Hernia (2007) 11:341346 DOI 10.

1007/s10029-007-0226-3

O R I G I N A L A R T I CL E

Factors aVecting morbidity and mortality in incarcerated abdominal wall hernias

H. Derici H. R. Unalp A. D. Bozdag O. Nazli T. Tansug E. Kamer

Received: 23 October 2006 / Accepted: 15 March 2007 / Published online: 18 April 2007 Springer-Verlag 2007

Abstract Background Incarcerated abdominal wall hernia cases may necessitate emergency interventions, but under such circumstances morbidity and mortality rates may increase. The aim of this study was to investigate the factors that aVect morbidity and mortality in patients with incarcerated abdominal wall hernias who underwent emergency surgery. Methods Urgent surgical interventions due to incarcerated abdominal wall hernias were performed in 182 patients in our clinics between January 1998 and January 2006. Factors that aVect morbidity and mortality in incarcerated abdominal wall hernias were investigated retrospectively by browsing the archives. Logistic regression analysis was used to evaluate parameters that aVect morbidity and mortality. Results Morbidity and mortality occurred in 43 (23.6%) and 9 (4.9%) patients, respectively. A symptomatic period of longer than 8 h, presence of accompanying disease, high American Society of Anesthesiology (ASA) score, general anesthesia, presence of strangulation, and necrosis were found to aVect morbidity signiWcantly by univariate analysis. Necrosis was the sole factor aVecting morbidity signiWcantly by multivariate analysis. Advanced age, presence of accompanying disease, high ASA score, presence of stran-

gulation, necrosis, and hernia repair with graft were found to aVect mortality signiWcantly by univariate analysis; however, necrosis was the sole factor aVecting mortality signiWcantly by multivariate analysis. Conclusions Intestinal necrosis, which was followed by bowel resection, was the sole factor aVecting morbidity and mortality using multivariate logistic regression analysis. Emergency surgery is required for incarcerated abdominal wall hernias before intestinal necrosis develops. Keywords Incarceration Hernia Predictive factors Morbidity Mortality

Introduction Patients with incarcerated abdominal wall hernias (AWH) (inguinal, femoral, umbilical and incisional) comprise a signiWcant portion of those presenting to emergency services with acute abdomenal complaints. Urgent operations may be required in 513% of AWH cases due to incarceration and obstruction [1, 2]. Moreover, intestinal resections may be required in 1015% of incarcerated AWHs due to necrosis [24]. Besides managing the patients original pathology, the major objective of surgery is to repair the defect using an appropriate technique. Synthetic grafts, which have been used in elective hernia surgery, have been used more frequently in surgical treatment of incarcerated AWH recently. The goal in surgical treatment of incarcerated AWH cases is to repair the hernia with low morbidity and mortality and to decrease recurrence rates in long-term follow-up. In spite of improvements in anesthesia, antisepsis, and antibiotics and Xuid resuscitation, rates of morbidity and mortality following emergency surgery performed for managing incarcerated AWHs are still high

H. Derici (&) A. D. Bozdag O. Nazli T. Tansug 3rd General Surgery Clinic, Atatrk Training and Research Hospital, 156 sok. No: 5/13 Bornova, Izmir, Turkey e-mail: hayrullahderici@yahoo.com H. R. Unalp E. Kamer 4th General Surgery Clinic, Atatrk Training and Research Hospital, Izmir, Turkey

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[5, 6]. Presurgical preparations are not adequate in these types of surgery; furthermore, it is generally an elderly cohort that receives urgent abdominal surgery [1, 5]. In this study, we aimed to investigate factors that aVect morbidity and mortality in incarcerated AWH patients using logistic regression analysis.

