E. R. Dadashzadeh1,2, D. Van Der Windt1, R. Handzel1,2, J. Moses1, P. Bou-Samra1, V. P. Anto1, M. Hossain1, A. Tsung1, M. R. Rosengart1 1University Of Pittsburgh,Department Of Surgery,Pittsburgh, PA, USA 2University Of Pittsburgh,Department Of Biomedical Informatics,Pittsburgh, PA, USA
Introduction:
Ventral hernias remain a frequent complication of abdominal surgery. To avoid incarceration, operative repair is the current accepted treatment. While the morbidity and mortality of ventral hernia elective repair (ER) are well-documented, the same cannot be said for watchful waiting (WW) as we lack knowledge of the natural history of untreated ventral hernias, including the true incidence of incarceration events. To date, no prospective randomized trials comparing ER to WW have been completed, and the largest retrospective cohort analysis was a 2016 European single-center study consisting of 569 patients. The purpose of this study was to leverage our institution’s large patient population by performing a descriptive analysis of the ventral hernia experience in Western Pennsylvania.
Methods:
This retrospective cohort study was conducted by utilizing linked quality improvement health administrative databases from the University of Pittsburgh Medical Center spanning from January 1, 2010 to December 31, 2017. ICD-9 and ICD-10 coding was used to identify patients with a diagnosis of ventral hernia. Additionally, surgical CPT coding and admission data were used to classify patients into one of the following 3 groups: Elective Repair (ER), Watchful Waiting (WW), and Failure of Watchful Waiting (FWW). Manual audits of randomly selected patients were performed to confirm accurate classification. All-cause mortality was determined using our inpatient database linked with the Social Security Death Index.
Results:
After excluding patients under the age of 18 and those who presented with an incarceration event as their initial encounter within our system, 24240 unique patients were identified with a diagnosis of ventral hernia. 4447 patients underwent ER, 79% of them within 3 months from their initial ventral hernia diagnosis. 19793 patients underwent WW, of whom 264 suffered an acute incarceration event (FWW). The incidence of incarceration events in our population was 3.7 per 1000 patient-years. The all-cause mortality for the FWW cohort was significantly higher than both the ER and WW cohorts (12.1% vs 3.0% and 3.8%, P<0.0001). The median follow-up duration for the entire study was 51 months.
Conclusion:
While watchful waiting appears to be a safe strategy for the majority of patients presenting with a ventral hernia, the mortality associated with its failure is fourfold that of those who underwent elective repair. Instead of awaiting the results of randomized prospective trials in the hope of a single, collective approach for all patients presenting with a ventral hernia, future studies can evaluate leveraging both clinical and imaging data to identify and select those patients with the highest risk of incarceration for elective repair.