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and combining repair techniques with bariatric surgery can improve outcomes and lower the rate of complication for select patients, according to recent guidelines released by the American Society for Metabolic and Bariatric Surgery and the American Hernia Society.
Emanuele Lo Menzo, MD, of the Bariatric and Metabolic Institute at Cleveland Clinic Florida in Weston, and his colleagues issued a statement, published in the journal Surgery for Obesity and Related Diseases, based on available evidence from scientific literature on the impact of obesity on hernia surgery and what effect treating obesity has on improving hernia repair outcomes.
The authors noted abdominal wall hernia in obese patients is “a significant and increasingly common challenge for surgeons” and cited recent data from the American College of Surgeons National Surgical Quality Improvement Program that shows 60% of ventral hernia repairs (VHR) are performed on patients with body mass indexes (BMIs) above 30 kg/m2. Overall, they noted that general surgeons perform approximately 350,000 conventional hernia repairs (CHR) and 800,000 incisional hernia (IH) repairs each year.
The literature on the impact of obesity on hernia repair outcomes and the feasibility of a combined operation to address each problem has significant gaps, leaving surgeons to decide on a correct course based on individual patient needs. The guideline offers some recommendations, and notes areas that remain understudied. First, “in patients with severe obesity and [ventral hernia] and both being amenable to laparoscopic repair, combined hernia repair and [metabolic/bariatric surgery] may be safe and associated with good short-term outcomes and low risk of infection.” But the use of synthetic mesh in these patients is not well studied and so the guideline passes on a recommendation of mesh. For those obese patients with symptomatic abdominal wall hernias (AWHs) not amenable to laparoscopy, the guideline notes that metabolic/bariatric surgery first may be the best option.
Risk of hernia in obese patients
Studies suggest there is an increased risk of primary and IH among patients with BMIs greater than 25 kg/m2, with one study finding an 18.2% complication rate after single-incision laparoscopic surgery for patients with BMIs of 40 kg/m2 or higher, compared with a 3.5% complication rate among patients at a normal body weight. Severe BMI also is a risk factor for developing surgical site infection (SSI), which can cause recurrence, the authors said. Evidence from multiple studies further supports BMI as a risk factor for hernia recurrence, and intra-abdominal pressure from obesity increases the risk of developing an AWH.
“While most authors attribute the increased risk for AWH formation in the setting of obesity to BMI alone, others have suggested that abdominal circumference and elevated visceral fat may play a more significant role,” the authors wrote.
However, Dr. Lo Menzo and his colleagues admitted the actual rate of IH is difficult to calculate because some patients may not seek treatment for minimally symptomatic hernias. Patients with higher BMIs may not be aware of or seek treatment for common symptoms of IH such as groin bulge, or when they do seek treatment, it can present with symptoms such as incarceration or strangulation, they said. Patients with higher BMIs also are more likely to be offered “watchful waiting” because of higher complication rates in this patient population, which may contribute to incarceration or strangulation symptoms in these patients, they added.
Complications and recurrence
There is no one recommended repair technique or ideal BMI for hernia repair in obese patients, the authors wrote. One study found laparoscopic VHRs had a complication rate of 1.2% and reoccurrence rate of 5.5% at mean 25-month follow-up in patients with BMIs of 38 kg/m2 or greater, while a different study with a similar design found a 3.8% reoccurrence rate at 18-month follow-up. Degree of obesity can affect complication rate: One study showed that 73% of all complications after laparoscopic VHR occurred in the group of patients with BMIs of 30 kg/m2 or greater; a different study of laparoscopic VHR had an 8.3% hernia reoccurrence rate in patients with BMIs of 40 kg/m2 or greater, compared with patients at a normal weight (2.9%), with time to hernia reoccurrence being shorter in the higher-BMI group. A study of obese patients undergoing retromuscular open repair had a wound complication rate of 16% and a reoccurrence rate of 6%, with another study of patients undergoing umbilical hernia repair showing similar rates of complication and reoccurrence.
