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Jalalian A, Gallagher S, Mathur M, Cohen D. Umbilical Wall Hernia Rupture: A Torrential Case of Flood Syndrome. Am J Med 2024; 137:e83-e84. [PMID: 38395295 DOI: 10.1016/j.amjmed.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 02/06/2024] [Indexed: 02/25/2024]
Affiliation(s)
- Aria Jalalian
- Department of Internal Medicine, Lankenau Medical Center, Wynnewood, Pa.
| | | | - Malini Mathur
- Department of Gastroenterology, Lankenau Medical Center, Wynnewood, Pa
| | - David Cohen
- Department of Internal Medicine, Lankenau Medical Center, Wynnewood, Pa
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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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Adiamah A, Rashid A, Crooks CJ, Hammond J, Jepsen P, West J, Humes DJ. The impact of urgency of umbilical hernia repair on adverse outcomes in patients with cirrhosis: a population-based cohort study from England. Hernia 2024; 28:109-117. [PMID: 38017324 PMCID: PMC10891219 DOI: 10.1007/s10029-023-02898-6] [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: 07/07/2023] [Accepted: 09/18/2023] [Indexed: 11/30/2023]
Abstract
INTRODUCTION Umbilical hernia is common in patients with cirrhosis; however, there is a paucity of dedicated studies on postoperative outcomes in this group of patients. This population-based cohort study aimed to determine the outcomes after emergency and elective umbilical hernia repair in patients with cirrhosis. METHODS Two linked electronic healthcare databases from England were used to identify all patients undergoing umbilical hernia repair between January 2000 and December 2017. Patients were grouped into those with and without cirrhosis and stratified by severity into compensated and decompensated cirrhosis. Length of stay, readmission, 90-day case fatality rate and the odds ratio of 90-day postoperative mortality were defined using logistic regression. RESULTS In total, 22,163 patients who underwent an umbilical hernia repair were included and 297 (1.34%) had cirrhosis. More patients without cirrhosis had an elective procedure, 86% compared with 51% of those with cirrhosis (P < 0.001). In both the elective and emergency settings, patients with cirrhosis had longer hospital length of stay (elective: 0 vs 1 day, emergency: 2 vs 4 days, P < 0.0001) and higher readmission rates (elective: 4.87% vs 11.33%, emergency:11.39% vs 29.25%, P < 0.0001) than those without cirrhosis. The 90-day case fatality rates were 2% and 0.16% in the elective setting, and 19% and 2.96% in the emergency setting in patients with and without cirrhosis respectively. CONCLUSION Emergency umbilical hernia repair in patients with cirrhosis is associated with poorer outcomes in terms of length of stay, readmissions and mortality at 90 days.
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Affiliation(s)
- A Adiamah
- National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit, E Floor West Block, QMC Campus, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK.
| | - A Rashid
- National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit, E Floor West Block, QMC Campus, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - C J Crooks
- National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit, E Floor West Block, QMC Campus, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - J Hammond
- Division of Hepatobiliary and Transplant Surgery, Freeman Hospital, Freeman Rd, High Heaton, Newcastle Upon Tyne, NE7 7DN, UK
| | - P Jepsen
- Department of Hepatology and Gastroenterology and Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - J West
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Clinical Sciences Building, City Hospital, Nottingham, NG5 1PB, UK
| | - D J Humes
- National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit, E Floor West Block, QMC Campus, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Clinical Sciences Building, City Hospital, Nottingham, NG5 1PB, UK
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Liang C, Zheng R, Liu X, Ma Q, Chen J, Shen Y. Predictive value of hematological parameters in cirrhotic patients with open umbilical hernia repair. Hernia 2024; 28:119-126. [PMID: 37848581 DOI: 10.1007/s10029-023-02908-7] [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: 08/07/2023] [Accepted: 10/01/2023] [Indexed: 10/19/2023]
Abstract
PURPOSE Patients with liver cirrhosis sometimes suffer from high recurrence rates and postoperative complications. We previously reported that platelet-related hematological parameters are associated with the outcomes after incisional herniorrhaphy, and aim to evaluate the predictive value of these criteria in cirrhotic patients undergoing open umbilical herniorrhaphy. METHODS This is a retrospective study. The data of 95 cirrhotic patients undergoing open umbilical herniorrhaphy were analyzed. Patients were grouped based on the recurrence and defined hematological values. Platelet-multiple-lymphocyte index (PLM), neutrophil-leukocyte ratio, lymphocyte-monocyte ratio, platelet-neutrophil ratio, systemic immune-inflammation index, and aspartate aminotransferase-leukocyte ratio values were calculated based on preoperative blood analyses. The outcomes were obtained from hospital records and follow-up calls to patients. RESULTS Using cutoff values acquired by the Youden Index, we found a PLM value < 27.9, and the history of inguinal herniorrhaphy were revealed to be statistically significant in the recurrence based on univariant and multivariant analyses (p < 0.05). We further divided patients into two groups based on the cutoff value of PLM and found that a PLM value < 27.9 was significantly associated with the recurrence of incisional hernias (p = 0.018) and the occurrence of postoperative foreign sensation (p = 0.044), and tended to result in other postoperative complications such as cardiopathy, respiratory infection, hypoproteinemia, and hepatic diseases (p = 0.089). CONCLUSION The preoperative hematological values, especially PLM, may indicate the outcomes in cirrhotic patients after open umbilical herniorrhaphy. Accurate identification of risks may alert the intraoperative and postoperative care for patients.
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Affiliation(s)
- C Liang
- Department of Hernia and Abdominal Wall Surgery, Beijing Chao-Yang Hospital, No. 5 JingYuan Road, Shijingshan District, Beijing, 100043, China
| | - R Zheng
- Department of Hernia and Abdominal Wall Surgery, Beijing Chao-Yang Hospital, No. 5 JingYuan Road, Shijingshan District, Beijing, 100043, China
| | - X Liu
- Department of Hernia and Abdominal Wall Surgery, Beijing Chao-Yang Hospital, No. 5 JingYuan Road, Shijingshan District, Beijing, 100043, China
| | - Q Ma
- Department of Hernia and Abdominal Wall Surgery, Beijing Chao-Yang Hospital, No. 5 JingYuan Road, Shijingshan District, Beijing, 100043, China
| | - J Chen
- Department of Hernia and Abdominal Wall Surgery, Beijing Chao-Yang Hospital, No. 5 JingYuan Road, Shijingshan District, Beijing, 100043, China
- Department of Hernia and Abdominal Wall Surgery, Peking University People's Hospital, No. 11 Xizhimen South Street, Xicheng District, Beijing, 100044, China
| | - Y Shen
- Department of Hernia and Abdominal Wall Surgery, Beijing Chao-Yang Hospital, No. 5 JingYuan Road, Shijingshan District, Beijing, 100043, China.
