Chapters Transcript Video The co-morbid patient — risk factors supporting surgical approach What does the data tell us? - William Cobb, M.D. our next speaker is gonna be doctor cop, and he's gonna tell us a little about the risk factors and the co morbid patient. Well, thanks so much to go, or, I mean, it's great to be back together. The last time I participated in the course was two years ago at this event. Um, and I think I can, uh, honestly say, I'm the only person that's been to every one of these courses in New York. And so this goes back to many years where we had Dr Bauer and several other faculty throughout the city that have sponsored this course. But Gore has always been, uh, strong supporter, and this is an unbelievable course. Great time of the year to come. So Peugeot, thanks for putting this on. And just thanks to Gore for continuing to support Hurney education and then you guys for taking time giving up your Saturday. Unfortunately, it is New York holiday time, so you can benefit from it later today. Hopefully, uh, but it really just shows a commitment on your part to your patients. Um, so I was tasked to talk about the co morbid patient, and specifically, what does the data. Tell us, um, which I thought was interesting, because, you know, Hannaford has all the damn data. So Well, why didn't he give this talk? But anyway, I will. I will go through this, um, and certainly did a pretty thorough review. As I thought. The literature is to kind of what what's out there and what helps to guide us and more so gives us outcomes data on some of these comorbidities that we face. Um, and so clearly, the complex incision of all patient, um, has been touched on by previous speakers. Uh, brings a lot of baggage to the table, figuratively and sometimes literally with their Ostuni appliances. And so lots of things to unpack here. Significant obesity, diabetes. Um, uh, smoking, which is really prominent for us in the southeast. I'm only an hour and a half down the road from Todd, and so we get a lot of these folks as well that, uh, just, you know, you have the right as an American and particularly the Southern to be stupid. And and so we have a lot of that going on, and folks that are participating in destructive behavior, but respiratory compromise and then, of course, contamination. That's present due to ostracize and fistulas and things like that. And a lot of times, when you look at results and outcomes from just eventual journey across the board, uh, we get away with it most of the time. We do pretty good job when a significant number of these comorbidities aren't present. But when you start stacking these things up, then the truth gets told, and that's when the real outcomes, uh, starting to come forward. And that's, I think, where really we have to have outstanding techniques and we just can't get away with as much as we can when they don't have as many of these comorbidities and so as Todd's already mentioned in an effort to try to improve our outcomes if we can, um, impact and improve what's what's now called these modifiable risk factors? Uh, we're certainly better off. And so again, um, I kind of walked through the four that are frequently referenced obesity, uh, smoking, diabetes and a previous wound or mesh infection, which hasn't been talked about too much time to talk about in your autumn ease and how that further complicates repairs. But I'll touch on that. A little bit of literature that's out there When you look at the American attorney society quality collaborative. Um, and so now, approaching 90,000 patients a little over 450 surgeons that are contributing to this, um, you can see What percentage of these folks, uh, present with one of these four common comorbidities that I just discussed. And so, um, as todd mentioned earlier, I think in his series, 78% of his patients undergoing open repair had some, uh, type of co morbidity. So it's not an insignificant number of these patients that present for hernia repair. Um, when you prepare these folks, obviously we've talked a little about already about smoking cessation, attempted attempted weight loss, uh, to share an office with bariatric surgeons. We try to get them over. Of course, there's always a lot of tact involved with that. When they come to see you to patch a hole and you're basically telling them, uh, you're fat, you need to go lose weight. They don't take that very well sometimes. So of course, they have to be very diplomatic about that. Come at it from a physics standpoint, like Fisher just mentioned uh, and then just try to get them to buy into it, and many times as well, they they failed multiple repairs. By the time they get to, uh, to that stage and so you can kind of they can relate to that and say, Look, it's not that you've had five previous bad operations. You know, you've had good surgeries in the past. Let's take a look and assess further why these things aren't working. Um, and, uh and that kind of helps, I think dr at home sometimes, but clearly, if there's Austin, he's presidents amazing to me. How many folks are walking around with, um, Ostuni is from previous Hartman's procedures or, you know, other disasters that were dealt with in the middle of the night. Um, and they're They've been told that that Ostuni can never be reversed, which just means that the surgeon who spent four hours in the middle of the night with them is not going to be the one to go back in their belly. But you can always find some unsuspecting colorectal surgeon to try to tackle an awesome reversal, so we typically send them over to our colorectal partners who? We'll study them in the vast majority. These folks, they can get rid of the OSCE to me, of course. You know, a PRS and folks that have horrible, um, uh, erectile disease from inflammatory bowel disease aren't candidates. But that's a pretty small percentage of these folks. They can usually get rid of that. Ostuni for you. Um, any folks that come in with, uh, suter Sinuses, infected mesh. Things like that will definitely stage those repairs. Go in, clean everything up if it's just taken out. A bunch of suits, permanent features that, you know, at the bonds or, uh, even sometimes pro lean futures that are infected. Do that rid the abdominal wall of any infection. So that when you go in like Todd talked about earlier, you know, having a clean case, uh, is certainly gonna, uh you're