Abstract
Purpose
Due to risks of postoperative morbidity and recurrence some patients with a ventral hernia are not offered surgical repair. There is limited data on the rate and consequences of a watchful waiting (WW) strategy for these patients. The objective of this cohort study was to analyse outcomes for patients with a ventral hernia who underwent watchful waiting, in terms of later requirement for hernia repair.
Methods
All patients (≥18 years) electively referred to our out-patient clinic from 1 January 2009 to 1 July 2014 with incisional, umbilical or epigastric hernia were included. Information on patient characteristics and whether patients underwent WW or surgery was obtained from hospital files and the Danish National Patient Register. A 100 % follow-up was obtained.
Results
The analyses comprised 569 patients with incisional hernia (WW = 58.1 %) and 789 patients with umbilical/epigastric hernia (WW = 43.2 %). Kaplan–Meier analyses estimated that the probability for patients who underwent watchful waiting to receive later surgical repair was 19 % for incisional hernias and 16 % for umbilical/epigastric hernias after 5 years. The probability of requiring emergency repair when in the WW group was 4 % for both incisional and umbilical/epigastric hernias after 5 years. There were no significant differences in 30-day readmission, reoperation or mortality rates between the WW patients who later underwent elective hernia repair and patients who were initially offered surgery (p > 0.05), for both incisional and umbilical/epigastric hernias.
Conclusions
Watchful waiting appears to be a safe strategy in the treatment of incisional, umbilical and epigastric hernias.
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References
Bisgaard T, Kehlet H, Bay-Nielsen M, Iversen MG, Rosenberg J, Jorgensen LN (2011) A nationwide study on readmission, morbidity, and mortality after umbilical and epigastric hernia repair. Hernia 15:541–546. doi:10.1007/s10029-011-0823-z
Helgstrand F, Rosenberg J, Kehlet H, Jorgensen LN, Bisgaard T (2013) Nationwide prospective study of outcomes after elective incisional hernia repair. J Am Coll Surg 216:217–228. doi:10.1016/j.jamcollsurg.2012.10.013
Nieuwenhuizen J, Kleinrensink GJ, Hop WC, Jeekel J, Lange JF (2008) Indications for incisional hernia repair: an international questionnaire among hernia surgeons. Hernia 12:223–225. doi:10.1007/s10029-007-0322-4
Fitzgibbons RJ Jr, Giobbie-Hurder A, Gibbs JO, Dunlop DD, Reda DJ, McCarthy M Jr, Neumayer LA, Barkun JS, Hoehn JL, Murphy JT, Sarosi GA Jr, Syme WC, Thompson JS, Wang J, Jonasson O (2006) Watchful waiting vs repair of inguinal hernia in minimally symptomatic men: a randomized clinical trial. JAMA 295:285–292. doi:10.1001/jama.295.3.285
Fitzgibbons RJ Jr, Ramanan B, Arya S, Turner SA, Li X, Gibbs JO, Reda DJ (2013) Long-term results of a randomized controlled trial of a nonoperative strategy (watchful waiting) for men with minimally symptomatic inguinal hernias. Ann Surg 258:508–515. doi:10.1097/SLA.0b013e3182a19725
Mizrahi H, Parker MC (2012) Management of asymptomatic inguinal hernia: a systematic review of the evidence. Arch Surg 147:277–281. doi:10.1001/archsurg.2011.914
O’Dwyer PJ, Norrie J, Alani A, Walker A, Duffy F, Horgan P (2006) Observation or operation for patients with an asymptomatic inguinal hernia: a randomized clinical trial. Ann Surg 244:167–173. doi:10.1097/01.sla.0000217637.69699.ef
Andersen TF, Madsen M, Jorgensen J, Mellemkjoer L, Olsen JH (1999) The Danish National Hospital Register. A valuable source of data for modern health sciences. Dan Med Bull 46:263–268
Lynge E, Sandegaard JL, Rebolj M (2011) The Danish National Patient Register. Scand J Public Health 39:30–33. doi:10.1177/1403494811401482
Helgstrand F, Rosenberg J, Jorgensen LN, Kehlet H, Bisgaard T (2010) Surgical treatment of ventral hernia. Ugeskr Laeger 172:1987–1989
Altman DG, Bland JM (1997) Statistics notes. Units of analysis. BMJ 314:1874
Nieuwenhuizen J, Halm JA, Jeekel J, Lange JF (2007) Natural course of incisional hernia and indications for repair. Scand J Surgery 96:293–296
Bellows CF, Robinson C, Fitzgibbons RJ, Webber LS, Berger DH (2014) Watchful waiting for ventral hernias: a longitudinal study. Am Surg 80:245–252
