A Risk Model and Cost Analysis of Incisional Hernia After Elective, Abdominal Surgery Based Upon 12,373 Cases

Objectives:Incisional hernia (IH) remains a common, highly morbid, and costly complication. Modest progress has been realized in surgical technique and mesh technology; however, few advances have been achieved toward understanding risk and prevention. In light of the increasing emphasis on prevention in today's health care environment and the billions in costs for surgically treated IH, greater focus on predictive risk models is needed. Methods:All patients undergoing gastrointestinal or gynecologic procedures from January 1, 2005 to June 1, 2013, within the University of Pennsylvania Health System were identified. Comorbidities and operative characteristics were assessed. The primary outcome was surgically treated IH after index procedures. Patients with prior hernia, less than 1-year follow-up, or emergency surgical procedures were excluded. Cox hazard regression modeling with bootstrapped validation, risk factor stratification, and assessment of model performance were conducted. Results:A total of 12,373 patients with a 3.5% incidence of surgically treated IH (follow-up 32.2 ± 26.6 months) were identified. The cost of surgical treatment of IH and management of associated complications exceeded $17.5 million. Notable independent risk factors for IH were ostomy reversal (HR = 2.76), recent chemotherapy (HR = 2.04), bariatric surgery (HR = 1.78), smoking history (HR = 1.74), liver disease (HR = 1.60), and obesity (HR = 1.96). High-risk patients (20.6%) developed IH compared with 0.5% of low-risk patients (C-statistic = 0.78). Conclusions:This study demonstrates an internally validated preoperative risk model of surgically treated IH after 12,000 elective, intra-abdominal procedures to provide more individualized risk counseling and to better inform evidence-based algorithms for the role of prophylactic mesh.

[1]  Naveen M. Krishnan,et al.  Cost-utility analysis of the use of prophylactic mesh augmentation compared with primary fascial suture repair in patients at high risk for incisional hernia. , 2015, Surgery.

[2]  J. Lopez-Monclus,et al.  Randomized controlled trial of the use of a large-pore polypropylene mesh to prevent incisional hernia in colorectal surgery. , 2015, Annals of surgery.

[3]  C. Bell,et al.  Malnutrition in the nursing home , 2015, Current opinion in clinical nutrition and metabolic care.

[4]  M. Ando,et al.  Incidence of and risk factors for incisional hernia after abdominal surgery , 2014, The British journal of surgery.

[5]  Benny Chong,et al.  Routine use of bioprosthetic mesh is not necessary: a retrospective review of 100 consecutive cases of intra-abdominal midweight polypropylene mesh for ventral hernia repair. , 2013, Surgery.

[6]  D. Candinas,et al.  Implantation of Prophylactic Nonabsorbable Intraperitoneal Mesh in Patients With Peritonitis Is Safe and Feasible , 2013, World Journal of Surgery.

[7]  O. El-khadrawy,et al.  Prophylactic Preperitoneal Mesh Placement in Open Bariatric Surgery: a Guard Against Incisional Hernia Development , 2013, Obesity Surgery.

[8]  G. Dumanian,et al.  Routine use of bioprosthetic mesh is not necessary: a retrospective review of 100 consecutive cases of intra-abdominal midweight polypropylene mesh for ventral hernia repair. , 2013, Surgery.

[9]  M. Dubois,et al.  Hypoalbuminemia in the first 24h of admission is associated with organ dysfunction in burned patients. , 2013, Burns : journal of the International Society for Burn Injuries.

[10]  W. Hop,et al.  Impact of incisional hernia on health-related quality of life and body image: a prospective cohort study. , 2012, American journal of surgery.

[11]  T. Anthony,et al.  The impact of surgical site infection on the development of incisional hernia and small bowel obstruction in colorectal surgery. , 2011, American journal of surgery.

[12]  T. Centorrino,et al.  Incisional Hernia Prophylaxis in Morbidly Obese Patients Undergoing Biliopancreatic Diversion , 2011, Obesity surgery.

[13]  G. Dumanian.  Discussion: Minimally Invasive Component Separation with Inlay Bioprosthetic Mesh (MCSIB) for Complex Abdominal Wall Reconstruction , 2011, Plastic and reconstructive surgery.

[14]  L. Goldman,et al.  Cost-Effectiveness of Statin Therapy for Primary Prevention in a Low-Cost Statin Era , 2011, Circulation.

[15]  Ewout W Steyerberg,et al.  Extensions of net reclassification improvement calculations to measure usefulness of new biomarkers , 2011, Statistics in medicine.