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Torabi J, Florman S, Divino C. Leaking Umbilical Hernias in Cirrhotic Patients, Repair or Observe? Am Surg 2023; 89:5365-5371. [PMID: 36571828 DOI: 10.1177/00031348221148362] [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] [Indexed: 12/22/2023]
Abstract
BACKGROUND Umbilical hernias (UHs) in cirrhotic patients are common, can be quite complicated and are associated with significant morbidity and mortality. Leakage of ascites is a challenging entity and poses significant risks. METHODS This is a retrospective study of patients with cirrhosis and UHs with ascitic leakage. Patients were divided into two groups: patients managed operatively during index admission (Group 1) and those managed non-surgically during index admission (Group 2). Group 2 was further divided into those that subsequently underwent repair of UH and those managed medically. RESULTS Of 47 cirrhotic patients with leaking UHs, 19 patients were managed surgically during index admission (Group 1). In Group 2, 15 patients were managed non-surgically and 13 subsequently underwent surgery. The groups had comparable demographics, MELD-Na and Child-Pugh class. Group 2 had a higher rate of emergency surgery (92% vs 58%, P = .04) and higher rate of recurrence (31 vs. 0%, P = .02). The non-surgical patients in Group 2 had higher 1-year mortality (67%) compared to Group 1 (21%) and surgical patients in Group 2 (31%, P = .007). Multi-variable logistic regression for 1-year mortality demonstrated MELD-Na as the most significant risk factor (OR = 1.2, P = .05) and undergoing UH repair as the most significant protective factor (OR = .16, P = .02). CONCLUSIONS Cirrhotic patients with leaking UHs should undergo urgent repair. Non-operative management confers high risk of continued or increased ascitic leakage necessitating more emergent surgery. Despite high rate of post-operative complications related to cirrhosis, there is a clear mortality benefit to the repair of leaking UHs in cirrhotic patients.
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Affiliation(s)
- Julia Torabi
- Division of General Surgery, Mount Sinai Hospital, New York, NY, USA
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sander Florman
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Mount Sinai Hospital, Recanati/Miller Transplantation Institute, New York, NY, USA
| | - Celia Divino
- Division of General Surgery, Mount Sinai Hospital, New York, NY, USA
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
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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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Campos ACL. PROFESSOR JULIO CEZAR UILI COELHO. FORMER PRESIDENT OF THE BRAZILIAN COLLEGE OF DIGESTIVE SURGERY. ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD = BRAZILIAN ARCHIVES OF DIGESTIVE SURGERY 2023; 36:e1765. [PMID: 37851751 PMCID: PMC10578146 DOI: 10.1590/0102-672020230047e1765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 07/10/2023] [Indexed: 10/20/2023]
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Kalluri S, Gonzalez SA, Wolfshohl J. Après Moi, Le Deluge: The identification and management of flood syndrome in the emergency department. Am J Emerg Med 2023; 72:223.e5-223.e6. [PMID: 37517872 DOI: 10.1016/j.ajem.2023.07.038] [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: 07/17/2023] [Accepted: 07/21/2023] [Indexed: 08/01/2023] Open
Abstract
Umbilical hernias develop in approximately 20% of patients with liver cirrhosis and ascites. Flood Syndrome is an eponym describing the spontaneous rupture of these umbilical hernias due to the elevated intrabdominal pressure associated with large-volume ascites. Though rare, Flood Syndrome is associated with several life-threatening sequela including infection, organ failure, and hypovolemic shock, leading to mortality or transplant in over 30% of patients. The following case is a single patient encounter describing an 80-year-old female with long-standing ascites who presented to the Emergency Department shortly after experiencing a spontaneous extravasation of fluid from her umbilical hernia.
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Affiliation(s)
- Sneha Kalluri
- Department of Medicine, Baylor Scott & White All-Saints Medical Center, Fort Worth, TX, United States of America.
| | - Stevan A Gonzalez
- Department of Medicine, Baylor Scott & White All-Saints Medical Center, Fort Worth, TX, United States of America; Division of Hepatology, Annette C. and Harold C. Simmons Transplant Institute, Baylor Scott & White All-Saints Medical Center, Fort Worth, TX, United States of America
| | - Jon Wolfshohl
- Department of Emergency Medicine, Baylor Scott & White All-Saints Medical Center, Fort Worth, TX, United States of America
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Muacevic A, Adler JR. Gangrene of the Colon Ascendens, Colon Transversum, and Lienal Flexure in a Massive Strangulated Umbilical Hernia. Cureus 2022; 14:e30022. [PMID: 36225246 PMCID: PMC9540527 DOI: 10.7759/cureus.30022] [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] [Accepted: 10/07/2022] [Indexed: 02/03/2023] Open
Abstract
This case describes an 80-year-old obese woman who presented with a giant, incarcerated umbilical hernia. The hernia was present for over 15 years, continuously increasing in size. The only symptom was the pain which lasted about two hours before arrival at the hospital. In an emergency laparotomy, gangrenous colon ascendens, transversum, and lienal flexure have been found. A subtotal colectomy with the creation of terminal ileostomy without hernia repair has been done. The recovery was uneventful, and the patient was discharged on the fifth postoperative day. After one month, the reconstruction of the digestive continuity with an L-L ileo-descendo anastomosis followed. The patient decided against the hernia repair.
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Risk factors for decompensation and death following umbilical hernia repair in patients with end-stage liver disease. Eur J Gastroenterol Hepatol 2022; 34:1060-1066. [PMID: 36062496 DOI: 10.1097/meg.0000000000002417] [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] [Indexed: 12/10/2022]
Abstract
INTRODUCTION Symptomatic umbilical hernias are a common cause of morbidity and mortality in patients with cirrhosis and end-stage liver disease (ESLD). This study set out to characterise the factors predicting outcome following repair of symptomatic umbilical hernias in ESLD at a single institution. METHODS A retrospective review was performed of all patients with ESLD who underwent repair of a symptomatic umbilical hernia between 1998 and 2020. Overall survival was predicted using the Kaplan-Meier method. Logistic regression was used to determine predictors of decompensation and 30-day, 90-day and 1-year mortality. RESULTS One-hundred-and-eight patients with ESLD underwent umbilical hernia repair (emergency n = 78, 72.2%). Transjugular shunting was performed in 29 patients (26.9%). Decompensation occurred in 44 patients (40.7%) and was predicted by emergency surgery (OR, 13.29; P = 0.001). Length of stay was shorter in elective patients compared to emergency patients (3-days vs. 7-days; P = 0.003). Thirty-day, 90-day and 1-year survival was 95.2, 93.2 and 85.4%, respectively. Model for ESLD score >15 predicted 90-day mortality (OR, 18.48; P = 0.030) and hyponatraemia predicted 1-year mortality (OR, 5.31; P = 0.047). Transjugular shunting predicted survival at 1 year (OR, 0.15; P = 0.038). CONCLUSIONS Repair of symptomatic umbilical hernias in patients with ESLD can be undertaken with acceptable outcomes in a specialist centre, however, this remains a high-risk intervention. Patients undergoing emergency repair are more likely to decompensate postoperatively, develop wound-related problems and have a longer length of stay. Transjugular shunting may confer a benefit to survival, but further prospective trials are warranted.