Verhelst J, Timmermans L, van de Velde M, Jairam A, Vakalopoulos KA, Jeekel J, Lange JF (2015) Watchful waiting in incisional hernia: is it safe? Surgery 157:297–303. doi:10.1016/j.surg.2014.09.017
Helgstrand F, Rosenberg J, Kehlet H, Bisgaard T (2013) Outcomes after emergency versus elective ventral hernia repair: a prospective nationwide study. World J Surg 37:2273–2279. doi:10.1007/s00268-013-2123-5
Helgstrand F, Rosenberg J, Bay-Nielsen M, Friis-Andersen H, Wara P, Jorgensen LN, Kehlet H, Bisgaard T (2010) Establishment and initial experiences from the Danish Ventral Hernia Database. Hernia 14:131–135. doi:10.1007/s10029-009-0592-0
Thompson JS, Gibbs JO, Reda DJ, McCarthy M Jr, Wei Y, Giobbie-Hurder A, Fitzgibbons RJ Jr (2008) Does delaying repair of an asymptomatic hernia have a penalty? Am J Surg 195:89–93. doi:10.1016/j.amjsurg.2007.07.021
Sauerland S, Walgenbach M, Habermalz B, Seiler CM, Miserez M (2011) Laparoscopic versus open surgical techniques for ventral or incisional hernia repair. Cochrane Database Syst Rev (3)Cd007781. doi:10.1002/14651858.CD007781.pub2
Mason RJ, Moazzez A, Sohn HJ, Berne TV, Katkhouda N (2011) Laparoscopic versus open anterior abdominal wall hernia repair: 30-day morbidity and mortality using the ACS-NSQIP database. Ann Surg 254:641–652. doi:10.1097/SLA.0b013e31823009e6
Sorensen LT, Malaki A, Wille-Jorgensen P, Kallehave F, Kjaergaard J, Hemmingsen U, Moller LN, Jorgensen T (2007) Risk factors for mortality and postoperative complications after gastrointestinal surgery. J Gastrointest Surg 11:903–910. doi:10.1007/s11605-007-0165-4
Christoffersen MW, Helgstrand F, Rosenberg J, Kehlet H, Strandfelt P, Bisgaard T (2015) Long-term recurrence and chronic pain after repair for small umbilical or epigastric hernias: a regional cohort study. Am J Surg 209:725–732. doi:10.1016/j.amjsurg.2014.05.021
Gronnier C, Wattier JM, Favre H, Piessen G, Mariette C (2012) Risk factors for chronic pain after open ventral hernia repair by underlay mesh placement. World J Surg 36:1548–1554. doi:10.1007/s00268-012-1523-2
Liang MK, Clapp M, Li LT, Berger RL, Hicks SC, Awad S (2013) Patient Satisfaction, chronic pain, and functional status following laparoscopic ventral hernia repair. World J Surg 37:530–537. doi:10.1007/s00268-012-1873-9
Lauscher JC, Martus P, Stroux A, Neudecker J, Behrens U, Hammerich R, Buhr HJ, Ritz JP (2012) Development of a clinical trial to determine whether watchful waiting is an acceptable alternative to surgical repair for patients with oligosymptomatic incisional hernia: study protocol for a randomized controlled trial. Trials 13:14. doi:10.1186/1745-6215-13-14
Janson M, Edlund G, Kressner U, Lindholm E, Pahlman L, Skullman S, Anderberg B, Haglind E (2009) Analysis of patient selection and external validity in the Swedish contribution to the COLOR trial. Surg Endosc 23:1764–1769. doi:10.1007/s00464-008-0203-7
Acknowledgments
The study was partly funded by a private foundation (“Edgar Schnohr and wife Gilberte Schnohr’s foundation”), which is established to support independent surgical and anesthesiological research. The foundation had no influence on design and conduct of the study; nor collection, management, analysis, and interpretation of the data. Furthermore, the foundation had no influence on preparation, review, or approval of the manuscript and on the decision to submit the manuscript for publication.
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Dunja Kokotovic, Henrik Sjølander, Ismail Gögenur and Frederik Helgstrand declare that they have no conflict of interest.
Funding
The study was partly funded by a private foundation (“Edgar Schnohr and wife Gilberte Schnohr’s foundation”), which is established to support independent surgical and anesthesiological research. The foundation had no influence on design and conduct of the study; nor collection, management, analysis, and interpretation of the data. Furthermore, the foundation had no influence on preparation, review, or approval of the manuscript and on the decision to submit the manuscript for publication.
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Kokotovic, D., Sjølander, H., Gögenur, I. et al. Watchful waiting as a treatment strategy for patients with a ventral hernia appears to be safe. Hernia 20, 281–287 (2016). https://doi.org/10.1007/s10029-016-1464-z
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DOI: https://doi.org/10.1007/s10029-016-1464-z