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Preop Adjuncts to Improve Outcomes After Hernia Repair
Kunoor Jain‐Spangler, MD, FACS, FASMBS
No Disclosures
What Are We Going To Talk About?• Who Cares?• Who Needs Surgery and Who
Needs Prehabilitation? – Risk Stratification
• What Can We Do?– Weight loss – Cardiac clearance (Duh)– Pulmonary (Duh again)– Exercise– Infection Control– Nutrition (metabolic and carbs)– Smoking Cessation– Glycemic Control
Why Do We Care?
Why Do We Care?• SHOW ME THE MONEY!!!
• 2013‐ $3.4 Billion– Poulose et al. The Chosen Few:
Disproportionate Resource Use in Ventral Hernia Repair. Am Surg. 2013
• Hernia Complications beget more hernia complications
Holihan JL, Martindale RG, Roth JS, Liang MK et al J. SurgRes 2016Liang MK, Roth S, Martindale R et al Surg Infections 2015
Risk Stratification• If we don’t properly select patients…
• What to eval?–Medical Comorbidities– Surgical History– Hernia Size, Characteristics, History
– Social Issues
Risk Stratification
• Diabetes• Tobacco• Previous Hernia Repair• Stoma/GI Tract Entry• Current Infection• Concomitant Flaps or Component Separation
• BMI
Risk Stratification• ACS Risk Calculator• Timed Stair Climb
– Reddy et al JACS 2016– 362 patients undergoing abdominal
surgery– Conclusion:
• Slow stair climb time associated with increase complications (97.3% able to complete)
• Univariate analysis : slow stair climb time was only parameter which was significantly associated with poor outcome (p<.0001)
• Multivariate analysis: slow time remains positively associated
• Better predictor than NSQIP risk calculator
Who Needs Surgery?• Align expectations with the patient• Surgeon expectations vs. patient
– Functionality– Pain– Cosmesis
• Medical Necessity?– Recurrent SBO– Mesh infection
• Sepsis• Drainage• Nonhealing wounds
WHAT CAN WE CHANGE PREOP?
Weight Loss• Disclaimer: I am also a bariatric surgeon!• Why does BMI matter?
– Tastaldi et al. Am J Surgery. 2019– 8,949 patients –Median BMI 31–Mean defect 7cm– Escalating BMI progressively increases relative log‐odds for SSI and SSOPI after OVHR
Weight Loss• Liang et al. Modifying Risks in Ventral Hernia Patients with Prehabilitation: A Randomized Controlled Trial. Ann Surg. 2018– Presentation at ASA 2018– Blinded RCT. n= 113. Prehab vs standard counseling for patients with BMI 30‐40
Table
N=113 Prehabilitation(n=55)
Standard Counseling(n=58) P value
Initial BMI(kg/m2)* 36.9 ± 2.6 36.6 ± 2.6
Met weight goal 18.1% 12.1% 0.435Lost weight 81.8% 67.2% 0.088Decrease in waist size (cm)* 4.6 ± 16.7 1.5 ± 8.8 0.016
Total weight loss (lbs)* 5.5 ± 9.3 3.8 ± 9.2 0.331
Underwent VHR 72.7% 58.6% 0.165Wound Complication5% 17.6% 0.133Hernia‐ and Complication‐Free 69.1% 48.3% 0.035
*Numbers represent mean and standard deviation
Weight Loss• No perfect cutoff
–Most papers say 40 or 50
• Referral for medical weight loss or bariatric surgery
• Not enough data yet to recommend concomitant repair
Exercise• Nakajima et al. Clinical Benefit of Preoperative Exercise and Nutritional Therapy for Patients Undergoing Hepato‐Pancreato‐Biliary Surgeries for Malignancy. Ann Surg Oncol. 2019.
Infection Control• Most important factor is clearance of any existing infection prior to operation
• Need to look at own hospital data• MRSA clearance protocols
– Increase in MRSA related SSIs• 12% in 2000; 40% in 2014
Young PY et al. SCNA 2014
Infection Control• The one thing that the data shows is decolonization of S. aureus is useful– 5 days preop start:
• Mupirocin to nares BID for 5 days• Chlorhexidine showers
Universal decolonization is not recommended due to emergence of mupirocin. Decolonization of those who test positive during screening should be performed.