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Johnson KM, Newman KL, Berry K, Itani K, Wu P, Kamath PS, Harris AHS, Cornia PB, Green PK, Beste LA, Ioannou GN. Risk factors for adverse outcomes in emergency versus nonemergency open umbilical hernia repair and opportunities for elective repair in a national cohort of patients with cirrhosis. Surgery 2022; 172:184-192. [PMID: 35058058 DOI: 10.1016/j.surg.2021.12.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 12/03/2021] [Accepted: 12/08/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND Whether to perform umbilical hernia repair in patients with cirrhosis is a common dilemma for surgeons. We aimed to determine the incidence, morbidity, and mortality associated with emergency and nonemergency umbilical hernia repair in patients with and without cirrhosis, and to explore opportunities for nonemergency repair. METHODS Veterans diagnosed with cirrhosis between 2001 and 2014 and a frequency-matched sample of veterans without cirrhosis were followed through September 2017. Veterans Affairs Surgical Quality Improvement Program data provided outcomes and risk factors for mortality after umbilical hernia repair. We performed chart review of a random sample of patients undergoing emergency umbilical hernia repair. RESULTS Among 119,605 veterans with cirrhosis and 118,125 matched veterans without cirrhosis, the Veterans Affairs Surgical Quality Improvement Program database included 1,475 and 552 open umbilical hernia repairs, respectively. In patients with cirrhosis, 30-day mortality was 1.2% after nonemergency umbilical hernia repair and 12.2% after emergency umbilical hernia repair, contrasting with zero deaths in patients without cirrhosis undergoing these repairs. In patients with cirrhosis but no ascites in the prior month, 30-day mortality after nonemergency umbilical hernia repair was 0.7%, compared to 2.2% in those with ascites. Chart review of patients requiring emergency umbilical hernia repair revealed that elective umbilical hernia repair may have been feasible in 30% of these patients in the prior year; fewer than half of those undergoing emergency umbilical hernia repair had received a general surgery consultation in the prior 2 years. CONCLUSIONS Nonemergency open umbilical hernia repair was associated with relatively low perioperative mortality in patients with cirrhosis and no recent ascites. About 30% of patients undergoing emergency umbilical hernia repair may have been candidates for nonemergency repair in the prior year.
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Affiliation(s)
- Kay M Johnson
- Hospital and Specialty Medicine Service Line, Veterans Affairs Puget Sound Health Care System, and Division of General Internal Medicine, University of Washington School of Medicine, Seattle, WA.
| | - Kira L Newman
- Gastroenterology Fellowship Program, University of Michigan Medical School, Ann Arbor, MI
| | - Kristin Berry
- Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA
| | - Kamal Itani
- Department of Surgery, Boston VA Health Care System, and Department of Surgery, Boston University, MA
| | - Peter Wu
- Department of Surgery, Veterans Affairs Puget Sound Health Care System and University of Washington School of Medicine, Seattle, WA
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Alex H S Harris
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, and Department of Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - Paul B Cornia
- Hospital and Specialty Medicine Service Line, Veterans Affairs Puget Sound Health Care System, and Division of General Internal Medicine, University of Washington School of Medicine, Seattle, WA
| | - Pamela K Green
- Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA
| | - Lauren A Beste
- Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA; Primary Care Service, Veterans Affairs Puget Sound Health Care System, Seattle WA and Division of General Internal Medicine, University of Washington School of Medicine, Seattle, WA
| | - George N Ioannou
- Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA; Division of Gastroenterology, Department of Medicine, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, WA
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Liu JK, Purdy AC, Moazzez A, La Riva A, Ozao-Choy J. Defining a Body Mass Index Threshold for Preventing Recurrence in Ventral Hernia Repairs. Am Surg 2022; 88:2514-2518. [PMID: 35578162 DOI: 10.1177/00031348221102608] [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: 11/17/2022]
Abstract
INTRODUCTION Body mass index (BMI) has been established as an independent risk factor for complications after abdominal hernia repairs. While various thresholds have been proposed, there is no consensus for an ideal BMI for elective hernia repair. OBJECTIVE To identify the BMI threshold at which risk for hernia recurrence is significantly increased in patients undergoing ventral and incisional hernia repair. METHODS This retrospective review of medical records included patients who underwent ventral or incisional hernia repairs from 2014 to 2020 at a single institution. Patients with hernia defects ≥4 cm were included. The primary outcome measure was hernia recurrence. Classification and Regression Tree (CART) analysis was used to determine the BMI threshold for recurrence. Bivariate and multivariate analyses were used to validate the threshold and to evaluate factors associated with recurrence. RESULTS Of the 175 patients included, 9.1% had a recurrence. Classification and Regression Tree analysis identified BMI 35.3 kg/m2 as the critical threshold for hernia recurrence. In bivariate analysis, compared to patients who had no recurrence, patients with recurrence were more likely to have cirrhosis (12.5% vs 0%, P = .008), incarcerated hernias (75.0% vs 31.4%, P = .001), urgent surgery (75.0% vs 22.0%, P = <.001), biologic and no mesh use (25.0% vs 6.4% and 12.5% vs 5.7%, P = .012), and BMI >35.3 kg/m2 (75.0% vs 25.8%, P < .001). In multivariate regression, only BMI >35.3 kg/m2 was associated with recurrence [OR: 20.58 (95% CI: 2.17-194.87), P = .008]. CONCLUSION Body mass index >35.3 kg/m2 was the only independent factor associated with hernia recurrence. This highlights the importance of determining a BMI threshold for patients undergoing ventral or incisional hernia repair.
