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Is Non-Operative Management Warranted in Comorbid Patients with Ventral Hernias?: A Prospective, Patient-Centered Study
Julie L Holihan*, Blake E Henchcliffe*, Jiandi Mo*, Juan R Flores-Gonzalez*, Tien C Ko*, Lillian S Kao, Mike K Liang*
University of Texas Health Science Center at Houston, Houston, TX
Non-operative management of ventral hernias (VHs) is often recommended for patients at increased risk of complications; however, the impact of this management strategy on outcome and quality of life (QoL) is unknown. We hypothesize that QoL is better among patients with VHs managed operatively.
Patients with a VH from a single-center hernia clinic were prospectively enrolled between 6/2014 and 6/2015. Non-operative management was recommended if smoking, body mass index >33 kg/m2, or poorly-controlled diabetes were present. Outcomes included surgical site infection (SSI), recurrence, and QoL measured using a validated, hernia-specific survey (modified Activities Assessment Scale) prior to surgeon consultation and at 6-months. Risk-adjusted outcomes between non-operative and operative groups were compared using: (1) paired t-test on a propensity score-matched subset and (2) multivariable analysis on the overall cohort.
152 patients (non-operative=97; operative=55) were enrolled. In the propensity-matched cohort (n=90), both groups had similar baseline QoL scores, but only repaired patients had improved scores on 6-month follow-up (Table). In the overall cohort, non-operative management was strongly associated with lower QoL scores (log odds ratio=-26.5; 95%CI=-35.0 to -18.0).
This is the first prospective study comparing management strategies in comorbid VH patients. Elective repair improves hernia-related QoL in low to moderate risk patients. Trade-offs of a conservative operative strategy need to be reevaluated in terms of estimating risk and incorporating patient-centered outcomes.
|Table: Matched Cohort*|
|Total (n=90)||Surgery (n=45)||Non-op (n=45)||p-value|
|Gender (male)||49 (54.4%)||23 (51.1%)||26 (57.8%)||0.67|
|Smoker||13 (14.4%)||7 (15.6%)||6 (13.3%)||<0.01|
|1||11 (12.2%)||5 (11.1%)||6 (13.3%)||0.52|
|2||51 (56.7%)||26 (57.8%)||25 (55.6%)|
|3||26 (28.9%)||14 (31.1%)||12 (26.7%)|
|4||2 (2.2%)||0||2 (4.4%)|
|Diabetes||20 (22.2%)||10 (22.2%)||10 (22.2%)||>0.99|
|Primary||26 (28.9%)||16 (35.6%)||10 (22.2%)||0.24|
|Incisional||64 (71.1%)||29 (64.4%)||35 (77.8%)|
|Ventral Hernia Working Group Grade|
|* Cohorts matched on baseline pain scores, body mass index (BMI), smoking, prior ventral hernia repair, diabetes mellitus, and hernia size|
** Based on the modified Activities Assessment Scale which is a validated, hernia-specific quality of life survey scored on 1-100 normalized points where 1=poor quality of life and 100=perfect quality of life
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