes in patients with liver disease undergoing surgery. The coagulopathy of liver failure is a balanced coagulopathy better assessed by thromboelastography than conventional testing, and it is not directly associated with bleeding risk.
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Affiliation(s)
- Aidan Spring
- Abdominal Organ Transplantation Anesthesia Fellowship Program, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, 3 Eaton North, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada
| | - Jagroop S Saran
- Abdominal Organ Transplantation Anesthesia Fellowship Program, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, 3 Eaton North, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada
| | - Sinead McCarthy
- Abdominal Organ Transplantation Anesthesia Fellowship Program, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, 3 Eaton North, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada
| | - Stuart A McCluskey
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, 3 Eaton North, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada.
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19
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Henriksen NA, Kaufmann R, Simons MP, Berrevoet F, East B, Fischer J, Hope W, Klassen D, Lorenz R, Renard Y, Garcia Urena MA, Montgomery A. EHS and AHS guidelines for treatment of primary ventral hernias in rare locations or special circumstances. BJS Open 2020; 4:342-353. [PMID: 32207571 PMCID: PMC7093793 DOI: 10.1002/bjs5.50252] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 11/26/2019] [Indexed: 01/11/2023] Open
Abstract
Background Rare locations of hernias, as well as primary ventral hernias under certain circumstances (cirrhosis, dialysis, rectus diastasis, subsequent pregnancy), might be technically challenging. The aim was to identify situations where the treatment strategy might deviate from routine management. Methods The guideline group consisted of surgeons from the European and Americas Hernia Societies. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used in formulating the recommendations. The Scottish Intercollegiate Guidelines Network (SIGN) critical appraisal checklists were used to evaluate the quality of full‐text papers. A systematic literature search was performed on 1 May 2018 and updated 1 February 2019. The Appraisal of Guidelines for Research and Evaluation (AGREE) instrument was followed. Results Literature was limited in quantity and quality. A majority of the recommendations were graded as weak, based on low quality of evidence. In patients with cirrhosis or on dialysis, a preperitoneal mesh repair is suggested. Subsequent pregnancy is a risk factor for recurrence. Repair should be postponed until after the last pregnancy. For patients with a concomitant rectus diastasis or those with a Spigelian or lumbar hernia, no recommendation could be made for treatment strategy owing to lack of evidence. Conclusion This is the first European and American guideline on the treatment of umbilical and epigastric hernias in patients with special conditions, including Spigelian and lumbar hernias. All recommendations were weak owing to a lack of evidence. Further studies are needed on patients with rectus diastasis, Spigelian and lumbar hernias.
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Affiliation(s)
- N A Henriksen
- Department of Surgery, Zealand University Hospital, Koege, Denmark
| | - R Kaufmann
- Erasmus University Medical Centre, Rotterdam, the Netherlands.,Tergooi, Hilversum, the Netherlands
| | - M P Simons
- Department of Surgery, OLVG Hospital, Amsterdam, the Netherlands
| | - F Berrevoet
- Department of General and Hepato-Pancreato-Biliary Surgery, Gent University Hospital, Gent, Belgium
| | - B East
- Third Department of Surgery, Motol University Hospital, Prague, Czech Republic.,First and Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - J Fischer
- University of Pennsylvania Health System, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania, USA
| | - W Hope
- New Hanover Regional Medical Center, Wilmington, North Carolina, USA
| | - D Klassen
- Department of Surgery, Dalhousie University, Halifax, Canada
| | - R Lorenz
- Praxis 3+CHIRURGEN, Berlin, Germany
| | - Y Renard
- Department of Digestive Surgery, Robert Debré University Hospital, Reims, France
| | - M A Garcia Urena
- Henares University Hospital, Faculty of Health Sciences, Francisco de Vitoria University, Madrid, Spain
| | - A Montgomery
- Department of Surgery, Lund University, Skåne University Hospital, Malmö, Sweden
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20
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Pinheiro RS, Andraus W, Waisberg DR, Nacif LS, Ducatti L, Rocha-Santos V, Diniz MA, Arantes RM, Lerut J, D'Albuquerque LAC. Abdominal hernias in cirrhotic patients: Surgery or conservative treatment? Results of a prospective cohort study in a high volume center: Cohort study. Ann Med Surg (Lond) 2019; 49:9-13. [PMID: 31853365 PMCID: PMC6911966 DOI: 10.1016/j.amsu.2019.11.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 11/13/2019] [Indexed: 01/15/2023] Open
Abstract
Background Surgical 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. Methods A 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. Results Elective 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. Conclusions Elective 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. Prospective study comparing “wait and see” approach with elective surgical repair of abdominal hernias in cirrhotic patients. About 22.7% (n = 43) of patients under conservative treatment developed hernia complications requiring emergency hernia repair. Five-year survival was higher in elective repair group than in conservative treatment (80% vs. 62%; p = 0.012). Among patients undergoing hernia repair MELD>11 and emergency surgery were independent risk factors for 30-day mortality. “Wait and see” approach jeopardizes cirrhotic patients, as a high incidence of emergency surgery negatively impact survival.
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Affiliation(s)
- Rafael Soares Pinheiro
- Digestive Organs Transplant Unit, Department of Gastroenterology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Wellington Andraus
- Digestive Organs Transplant Unit, Department of Gastroenterology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Daniel Reis Waisberg
- Digestive Organs Transplant Unit, Department of Gastroenterology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Lucas Souto Nacif
- Digestive Organs Transplant Unit, Department of Gastroenterology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Liliana Ducatti
- Digestive Organs Transplant Unit, Department of Gastroenterology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Vinicius Rocha-Santos
- Digestive Organs Transplant Unit, Department of Gastroenterology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Márcio A Diniz
- Biostatistics and Bioinformatics Research Center, Department of Medicine, Cedars Sinai Medical Center, Los Angeles, United States
| | - Rubens Macedo Arantes
- Digestive Organs Transplant Unit, Department of Gastroenterology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Jan Lerut
- Starzl Unit of Abdominal Transplantation, University Hospital of Saint Luc, Université Catholique Louvain, Brussels, Belgium
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21
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Licari L, Salamone G, Ciolino G, Campanella S, Parinisi Z, Sabatino C, Carfì F, Bonventre S, Gulotta G. The abdominal wall incisional hernia repair in cirrhotic patients. G Chir 2019; 39:20-23. [PMID: 29549677 DOI: 10.11138/gchir/2018.39.1.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND The incidence of abdominal wall hernia in cirrhotic patients with ascites is between 20 and 40%. Controversies regarding the treatment modality and surgical timing of abdominal wall incisional hernia repair in cirrhotic patients remain. The study proposed wants to analyze the abdominal incisional hernia repair in cirrhotic patients with ascites performed in a single center to determine post-operative morbidity, mortality and complication rate. PATIENTS AND METHODS Cirrhotic patients with abdominal incisional hernia that underwent surgical operation for abdominal wall hernia repair at the "Policlinico Paolo Giaccone" at Palermo University Hospital between January 2015 and December 2016 were identified and the data collected were retrospectively reviewed; patients' medical and surgical records were collected from charts and the surgical and ICU registries. The degree of hepatic dysfunction was classified using Child-Pugh classification. Post-operative mortality was considered up to 30-days after surgery. A follow-up period of 6 months at least was performed to evaluate hernia recurrence and complications. RESULTS Mortality rate is of 18.5% (p 0.002). Recurrence rate (p 0.004) and seroma formation rate (p 0.001) are most frequent in urgency group. The elevated ASA score and the prediction of a complicated post-operative course is higher in urgency group (p 0.004) as higher is the in-hospital stay (p 0.001) and the ICU stay (p 0.001). CONCLUSIONS Elective surgery for abdominal wall hernia repair in cirrhotic patients seems to be successful and associated with lower mortality/morbidity rate and recurrence rate than urgency.
