About 20-40% of cirrhotic patients will develop an abdominal wall hernia. To repair it is a challenge for all doctors due to the high risk of complications and hepatic decompensation associated to surgery. That is why the majority of surgeons fear to operate on these patients. Whether to perform an elective hernia repair or adopt a “watch and wait” strategy and operate only if symptoms arise is still a matter of debate. I believe many of us have already had this dilemma and chose the second option. This puts the patient at risk of needing an emergent repair. So… Was it a wise choose?
Clayton Petro et al from the Cleveland Clinic, Ohio, USA, retrospectively analysed and compared 186 patients with chronic liver disease (CLD) submitted to elective hernia repair with a second group of 67 patients with CLD submitted to emergent hernia repair. Inguinal and ventral (primary and secondary) hernias were included. Primary outcome: 30-day post-operative morbidity and mortality. Severity of CLD was collected for each patient at time of pre-operative evaluation. Data related to surgery were collected, including hernia type, surgical approach, and emergent surgery, mesh utilization, and drain placement. Results are interesting.
In the emergent repair group there was a complication’s rate of 60% (morbidity and mortality), and MELD score was associated with increased rate of complications. Conversely, the non-emergent group had a complication’s rate of 27%, and both MELD score and drain placement were risk factors for complications. Interestingly, Child-Pugh score was not a risk factor. Also mesh utilization was not a risk factor in both groups. Comparing emergent and non-emergent repairs, emergent repair had higher rates of Intensive Care Unit admissions, re-operation, bacterial peritonitis, and overall 30-day morbidity and mortality. Additionally, 90-day mortality for elective repair was 3,7%, while for emergent repair was 10%. Although advanced liver disease (MELD≥15) had no impact in mortality when elective repair was performed, in an emergent setting it carried a 90-day mortality rate of 25% and an increased risk of complications.
MELD score and drain placement are risk factors for complications.
From these data the authors conclude that elective hernia repair is the preferred treatment even in patients with advanced CLD. To support this idea, Clayton Petro presents results from other author that should make us avoid a “watch and wait” strategy. Marsman et al studied patients with ascites and umbilical hernia treated with a “watch and wait” approach. They found a 77% rate of acute incarceration, a 46% of emergent repair and 15% of mortality. Additionally there is reference to a review paper published by Carbonell et al comparing umbilical hernia repair in cirrhotic and non-cirrhotic patients. In this work there was no difference in morbidity or mortality in elective repair setting, but in an emergent setting cirrhotic had an increased morbidity (p<0.04) and mortality (p<0.0001).
All these results and data support the idea that surgeons should choose elective hernia repair in cirrhotic patients (even with advanced CLD) “in order to avoid incarcerated and strangulated/contaminated scenarios”. However, data from Denmark hernia registry concluded that cirrhotic patients will have an increased rate of complications during elective repair comparing with non-cirrhotic patients. (I believe this is an idea to remember).
Elective hernia repair is the preferred approach in CLD patients.
Let me make a final note about drain placement. As I state above, intraperitoneal drain placement (in ventral hernias) was a risk factor for complications. Like Clayton Petro says, this result contradicts the general idea that intraperitoneal drain placement in a patient with ascites protects the “suture line, divert ascites and improves wound healing”. Will it? I do think the same way but… Should I continue placing the drain? Is this true only for hernia repairs? How about in laparotomies for other pathologies? There is no answer for this… I will probably continue placing the drain.
Finally, this paper from Clayton Petro et al gives live to a problem in a difficult group of patients who are the reason for the difficulty in decision making. To operate or not to operate might not be the only hard question. When to operate should also be a question to answer. As there is no guideline, this is decision without "net", this is "true and raw" medicine. The art of decision-making is what makes a surgeon better than the other.
Link to PubMed:
Dr. Carlos Eduardo Costa Almeida
General Surgeon