Panniculectomy
Among patients who underwent IH repair with panniculectomy, the authors found a 40% complication rate and a 10% reoccurrence rate in patients with BMIs of 40 kg/m2 or greater who received a partial underlay mesh placement hernia repair, while a different study found an increased risk of surgical site occurrences but not SSI in patients with BMIs of 34.3 kg/m2 or greater who underwent open ventral incisional hernia repair with panniculectomy. A third study found BMIs were not linked to a 55% complication rate in patients who underwent open ventral IH repair with and without mesh.
Simultaneous surgery
The authors noted that studies have shown that performing laparoscopic hernia repair and metabolic and bariatric surgery simultaneously is safe and has good short-term results. Specifically, patients who underwent the surgery with synthetic mesh had a low rate of infection or reoccurrence. Patients who underwent simultaneous weight-loss surgery and VHR had an elevated risk of SSI but no increased rate of 30-day mortality or morbidity, according to results from a large-scale registry. However, the authors noted patients with severe obesity may not be good candidates for simultaneous metabolic and bariatric surgery [MBS] and VHR, such as in patients with “large abdominal wall defects, loss of abdominal domain, extensive intestinal adhesive disease, poor quality skin (i.e., attenuated skin, prior skin graft, or ulcerated skin), incarcerated hernias containing bowel, hernias with previous synthetic mesh, hernias with chronic infection, or patients who have already undergone MBS with altered anatomy that is still intact.”
Preop weight loss
There is mixed data on the effect of weight loss prior to VHR through interventions such as very-low-calorie diets, pharmacotherapy, intragastric balloon therapy, and MBS as a first-stage procedure prior to VHR. Many patients treating their obesity with very-low-calorie diets lose approximately 10%-20% of their initial body weight and keep the weight off for at least 18 months, while one study showed patients who underwent intragastric balloon therapy lost approximately 10% of their body weight over 6 months; however, other studies have questioned the efficacy of this therapy, compared with a structured weight loss program or bariatric surgery. The authors also noted the difficulty of coordinating VHR after weight-loss surgery, lack of support from insurers, and they cited reports that cautioned bariatric surgeons to not leave hernias untreated during MBS. There is no current evidence pharmacotherapy through Food and Drug Administration–approved weight-loss drugs prior to hernia repair yield the weight-loss results needed for these patients to improve hernia outcomes, they added.
“Ultimately, there are various appropriate treatment modalities for each patient, and surgeons must use their judgment in selecting from among the different feasible options,” Dr. Lo Menzo and his colleagues wrote in the guidelines.
The authors report no relevant conflicts of interest.
SOURCE: Lo Menzo E et al. Surg Obes Relat Dis. 2018 Jul 19. doi: 10.1016/j.soard.2018.07.005.
and combining repair techniques with bariatric surgery can improve outcomes and lower the rate of complication for select patients, according to recent guidelines released by the American Society for Metabolic and Bariatric Surgery and the American Hernia Society.
Emanuele Lo Menzo, MD, of the Bariatric and Metabolic Institute at Cleveland Clinic Florida in Weston, and his colleagues issued a statement, published in the journal Surgery for Obesity and Related Diseases, based on available evidence from scientific literature on the impact of obesity on hernia surgery and what effect treating obesity has on improving hernia repair outcomes.
The authors noted abdominal wall hernia in obese patients is “a significant and increasingly common challenge for surgeons” and cited recent data from the American College of Surgeons National Surgical Quality Improvement Program that shows 60% of ventral hernia repairs (VHR) are performed on patients with body mass indexes (BMIs) above 30 kg/m2. Overall, they noted that general surgeons perform approximately 350,000 conventional hernia repairs (CHR) and 800,000 incisional hernia (IH) repairs each year.
The literature on the impact of obesity on hernia repair outcomes and the feasibility of a combined operation to address each problem has significant gaps, leaving surgeons to decide on a correct course based on individual patient needs. The guideline offers some recommendations, and notes areas that remain understudied. First, “in patients with severe obesity and [ventral hernia] and both being amenable to laparoscopic repair, combined hernia repair and [metabolic/bariatric surgery] may be safe and associated with good short-term outcomes and low risk of infection.” But the use of synthetic mesh in these patients is not well studied and so the guideline passes on a recommendation of mesh. For those obese patients with symptomatic abdominal wall hernias (AWHs) not amenable to laparoscopy, the guideline notes that metabolic/bariatric surgery first may be the best option.