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22
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Kim SW, Kim MA, Chang Y, Lee HY, Yoon JS, Lee YB, Cho EJ, Lee JH, Yu SJ, Yoon JH, Park KJ, Kim YJ. Prognosis of surgical hernia repair in cirrhotic patients with refractory ascites. Hernia 2019; 24:481-488. [PMID: 31512088 DOI: 10.1007/s10029-019-02043-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Accepted: 08/27/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Abdominal wall hernias are common in patients with ascites. Elective surgical repair is recommended for the treatment of abdominal wall hernias. However, surgical hernia repair in cirrhotic patients with refractory ascites is controversial. In this study, we aimed to evaluate the outcomes of elective surgical hernia repair in patients with liver cirrhosis with and without refractory ascites. METHOD From January 2005 to June 2018, we retrospectively reviewed the records of consecutive patients with liver cirrhosis who underwent a surgical hernia repair. RESULTS This study included 107 patients; 31 patients (29.0%) had refractory ascites. Preoperatively, cirrhotic patients with refractory ascites had a higher median model for end-stage liver disease (MELD) score (13.0 vs 11.0, P = 0.001) than those without refractory ascites. The 30-day mortality rate (3.2% vs 0%, P = 0.64) and the risk of recurrence (hazard ratio 0.410; 95% CI 0.050-3.220; P = 0.39) did not differ significantly between cirrhotic patients with refractory ascites and cirrhotic patients without refractory ascites. Among cirrhotic patients with refractory ascites, albumin (P = 0.23), bilirubin (P = 0.37), creatinine (P = 0.97), and sodium levels (P = 0.35) did not change significantly after surgery. CONCLUSION In advanced liver cirrhosis patients with refractory ascites, hernias can be safely treated with elective surgical repair. Mortality rate within 30 days did not differ by the presence or absence of refractory ascites. Elective hernia repair might be beneficial for treatment of abdominal wall hernia in cirrhotic patients with refractory ascites.
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Affiliation(s)
- S W Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - M A Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - Y Chang
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - H Y Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, South Korea.,Department of Internal Medicine, Eulji General Hospital, Eulji University School of Medicine, Seoul, South Korea
| | - J S Yoon
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, South Korea.,Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, South Korea
| | - Y B Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - E J Cho
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - J-H Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - S J Yu
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - J-H Yoon
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - K J Park
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Y J Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, South Korea. .,Department of Internal Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea.
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23
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Adamson DT, Bozeman MC, Benns MV, Burton A, Davis EG, Jones CM. Operative Considerations for the General Surgeon in Patients with Chronic Liver Disease. Am Surg 2019. [DOI: 10.1177/000313481908500236] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Chronic liver disease remains a prevalent and challenging comorbidity in the American population at large. Scarring and fibrosis cause physical and physiological changes that may prove challenging in both medical and surgical management. However, because there has been relevant improvements in preoperative diagnostic, perioperative hepatologic, and intensive care management, as well as in surgical techniques, patients with cirrhosis can safely be operated on but patient selection remains vital. Patients with chronic liver disease may present to a general surgeon for evaluation of a number of elective or emergent surgical conditions. Here, we review current literature on the perioperative management and operative strategies of seemingly routine general surgery issues and provide a review of the pathophysiology associated with chronic liver disease.
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Affiliation(s)
- Dylan T. Adamson
- Hiram C. Polk, Jr., M.D., Department of Surgery, University of Louisville, Louisville, Kentucky and
| | - Matthew C. Bozeman
- Hiram C. Polk, Jr., M.D., Department of Surgery, University of Louisville, Louisville, Kentucky and
| | - Matthew V. Benns
- Hiram C. Polk, Jr., M.D., Department of Surgery, University of Louisville, Louisville, Kentucky and
| | - Alison Burton
- Department of Surgery, University of Kentucky, Lexington, Kentucky
| | - Eric G. Davis
- Hiram C. Polk, Jr., M.D., Department of Surgery, University of Louisville, Louisville, Kentucky and
| | - Christopher M. Jones
- Hiram C. Polk, Jr., M.D., Department of Surgery, University of Louisville, Louisville, Kentucky and
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24
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Hernia Management in Cirrhosis: Risk Assessment, Operative Approach, and Perioperative Care. J Surg Res 2019; 235:1-7. [PMID: 30691782 DOI: 10.1016/j.jss.2018.09.052] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 08/31/2018] [Accepted: 09/13/2018] [Indexed: 12/28/2022]
Abstract
BACKGROUND The rising incidence of liver disease has complicated the management of common surgical pathologies. Hernias, in particular, are problematic given the shortage of high-quality data and differing expert opinions. We aim to provide a narrative review of hernia management in cirrhosis as a first step toward developing evidence-based recommendations for the care of these patients. MATERIALS AND METHODS A literature review using separate search strings was conducted for PubMed and Cochrane Central Register of Controlled Trials databases. Review articles, conference abstracts, randomized clinical trials, and observational studies were included. Articles without a focus on patients with end-stage liver disease were excluded. Manuscripts were selected based on relevance to perioperative risk assessment, medical optimization, surgical decision-making, and considerations of hernia repair in patients with cirrhosis. RESULTS The existing literature is varied with regard to focus and quality of data. Of the 4516 articles identified, 51 full-text articles were selected for review. In general, there is evidence to suggest that individuals with compensated cirrhosis may successfully undergo and benefit from hernia repair. Patients at high risk for decompensated cirrhosis may be best served by nonoperative management. CONCLUSIONS Carefully selected patients with cirrhosis may proceed with herniorrhaphy. A multidisciplinary approach is essential to provide high-quality care and improve outcomes.