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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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14
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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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15
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McDaniel C, Bell R, Farha N, Vozzo C, Bullen J, Rosen M, Romero-Marrero C, Partovi S, Kapoor B. Risk of hernia-related complications after transjugular intrahepatic portosystemic shunt creation in patients with pre-existing ventral abdominal hernias: 15-year experience at a quaternary medical center. BMJ Open Gastroenterol 2022; 9:bmjgast-2022-000876. [PMID: 35318192 PMCID: PMC8943763 DOI: 10.1136/bmjgast-2022-000876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 02/16/2022] [Indexed: 11/12/2022] Open
Abstract
Objective Transjugular intrahepatic portosystemic shunt (TIPS) placement is used to treat the sequelae of portal hypertension, including refractory variceal bleeding, ascites and hepatic hydrothorax. However, hernia-related complications such as incarceration and small bowel obstruction can occur after TIPS placement in patients with pre-existing hernias. The aim of this study was to determine the incidence of hernia complications in the first year after TIPS placement and to identify patient characteristics leading to an increased risk of these complications. Design This retrospective analysis included patients with pre-existing abdominal hernias who underwent primary TIPS placement with covered stents at our institution between 2004 and 2018. The 1-year hernia complication rate and the average time to complications were documented. Using a Wilcoxon rank-sum test, the characteristics of patients who developed hernia-related complications versus the characteristics of those without complications were compared. Results A total of 167 patients with pre-existing asymptomatic abdominal hernias were included in the analysis. The most common reason for TIPS placement was refractory ascites (80.6%). A total of 36 patients (21.6%) developed hernia-related complications after TIPS placement, including 20 patients with acute complications and 16 with non-acute complications. The mean time to presentation of hernia-related complications was 66 days. Patients who developed hernia-related complications were more likely than those without complications to have liver cirrhosis secondary to alcohol consumption (p=0.049), although this association was no longer significant after multivariate analysis. Conclusion Within 1 year after TIPS placement, approximately 20% of patients with pre-existing hernias develop hernia-related complications, typically within the first 2 months after the procedure. Patients with pre-existing hernia undergoing TIPS placement should be educated regarding the signs and symptoms of hernia-related complications, including incarceration and small bowel obstruction.
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Affiliation(s)
- Charles McDaniel
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ruth Bell
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Natalie Farha
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Catherine Vozzo
- Department of Gastroenterology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Jennifer Bullen
- Department of Radiology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Michael Rosen
- Department of General Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Sasan Partovi
- Department of Radiology, Cleveland Clinic, Cleveland, Ohio, USA
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16
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Risk factors of incisional hernia after laparoscopic colorectal surgery with periumbilical minilaparotomy incision: a propensity score matching analysis. JOURNAL OF MINIMALLY INVASIVE SURGERY 2022; 25:24-31. [PMID: 35603344 PMCID: PMC8977500 DOI: 10.7602/jmis.2022.25.1.24] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 03/08/2022] [Accepted: 03/12/2022] [Indexed: 12/03/2022]
Abstract
Purpose Incisional hernia is one of the most common complications after abdominal surgery conducted through a midline incision. Considerable debate remains regarding the design, comorbidity, suture material, and method. We investigated the risk factors for incisional hernia after laparoscopic colorectal surgery in the presence of limited surgery-related factors. Methods A retrospective study was designed with 541 patients who underwent laparoscopic colorectal surgery performed by a single operator from January 2015 to December 2017. Due to open conversions, other abdominal operations, or follow-up loss, only 445 patients were included in the study. After propensity score matching, 266 patients were included. The study was based on diagnosis of incisional hernia on computed tomography at 6 and 12 months postoperatively. Results Of the 266 total patients, 133 underwent abdominal closure using PDS (Ethicon), while the remaining 133 underwent closure with Vicryl (Ethicon). Of these patients, nine were diagnosed with incisional hernia at the 12-month follow-up six (4.5%) in the Vicryl group and three (2.3%) in the PDS group (p = 0.309). The incidence of incisional hernia was significantly increased in females (odds ratio [OR], 15.233; 95% confidence interval [CI], 1.905–121.799; p = 0.010), in patients with body mass index (BMI) of >25 kg/m2 (OR, 4.740; 95% CI, 1.424–15.546; p = 0.011), and in patients with liver disease (OR, 19.899; 95% CI, 1.614–245.376; p = 0.020). Conclusion BMI of >25 kg/m2, female, and liver disease were significant risk factors for incisional hernia after elective laparoscopic colorectal surgery performed through a transumbilical minilaparotomy incision.
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17
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Aryan M, McPhail J, Ravi S, Harris P, Allamneni C, Shoreibah M. Perioperative Transjugular Intrahepatic Portosystemic Shunt Is Associated With Decreased Postoperative Complications in Decompensated Cirrhotics Undergoing Abdominal Surgery. Am Surg 2022; 88:1613-1620. [PMID: 35113676 DOI: 10.1177/00031348211069784] [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] [Indexed: 12/23/2022]
Abstract
BACKGROUND Operative risk in patients with cirrhosis is related to the severity of liver disease and nature of procedure. Pre and postoperative portal decompression via transjugular intrahepatic portosystemic shunt (TIPS) are logical approaches to facilitate surgery and improve postoperative outcomes. We compared postoperative outcomes of decompensated cirrhotics undergoing abdominal surgery either with or without perioperative TIPS placement. METHODS We performed a retrospective review of 41 decompensated cirrhotic patients who had abdominal surgery from 2010-2019 at the University of Alabama at Birmingham. Patients were stratified based on having received either perioperative TIPS or no TIPS. Demographics, laboratory data, perioperative TIPS status and postoperative complications were compared between the 2 groups using Fisher exact test and Student 2 sample t-test. RESULTS Group 1 consisted of 28 patients who had TIPS procedure, with 21 being preoperative and 7 being postoperative. Group 2 had 13 patients who had abdominal surgery without TIPS. When compared to those with perioperative TIPS, patients without TIPS had a significantly increased incidence of postoperative ascites (33% vs 77%, P = .0026), infection (18% vs 54%, P = .028), and acute kidney injury (AKI) (14% vs 46%, P = .0485). Additionally, postoperative Model of End Stage Liver Disease Sodium score was significantly higher in patients without TIPS (22 ± 4.74) when compared to those who had TIPS (17.14 ± 5.48) (P = .009). DISCUSSION Perioperative TIPS placement in decompensated cirrhotics was associated with decreased postoperative ascites, infection, and AKI when compared to those without TIPS. Further studies are needed to validate our findings.