Risk of hernia in obese patients
Studies suggest there is an increased risk of primary and IH among patients with BMIs greater than 25 kg/m2, with one study finding an 18.2% complication rate after single-incision laparoscopic surgery for patients with BMIs of 40 kg/m2 or higher, compared with a 3.5% complication rate among patients at a normal body weight. Severe BMI also is a risk factor for developing surgical site infection (SSI), which can cause recurrence, the authors said. Evidence from multiple studies further supports BMI as a risk factor for hernia recurrence, and intra-abdominal pressure from obesity increases the risk of developing an AWH.
“While most authors attribute the increased risk for AWH formation in the setting of obesity to BMI alone, others have suggested that abdominal circumference and elevated visceral fat may play a more significant role,” the authors wrote.
However, Dr. Lo Menzo and his colleagues admitted the actual rate of IH is difficult to calculate because some patients may not seek treatment for minimally symptomatic hernias. Patients with higher BMIs may not be aware of or seek treatment for common symptoms of IH such as groin bulge, or when they do seek treatment, it can present with symptoms such as incarceration or strangulation, they said. Patients with higher BMIs also are more likely to be offered “watchful waiting” because of higher complication rates in this patient population, which may contribute to incarceration or strangulation symptoms in these patients, they added.
Complications and recurrence
There is no one recommended repair technique or ideal BMI for hernia repair in obese patients, the authors wrote. One study found laparoscopic VHRs had a complication rate of 1.2% and reoccurrence rate of 5.5% at mean 25-month follow-up in patients with BMIs of 38 kg/m2 or greater, while a different study with a similar design found a 3.8% reoccurrence rate at 18-month follow-up. Degree of obesity can affect complication rate: One study showed that 73% of all complications after laparoscopic VHR occurred in the group of patients with BMIs of 30 kg/m2 or greater; a different study of laparoscopic VHR had an 8.3% hernia reoccurrence rate in patients with BMIs of 40 kg/m2 or greater, compared with patients at a normal weight (2.9%), with time to hernia reoccurrence being shorter in the higher-BMI group. A study of obese patients undergoing retromuscular open repair had a wound complication rate of 16% and a reoccurrence rate of 6%, with another study of patients undergoing umbilical hernia repair showing similar rates of complication and reoccurrence.
Panniculectomy
Among patients who underwent IH repair with panniculectomy, the authors found a 40% complication rate and a 10% reoccurrence rate in patients with BMIs of 40 kg/m2 or greater who received a partial underlay mesh placement hernia repair, while a different study found an increased risk of surgical site occurrences but not SSI in patients with BMIs of 34.3 kg/m2 or greater who underwent open ventral incisional hernia repair with panniculectomy. A third study found BMIs were not linked to a 55% complication rate in patients who underwent open ventral IH repair with and without mesh.
Simultaneous surgery
The authors noted that studies have shown that performing laparoscopic hernia repair and metabolic and bariatric surgery simultaneously is safe and has good short-term results. Specifically, patients who underwent the surgery with synthetic mesh had a low rate of infection or reoccurrence. Patients who underwent simultaneous weight-loss surgery and VHR had an elevated risk of SSI but no increased rate of 30-day mortality or morbidity, according to results from a large-scale registry. However, the authors noted patients with severe obesity may not be good candidates for simultaneous metabolic and bariatric surgery [MBS] and VHR, such as in patients with “large abdominal wall defects, loss of abdominal domain, extensive intestinal adhesive disease, poor quality skin (i.e., attenuated skin, prior skin graft, or ulcerated skin), incarcerated hernias containing bowel, hernias with previous synthetic mesh, hernias with chronic infection, or patients who have already undergone MBS with altered anatomy that is still intact.”
