Elective Surgical Treatment for Symptomatic Abdominal Hernia Beneficial to Most

Nadim Mahmud, MD, MS, MPH, MSCE

A new model shows the benefit of elective surgeries for the treatment of symptomatic abdominal hernia, a common cirrhosis surgical scenario.

A team, led by Nadim Mahmud, MD, MS, MPH, MSCE, Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, identified clinical optimal thresholds to favor operative or nonoperative management for symptomatic abdominal hernias.

“As the cirrhosis burden in the US increases,1 so has the volume of surgical treatments for cirrhosis,” the authors wrote. “Preoperative risk stratification has been challenging owing to myriad contributors of cirrhosis to surgical risk, such as impaired synthetic function, malnutrition and frailty, portal hypertension, and deranged hemostasis.”

The Mortality Risk

Patients with cirrhosis can often have an increased risk of postoperative mortality. While there are several models estimating the risk, current risk estimation scores cannot compare surgical risk with the risk of not operating.

In the Markov cohort decision analytical modeling study, the investigators evaluated elective surgery and nonoperative management for a symptomatic abdominal hernia in patients with cirrhosis. The team derived transition probabilities and utilities from the literature and data using an established cirrhosis cohort from the Veterans Health Administration.

The patients included in the analysis were referred to a surgery clinic for a symptomatic abdominal hernia and were diagnosed with cirrhosis between 2008-2018.

Quality-Adjusted Life-Years

The investigators also estimated expected quality-adjusted life-years for each pathway and iterated over baseline model for end-stage liver disease-sodium (MELD-Na) scores ranging from 6-25 and cycled Markov models over a 5-year time horizon.

The final analysis included 2740 patients with cirrhosis with a median age of 62 years. The patient population was overwhelmingly male (n = 2699; 98.5%).

Each patient was referred to a surgery clinic for a symptomatic abdominal hernia, 63.9% (n = 1752) of which did not receive the surgery. There was a median follow-up of 42.1 months.

The investigators estimated the mortality risk of operative and nonoperative pathways, an initial MELD-Na threshold of 21.3 points, below which surgery was associated with maximized quality-adjusted life-years was identified.In addition, nonoperative management was linked to an increased quality-adjusted life-years above the MELD-Na threshold.

While more patients experienced death in the surgery group across all initial MELD-Na values, this was counterbalanced by increased time spent in a resolved hernia state associated with increased utility.

Model results were also sensitive to the probability of hernia recurrence and hernia incarceration and utility decrement in the symptomatic hernia state.

“This decision analytical model study found that elective surgical treatment for a symptomatic abdominal hernia was favored even in the setting of relatively high MELD-Na scores,” the authors wrote. “Patient symptoms, hernia-specific characteristics, and surgeon and center expertise may potentially impact the optimal strategy, emphasizing the importance of shared decision-making.”

The study, “Modeling Optimal Clinical Thresholds for Elective Abdominal Hernia Repair in Patients With Cirrhosis,” was published online in JAMA Network Open.