gonna you're gonna do better at the end of the day from that standpoint. Encourage weight loss. Um, again. Certainly try. I mean, I've never I lost £40 because a patient challenged me too. But that's a that's a good thought. There, uh is a little bit more motivated, however, than than Certainly, I am, um and, uh, you know, again, we we we really get our bariatric surgeons involved to help out. I think the sleeve is Todd pointed out as well has been a more attractive option for a lot of these folks. Demand smoking cessation. Um, you know, this is controversy, which I'll get into here with the data. We certainly, uh, really want them to and at least cut back significantly. We don't go so far as to do the urine cotinine studies and things like that that others, um, and cancel the the are necessarily. But we do try to get them to lose. I'm sorry to at least stop smoking, but we're not a hard and fast stop. And we do put a sign right outside of Henry Ford's office that says, if he made you quit smoking, Greenville's only an hour and a half away. So, um, so when you look at these patient factors, that will go through each one of them, like like I said earlier. So obesity being a big one? Um, you know, this is a study back in 2000 that even then talked about, um, the recurrence of the increased risk of recurrence, uh, and folks that were carrying extra weight and so that if you had a b m i of greater than 28 You started seeing recurrence rates increase. Uh, that's a snack in South Carolina that that's a really, uh we're fortunate we can get anybody under 30. So, um, to consider that patients that as you start to increase over 28, um, they increase their recurrence rate. That's that's pretty low gold there. So certainly prosthetic prepares. And this patient were advocated for all decisional hernias and obese patients. But just speaking to the higher risk of recurrence in these individuals, this is a really nice study by Fisher and his group. Uh, they went through just shy of 13,000 abdominal operations at the University of Penn and, um, assessed these for risk of incision, a hernia, And, uh, interestingly, the overall instance was 3.5% in this study. And when they peeled out independent risk factors for what caused the incision Hernandez, you can see the highest awesome reversal recent Chemo and then obesity. It was essentially the highest modifiable risk factor in that series. Um, previous bariatric surgery. Sorry. Previous bariatric surgery. Uh, continued smoking and liver disease are also in that category, but you can see that obesity portended high incidence of incisions. Hernia formation. Um, really Nice study. Uh, this was looking at, um, the impact of B m i on open incision or hernia repair retrospective review, um, and broke these patients out into seven different categories. Uh, and so you can see the different variations of B m I there. And once you started getting up over 30 uh, the incidence of recurrence was significantly higher in those patients and then continued to rise as the BMI rose. And so once you got to BMI of 40 the risk of recurrence was over two times that someone who was not obese. So, um, that was their cut off. And the paper suggested that, uh, should demand weight loss for anyone, has a b. M. I greater than 40. A lot of other studies have now referenced this paper, and that seems to be the target. Now that you see in the literature that 40 certainly when you should start considering or demanding weight loss prior to any embarking on any repair. Um, there's another interesting study looking at folks that undergo bariatric surgery. And so again, uh, folks are talking about medical weight loss and things like that, which I don't think is nearly as successful, uh, surgical weight loss. But these are patients that underwent ventral hernia repairs, either Ignoring the weight and just going ahead and proceeding with the hernia repair. Um, or looking at a patient population that underwent bariatric surgery, then had their honey repaired once they had £100 weight loss. Um, and you can see that the recurrence rate was 24% and the group that did not have a bariatric intervention vs 6.7%,, And that's a medium follow up just shy of five years. So very respectable. Follow up there. Not a huge study. Um, only 30 patients that they case matched to 60 that, um, that did not have the bariatric procedure, but still pretty cool study and just showing the importance of getting that weight loss off for tobacco use. Um, Todd talked about this extensively, but certainly as we know, uh, the nicotine is. What does it? It reduces the subcutaneous blood flow. Really? Nice study. Looking at a single cigarette with a 38% reduction in smokers. Um, And even a 28% reduction in non, smokers which is statistically, significant obviously. um, and then that cutaneous blood flow does recover quicker. Uh, and folks that aren't chronic smokers. But this is the justification for why even a four week hiatus, if you will, from smoking returns some of this cutaneous blood flow to help with a wound healing. Um, you know, looking at the literature. And you know what What are the studies that are out there looking at smoking and the impact on outcomes with incision A hernia? You're starting to see more of that. There's very few studies that, specifically just look at smoking cessation. A lot of it are rolled up in these big studies, like what's coming out of Charlotte? What's what Fisher is done and sort of this patient reported outcome stuff, But this was one of the earlier manuscripts studies looking at the wound infections. Um, and this wasn't just, um Uh this was just a hernia. Patients can see, uh, just over 1500. Um, interestingly, the use of mesh did not influence the risk of infection, which we always think about mesh increasing infection. But tobacco was the only modifiable risk factor in this study. Yuri and his group looked at their series of open retro muscular repairs with mesh. Um, and all of the mesh infections occurred in smokers, and again, smoking was the only predictor of wounded mesh related complications. And so, again, this justification in this thought for having patients or demand smoking cessation prior to repair. So we felt really good about that and thought we knew what we were doing in terms of demanding smoking cessation. And then this was reported out of the HS QC. So again, that large database that