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25
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Hickman L, Tanner L, Christein J, Vickers S. Non-Hepatic Abdominal Surgery in Patients with Cirrhotic Liver Disease. J Gastrointest Surg 2019; 23:634-642. [PMID: 30465191 PMCID: PMC7102012 DOI: 10.1007/s11605-018-3991-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 09/20/2018] [Indexed: 01/31/2023]
Abstract
Cirrhotic liver disease is an important cause of peri-operative morbidity and mortality in general surgical patients. Early recognition and optimization of liver dysfunction is imperative before any elective surgery. Patients with MELD <12 or classified as Child A have a higher morbidity and mortality than matched controls without liver dysfunction, but are generally safe for elective procedures with appropriate patient education. Patients with MELD >20 or classified as Child C should undergo transplantation before any elective procedure given mortality exceeds 40%. Laparoscopic procedures are feasible and safe in cirrhotic patients.
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Affiliation(s)
- Laura Hickman
- Department of Surgery, Division of Gastrointestinal Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - John Christein
- Department of Surgery, Division of Gastrointestinal Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Selwyn Vickers
- Department of Surgery, Division of Gastrointestinal Surgery, University of Alabama at Birmingham, Birmingham, AL, USA.
- Dean's Office, UAB School of Medicine, FOT 1203, 510 20th Street South, Birmingham, AL, 35233, USA.
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26
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Petro CC, Haskins IN, Perez AJ, Tastaldi L, Strong AT, Ilie RN, Tu C, Krpata DM, Prabhu AS, Eghtesad B, Rosen MJ. Hernia repair in patients with chronic liver disease - A 15-year single-center experience. Am J Surg 2019; 217:59-65. [DOI: 10.1016/j.amjsurg.2018.10.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 10/04/2018] [Accepted: 10/12/2018] [Indexed: 12/28/2022]
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27
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Alsina AE, Athienitis A, Nakshabandi A, Claudio RE, Aslam S, Arroyo J, Hillenberg I, Mallorga A, Lahoti M, Kemmer N. Outcomes of abdominal surgeries in cirrhotic patients performed by liver transplant surgeons: Are these safe? Am J Surg 2018; 216:518-523. [DOI: 10.1016/j.amjsurg.2018.05.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 05/01/2018] [Accepted: 05/06/2018] [Indexed: 12/17/2022]
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28
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Salamone G, Licari L, Guercio G, Campanella S, Falco N, Scerrino G, Bonventre S, Geraci G, Cocorullo G, Gulotta G. The abdominal wall hernia in cirrhotic patients: a historical challenge. World J Emerg Surg 2018; 13:35. [PMID: 30065783 PMCID: PMC6064098 DOI: 10.1186/s13017-018-0196-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 07/18/2018] [Indexed: 12/20/2022] Open
Abstract
Background The incidence rate of abdominal wall hernia is 20–40% in cirrhotic patients. A surgical approach was originally performed only if complication signs and symptoms occurred. Several recent studies have demonstrated the usefulness of elective surgery. During recent decades, the indications for surgical timing have changed. Methods Cirrhotic patients with abdominal hernia who underwent surgical operation for abdominal wall hernia repair at the Policlinico “Paolo Giaccone” at Palermo University Hospital between January 2010 and September 2016 were identified in a prospective database, and the data collected were retrospectively reviewed; patients’ medical and surgical records were collected from charts and surgical and intensive care unit (ICU) registries. Postoperative morbidity was determined through the Clavien-Dindo classification. Cirrhosis severity was estimated by the Child-Pugh-Turcotte (CPT) score and MELD (model of end-stage liver disease) score. Postoperative mortality was considered up to 30 days after surgery. A follow-up period of at least 1 year was used to evaluate hernia recurrence. Results The univariate and multivariate analyses demonstrated the unique independent risk factors for the development of postsurgical morbidity (emergency surgery (OR 6.42; p 0.023), CPT class C (OR 3.72; p 0.041), American Society of Anesthesiologists (ASA) score ≥ 3 (OR 4.72; p 0.012) and MELD ≥ 20 (OR 5.64; p 0.009)) and postsurgical mortality (emergency surgery (OR 10.32; p 0.021), CPT class C (OR 5.52; p 0.014), ASA score ≥ 3 (OR 8.65; p 0.018), MELD ≥ 20 (OR 2.15; p 0.02)). Conclusions Concerning abdominal wall hernia repair in cirrhotic patients, the worst outcome is associated with emergency surgery and with uncontrolled disease. The correct timing of the surgical operation is elective surgery after ascites drainage and albumin/electrolyte serum level and coagulation alteration correction.
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Affiliation(s)
- Giuseppe Salamone
- Department of Surgical, Oncological and Oral Science, University of Palermo, Policlinico P. Giaccone. Via Liborio Giuffré 5, 90127 Palermo, Italy
| | - Leo Licari
- Department of Surgical, Oncological and Oral Science, University of Palermo, Policlinico P. Giaccone. Via Liborio Giuffré 5, 90127 Palermo, Italy
| | - Giovanni Guercio
- Department of Surgical, Oncological and Oral Science, University of Palermo, Policlinico P. Giaccone. Via Liborio Giuffré 5, 90127 Palermo, Italy
| | - Sofia Campanella
- Department of Surgical, Oncological and Oral Science, University of Palermo, Policlinico P. Giaccone. Via Liborio Giuffré 5, 90127 Palermo, Italy
| | - Nicolò Falco
- Department of Surgical, Oncological and Oral Science, University of Palermo, Policlinico P. Giaccone. Via Liborio Giuffré 5, 90127 Palermo, Italy
| | - Gregorio Scerrino
- Department of Surgical, Oncological and Oral Science, University of Palermo, Policlinico P. Giaccone. Via Liborio Giuffré 5, 90127 Palermo, Italy
| | - Sebastiano Bonventre
- Department of Surgical, Oncological and Oral Science, University of Palermo, Policlinico P. Giaccone. Via Liborio Giuffré 5, 90127 Palermo, Italy
| | - Girolamo Geraci
- Department of Surgical, Oncological and Oral Science, University of Palermo, Policlinico P. Giaccone. Via Liborio Giuffré 5, 90127 Palermo, Italy
| | - Gianfranco Cocorullo
- Department of Surgical, Oncological and Oral Science, University of Palermo, Policlinico P. Giaccone. Via Liborio Giuffré 5, 90127 Palermo, Italy
| | - Gaspare Gulotta
- Department of Surgical, Oncological and Oral Science, University of Palermo, Policlinico P. Giaccone. Via Liborio Giuffré 5, 90127 Palermo, Italy
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The emergency medicine evaluation and management of the patient with cirrhosis. Am J Emerg Med 2018; 36:689-698. [DOI: 10.1016/j.ajem.2017.12.047] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 12/21/2017] [Accepted: 12/22/2017] [Indexed: 12/12/2022] Open
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Safety and effectiveness of umbilical hernia repair in patients with cirrhosis. Hernia 2018; 22:759-765. [DOI: 10.1007/s10029-018-1761-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 03/21/2018] [Indexed: 01/22/2023]