Results Patients with inguinal, umbilical, incisional and femoral hernias comprised 57.1% (n = 104), 20.3% (n = 37), 12.1% (n = 22), and 10.5% (n = 19) of those who received emergency surgery due to incarcerated AWHs, respectively. All patients received surgery within 24 h of hospital admission. Males and females comprised 62.6% (n = 114) and 37.4% (n = 68) of all patients, respectively; mean age of patients was 57.71 17.72 (range: 1592) years. Incarcerated inguinal and incisional hernias were more commonly detected in males, whereas femoral and umbilical hernias were more commonly encountered in females (P < 0.001). The interval between the onset of symptoms and hospital admission averaged 12.73 7.52 (range: 139) h; among all patients, this interval was the shortest in those with incarcerated incisional hernias (P = 0.001). Eighty-three patients had such accompanying diseases as chronic obstructive pulmonary disease, coronary artery disease, congestive heart failure, hypertension, and type 2 diabetes. High ASA scores (ASA III and IV) were most commonly detected in patients with incarcerated inguinal hernias (P = 0.009). General anesthesia and spinal anesthesia were preferred anesthesia methods in 65 (35.7%) and 117 (64.3%) patients, respectively. General anesthesia was used at a statistically signiWcant rate in umbilical and incisional hernia surgery (P < 0.001). Hernias were simply reduced in 104 (57.1%) patients, whereas strangulations were detected in 78 (42.9%) patients during surgery. While intestinal blood circulation recovered in 43 patients (23.6%) with strangulation, 35 patients (19.2%) received intestinal resection and anastomosis due to necrosis. Rate of intestinal resection in patients with incarcerated incisional and femoral hernias was slightly higher than that in patients with other types of incarcerated hernias, and the diVerence did not reach signiWcance (P = 0.964). Primary hernia repair and repair with graft (monoWlament polypropylene mesh) were employed in 140 (76.9%) and 42 (23.1%) patients, respectively. Repair with graft was found to be used most commonly in patients with incarcerated incisional hernias compared with other types of hernias (P = 0.011). Patient characteristics and diVerences between categories are listed in Table 1. Mean length of hospital stay was 4.50 3.41 (range 124) days. Postoperative morbidity occurred in 43 (23.6%) patients. Anastomotic leakage was observed in Wve cases; intraabdominal abscess, pneumonia, atelectasis, and postoperative ileus in four cases each; intraabdominal hemorrhage, urinary bladder injury, pulmonary embolism, renal failure, congestive heart failure and myocardial infarction in one case each. Local wound complications developed in 19 patients (eleven wound infections, Wve seroma, two hematomas and one wound dehiscence). Relaparotomy was employed in seven cases due to postoperative complications

Materials and methods Urgent surgical interventions due to incarcerated AWH were performed in 182 patients in our clinics between January 1998 and January 2006. No criterion was employed for repairing the defect; the surgeon decided the type of surgery to be performed and the anesthetist decided the type of anesthesia to be given. All of the patients were examined systematically after detailed history was recorded. Routine preoperative tests (whole blood count, blood chemistry, coagulation tests, chest X-ray and ECG) were performed. All of the patients were evaluated by an anesthesiologist several days before and on the day of surgery. Subspecialty consultations were obtained when required. Spinal anesthesia was preferred in the presence of a contraindication for general anesthesia. General anesthesia was the method of choice for incarcerated umbilical hernias and upper abdominal incisional hernias. Spinal or general anesthesia was used in cases of incarcerated inguinal, femoral, and lower abdominal incisional hernias. A single dose of a second-generation cephalosporin was used for antibacterial prophylaxis. Antibiotic treatment was continued for 5 additional days in patients with infections in the abdominal surgery area even if these cases did not receive mesh repair. Factors that aVect morbidity and mortality in incarcerated AWHs, such as age, gender, duration of symptoms, accompanying diseases, American Society of Anesthesiology (ASA) score, type of anesthesia, presence of intestinal strangulation and necrosis, and method preferred for hernia repair (primary repair vs. repair with graft),were investigated retrospectively by browsing the archives. The term morbidity refers to major and minor postoperative complications (anastomotic leak, pulmonary and cardiac complications, wound complications, etc.) that prolonged hospitalization period, while the term mortality refers to death within 30 days of surgery associated either directly or indirectly with the surgery. Logistic regression analysis was used to evaluate parameters that aVect morbidity and mortality. These factors were Wrst analyzed by univariate analysis for which chi-square and Students t-tests were employed. Factors that were found to be statistically signiWcant were then analyzed using multivariate analysis; statistical signiWcance level was set to P < 0.05. Continuous, normally distributed data are expressed as means SD. MedCalc version 9.0.0.0 software was used for statistics.