Preop weight loss
There is mixed data on the effect of weight loss prior to VHR through interventions such as very-low-calorie diets, pharmacotherapy, intragastric balloon therapy, and MBS as a first-stage procedure prior to VHR. Many patients treating their obesity with very-low-calorie diets lose approximately 10%-20% of their initial body weight and keep the weight off for at least 18 months, while one study showed patients who underwent intragastric balloon therapy lost approximately 10% of their body weight over 6 months; however, other studies have questioned the efficacy of this therapy, compared with a structured weight loss program or bariatric surgery. The authors also noted the difficulty of coordinating VHR after weight-loss surgery, lack of support from insurers, and they cited reports that cautioned bariatric surgeons to not leave hernias untreated during MBS. There is no current evidence pharmacotherapy through Food and Drug Administration–approved weight-loss drugs prior to hernia repair yield the weight-loss results needed for these patients to improve hernia outcomes, they added.
“Ultimately, there are various appropriate treatment modalities for each patient, and surgeons must use their judgment in selecting from among the different feasible options,” Dr. Lo Menzo and his colleagues wrote in the guidelines.
The authors report no relevant conflicts of interest.
SOURCE: Lo Menzo E et al. Surg Obes Relat Dis. 2018 Jul 19. doi: 10.1016/j.soard.2018.07.005.
and combining repair techniques with bariatric surgery can improve outcomes and lower the rate of complication for select patients, according to recent guidelines released by the American Society for Metabolic and Bariatric Surgery and the American Hernia Society.
Emanuele Lo Menzo, MD, of the Bariatric and Metabolic Institute at Cleveland Clinic Florida in Weston, and his colleagues issued a statement, published in the journal Surgery for Obesity and Related Diseases, based on available evidence from scientific literature on the impact of obesity on hernia surgery and what effect treating obesity has on improving hernia repair outcomes.
The authors noted abdominal wall hernia in obese patients is “a significant and increasingly common challenge for surgeons” and cited recent data from the American College of Surgeons National Surgical Quality Improvement Program that shows 60% of ventral hernia repairs (VHR) are performed on patients with body mass indexes (BMIs) above 30 kg/m2. Overall, they noted that general surgeons perform approximately 350,000 conventional hernia repairs (CHR) and 800,000 incisional hernia (IH) repairs each year.
The literature on the impact of obesity on hernia repair outcomes and the feasibility of a combined operation to address each problem has significant gaps, leaving surgeons to decide on a correct course based on individual patient needs. The guideline offers some recommendations, and notes areas that remain understudied. First, “in patients with severe obesity and [ventral hernia] and both being amenable to laparoscopic repair, combined hernia repair and [metabolic/bariatric surgery] may be safe and associated with good short-term outcomes and low risk of infection.” But the use of synthetic mesh in these patients is not well studied and so the guideline passes on a recommendation of mesh. For those obese patients with symptomatic abdominal wall hernias (AWHs) not amenable to laparoscopy, the guideline notes that metabolic/bariatric surgery first may be the best option.
Risk of hernia in obese patients
Studies suggest there is an increased risk of primary and IH among patients with BMIs greater than 25 kg/m2, with one study finding an 18.2% complication rate after single-incision laparoscopic surgery for patients with BMIs of 40 kg/m2 or higher, compared with a 3.5% complication rate among patients at a normal body weight. Severe BMI also is a risk factor for developing surgical site infection (SSI), which can cause recurrence, the authors said. Evidence from multiple studies further supports BMI as a risk factor for hernia recurrence, and intra-abdominal pressure from obesity increases the risk of developing an AWH.
“While most authors attribute the increased risk for AWH formation in the setting of obesity to BMI alone, others have suggested that abdominal circumference and elevated visceral fat may play a more significant role,” the authors wrote.
However, Dr. Lo Menzo and his colleagues admitted the actual rate of IH is difficult to calculate because some patients may not seek treatment for minimally symptomatic hernias. Patients with higher BMIs may not be aware of or seek treatment for common symptoms of IH such as groin bulge, or when they do seek treatment, it can present with symptoms such as incarceration or strangulation, they said. Patients with higher BMIs also are more likely to be offered “watchful waiting” because of higher complication rates in this patient population, which may contribute to incarceration or strangulation symptoms in these patients, they added.