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Lahat E, Lim C, Bhangui P, Fuentes L, Osseis M, Moussallem T, Salloum C, Azoulay D. Transjugular intrahepatic portosystemic shunt as a bridge to non-hepatic surgery in cirrhotic patients with severe portal hypertension: a systematic review. HPB (Oxford) 2018; 20:101-109. [PMID: 29110990 DOI: 10.1016/j.hpb.2017.09.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 09/18/2017] [Accepted: 09/21/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Portal hypertension (PHTN) increases the risk of non-hepatic surgery in cirrhotic patients. This first systematic review analyzes the place of transjugular intrahepatic portosystemic shunt (TIPS) in preparation for non-hepatic surgery in such patients. METHODS Medline, EMBASE, and Scopus databases were searched from 1990 to 2017 to identify reports on outcomes of non-hepatic surgery in cirrhotic patients with PHTN prepared by TIPS. Feasibility of TIPS and the planned surgery, and the short- and long-term outcomes of the latter were assessed. RESULTS Nineteen studies (64 patients) were selected. TIPS was indicated for past history of variceal bleeding and/or ascites in 22 (34%) and 33 (52%) patients, respectively. The planned surgery was gastrointestinal tract cancer in 38 (59%) patients, benign digestive or pelvic surgery in 21 (33%) patients and others in 4 (6%) patients. The TIPS procedure was successful in all, with a nil mortality rate. All patients could be operated within a median delay of 30 days from TIPS (mortality rate = 8%; overall morbidity rate = 59.4%). One year overall survival was 80%. CONCLUSIONS TIPS allows non-hepatic surgery in cirrhotic patients deemed non operable due to PHTN. Further evidence in larger cohort of patients is essential for wider applicability.
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Affiliation(s)
- Eylon Lahat
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France
| | - Chetana Lim
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France; Université Paris-Est UPEC, Créteil, France
| | - Prashant Bhangui
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, New Delhi, India
| | - Liliana Fuentes
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France
| | - Michael Osseis
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France
| | - Toufic Moussallem
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France
| | - Chady Salloum
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France
| | - Daniel Azoulay
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France; Université Paris-Est UPEC, Créteil, France; INSERM, U955, Créteil, France.
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Computed tomography findings associated with the risk for emergency ventral hernia repair. Am J Surg 2016; 214:42-46. [PMID: 28277230 DOI: 10.1016/j.amjsurg.2016.09.035] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Revised: 09/06/2016] [Accepted: 09/12/2016] [Indexed: 01/27/2023]
Abstract
BACKGROUND Conventional wisdom teaches that small hernia defects are more likely to incarcerate. We aim to identify radiographic features of ventral hernias associated with increased risk of bowel incarceration. METHODS We assessed all patients who underwent emergent ventral hernia repair for bowel complications from 2009 to 2015. Cases were matched 1:3 with elective controls. Computed tomography scans were reviewed to determine hernia characteristics. Univariate and multivariable analyses were performed to identify variables associated with emergent surgery. RESULTS The cohort consisted of 88 patients and 264 controls. On univariate analysis, older age, higher ASA score, elevated BMI, ascites, larger hernias, small angle, and taller hernias were associated with emergent surgery. On multivariable analysis, morbid obesity, ascites, smaller angle, and taller hernias were independently associated with emergent surgery. CONCLUSIONS The teaching that large defects do not incarcerate is inaccurate; bowel compromise occurs with ventral hernias of all sizes. Instead, taller height and smaller angle are associated with the need for emergent repair. Early elective repair should be considered for patients with hernia features concerning for increased risk of bowel compromise.
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Coelho JCU, Claus CMP, Campos ACL, Costa MAR, Blum C. Umbilical hernia in patients with liver cirrhosis: A surgical challenge. World J Gastrointest Surg 2016; 8:476-482. [PMID: 27462389 PMCID: PMC4942747 DOI: 10.4240/wjgs.v8.i7.476] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 04/02/2016] [Accepted: 05/11/2016] [Indexed: 02/06/2023] Open
Abstract
Umbilical hernia occurs in 20% of the patients with liver cirrhosis complicated with ascites. Due to the enormous intraabdominal pressure secondary to the ascites, umbilical hernia in these patients has a tendency to enlarge rapidly and to complicate. The treatment of umbilical hernia in these patients is a surgical challenge. Ascites control is the mainstay to reduce hernia recurrence and postoperative complications, such as wound infection, evisceration, ascites drainage, and peritonitis. Intermittent paracentesis, temporary peritoneal dialysis catheter or transjugular intrahepatic portosystemic shunt may be necessary to control ascites. Hernia repair is indicated in patients in whom medical treatment is effective in controlling ascites. Patients who have a good perspective to be transplanted within 3-6 mo, herniorrhaphy should be performed during transplantation. Hernia repair with mesh is associated with lower recurrence rate, but with higher surgical site infection when compared to hernia correction with conventional fascial suture. There is no consensus on the best abdominal wall layer in which the mesh should be placed: Onlay, sublay, or underlay. Many studies have demonstrated several advantages of the laparoscopic umbilical herniorrhaphy in cirrhotic patients compared with open surgical treatment.
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Juo YY, Skancke M, Holzmacher J, Amdur RL, Lin PP, Vaziri K. Laparoscopic versus open ventral hernia repair in patients with chronic liver disease. Surg Endosc 2016; 31:769-777. [PMID: 27334967 DOI: 10.1007/s00464-016-5031-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2016] [Accepted: 06/11/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Previous studies demonstrated laparoscopic ventral hernia repair (LVHR) to be associated with fewer short-term complications than open ventral hernia repair (OVHR). Little literature is available comparing LVHR and OVHR in chronic liver disease (CLD) patients. METHODS Patients with model for end-stage liver disease score ≥9 who underwent elective ventral hernia repair in the National Surgical Quality Improvement Program Database were included. 30-day outcomes were compared between LVHR and OVHR after adjusting for hernia disease severity, baseline comorbidities and demographic factors. RESULTS A total of 3594 ventral hernia repairs were included, 536 (14.9 %) of which were LVHR. After adjusting for other confounders, LVHR was associated with a lower incidence of wound-related complications (0.23, 95 % CI 0.07-0.74, p = 0.01), shorter length of stay (mean 3.7 vs. 5.0 days, p < 0.01) than OVHR, but similar systemic complications (p = 0.77), bleeding complications (p = 0.69), unplanned reoperation (p = 0.74) or readmission (p = 0.40). Propensity score-matched comparison showed similar conclusions. Five hundred and sixty-two patients had ascites, among whom 35 (6.2 %) underwent LVHR. In this subcohort, LVHR was associated with higher mortality (OR 5.36, 95 % CI 1.00-28.60, p = 0.05), systemic complications (OR 7.03, 95 % CI 2.06-24.00, p < 0.01), and unplanned reoperation (OR 6.03, 95 % CI 1.51-24.12, p = 0.01) than OVHR. CONCLUSIONS In comparison with OVHR, LVHR is associated with similar short-term outcomes except for lower wound-related complications and shorter length of stay in CLD patients. However, when patients have ascites, LVHR is associated with higher mortality, systemic complications, and unplanned reoperation.
