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Incarceration during nonoperative management of incisional hernia is uncommon but increases the risk of death
Question clinique
What is the risk of incarceration and associated morbidity/mortality with nonoperative management of incisional hernias?
L’Essentiel
This study found that incarceration is an uncommon complication of NOM of incisional hernias (1-year and 5-year cumulative incidence = 1.24% and 2.59%, respectively), but is significantly associated with an increased risk of all-cause mortality. 2b
Référence
Plan de l'etude: Cohort (retrospective)
Financement: Unknown/not stated
Cadre: Inpatient (any location) with outpatient follow-up
Sommaire
Both the rate of incarceration during nonoperative management (NOM) of incisional hernias and any predisposing factors for incarceration are currently uncertain. These investigators retrospectively assessed outcomes of all patients given a diagnosis of an incisional hernia at 15 hospitals within a large university health care system from 2010 to 2017. Eligible patients included adults, 18 years or older, with a diagnosis of abdominal wall hernia, including incisional hernias (N = 30,998). After excluding patients undergoing operative repair, 78.1 % (23,022) initially underwent NOM for a median duration of 47.2 months. Of these, 540 (2.3%) experienced an incarceration event, leading to an incarceration incidence of 6.05 per 1000 patient-years (cumulative incidence at 1 year and 5 years = 1.24% and 2.59%, respectively). All-cause mortality was also significantly increased at 1 year in the incarceration group compared with those remaining in the NOM group (14% vs 5.3%, respectively). Variables associated with an increased risk of incarceration included increasing age, current smoker, female sex, body mass index 30 or higher, and African American race.
Reviewer
David C. Slawson, MD
Professor and Vice Chair of Family Medicine for Education and Scholarship
Atrium Health
Professor of Family Medicine, UNC Chapel Hill
Charlotte, NC
Commentaires
Risk of death related to NOM of incisional hernia
This might be a very important finding. The paper reports what looks to be a HUGE difference in the 1 yr cumulative incidence of death (14% vs 5.3%) in patients who subsequently incarcerate (and hence require emergency surgery) compared to patient who did not experience incarceration. Wish the results had been presented as an odds ratio though. The clinical dilemma is that patients who are managed by non-operative management to begin with are those who are already considered to be at high operative risk for elective repair. No easy management solution. Ultimately an RCT is required but I'd first like to see the findings of the paper are reproducible. It also seems too worrisome to be true.
We also need to consider the…
We also need to consider the incarcerating group in this study are more likely to be older, smokers, etc. How much of the increase in mortality is related to the incarceration vs a result in between group differences in baseline risk factors for all cause mortality? This would impact whether or not an intervention targeting the hernia is likely to have any impact or whether the event is mearly a proxy for poor health.