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Affiliation(s)
- Mahmoud Aryan
- Tinsley Harrison Internal Medicine Residency, Department of Medicine, 9968University of Alabama at Birmingham, Birmingham, AL, USA
| | - James McPhail
- Division of Gastroenterology and Hepatology, Department of Medicine, 9968University of Alabama at Birmingham, Birmingham, AL, USA
| | - Sujan Ravi
- Division of Gastroenterology and Hepatology, Department of Medicine, 9968University of Alabama at Birmingham, Birmingham, AL, USA
| | - Patrick Harris
- Division of Gastroenterology and Hepatology, Department of Medicine, 3989Baylor University, Houston, TX, USA
| | - Chaitanya Allamneni
- Division of Digestive Diseases, Department of Medicine, 1371Emory University, Atlanta, GA, USA
| | - Mohamed Shoreibah
- Division of Gastroenterology and Hepatology, Department of Medicine, 9968University of Alabama at Birmingham, Birmingham, AL, USA
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18
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Srivastava KS. OUP accepted manuscript. J Surg Case Rep 2022; 2022:rjac011. [PMID: 35145625 PMCID: PMC8826029 DOI: 10.1093/jscr/rjac011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 01/03/2022] [Accepted: 01/04/2022] [Indexed: 11/14/2022] Open
Abstract
Flood syndrome is a very rare complication that can be found in patients with end-stage liver cirrhosis with concurrent ventral hernias. If the hernia ruptures, ascites can begin to leak uncontrollably from the opening which can become a nidus for infection if left untreated. This scenario is known as Flood syndrome, which was first described by Frank Flood in 1961. Flood syndrome is very difficult to manage for physicians as these patients are poor candidates for surgery but the ascitic leak will continue without surgical intervention. Currently, there is no standard of care for Flood syndrome. As such, physicians must rely on case reports to help guide their treatment plan. Our case report highlights the case of a 66-year-old cirrhotic patient with an ascitic leak from a ruptured umbilical hernia with discussion of both medical and surgical approaches to managing this very rare syndrome.
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Affiliation(s)
- Kumaraman S Srivastava
- TCU School of Medicine, Fort Worth 76105, TX, USA
- Correspondence address. TCU and UNTHSC School of Medicine, Fort Worth 76105, TX, USA. Tel: 781-927-4817; E-mail:
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19
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Johnson KM, Newman KL, Green PK, Berry K, Cornia PB, Wu P, Beste LA, Itani K, Harris AHS, Kamath PS, Ioannou GN. Incidence and Risk Factors of Postoperative Mortality and Morbidity After Elective Versus Emergent Abdominal Surgery in a National Sample of 8193 Patients With Cirrhosis. Ann Surg 2021; 274:e345-e354. [PMID: 31714310 DOI: 10.1097/sla.0000000000003674] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To describe the incidence and risk factors for mortality and morbidity in patients with cirrhosis undergoing elective or emergent abdominal surgeries. BACKGROUND Postoperative morbidity and mortality are higher in patients with cirrhosis; variation by surgical procedure type and cirrhosis severity remain unclear. METHODS We analyzed prospectively-collected data from the Veterans Affairs (VA) Surgical Quality Improvement Program for 8193 patients with cirrhosis, 864 noncirrhotic controls with chronic hepatitis B infection, and 5468 noncirrhotic controls without chronic liver disease, who underwent abdominal surgery from 2001 to 2017. Data were analyzed using random-effects models controlling for potential confounders. RESULTS Patients with cirrhosis had significantly higher 30-day mortality than noncirrhotic patients with chronic hepatitis B [4.4% vs 1.3%, adjusted odds ratio (aOR) 2.80, 95% confidence interval (CI) 1.57-4.98] or with no chronic liver disease (0.8%, aOR 4.68, 95% CI 3.27-6.69); mortality difference was highest in patients with Model for End-stage Liver Disease (MELD) score ≥10. Among patients with cirrhosis, postoperative mortality was almost 6 times higher after emergent rather than elective surgery (17.2% vs. 2.1%, aOR 5.82, 95% CI 4.66-7.27). For elective surgeries, 30-day mortality was highest after colorectal resection (7.0%) and lowest after inguinal hernia repair (0.6%). Predictors of postoperative mortality included cirrhosis-related characteristics (high MELD score, low serum albumin, ascites, encephalopathy), surgery-related characteristics (emergent vs elective, type of surgery, intraoperative blood transfusion), comorbidities (chronic obstructive pulmonary disease, cancer, sepsis, ventilator dependence, functional status), and age. CONCLUSIONS Accurate preoperative risk assessments in patients with cirrhosis should account for cirrhosis severity, comorbidities, type of procedure, and whether the procedure is emergent versus elective.
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Affiliation(s)
- Kay M Johnson
- Hospital and Specialty Medicine Service Line, Veterans Affairs Puget Sound Health Care System, Seattle, WA
- Division of General Internal Medicine, University of Washington School of Medicine, Seattle, WA
| | - Kira L Newman
- Internal Medicine Residency Program, University of Washington School of Medicine, Seattle, WA
| | - Pamela K Green
- Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA
| | - Kristin Berry
- Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA
| | - Paul B Cornia
- Hospital and Specialty Medicine Service Line, Veterans Affairs Puget Sound Health Care System, Seattle, WA
- Division of General Internal Medicine, University of Washington School of Medicine, Seattle, WA
| | - Peter Wu
- Department of Surgery, Veterans Affairs Puget Sound Health Care System and University of Washington School of Medicine, Seattle, WA
| | - Lauren A Beste
- Division of General Internal Medicine, University of Washington School of Medicine, Seattle, WA
- Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA
- Primary Care Service, Veterans Affairs Puget Sound Health Care System, Seattle, WA
| | - Kamal Itani
- Department of Surgery, Boston VA Health Care System, and Department of Surgery, Boston University, Boston, MA
| | - Alex H S Harris
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - Patrick S Kamath
- Division of Gastroenterology, Department of Medicine, Mayo Clinic, Rochester, MN
| | - George N Ioannou
- Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA
- Division of Gastroenterology, Department of Medicine Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, WA
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20
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Strainiene S, Peciulyte M, Strainys T, Stundiene I, Savlan I, Liakina V, Valantinas J. Management of Flood syndrome: What can we do better? World J Gastroenterol 2021; 27:5297-5305. [PMID: 34539133 PMCID: PMC8409160 DOI: 10.3748/wjg.v27.i32.5297] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 05/03/2021] [Accepted: 08/03/2021] [Indexed: 02/06/2023] Open
Abstract
Approximately 20% of cirrhotic patients with ascites develop umbilical herniation. These patients usually suffer from multisystemic complications of cirrhosis, have a significantly higher risk of infection, and require accurate surveillance– especially in the context of the coronavirus disease 2019 pandemic. The rupture of an umbilical hernia, is an uncommon, life-threatening complication of large-volume ascites and end-stage liver disease resulting in spontaneous paracentesis, also known as Flood syndrome. Flood syndrome remains a challenging condition for clinicians, as recommendations for its management are lacking, and the available evidence for the best treatment approach remains controversial. In this paper, four key questions are addressed regarding the management and prevention of Flood syndrome: (1) Which is the best treatment approach–conservative treatment or urgent surgery? (2) How can we establish the individual risk for herniation and possible hernia rupture in cirrhotic patients? (3) How can we prevent umbilical hernia ruptures? And (4) How can we manage these patients in the conditions created by the coronavirus disease 2019 pandemic?