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Affiliation(s)
- Yen-Yi Juo
- Department of Surgery, George Washington University Medical Center, 22nd and I Street, NW, 6th Floor, Washington, DC, 20037, USA.
| | - Matthew Skancke
- Department of Surgery, George Washington University Medical Center, 22nd and I Street, NW, 6th Floor, Washington, DC, 20037, USA
| | - Jeremy Holzmacher
- Department of Surgery, George Washington University Medical Center, 22nd and I Street, NW, 6th Floor, Washington, DC, 20037, USA
| | - Richard L Amdur
- Department of Surgery, George Washington University Medical Center, 22nd and I Street, NW, 6th Floor, Washington, DC, 20037, USA
| | - Paul P Lin
- Department of Surgery, George Washington University Medical Center, 22nd and I Street, NW, 6th Floor, Washington, DC, 20037, USA
| | - Khashayar Vaziri
- Department of Surgery, George Washington University Medical Center, 22nd and I Street, NW, 6th Floor, Washington, DC, 20037, USA
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The Hernia–Neck-Ratio (HNR), a Novel Predictive Factor for Complications of Umbilical Hernia. World J Surg 2016; 40:2084-90. [DOI: 10.1007/s00268-016-3556-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Lopez-Delgado JC, Ballus J, Esteve F, Betancur-Zambrano NL, Corral-Velez V, Mañez R, Betbese AJ, Roncal JA, Javierre C. Outcomes of abdominal surgery in patients with liver cirrhosis. World J Gastroenterol 2016; 22:2657-2667. [PMID: 26973406 PMCID: PMC4777990 DOI: 10.3748/wjg.v22.i9.2657] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 10/30/2015] [Accepted: 12/14/2015] [Indexed: 02/06/2023] Open
Abstract
Patients suffering from liver cirrhosis (LC) frequently require non-hepatic abdominal surgery, even before liver transplantation. LC is an important risk factor itself for surgery, due to the higher than average associated morbidity and mortality. This high surgical risk occurs because of the pathophysiology of liver disease itself and to the presence of contributing factors, such as coagulopathy, poor nutritional status, adaptive immune dysfunction, cirrhotic cardiomyopathy, and renal and pulmonary dysfunction, which all lead to poor outcomes. Careful evaluation of these factors and the degree of liver disease can help to reduce the development of complications both during and after abdominal surgery. In the emergency setting, with the presence of decompensated LC, alcoholic hepatitis, severe/advanced LC, and significant extrahepatic organ dysfunction conservative management is preferred. A multidisciplinary, individualized, and specialized approach can improve outcomes; preoperative optimization after risk stratification and careful management are mandatory before surgery. Laparoscopic techniques can also improve outcomes. We review the impact of LC on surgical outcome in non-hepatic abdominal surgeries required in this cirrhotic population before, during, and after surgery.
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Khodarahmi I, Shahid MU, Contractor S. Incarceration of umbilical hernia: a rare complication of large volume paracentesis. J Radiol Case Rep 2015; 9:20-5. [PMID: 26629305 DOI: 10.3941/jrcr.v9i9.2614] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
We present two cases of umbilical hernia incarceration following large volume paracentesis (LVP) in patients with cirrhotic ascites. Both patients became symptomatic within 48 hours after the LVP. Although being rare, given the significantly higher mortality rate of cirrhotic patients undergoing emergent herniorrhaphy, this complication of LVP is potentially serious. Therefore, it is recommended that patients be examined closely for the presence of umbilical hernias before removal of ascitic fluid and an attempt should be made for external reduction of easily reducible hernias, if a hernia is present.
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Affiliation(s)
- Iman Khodarahmi
- Department of Radiology, Rutgers, The State University of New Jersey, Newark, NJ, USA
| | - Muhammad Usman Shahid
- Department of Radiology, Rutgers, The State University of New Jersey, Newark, NJ, USA
| | - Sohail Contractor
- Department of Radiology, Rutgers, The State University of New Jersey, Newark, NJ, USA
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Yu BC, Chung M, Lee G. The repair of umbilical hernia in cirrhotic patients: 18 consecutive case series in a single institute. Ann Surg Treat Res 2015; 89:87-91. [PMID: 26236698 PMCID: PMC4518035 DOI: 10.4174/astr.2015.89.2.87] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Revised: 02/15/2015] [Accepted: 03/10/2015] [Indexed: 02/07/2023] Open
Abstract
Purpose Traditionally, the surgical repair of umbilical hernia in cirrhotic patients with ascites is avoided because of a significant recurrence rate and perioperative morbidity/mortality. However, recent reports recommend early elective surgery in these patients because surgery-related complications can be reduced with minimally invasive surgery and development of perioperative patient care. The current study was conducted to analyze safety and feasibility of umbilical hernia repairs performed in a single institute. Methods A single center retrospective analysis of patients' data was conducted. Eighteen patients with umbilical hernia accompanied by liver cirrhosis underwent hernia repair in the period between 2005 and 2012. The charts of these patients were reviewed and demographic data, postoperative complications, and recurrence were recorded. Results Eleven males and seven females with a mean age of 62.9 years were analyzed. Two of the patients were classified as Child's class A, 11 as Child's class B, and five as Child's class C. Four patients underwent emergency surgery because of perforations in the hernia sac in two cases and incarcerated hernias in the other two cases. Of the 18 patients who underwent surgery, four (22%) experienced a recurrence, three (17%) developed edema at the surgical sites, one (5%) experienced hepatic coma, and one (5%) showed postoperative variceal hemorrhage. All of these events occurred after emergency surgery. Conclusion In contrast to traditional concepts, early and elective repair of umbilical hernia can be performed easily and safely in cirrhotic patients.