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Hernia (2007) 11:341346 Table 1 Patient characteristics classiWed according to hernia types and diVerences between these categories Patient characteristics Age (years) 65 <65 Gender Female Male Duration of symptoms (h) 8 >8 Accompanying disease Positive Negative ASA score I II III IV Type of anesthesia Spinal General Hernia repair Primary Mesh Strangulation Positive Negative Necrosis Positive Negative Morbidity Positive Negative Mortality Positive Negative 9 (4.9) 173 (95.1) 6 (3.3) 98 (53.8) 1 (0.5) 36 (19.8) 1 (0.5) 21 (11.5) 1 (0.5) 18 (9.9) 43 (23.6) 139 (76.4) 21 (11.5) 83 (45.6) 8 (4.4) 29 (15.9) 9 (4.9) 13 (7.1) 5 (2.7) 14 (7.7) 35 (19.2) 147 (80.8) 19 (10.4) 85 (46.7) 7 (3.8) 30 (16.5) 5 (2.7) 17 (9.3) 4 (2.2) 15 (8.2) 78 (42.9) 104 (57.1) 46 (25.3) 58 (31.9) 15 (8.2) 22 (12.1) 10 (5.5) 12 (6.6) 7 (3.8) 12 (6.6) 140 (76.9) 42 (23.1) 86 (47.2) 18 (9.9) 28 (15.4) 9 (4.9) 11 (6.1) 11 (6.1) 15 (8.2) 4 (2.2) 117 (64.3) 65 (35.7) 79 (43.4) 25 (13.7) 16 (8.8) 21 (11.5) 7 (3.8) 15 (8.2) 15 (8.2) 4 (2.2) 52 (28.6) 57 (31.3) 43 (23.6) 30 (16.5) 36 (19.8) 24 (13.2) 24 (13.2) 20 (11.0) 4 (2.2) 21 (11.5) 9 (4.9) 3 (1.6) 5 (2.7) 5 (2.7) 8 (4.4) 4 (2.2) 7 (3.8) 7 (3.8) 2 (1.1) 3 (1.6) 83 (45.6) 99 (54.4) 49 (26.9) 55 (30.2) 16 (8.8) 21 (11.5) 10 (5.5) 12 (6.6) 8 (4.4) 11 (6.1) 60 (33.0) 122 (67.0) 24 (13.2) 80 (43.4) 14 (7.7) 23 (12.6) 14 (7.7) 8 (4.4) 8 (4.4) 11 (6.1) 68 (37.4) 114 (62.6) 22 (12.1) 82 (45.1) 24 (13.2) 13 (7.1) 9 (4.9) 13 (7.1) 13 (7.1) 6 (3.3) 106 (58.2) 76 (41.8) 59 (32.4) 45 (24.7) 21 (11.5) 16 (8.8) 15 (8.2) 7 (3.9) 11 (6.1) 8 (4.4) n (%) Inguinal, n (%) Umbilical, n (%) Incisional, n (%) Femoral, n (%) P

343

0.795

<0.001

<0.001

0.965

0.009

<0.001

0.011

0.918

0.964

0.214

0.906

such as anastomosis failure, intraabdominal abscess, postoperative ileus and intraabdominal hemorrhage. A symptomatic period of longer than 8 h (P = 0.013), presence of accompanying disease (P < 0.001), high (III and IV) ASA score (P < 0.001), general anesthesia (P = 0.025), presence of strangulation (P = 0.012), and necrosis (P < 0.001) were found to aVect morbidity signiWcantly by univariate analysis, while necrosis was the sole factor aVecting morbidity signiWcantly by multivariate analysis (P = 0.004, odds ratio = 4.52). Postoperative mortality was recorded in nine (4.9%) patients who had major complications and accompanying

diseases. Anastomotic leakage and intraabdominal sepsis (three cases), postoperative ileus (two cases), adult respiratory distress syndrome (one case), pulmonary embolism (one case), congestive heart failure (one case) and myocardial infarction (one case) were the causes of death. Advanced age (65; P = 0.023), presence of accompanying disease (P = 0.002), high (III and IV) ASA score (P < 0.001), presence of strangulation (P < 0.001), necrosis (P < 0.001), and hernia repair with graft (P = 0.049) were found to aVect mortality signiWcantly by univariate analysis; necrosis was the sole factor aVecting mortality signiWcantly by multivariate analysis (P = 0.019, odds

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344 Table 2 Univariate analyses of the factors aVecting morbidity and mortality Variables Morbidity Negative, n (%) Age (years) 65 <65 Gender Male Female Type of hernia Inguinal Femoral Umbilical Incisional 8 >8 Positive Negative ASA score I-II III-IV Type of anesthesia General Spinal Strangulation Positive Negative Necrosis Positive Negative Hernia repair Mesh Primary 29 (15.9) 110 (60.4) 13 (7.1) 30 16.5) 0.285 37 (20.3) 136 (74.7) 14 (7.7) 125 (68.7) 21 (11.5) 22 (12.1) <0.001 28 (15.4) 145 (79.7) 52 (28.6) 87 (47.8) 26 (14.3) 17 (9.3) 0.012 36 (19.8) 137 (75.3) 43 (23.6) 96 (52.7) 22 (12.1) 21 (11.5) 0.025 59 (32.4) 114 (62.6) 97 (53.3) 42 (23.1) 12 (6.6) 31 (17.0) <0.001 109 (59.9) 64 (35.2) 83 (45.6) 14 (7.7) 29 (15.9) 13 (7.1) 53 (29.1) 86 (47.2) 50 (27.5) 89 (48.9) 21 (11.5) 5 (2.7) 8 (4.4) 9 (4.9) 7 (3.8) 36 (19.8) 33 (18.1) 10 (5.5) <0.001 0.013 0.214 98 (53.8) 18 (9.9) 36 (19.8) 21 (11.5) 60 (33.0) 113 (62.1) 74 (40.7) 99 (54.4) 92 (50.5) 47 (25.8) 22 (12.1) 21 (11.5) 0.109 109 (59.9) 64 (35.2) 77 (42.3) 62 (34.1) 29 (15.9) 14 (7.7) 0.221 97 (53.3) 76 (41.8) Positive, n (%) P Mortality Negative, n (%)