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Affiliation(s)
- Sandra Strainiene
- Clinic of Gastroenterology, Nephrourology and Surgery, Centre of Hepatology, Gastroenterology and Dietetics, Institute of Clinical Medicine, Vilnius University, Vilnius 03104, Lithuania
| | - Milda Peciulyte
- Clinic of Gastroenterology, Nephrourology and Surgery, Centre of Hepatology, Gastroenterology and Dietetics, Institute of Clinical Medicine, Vilnius University, Vilnius 03104, Lithuania
| | - Tomas Strainys
- Clinic of Anesthesiology and Reanimatology, Centre of Anesthesiology, Intensive Care and Pain Management, Institute of Clinical Medicine, Vilnius University, Vilnius 03104, Lithuania
| | - Ieva Stundiene
- Clinic of Gastroenterology, Nephrourology and Surgery, Centre of Hepatology, Gastroenterology and Dietetics, Institute of Clinical Medicine, Vilnius University, Vilnius 03104, Lithuania
| | - Ilona Savlan
- Clinic of Gastroenterology, Nephrourology and Surgery, Centre of Hepatology, Gastroenterology and Dietetics, Institute of Clinical Medicine, Vilnius University, Vilnius 03104, Lithuania
| | - Valentina Liakina
- Clinic of Gastroenterology, Nephrourology and Surgery, Centre of Hepatology, Gastroenterology and Dietetics, Institute of Clinical Medicine, Vilnius University, Vilnius 03104, Lithuania
- Department of Chemistry and Bioengineering, Faculty of Fundamental Science, Vilnius Gediminas Technical University, Vilnius 10223, Lithuania
| | - Jonas Valantinas
- Clinic of Gastroenterology, Nephrourology and Surgery, Centre of Hepatology, Gastroenterology and Dietetics, Institute of Clinical Medicine, Vilnius University, Vilnius 03104, Lithuania
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21
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Biggins SW, Angeli P, Garcia-Tsao G, Ginès P, Ling SC, Nadim MK, Wong F, Kim WR. Diagnosis, Evaluation, and Management of Ascites, Spontaneous Bacterial Peritonitis and Hepatorenal Syndrome: 2021 Practice Guidance by the American Association for the Study of Liver Diseases. Hepatology 2021; 74:1014-1048. [PMID: 33942342 DOI: 10.1002/hep.31884] [Citation(s) in RCA: 290] [Impact Index Per Article: 96.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 04/07/2021] [Indexed: 12/13/2022]
Affiliation(s)
- Scott W Biggins
- Division of Gastroenterology and Hepatology, and Center for Liver Investigation Fostering discovEryUniversity of WashingtonSeattleWA
| | - Paulo Angeli
- Unit of Hepatic Emergencies and Liver TransplantationDepartment of MedicineDIMEDUniversity of PadovaPaduaItaly
| | - Guadalupe Garcia-Tsao
- Department of Internal MedicineSection of Digestive DiseasesYale UniversityNew HavenCT.,VA-CT Healthcare SystemWest HavenCT
| | - Pere Ginès
- Liver Unit, Hospital Clinic, and Institut d'Investigacions Biomèdiques August Pi i SunyerUniversity of BarcelonaBarcelonaSpain.,Centro de Investigación Biomèdica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD)MadridSpain
| | - Simon C Ling
- The Hospital for Sick Children, Division of Gastroenterology, Hepatology and Nutrition, and Department of PaediatricsUniversity of TorontoTorontoOntarioCanada
| | - Mitra K Nadim
- Division of NephrologyUniversity of Southern CaliforniaLos AngelesCA
| | - Florence Wong
- Division of Gastroenterology and HepatologyUniversity Health NetworkUniversity of TorontoTorontoOntarioCanada
| | - W Ray Kim
- Division of Gastroenterology and HepatologyStanford UniversityPalo AltoCA
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22
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Aithal GP, Palaniyappan N, China L, Härmälä S, Macken L, Ryan JM, Wilkes EA, Moore K, Leithead JA, Hayes PC, O'Brien AJ, Verma S. Guidelines on the management of ascites in cirrhosis. Gut 2021; 70:9-29. [PMID: 33067334 PMCID: PMC7788190 DOI: 10.1136/gutjnl-2020-321790] [Citation(s) in RCA: 152] [Impact Index Per Article: 50.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 08/27/2020] [Accepted: 09/04/2020] [Indexed: 12/15/2022]
Abstract
The British Society of Gastroenterology in collaboration with British Association for the Study of the Liver has prepared this document. The aim of this guideline is to review and summarise the evidence that guides clinical diagnosis and management of ascites in patients with cirrhosis. Substantial advances have been made in this area since the publication of the last guideline in 2007. These guidelines are based on a comprehensive literature search and comprise systematic reviews in the key areas, including the diagnostic tests, diuretic use, therapeutic paracentesis, use of albumin, transjugular intrahepatic portosystemic stent shunt, spontaneous bacterial peritonitis and beta-blockers in patients with ascites. Where recent systematic reviews and meta-analysis are available, these have been updated with additional studies. In addition, the results of prospective and retrospective studies, evidence obtained from expert committee reports and, in some instances, reports from case series have been included. Where possible, judgement has been made on the quality of information used to generate the guidelines and the specific recommendations have been made according to the 'Grading of Recommendations Assessment, Development and Evaluation (GRADE)' system. These guidelines are intended to inform practising clinicians, and it is expected that these guidelines will be revised in 3 years' time.