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Affiliation(s)
- Byung Chul Yu
- Department of Surgery, Gachon University Gil Medical Center, Incheon, Korea
| | - Min Chung
- Department of Surgery, Gachon University Gil Medical Center, Incheon, Korea
| | - Giljae Lee
- Department of Surgery, Gachon University Gil Medical Center, Incheon, Korea
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Silecchia G, Campanile FC, Sanchez L, Ceccarelli G, Antinori A, Ansaloni L, Olmi S, Ferrari GC, Cuccurullo D, Baccari P, Agresta F, Vettoretto N, Piccoli M. Laparoscopic ventral/incisional hernia repair: updated Consensus Development Conference based guidelines [corrected]. Surg Endosc 2015; 29:2463-84. [PMID: 26139480 DOI: 10.1007/s00464-015-4293-8] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Accepted: 04/27/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND The Executive board of the Italian Society for Endoscopic Surgery (SICE) promoted an update of the first evidence-based Italian Consensus Conference Guidelines 2010 because a large amount of literature has been published in the last 4 years about the topics examined and new relevant issues. METHODS The scientific committee selected the topics to be addressed: indications to surgical treatment including special conditions (obesity, cirrhosis, diastasis recti abdominis, acute presentation); safety and outcome of intraperitoneal meshes (synthetic and biologic); fixing devices (absorbable/non-absorbable); abdominal border and parastomal hernia; intraoperative and perioperative complications; and recurrent ventral/incisional hernia. All the recommendations are the result of a careful and complete literature review examined with autonomous judgment by the entire panel. The process was supervised by experts in methodology and epidemiology from the most qualified Italian institution. Two external reviewers were designed by the EAES and EHS to guarantee the most objective, transparent, and reliable work. The Oxford hierarchy (OCEBM Levels of Evidence Working Group*. "The Oxford 2011 Levels of Evidence") was used by the panel to grade clinical outcomes according to levels of evidence. The recommendations were based on the grading system suggested by the GRADE working group. RESULTS AND CONCLUSIONS The availability of recent level 1 evidence (a meta-analysis of 10 RCTs) allowed to recommend that not only laparoscopic repair is an acceptable alternative to the open repair, but also it is advantageous in terms of shorter hospital stay and wound infection rate. This conclusion appears to be extremely relevant in a clinical setting. Indications about specific conditions could also be issued: laparoscopy is recommended for the treatment of recurrent ventral hernias and obese patients, while it is a potential option for compensated cirrhotic and childbearing-age female patients. Many relevant and controversial topics were thoroughly examined by this consensus conference for the first time. Among them are the issue of safety of the intraperitoneal mesh placement, traditionally considered a major drawback of the laparoscopic technique, the role for the biologic meshes, and various aspects of the laparoscopic approach for particular locations of the defect such as the abdominal border or parastomal hernias.
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Affiliation(s)
- Gianfranco Silecchia
- Division of General Surgery and Bariatric Centre of Excellence, Department of Medico-Surgical Sciences and Biotechnology, Sapienza University of Rome, Via Faggiana 1668, 04100, Latina, LT, Italy
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Andraus W, Pinheiro RS, Lai Q, Haddad LBP, Nacif LS, D'Albuquerque LAC, Lerut J. Abdominal wall hernia in cirrhotic patients: emergency surgery results in higher morbidity and mortality. BMC Surg 2015; 15:65. [PMID: 25990110 PMCID: PMC4443633 DOI: 10.1186/s12893-015-0052-y] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Accepted: 05/11/2015] [Indexed: 02/07/2023] Open
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.
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Affiliation(s)
- Wellington Andraus
- Digestive Organs Transplant Unit, Department of Gastroenterology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil.
| | - Rafael Soares Pinheiro
- Digestive Organs Transplant Unit, Department of Gastroenterology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Quirino Lai
- Department of Hepatic Surgery and Liver Transplantation, Azienda Universitario-ospedaliera Pisana, Pisa, Italy
| | - Luciana B P Haddad
- Digestive Organs Transplant Unit, Department of Gastroenterology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Lucas S Nacif
- Digestive Organs Transplant Unit, Department of Gastroenterology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Luiz Augusto C D'Albuquerque
- Digestive Organs Transplant Unit, Department of Gastroenterology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Jan Lerut
- Starzl Unit of Abdominal Transplantation, University Hospital of Saint Luc, Université Catholique of Louvain, Brussels, Belgium
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Chatzizacharias NA, Bradley JA, Harper S, Butler A, Jah A, Huguet E, Praseedom RK, Allison M, Gibbs P. Successful surgical management of ruptured umbilical hernias in cirrhotic patients. World J Gastroenterol 2015; 21:3109-3113. [PMID: 25780312 PMCID: PMC4356934 DOI: 10.3748/wjg.v21.i10.3109] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2014] [Revised: 09/11/2014] [Accepted: 11/19/2014] [Indexed: 02/06/2023] Open
Abstract
Acute umbilical hernia rupture in patients with hepatic cirrhosis and ascites is an unusual, but potentially life-threatening complication, with postoperative morbidity about 70% and mortality between 60%-80% after supportive care and 6%-20% after urgent surgical repair. Management options include primary surgical repair with or without concomitant portal venous system decompression for the control of the ascites. We present a retrospective analysis of our centre’s experience over the last 6 years. Our cohort consisted of 11 consecutive patients (median age: 53 years, range: 36-63 years) with advanced hepatic cirrhosis and refractory ascites. Appropriate patient resuscitation and optimisation with intravenous fluids, prophylactic antibiotics and local measures was instituted. One failed attempt for conservative management was followed by a successful primary repair. In all cases, with one exception, a primary repair with non-absorbable Nylon, interrupted sutures, without mesh, was performed. The perioperative complication rate was 25% and the recurrence rate 8.3%. No mortality was recorded. Median length of hospital stay was 14 d (range: 4-31 d). Based on our experience, the management of ruptured umbilical hernias in patients with advanced hepatic cirrhosis and refractory ascites is feasible without the use of transjugular intrahepatic portosystemic shunt routinely in the preoperative period, provided that meticulous patient optimisation is performed.