Complications and recurrence
There is no one recommended repair technique or ideal BMI for hernia repair in obese patients, the authors wrote. One study found laparoscopic VHRs had a complication rate of 1.2% and reoccurrence rate of 5.5% at mean 25-month follow-up in patients with BMIs of 38 kg/m2 or greater, while a different study with a similar design found a 3.8% reoccurrence rate at 18-month follow-up. Degree of obesity can affect complication rate: One study showed that 73% of all complications after laparoscopic VHR occurred in the group of patients with BMIs of 30 kg/m2 or greater; a different study of laparoscopic VHR had an 8.3% hernia reoccurrence rate in patients with BMIs of 40 kg/m2 or greater, compared with patients at a normal weight (2.9%), with time to hernia reoccurrence being shorter in the higher-BMI group. A study of obese patients undergoing retromuscular open repair had a wound complication rate of 16% and a reoccurrence rate of 6%, with another study of patients undergoing umbilical hernia repair showing similar rates of complication and reoccurrence.
Panniculectomy
Among patients who underwent IH repair with panniculectomy, the authors found a 40% complication rate and a 10% reoccurrence rate in patients with BMIs of 40 kg/m2 or greater who received a partial underlay mesh placement hernia repair, while a different study found an increased risk of surgical site occurrences but not SSI in patients with BMIs of 34.3 kg/m2 or greater who underwent open ventral incisional hernia repair with panniculectomy. A third study found BMIs were not linked to a 55% complication rate in patients who underwent open ventral IH repair with and without mesh.
Simultaneous surgery
The authors noted that studies have shown that performing laparoscopic hernia repair and metabolic and bariatric surgery simultaneously is safe and has good short-term results. Specifically, patients who underwent the surgery with synthetic mesh had a low rate of infection or reoccurrence. Patients who underwent simultaneous weight-loss surgery and VHR had an elevated risk of SSI but no increased rate of 30-day mortality or morbidity, according to results from a large-scale registry. However, the authors noted patients with severe obesity may not be good candidates for simultaneous metabolic and bariatric surgery [MBS] and VHR, such as in patients with “large abdominal wall defects, loss of abdominal domain, extensive intestinal adhesive disease, poor quality skin (i.e., attenuated skin, prior skin graft, or ulcerated skin), incarcerated hernias containing bowel, hernias with previous synthetic mesh, hernias with chronic infection, or patients who have already undergone MBS with altered anatomy that is still intact.”
Preop weight loss
There is mixed data on the effect of weight loss prior to VHR through interventions such as very-low-calorie diets, pharmacotherapy, intragastric balloon therapy, and MBS as a first-stage procedure prior to VHR. Many patients treating their obesity with very-low-calorie diets lose approximately 10%-20% of their initial body weight and keep the weight off for at least 18 months, while one study showed patients who underwent intragastric balloon therapy lost approximately 10% of their body weight over 6 months; however, other studies have questioned the efficacy of this therapy, compared with a structured weight loss program or bariatric surgery. The authors also noted the difficulty of coordinating VHR after weight-loss surgery, lack of support from insurers, and they cited reports that cautioned bariatric surgeons to not leave hernias untreated during MBS. There is no current evidence pharmacotherapy through Food and Drug Administration–approved weight-loss drugs prior to hernia repair yield the weight-loss results needed for these patients to improve hernia outcomes, they added.
“Ultimately, there are various appropriate treatment modalities for each patient, and surgeons must use their judgment in selecting from among the different feasible options,” Dr. Lo Menzo and his colleagues wrote in the guidelines.
The authors report no relevant conflicts of interest.
SOURCE: Lo Menzo E et al. Surg Obes Relat Dis. 2018 Jul 19. doi: 10.1016/j.soard.2018.07.005.
FROM SURGERY FOR OBESITY AND RELATED DISEASES