Hernia (2007) 11:341346

Positive, n (%)

9 (4.9) 5 (2.7) 4 (2.2) 6 (3.3) 1 (0.5) 1 (0.5) 1 (0.5) 9 (4.9) 9 (4.9)

0.023

0.922

0.906

Duration of symptoms (h) 0.072

Accompanying disease 0.002

<0.001

9 (4.9) 6 (3.3) 3 (1.6) 7 (3.8) 2 (1.1) 7 (3.8) 2 (1.1) 5 (2.7) 4 (2.2) 0.049 <0.001 <0.001 0.102

ratio = 12.23). Univariate analyses of the factors that aVect morbidity and mortality are shown in Table 2, and multivariate analyses of those that were found to be signiWcant on univariate analyses are given in Table 3.

Discussion Incarcerated AWH surgery comprises a major portion of surgeries performed under urgent conditions with high postoperative morbidity and mortality rates. Univariate analyses have been used to determine the factors that aVect morbidity and mortality of incarcerated inguinal hernia in most of the reports in the literature [13]. It may be possi-

ble to Wnd which factors increase risk using odds ratios in multivariate analysis. Dunne et al. [7] investigated postoperative complications and the risk factors for infection in incarcerated AWH patients by employing multivariate analyses. They found that chronic obstructive pulmonary disease and low preoperative serum albumin were independent predictors of wound infections, and coronary artery disease, chronic obstructive pulmonary disease, low preoperative serum albumin, and steroid use were independent predictors of increased hospital length of stay. In our study, multivariate analyses revealed that only the presence of necrosis was signiWcant among the several factors that were signiWcant in univariate analyses, and necrosis had an odds ratio for morbidity of 4.52 and for mortality of 12.23.

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Hernia (2007) 11:341346 Table 3 Multivariate analyses of factors that were found to be signiWcant on univariate analyses

345

Variables

Morbidity P OR 1.66 2.41 2.79 1.73 0.88 4.52 95% CI 0.614.51 0.747.78 0.898.70 0.744.02 0.352.20 1.5912.84

Mortality P 0.989 0.990 0.988 0.576 0.019 0.087 OR 3.87 3.70 2.10 0.53 12.23 4.29 95% CI 0.729.16 0.6910.22 0.305.40 0.064.79 1.5099.49 0.8122.85

Age Duration of symptoms Accompanying disease ASA score Type of anesthesia Strangulation OR Odds ratio, CI conWdence interval Necrosis Hernia repair

0.315 0.140 0.076 0.201 0.785 0.004

Mortality rates ranging from 1.4 to 13.4%, and morbidity rates ranging from 19 to 30% after surgical treatment of incarcerated AWH patients have been reported [1, 2, 5, 8]. In our study, we found a mortality rate of 4.9% and a morbidity rate of 23.6%. Morbidity and mortality were related to the viability of entrapped bowel, and bowel resection and anastomosis directly aVected the outcome. Advanced age is one of the factors causing unfavorable outcomes in incarcerated AWH patients [2, 3, 9]. Kurt et al. [4] reported a higher risk of bowel resection for patients who were older than 65 years of age. Alvarez et al. [10] reported higher rates of postoperative pulmonary and cardiovascular complications and an increased length of hospital stay in an elderly cohort. In our study, we did not observe a signiWcant eVect of advanced age (>65) on morbidity. Advanced age was found to aVect mortality (P = 0.023) by univariate analysis, but not by multivariate logistic regression analysis in this study. Incarcerated inguinal hernias have been commonly reported in males, while femoral and umbilical hernias have been commonly reported in females [1, 2, 4, 11]. Gender has not been reported to aVect morbidity and mortality although strangulation and bowel necrosis have been more commonly observed in females than in males [2, 10]. Consistently, we observed in our study that incarcerated inguinal and incisional hernias were common in males, and femoral and umbilical hernias were common in females; however, gender did not signiWcantly aVect morbidity and mortality rates. Development of strangulation and bowel necrosis has been more commonly reported in patients with femoral, incisional, and umbilical hernias compared to those with inguinal hernias [2, 4]. Although bowel necrosis has been commonly observed in patients with incarcerated femoral hernias, type of hernia has not been reported to aVect morbidity and mortality [1, 5]. In good accord with previous studies, we did not Wnd a signiWcant eVect of hernia type on morbidity and mortality although patients with femoral and incisional hernias more commonly received bowel resection compared to those with other types of hernias.