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Management of umbilical hernias in patients with ascites: development of a nomogram to predict mortality. Am J Surg 2014; 209:302-7. [PMID: 25066022 DOI: 10.1016/j.amjsurg.2014.04.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Revised: 04/11/2014] [Accepted: 04/18/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND The objective of this study was to develop an easy-to-use nomogram to assist clinicians in predicting patient-specific mortality in this patient population. METHODS American College of Surgeons National Surgical Quality Improvement Program participant use files were used from 2005 to 2011. Multivariable logistic regression was used to model 30-day postoperative mortality in patients with ascites who underwent umbilical hernia repair. RESULTS A total of 688 patients with ascites undergoing umbilical hernia repair were included. There were 643 (94%) survivors and 45 (7%) mortalities. A total of 300 (44%) patients were classified as emergent cases. Using logistic regression to predict 30-day mortality, preoperative Model for End-Stage Liver Disease score, albumin, white blood cell count, and platelet count were found to be significant predictors (P < .05) of mortality and were included in our model. CONCLUSION We propose a nomogram to enable clinicians to better estimate mortality in patients with ascites undergoing umbilical hernia repair.
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Im GY, Lubezky N, Facciuto ME, Schiano TD. Surgery in patients with portal hypertension: a preoperative checklist and strategies for attenuating risk. Clin Liver Dis 2014; 18:477-505. [PMID: 24679507 DOI: 10.1016/j.cld.2014.01.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Patients with liver disease and portal hypertension are at increased risk of complications from surgery. Recent advances have allowed better optimization of patients with cirrhosis before surgery and a reduction in postoperative complications. Despite this progress, the estimation of surgical risk in a patient with cirrhosis is challenging. The MELD score has shown promise in predicting postoperative mortality compared with the Child-Turcotte-Pugh score. This article addresses current concepts in the perioperative evaluation of patients with liver disease and portal tension, including a preoperative liver assessment (POLA) checklist that may be useful towards mitigating perioperative complications.
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Affiliation(s)
- Gene Y Im
- Icahn School of Medicine at Mount Sinai, The Mount Sinai Medical Center, Recanati/Miller Transplantation Institute, One Gustave Levy Place, Box 1104, New York, NY 10029-6574, USA
| | - Nir Lubezky
- Icahn School of Medicine at Mount Sinai, The Mount Sinai Medical Center, Recanati/Miller Transplantation Institute, One Gustave Levy Place, Box 1104, New York, NY 10029-6574, USA
| | - Marcelo E Facciuto
- Icahn School of Medicine at Mount Sinai, The Mount Sinai Medical Center, Recanati/Miller Transplantation Institute, One Gustave Levy Place, Box 1104, New York, NY 10029-6574, USA
| | - Thomas D Schiano
- Icahn School of Medicine at Mount Sinai, The Mount Sinai Medical Center, Recanati/Miller Transplantation Institute, One Gustave Levy Place, Box 1104, New York, NY 10029-6574, USA.
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Shrikhande SV, Gaikwad V, Purohit D, Goel M. Major abdominal cancer resections in cirrhotic patients: how frequent is postoperative hepatocellular decompensation? Indian J Gastroenterol 2014; 33:258-64. [PMID: 24214581 DOI: 10.1007/s12664-013-0426-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Accepted: 10/14/2013] [Indexed: 02/04/2023]
Abstract
BACKGROUND The reported incidence of postoperative liver failure in cirrhotic patients is highly varied with diverse risk factors identified to predict risk, mainly drawn from organ or disease-specific studies. We aimed to assess risk factors for the development of postoperative liver failure in a specific cohort of patients with cirrhosis undergoing abdominal cancer resection. METHODS From November 2007 to October 2012, 30 cirrhotic patients who underwent curative resection for abdominal cancer were analyzed. The postoperative trends in liver function were followed and the incidence of postoperative liver failure was demonstrated. RESULTS Among the 30 patients, the tumors were located in the stomach (n = 5), pancreas (n = 5), colon/rectum (6), liver (n = 11), gallbladder (n = 1), and retroperitoneum (n = 2). Eighteen (60 %) patients experienced postoperative liver failure of which 7 (23 %) patients required deviation from the clinical course or management. There was one mortality due to grade C liver failure and hepatorenal syndrome. On multivariate analysis, only age (>55 years) was found to be statistically significant to predict postoperative liver failure (p = 0.024). CONCLUSION Liver dysfunction remains a major problem during the postoperative phase of major gastrointestinal cancer resections. However, less than one fourth of well-selected patients will develop significant postoperative liver failure. This incidence may be further reduced if the selection is restricted to younger patients.
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Affiliation(s)
- Shailesh Vinayak Shrikhande
- Division of Gastrointestinal and Hepato-Pancreato-Biliary Surgical Oncology, Tata Memorial Centre, Parel, Mumbai, 400 012, India,
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Hassan AMA, Salama AF, Hamdy H, Elsebae MM, Abdelaziz AM, Elzayat WA. Outcome of sublay mesh repair in non-complicated umbilical hernia with liver cirrhosis and ascites. Int J Surg 2013; 12:181-5. [PMID: 24378913 DOI: 10.1016/j.ijsu.2013.12.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Accepted: 12/19/2013] [Indexed: 01/04/2023]
Abstract
BACKGROUND Umbilical hernia repair is often accompanied by complications in patients with liver cirrhosis and ascites. It appears that the early elective repair of umbilical hernias in these patients is safer and can be considered for selected patients. The objective of this study is to evaluate the feasibility, safety, complications and technical aspects of sublay mesh repair of umbilical hernia in cirrhotic patients with ascites. METHODS Between October 2010 and April 2013, 70 patients with non-complicated umbilical hernia, liver cirrhosis and ascites were enrolled in this study. All patients underwent sublay mesh repair. Demographic data, preoperative variables, peri-operative course, and postoperative complications were recorded and analyzed. RESULTS A total of 38 women and 32 men underwent operation at an average age 51.24 years. The patients mean MELD score was 18 (range 12-25). The mean operative time was 67.45 min and the average hospital stay was 3.8 days. 2 patients had wound infection, 3 patients developed seroma and 1 patient had an ascitic fistula. Recurrence occurred in 1 (1.4%) patient and no mortality related to the procedure. CONCLUSION elective sublay umbilical hernia mesh repair is a safe approach and feasible technique in selected non-complicated cirrhotic patients with ascites.
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Affiliation(s)
| | - Asaad Fayrouz Salama
- General Surgery Department, Theodor Bilharz Research Institute, Giza 12411, Egypt.
| | - Hussam Hamdy
- General Surgery Department, Theodor Bilharz Research Institute, Giza 12411, Egypt.