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Affiliation(s)
- Guruprasad P Aithal
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
- Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Naaventhan Palaniyappan
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
- Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Louise China
- Institute of Liver Disease and Digestive Health, University College London, London, UK
| | - Suvi Härmälä
- Institute of Health Informatics, University College London, London, UK
| | - Lucia Macken
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, Brighton, UK
- Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Jennifer M Ryan
- Institute of Liver Disease and Digestive Health, University College London, London, UK
- Royal Free London NHS Foundation Trust, London, UK
| | - Emilie A Wilkes
- Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham, UK
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Kevin Moore
- Institute of Liver Disease and Digestive Health, University College London, London, UK
| | - Joanna A Leithead
- Liver Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Peter C Hayes
- Hepatology Department, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Alastair J O'Brien
- Institute of Liver Disease and Digestive Health, University College London, London, UK
| | - Sumita Verma
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, Brighton, UK
- Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
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23
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Guo C, Liu Q, Wang Y, Li J. Umbilical Hernia Repair in Cirrhotic Patients With Ascites: A Systemic Review of Literature. Surg Laparosc Endosc Percutan Tech 2020; 31:356-362. [PMID: 33347087 DOI: 10.1097/sle.0000000000000891] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 10/05/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND Umbilical hernia is a common abdominal complication in cirrhotic patients. The incidence of umbilical hernias can be up to 20% in the presence of ascites. However, there is no consensus regarding the optimal management of umbilical hernias in cirrhotic patients. The purpose of this study is to review the management of umbilical hernias in cirrhotic patients with ascites. METHODS A search of the available literature in English since 1980 was performed using PubMed, the Cochrane Library, and a search of relevant journals and reference lists. The search terms included "umbilical hernia," "ascites," "cirrhosis," and any derivatives of these terms, and the literature search identified all the relevant publications. RESULTS Thirty-three relevant articles published in the language of English were identified. Fourteen studies involved the management of refractory ascites in cirrhotic patients. Twenty-four studies included cirrhotic patients receiving elective or emergency surgery. Because of much lower morbidity and mortality in elective surgery than in emergency surgery, many authors advocated early elective repair of uncomplicated umbilical hernias in cirrhotic patients. Of these, 2 studies described laparoscopic umbilical hernioplasty, with a significant lower morbidity and hernia recurrence than open repair. Fifteen studies described the use of prosthetic mesh umbilical hernia repair in cirrhotic patients, which was associated with minimal wound-related morbidity and markedly lower recurrences. CONCLUSIONS Our results indicate that early elective repair of uncomplicated umbilical hernias is recommended in cirrhotic patients with tolerable hepatic functional reserve or when the expected time for liver transplantation is >3 months. Umbilical hernias are supposed to be corrected in the process of liver transplantation, provided that patients could have a better prospect to be transplanted within 3 months. Control of ascites is a crucial part to successful outcomes of umbilical hernia repair. Large volume paracentesis, concomitant peritoneovenous shunting with herniorrhaphy and transjugular intrahepatic portosystemic shunting can be applied to control refractory ascites. Emergency repair of umbilical hernias is indicated in cirrhotic patients with ascites when complications develop.
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Affiliation(s)
| | | | - Yong Wang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Junsheng Li
- Department of General Surgery, Affiliated Zhongda Hospital, Southeast University, Nanjing
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24
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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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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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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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Fatah A, Audiyanto T. Refractory Chylous Ascites with Chylothorax and an Umbilical Hernia in a Patient Ineligible for a Transjugular Intrahepatic Portosystemic Shunt. AMERICAN JOURNAL OF CASE REPORTS 2020; 21:e925026. [PMID: 32865187 PMCID: PMC7483474 DOI: 10.12659/ajcr.925026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 07/22/2020] [Accepted: 06/26/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND Chylous ascites is a rare condition, which is defined by accumulation of a milky fluid due to high triglyceride levels. It is most commonly secondary to malignancy, liver cirrhosis, infection, and tuberculosis. CASE REPORT A 21-year-old woman from rural Indonesia, came to the hospital with chronic dyspnea and a history of repeated paracentesis. Six years ago, she was diagnosed with chronic hepatitis B. For the past 2 years, she had complaints of progressive dyspnea and increased abdominal swelling. On examination, there was dullness on chest percussion and decreased breath sounds. Shifting dullness was positive on abdominal examination. Paracentesis and thoracentesis were performed and showed high triglyceride levels. She underwent an abdominal computed tomography scan and was diagnosed with liver cirrhosis, complicated with chylous ascites and chylothorax. Repeated paracentesis was performed as a therapeutic approach; she had strict diet guidelines, and was prescribed octreotide, furosemide, spironolactone, and albumin. Despite this treatment, two years later, she developed an umbilical hernia complicated with ulceration. Hernia repair was not possible due to her comorbidities. She was indicated for a transjugular intrahepatic portosystemic shunt (TIPS) for the refractory chylous ascites. However, this could not be performed as the patient could not afford this expensive procedure, which was not covered by insurance. CONCLUSIONS Management of refractory chylous ascites is challenging, especially in underdeveloped countries due to socioeconomic problems and limited health care facilities. Although TIPS is indicated in refractory chylous ascites, repeated paracentesis can be useful as an alternative method.
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Affiliation(s)
- Abraham Fatah
- Faculty of Medicine, Pelita Harapan University, Tangerang, Indonesia
| | - Theo Audiyanto
- Department of Internal Medicine, Siloam General Hospital, Tangerang, Indonesia
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Laparoscopic major hepatectomy for hepatocellular carcinoma in elderly patients: a multicentric propensity score‑based analysis. Surg Endosc 2020; 35:3642-3652. [PMID: 32748269 DOI: 10.1007/s00464-020-07843-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 07/24/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Considering the increase in overall life expectancy and the rising incidence of hepatocellular carcinoma (HCC), more elderly patients are considered for hepatic resection. Traditionally, major hepatectomy has not been proposed to the elderly due to severe comorbidities. Indeed, only a few case series are reported in the literature. The present study aimed to compare short-term and long-term outcomes between laparoscopic major hepatectomy (LMH) and open major hepatectomy (OMH) in elderly patients with HCC using propensity score matching (PSM). METHODS We performed a multicentric retrospective study including 184 consecutive cases of HCC major liver resection in patients aged ≥ 70 years in _8 European Hospital Centers. Patients were divided into LMH and OMH groups, and perioperative and long-term outcomes were compared between the 2 groups. RESULTS After propensity score matching, 122 patients were enrolled, 38 in the LMH group and 84 in the OMH group. Postoperative overall complications were lower in the LMH than in the OMH group (18 vs. 46%, p < 0.001). Hospital stay was shorter in the LMH group than in the OMH group (5 vs. 7 days, p = 0.01). Mortality at 90 days was comparable between the two groups. There were no significant differences between the two groups in terms of overall survival (OS) and disease-free survival (DFS) at 1, 3, and 5 years. CONCLUSION LMH for HCC is associated with appropriate short-term outcomes in patients aged ≥ 70 years as compared to OMH. LMH is safe and feasible in elderly patients with HCC.