Late hospital admission is an important factor aVecting morbidity due to bowel resection [1, 2, 4]. Andrews et al. [1] reported a bowel resection rate of 7 and 27% in patients who received surgical intervention in the Wrst 24 h and Wrst 48 h of inguinal hernia incarceration, respectively. These authors concluded that mortality was associated with duration of symptoms upon Wnding mortality rates of 1.4, 10, and 21% in patients who underwent incarcerated inguinal hernia surgery in the Wrst 24, 2447 and 48 h, respectively [1]. Kulah et al. [5] reported signiWcantly higher rates of strangulation, necrosis, morbidity, and mortality, and longer hospital stays in patients with late hospital admission than in those with early admission. Kurt et al. [4] reported that hospital admission more than 6 h after symptoms had started increased rate of bowel resection signiWcantly. In our study, hospital admission more than 8 h after the onset of symptoms signiWcantly aVected morbidity using univariate, but not multivariate, analysis. The reason for late admission to our hospital might be that ours is a reference hospital, and patients are transferred to our hospital from other surgery centers that are located either inside or outside the city. Accompanying diseases and ASA score are important parameters in deWning degrees of surgery-related and anesthesia-related risks [10]. Golub et al. [12] reported high ASA score to be one of the most signiWcant independent risk factors aVecting mortality. Kulah et al. [5] found that morbidity and mortality rates and length of hospital stay were increased in elderly incarcerated hernia patients with high ASA scores. Similarly, Alvarez et al. [10] found that morbidity and mortality rates and length of hospital stay were increased signiWcantly in elderly patients with accompanying diseases and high ASA scores. We did not detect any signiWcant eVect of high ASA score on morbidity and mortality using multivariate analysis, although there was a signiWcant eVect by univariate analysis in this study. Type of anesthesia (spinal and general) has not been reported to aVect postoperative morbidity in patients who have undergone emergency surgery, although morbidity has been attributed directly to accompanying diseases [5, 10].

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Alvarez et al. [10] reported increased length of hospital stay only in patients who received general anesthesia. We found that type of anesthesia did not aVect morbidity since only univariate, but not multivariate, analysis revealed a signiWcant eVect of general anesthesia on morbidity. Likewise, we did not Wnd a signiWcant eVect of anesthesia type on mortality using logistic regression analysis. Development of necrosis, which is generally followed by bowel resection, has been reported to increase length of hospital stay and cause unfavorable outcomes in incarcerated AWH [2, 13]. Many studies have shown a direct eVect of intestinal viability on morbidity and mortality [1, 3, 14]. Kurt et al. [4] and Alvarez et al. [10] reported that bowel resection did not aVect mortality but did increase length of hospital stay and rates of such postoperative complications as wound infection. Kurt et al. [4] reported that 2 out of 102 patients that they investigated died; mortality was associated with accompanying diseases in both cases. Intestinal necrosis, which was followed by bowel resection, was the sole factor signiWcantly aVecting morbidity and mortality by multivariate analysis in this study. ConWdence interval (CI) of necrosis, the only signiWcant factor in the multivariate analyses, was in a wide range (95% CI 1.5099.49). There were no other factors correlated with necrosis. This may be due to the small number of patients who died. Recent studies have reported beneWcial outcomes of monoWlament polypropylene mesh repair during elective hernia surgery in patients with AWH [1517]. There are a few reports on synthetic mesh repair in incarcerated hernias [18, 19], however, their use in cases with intestinal necrosis is still debatable. We found in our study that mesh repair was used more commonly in incarcerated incisional hernias compared to other types of hernias (P = 0.011), but type of repair was not found to aVect morbidity. Mortality, on the other hand, was found to be aVected by type of repair by univariate (P = 0.049), but not by multivariate, analysis. In conclusion, incarcerated AWH is an important surgical problem with a high mortality rate. We found in our study that intestinal necrosis, which was followed by bowel resection, was the sole factor aVecting morbidity and mortality using multivariate logistic regression analysis. We suggest that emergency surgery is required for incarcerated abdominal wall hernias before intestinal necrosis develops.

References
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