Predictors of Poor Outcomes in Functionally Dependent Patients Undergoing Elective Ventral Hernia Repair

Drew Reynolds, MD, Daniel Davenport, PhD, J. Scott Roth, MD. University of Kentucky

 INTRODUCTION:
Pre-operative functional health status has previously been shown to affect outcomes following ventral hernia repair. As the patient population ages, there is an associated increase in comorbidities and concomitant decrease in patients’ autonomy. Within the ACS NSQIP database, progressive lack of autonomy is defined as either partial or total dependence based on the degree to which patients are able to perform acitivities of daily living. Given the trend of increasing complications in those with limited functional health status, the decision to proceed with elective hernia repair can be challenging. The objective of this study is to identify specific factors contributing to morbidity and mortality in functionally dependent patients undergoing elective ventral hernia repair.

METHODS AND PROCEDURES:
We reviewed all patients in the ACS NSQIP database that underwent elective ventral hernia repair from 2005-2009. Patients were selected based on the following CPT codes: 49560, 49561, 49565, 49566, 49568, 49570, 49572, 49585, 49587, 49652, 49653, 49654, 49655, 49656, and 49657. Only patients classified as partially or totally dependent were included in the study. Thirty-day outcome measures included mortality, wound complications (superficial, deep, or organ/space surgical site infection, dehiscence), pulmonary occurrences (pneumonia, ventilation >48 hours, unplanned intubation), venous thromboembolism, and the development of sepsis/shock. We analyzed risk factors using chi-square univariate testing and multivariable logistic regression.

RESULTS:
We identified 75,865 patients who underwent elective ventral hernia repair. 1,114 functionally dependent patients were identified, 979 of which (85.6%) were classified as partially dependent and165 (14.4%) as totally dependent. Adverse outcomes included 115 wound complications (10.1%), 122 pulmonary occurrences ( 11%), and 26 cases of venous thromboembolism (2.3%). Postoperative sepsis was seen in 104 cases (9.1%). Post-operative mortality occurred in 43 functionally dependent patients (3.8%). Amongst functionally dependent patients, there was no significant difference in any mortality between laparoscopic and open hernia repairs nor were there any differences in mortality between incarcerated or reducible hernias. Operative duration did not impact mortality rates. Multivariate logistic regression demonstrated increasing age to be an independent predictor of mortality (age 70-79, Odds ratio =15.8; age 80+, Odds ratio =19.3). Similarly, the presence of ascites and preoperative renal failure were also identified as independent predictors of mortality, odds ratio 9 and 13.2, respectively.

CONCLUSIONS:
Elective hernia repair in the functionally dependent patient population carries significant morbidity and mortality. Laparoscopic ventral hernia repair offers no survival advantage over open hernia repair in this patient group. Increasing age, ascites, and preoperative renal failure are independent predictors of mortality, and nonoperative management should be strongly considered in functionally dependent patients with these risk factors.

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