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29
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Abdominal Pain in a Patient With Ascites. J Emerg Med 2020; 59:710-711. [PMID: 32712038 DOI: 10.1016/j.jemermed.2020.06.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 06/01/2020] [Indexed: 11/22/2022]
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30
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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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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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Lora-Aguirre A, Vega-Peña NV, Barrios-Parra AJ, Ruiz-Pineda JP. Hernia umbilical: un problema no resuelto. IATREIA 2019. [DOI: 10.17533/udea.iatreia.28] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
La cirugía de la hernia umbilical ha sido considerada tradicionalmente como sencilla y de fácil ejecución. El cambio conceptual de la hernia umbilical y los avances en su tratamiento han modificado su abordaje, estableciéndose escenarios de complejidad variable (obesidad, embarazo, cirróticos, distasis de los rectos, etc.) que demandan un conocimiento más profundo del tema por parte de la comunidad médica. El impacto económico en el sistema de salud, debido a su alta prevalencia como patología quirúrgica, implica un uso racional de recursos, así como la necesidad de una nueva categorización dentro de la cirugía de la pared abdominal. Es necesario establecer modificaciones en los procesos diagnósticos y terapéuticos en una entidad que ha sido relegada a los niveles básicos del ejercicio quirúrgico habitual.
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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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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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Herniated Umbilical Varix in a Patient With Cirrhosis. ACG Case Rep J 2019; 6:e00151. [PMID: 31737694 PMCID: PMC6791630 DOI: 10.14309/crj.0000000000000151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Revised: 04/02/2019] [Accepted: 05/31/2019] [Indexed: 11/24/2022] Open
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Abstract
PURPOSE Though perineal hernias remain rare, the incidence is reportedly rising. Secondary to the historical rarity, optimal method of repair and outcomes after repair remain poorly understood. Therefore, we reviewed the past 25 years of our institutional experience with perineal hernia repair. METHODS A retrospective review of an institution-maintained database was conducted from January 1, 1994 to January 31, 2018 for patients undergoing perineal hernia repair. Data were collected on patient characteristics, operative technique, and post-operative outcomes. RESULTS Twenty-one patients (n = 12 male) underwent perineal hernia repair in the study period with two-thirds of the operations occurring in the most recent 7 years (since January 1, 2011). The median time to repair was 13 months (range 2-127) after index operation. The approach was transabdominal in nine, perineal in nine, and combined in three. Mesh, a tissue flap, or a combination of these was used in 19 of the cases and 6 additional abdominal wall hernias were repaired concurrently. Post-operative complications consisted of superficial surgical-site infection (n = 2), infected seroma (n = 1), and a missed enterotomy (n = 1). Follow-up ranged from 0 to 112 months (median 2 months) and only one recurrence was noted. CONCLUSION Presentation for repair of perineal hernia has increased at our instituion over the past 2 decades. Outcomes did not differ between the three repair approaches and the choice of mesh or tissue-based repair. Surgeons should base these decisions on hernia complexity and local tissue conditions.
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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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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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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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Maimone S, Saffioti F, Filomia R, Caccamo G, Saitta C, Pallio S, Consolo P, Sabatini S, Sitajolo K, Franzè MS, Cacciola I, Raimondo G, Squadrito G. Elective endoscopic variceal ligation is not a risk factor for bacterial infection in patients with liver cirrhosis. Dig Liver Dis 2018; 50:366-369. [PMID: 29317174 DOI: 10.1016/j.dld.2017.12.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 11/11/2017] [Accepted: 12/11/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Patients with cirrhosis are at high risk of bacterial infections. Invasive procedures are generally believed to increase this susceptibility. AIMS We investigated the incidence of bacterial infections in cirrhotic patients undergoing elective endoscopic variceal ligation (EVL). METHODS We enrolled 60 consecutive cirrhotic patients who underwent a total number of 112 elective EVL procedures. One to seven bands were applied at each session until variceal eradication. Markers of inflammation/infection and blood cultures were obtained before and 24 h after EVL. RESULTS Aetiology of liver disease was metabolic in 27 (45%), viral in 21 (35%), alcoholic in 12 (20%) patients. Child-Pugh class A/B/C distribution was 29/26/5, respectively, 23 (38%) patients had ascites and 15 (25%) had hepatocellular carcinoma. Blood cultures were negative in all samples before EVL, whereas 3/112 (2.7%) cultures tested positive after endoscopy. Streptococcus mitis and Staphylococcus epidermidis were isolated in 1 and 2 cases, respectively. None of these three patients developed any features of clinically relevant infection, suggesting that the positive cultures were an expression of a transient bacteraemia with no clinical sequelae. CONCLUSIONS Bacterial infection is an uncommon occurrence after elective EVL in cirrhotic patients, and antibiotic prophylaxis is not necessary in this clinical setting.
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Affiliation(s)
- Sergio Maimone
- Division of Clinical and Molecular Hepatology, University Hospital of Messina, Messina, Italy.
| | - Francesca Saffioti
- Division of Clinical and Molecular Hepatology, University Hospital of Messina, Messina, Italy; Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Roberto Filomia
- Division of Clinical and Molecular Hepatology, University Hospital of Messina, Messina, Italy; Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Gaia Caccamo
- Division of Clinical and Molecular Hepatology, University Hospital of Messina, Messina, Italy
| | - Carlo Saitta
- Division of Clinical and Molecular Hepatology, University Hospital of Messina, Messina, Italy
| | - Socrate Pallio
- Division of Digestive Endoscopy, University Hospital of Messina, Italy
| | - Pierluigi Consolo
- Division of Digestive Endoscopy, University Hospital of Messina, Italy
| | - Sara Sabatini
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Krizia Sitajolo
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Maria Stella Franzè
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Irene Cacciola
- Division of Clinical and Molecular Hepatology, University Hospital of Messina, Messina, Italy; Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Giovanni Raimondo
- Division of Clinical and Molecular Hepatology, University Hospital of Messina, Messina, Italy; Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Giovanni Squadrito
- Division of Clinical and Molecular Hepatology, University Hospital of Messina, Messina, Italy; Department of Human Pathology of the Adult and Evolutive Age, University of Messina, Messina, 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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Abbas AE, ElHadidi A, AbdElaziz TF, Ibrahim MA. Patient Optimization is the Key in Surgical Repair of Ruptured Umblical Hernia in Cirrhotic Patients and Tense Ascitis. Hernia 2017. [DOI: 10.5772/intechopen.69446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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