Nutrition• Assessment Based Intervention
–Most studies look at treatment of malnutrition
Nutrition
1. Screen EMR and message the schedulers to make appt with RD pre‐op for nutrition optimization and/or weight management counseling
• BMI <18.5 (age less than 65 years)• BMI <20 (age 65 years or older)• BMI > 35• Patient eating <50% of usual intake• Unintentional weight loss of 10 lbs. in one month• A1C >8% (will need endocrinology referral in addition to nutrition)• Albumin 3.0
Nutrition2. RD sees patient for initial evaluation of nutritional status, eating habits and labs. A weight management diet is prescribed and discussed with patient. We use the Academy of Nutrition and Dietetics weight management meal plans and sample menus, which are evidence‐based recommendations.
3. Follow up with RD to monitor progress with weight loss prior to surgery.
‐ Number of follow ups with RD for weight loss monitoring depends on urgency of need for surgery and patient adherence with recommendations.
Nutrition4. Patient may be scheduled for post op diet advancement as well as needed or as recommended by surgeon.
5. Patients with A1C >8% will be referred to Endocrinology to help with A1C reduction, DM management.
6. Surgeon will be notified by RD of patients deemed not nutritionally ready for surgery.
Nutrition• Metabolic Manipulation
– Arginine‐ Fish Oil (Drover et al. JACS. 2012)• Decreased infection rate and hospital stay
– Isonitrogenous/Isocaloric (Marimuthu et al. Ann Surg. 012)• Decreased infectious and noninfectious complication rates and length of stay
Nutrition• Carb Loading
– Drink 300cc isotonic CHO drink (50 gm)• Reported outcomes:
– No increase risk of aspiration– Protects lean body mass post op
• Maintain hand grip strength, “well being” etc– Decreases insulin resistance post op (up to 50%)
• Insulin resistance directly correlated with post op complications
• Multiple mechanisms– Mitochondrial changes noted
• Note:– Benefit of decrease anxiety, LOS benefit variable– Better intra‐op glycemic control– No major outcome differences
GianottiL et al Ann Surg2018SchrickerT Ann Surg2012BilkuDK Ann R CollSurg2014Lundquist et al 2011AwadS CurrOpinNutr2012Sato AJCEM 2010 Smith MD et al Cochrane 2014AmerMA et al Br J Surg2016
Nutrition• 52 patients undergoing elective
open colorectal cancer resection• Preoperative oral carbohydrate
drink (50 g complex carbohydrate), fasting or placebo
• Post‐operative insulin resistance significantly greater in fasting and placebo groups (P< 0.010)
• Patient well‐being was improved due to reduced thirst (P= 0.005) and hunger (P= 0.041
Wang ZG, et al. Br J Surg. 2010;97:317‐27.
Nutrition
Arginine• Improved protein kinetics• Improved wound healing• Restores T cell function• Clinical outcomes
– Decrease infection– Decrease LOS
Fish Oil• Attenuates metabolic
response to stress• Decreases inflammation• Enhance diaphragm
function• Bowel motility via vagal
mechanisms
Smoking Cessation• More questions than answers
• Excellent data showing smoking related to:– Increased infection rate– Decreased collagen deposition
– Increased anastomotic leak rate
• E‐cigs, Vaping, MJ???
DeLanceyJO Am J Surg2018Sorensen LT et al Ann Surg2003Warner DO JAMA 2014 LundstromD Ann Surg2008AlverdyJ et al JAMA Surg2017GoniewiczML BJS 2013SchmidM et al Am J Surg2013KhullarD JACS 2013BaucomRB et al Am J Surg2015McEachemEK et al ImmunInfect 2015Nolan MB et al JAMA Surg2016
Glycemic Control• Recommendations:
– Remote pre‐op setting (30 to 60 days preop)• Measure HbA1c with preoplabs in high risk patients• If > 8.0 significant evidence to support postponing surgery for better control (> 7.5 infection curve rises sharply)
• High risk surgical populations: Bariatric, vascular, cardiac, AWR, obese, elderly
– Immediate peri‐op and post‐op period• Target between 140 and 180 mg/dl is safe and rarely results in hypoglycemia– NSQIP suggests post op bit lower < 130mg/dl– N=11,633
• “Sweet” spot 120 to 140 mg/dl• Example: Complex ventral hernia repair
– 21% complications with glucose control– 37% without adequate glucose control
Won E et al JAMA Surg 2015Marfalla, R JCEM 2012Scopinaro, N Obes Surg 2011Marsala, M J Cardiothor Vas Anes 2011Moghissi, ES Am J Health Sys Pharm 2010Kwon, S Ann Surg 2013Rollins KE et al Nutr Clin Pract2015
Questions??