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Abstract
BACKGROUND The optimal treatment for abdominal wall hernias in the setting of ascites is not clear. We describe our experience with emergent surgery for hernias in patients with cirrhosis and ascites and assess variables associated with poor short- and long-term outcomes to inform decisions about aggressive early repair. METHODS We performed a retrospective review of all emergency abdominal wall hernia repairs admitted from the emergency department from January 2000 to December 2011 in all patients with ascites caused by liver cirrhosis. Demographic data, comorbidities, complications, operative details, hospital length of stay, and admission model of end-stage liver disease (MELD) score was determined. Follow-up was detailed via comprehensive liver service electronic records. RESULTS There were 69 emergent hernia surgeries in 68 patients during the study period. There were two early deaths (both MELD score> 20). Multivariate analysis revealed MELD score (18% increase in risk with each point of MELD), preoperative anemia (sevenfold increase in risk), and preoperative small bowel obstruction (ninefold increase in risk) as predictive factors of major complication. In patients with MELD score greater than 10, morbidity was more than 50%, and major morbidity is greater than 12% when MELD score is greater than 20. CONCLUSION Emergent hernia surgery in patients with ascites has low mortality but high morbidity and requires intense use of resources. To decrease the incidence of emergent hernia surgery, we recommend the aggressive use of elective repair. Emergent hernia repair, when necessary, should be performed at experienced centers and must include adequate ascites control with diuretic therapy and percutaneous paracentesis. Preoperative anemia and electrolyte abnormalities should be aggressively treated. Finally, while wound complications are common and frequently require reintervention, they are not associated with increased mortality. LEVEL OF EVIDENCE Prognostic and epidemiologic study, level V.
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Abstract
Umbilical and epigastric hernias are primary midline defects that are present in up to 50% of the population. In the United States, only about 1% of the population carries this specific diagnosis, and only about 11% of these are repaired. Repair is aimed at symptoms relief or prevention, and the patient's goals and expectations should be explicitly identified and aligned with the health care team. This article details some relevant and interesting anatomic issues, reviews existing data, and highlights some common and important surgical techniques. Emphasis is placed on a patient-centered approach to the repair of umbilical and epigastric hernias.
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Smith MT, Rase B, Woods A, Trotter J, Gipson M, Kondo K, Ray C, Durham J. Risk of hernia incarceration following transjugular intrahepatic portosystemic shunt placement. J Vasc Interv Radiol 2013; 25:58-62. [PMID: 24269791 DOI: 10.1016/j.jvir.2013.09.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Revised: 09/04/2013] [Accepted: 09/05/2013] [Indexed: 01/28/2023] Open
Abstract
PURPOSE Hernia complications after creation of a transjugular intrahepatic portosystemic shunt (TIPS) have been reported, although the incidence of this complication is unknown. This study was designed to determine the incidence, morbidity, and outcome of hernia complications in patients with preexisting abdominal or inguinal hernias after TIPS creation. MATERIALS AND METHODS The medical records of 244 consecutive patients undergoing TIPS creation between 1999 and 2007 at a single institution were reviewed. The study population was 57 patients (23%) with a preprocedural abdominal or inguinal hernia. The investigated outcome was small bowel obstruction or postprocedural incarceration of a preexisting hernia. Demographic and procedural variables were evaluated for an associated increased risk of hernia complications. RESULTS Hernia complications developed in 25% of patients (14 of 57) after TIPS creation at a mean presentation of 62 days (range, 2-588 d). Thirteen complications (93%) required emergent surgery, of which four (29%) required bowel resection for necrosis. There were no resulting deaths. Ninety-eight percent of patients with a hernia complication had the procedure to treat refractory ascites. The indication of refractory ascites was significantly associated with the risk of a hernia complication (P = .002). CONCLUSIONS A 25% incidence of hernia complications following TIPS creation in patients being treated for refractory ascites is higher than expected; emergent surgery is required in most cases. Further investigation to formulate a plan for elective management is warranted.
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Affiliation(s)
- Mitchell T Smith
- Department of Radiology, Division of Interventional Radiology, University of Colorado Denver, 12700 E. 19th Ave, Room P15-1205, Aurora, CO 80045.
| | - Benjamin Rase
- Department of Radiology, University of Colorado School of Medicine, Denver, Colorado
| | - Alyn Woods
- Department of Radiology, David Grant Medical Center, Travis AFB, California
| | - James Trotter
- Liver Transplantation Center, Baylor University Medical Center at Dallas, Dallas, Texas
| | - Matt Gipson
- Department of Radiology, Division of Interventional Radiology, University of Colorado Denver, 12700 E. 19th Ave, Room P15-1205, Aurora, CO 80045
| | - Kimi Kondo
- Department of Radiology, Division of Interventional Radiology, University of Colorado Denver, 12700 E. 19th Ave, Room P15-1205, Aurora, CO 80045
| | - Charles Ray
- Department of Radiology, Division of Interventional Radiology, University of Colorado Denver, 12700 E. 19th Ave, Room P15-1205, Aurora, CO 80045
| | - Janette Durham
- Department of Radiology, Division of Interventional Radiology, University of Colorado Denver, 12700 E. 19th Ave, Room P15-1205, Aurora, CO 80045
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Umbilical hernia management during liver transplantation. Hernia 2013; 17:515-9. [PMID: 23793929 DOI: 10.1007/s10029-013-1131-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2013] [Accepted: 06/14/2013] [Indexed: 12/17/2022]
Abstract
PURPOSE Patients with liver cirrhosis scheduled for liver transplantation often present with a concurrent umbilical hernia. Optimal management of these patients is not clear. The objective of this study was to compare the outcomes of patients who underwent umbilical hernia correction during liver transplantation through a separate infra-umbilical incision with those who underwent correction through the same incision used to perform the liver transplantation. METHODS In the period between 1990 and 2011, all 27 patients with umbilical hernia and liver cirrhosis who underwent hernia correction during liver transplantation were identified in our hospital database. In 17 cases, umbilical hernia repair was performed through a separate infra-umbilical incision (separate incision group) and 10 were corrected from within the abdominal cavity without a separate incision (same incision group). Six patients died during follow-up; no deaths were attributable to intraoperative umbilical hernia repair. All 21 patients who were alive visited the outpatient clinic to detect recurrent umbilical hernia. RESULTS One recurrent umbilical hernia was diagnosed in the separate incision group (6 %) and four (40 %) in the same incision group (p = 0.047). Two patients in the same incision group required repair of the recurrent umbilical hernia; one of whom underwent emergency surgery for bowel incarceration. The one recurrent hernia in the separate incision group was corrected electively. CONCLUSION In the event of liver transplantation, umbilical hernia repair through a separate infra-umbilical incision is preferred over correction through the same incision used to perform the transplantation.
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Ferreira AO, Marinho RT, Ramalho F, Velosa J. Ascitic eruption in an umbilical hernia in cirrhosis. BMJ Case Rep 2013; 2013:bcr-2012-007741. [PMID: 23283619 DOI: 10.1136/bcr-2012-007741] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Affiliation(s)
- Alexandre Oliveira Ferreira
- Department of Gastroenterology and Hepatology, Medical School of Lisbon, Hospital Santa Maria, Lisbon, Portugal.
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