[16]  Kirsten Bibbins-Domingo,et al.  Projected effect of dietary salt reductions on future cardiovascular disease. , 2010, The New England journal of medicine.

[17]  Daniel Millbourn,et al.  Effect of stitch length on wound complications after closure of midline incisions: a randomized controlled trial. , 2009, Archives of surgery.

[18]  Benjamin C. Paul,et al.  Soft Polypropylene Mesh, But Not Cadaveric Dermis, Significantly Improves Outcomes in Midline Hernia Repairs Using the Components Separation Technique , 2009, Plastic and Reconstructive Surgery.

[19]  S. Navarro-Soto,et al.  Randomized, Controlled, Prospective Trial of the Use of a Mesh to Prevent Parastomal Hernia , 2009, Annals of surgery.

[20]  M. Büchler,et al.  Interrupted or Continuous Slowly Absorbable Sutures For Closure of Primary Elective Midline Abdominal Incisions: A Multicenter Randomized Trial (INSECT: ISRCTN24023541) , 2009, Annals of surgery.

[21]  M. Rosen,et al.  Abdominal hernia repair with bridging acellular dermal matrix--an expensive hernia sac. , 2008, American journal of surgery.

[22]  Ziding Feng,et al.  Evaluating the Predictiveness of a Continuous Marker , 2007, Biometrics.

[23]  G. Pascual,et al.  Midline abdominal wall closure: a new prophylactic mesh concept. , 2006, Journal of the American College of Surgeons.

[24]  E. Verdaasdonk,et al.  Long-term Follow-up of a Randomized Controlled Trial of Suture Versus Mesh Repair of Incisional Hernia , 2004, Annals of surgery.

[25]  T. Koepsell,et al.  Have Outcomes of Incisional Hernia Repair Improved With Time?: A Population-Based Analysis , 2003, Annals of surgery.

[26]  L. Czupryniak,et al.  The use of polypropylene mesh in midline incision closure following gastric by-pass surgery reduces the risk of postoperative hernia , 2002, Langenbeck's Archives of Surgery.

[27]  Anke Richter,et al.  Cost-effectiveness of intensive glycemic control, intensified hypertension control, and serum cholesterol level reduction for type 2 diabetes. , 2002, JAMA.

[28]  J. Habbema,et al.  Internal validation of predictive models: efficiency of some procedures for logistic regression analysis. , 2001, Journal of clinical epidemiology.

[29]  L. Goldman,et al.  Health and Economic Benefits of Increased β-Blocker Use Following Myocardial Infarction , 2000 .

[30]  K. Flegal,et al.  Criteria for definition of overweight in transition: background and recommendations for the United States. , 2000, The American journal of clinical nutrition.

[31]  L. Coupal,et al.  Cost-effectiveness of treating hyperlipidemia in the presence of diabetes : who should be treated? , 2000, Circulation.

[32]  J. Jeekel,et al.  A comparison of suture repair with mesh repair for incisional hernia. , 2000, The New England journal of medicine.

[33]  W. Zhu,et al.  Making bootstrap statistical inferences: a tutorial. , 1997, Research quarterly for exercise and sport.

[34]  A. Dellon,et al.  "Components separation" method for closure of abdominal-wall defects: an anatomic and clinical study. , 1990, Plastic and reconstructive surgery.

[35]  E. DeLong,et al.  Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach. , 1988, Biometrics.

[36]  E. Steyerberg,et al.  Short-term results of a randomized controlled trial comparing primary suture with primary glued mesh augmentation to prevent incisional hernia. , 2015, Annals of surgery.

[37]  A. Wimo,et al.  Cost analysis of the use of small stitches when closing midline abdominal incisions , 2013, Hernia.

[38]  L. Czupryniak,et al.  Polypropylene mesh in prevention of postoperative hernia in bariatric surgery. , 2005, Annals of Surgery.

[39]  L. Goldman,et al.  Health and economic benefits of increased beta-blocker use following myocardial infarction. , 2000, JAMA.

[40]  John S. Greenlees.  Consumer price indexes: methods for quality and variety change , 2000 .

[41]  C. Steiner,et al.  Comorbidity measures for use with administrative data. , 1998, Medical care.

[42]  C. C. Chen,et al.  The bootstrap and identification of prognostic factors via Cox's proportional hazards regression model. , 1985, Statistics in medicine.

[43]  D. Hosmer,et al.  A review of goodness of fit statistics for use in the development of logistic regression models. , 1982, American journal of epidemiology.