are referenced earlier, Um, with just shy of 90,000 patients now, but looking at, um, clean ventral hernia repairs, Um, and they took current smokers. So those were patients that had documented use of tobacco within 30 days of the surgery and matched to folks that had never smoked. Um, and as you can see for, you know, s s I s s O, which would be surgical site occurrences. So that would roll up your Ciroma. Zira, thema, eca, Moses. Things like that that wouldn't necessarily warrant an infection and then surgical site occurrences requiring procedural intervention. None of those were statistically different in the smokers versus the nonsmokers. So really called into question, Um, is smoking that big of a deal? Um, which certainly it is. Um, but it was just interesting that this paper came out very controversial when it was reported. Uh, there was actually several letters written in response to this, which were not very nice, but but as you can imagine, uh, this really flies in the face of what we've been told for all these years, and I think, and I'll get here in a little bit of paper that, um, came out. I think it was Fisher's group again. Kind of maybe explains why where smoking does impact things here, uh, looking at, like, scenic control again. Not a lot specifically in regards to, um, hyperglycemia and hernia repair. Specifically, there are larger series again and what's currently in the literature, but nothing specifically looking at glycemic control. But there are several papers when you roll up different types of procedures of colorectal surgery. So just, uh, glucose level greater than 200 independent risk factor for s s. I, um for general and vascular surgery again going down to 140 saw, uh, levels above 100 and 40 saw increases in S s I and those patients in that patient population. Um, and then, um, just increasing 40. You know, points over normal glossy mia Increase the risk of a postoperative infections by 30%. So again, not insignificant. And we've seen it in other areas, which would certainly makes sense to relate to her knee repair. So this was a study of the HSK you see then published here fairly recently. And this may explain some of the disconnect. You know why smoking alone maybe doesn't necessarily identify, but this was looking at smoking, obesity and diabetes. And so when you look at each one of them individually, it slightly elevates the risk. But then when you start compounding these things, you add obesity to smoking. You know your risk of S s I, which would be the blue lines, goes up to one a little bit over 1.5. You get diabetes and smoking combined 1.8. You start playing with obesity and diabetes together up to two, and then all three of them present, uh, you know, 2.3, almost 2.4 times risk of SS I after clean and cities already repair. So I think you know, these things are additive, and it's pretty rare that you find someone that's just, uh, morbidly obese. They almost typically, you know, diabetes in their back pocket as well. And a lot of these folks, because of the poor choices that they make, um, you know, throw smoking on top of on top of all that as well. So it's very common to see, uh, to see multiple of these stack, if you will. So previous wound infections a lot of times. Uh, these hernia repairs are complicated by that. Todd showed earlier that when you have, um, wound infections, uh, it certainly impacts your risk of recurrence. It impacts while these people got their institutional hernia repair in the first place. I've heard Todd said many times before, and I think it's a fantastic quote that these patients are failures in the sense that they failed wound healing, right? For some reason, um, whether it was poor, um, you know, steroid use or some you know, college and deficit. Whether it was wound infection that that impacted the wound healing environment, which is many times the case. Uh, they have failed wound healing, which is why they are presenting to you with the incision. A hernia? Uh, this was a really interesting study, going all the way back to the eighties and nineties looking at, um, culturing wounds and patients with incision, a hernia. And many times they found the same organism that was present at the time of the initial wound complication prior to the patient, even developing the incision, a hernia. So the authors recommended that incision he repairs shouldn't be considered as clean cases. The minimum probably clean contaminated, which is an interesting way to look at it, but certainly suggests that a lot of times these folks are still colonized. And this has really been, um, brought to the front and concerning with M. R s a infections. You know, as virulent as those are particularly M. R. S a mesh infection. Um, you know, could that maybe never You never place a synthetic mesh back in that patient population. This was an earlier study. Um, when, uh, mike and Yuri were actually talking together or talking to one another. And we're partners in Cleveland at the time case, Um, and they looked very early on at 10 patients that had previous M R S A S s. I and 20% of them went on to develop superficial sees, but they didn't have to remove the mesh. They didn't have to breed anything. And they said, Oh, it's probably fine in Marseille is, you know, probably okay, don't really worry about it. Uh, but recently and you'll see some of the same authors on that paper, at least at least. Mike Um, now, after a large review of the HSBC data base again looking at clean patients, almost 600 of these patients had previous S s. I s of any type, not just m R s A, um, and you can see that the risk of 30 day S s I as well as an SS I requiring a procedural intervention were statistically higher, uh, in both of the groups that it had the previous, um, surgical site infection. So there is something to you know, whether you might sort of initially said, I don't think it's that big of a deal. Um, this data would certainly support that. Folks haven't had previous infection. Um, you know, look out there. Certainly at a higher risk performing another infection. Interestingly, previous M. R s. A. Did not incur a higher risk than if it was just a non m r s a pathogen. But previous infection proceed with caution. So again, a lot of these folks show up to your office with with significant comorbidities. Uh, you know, we've talked a little bit about some of the preoperative measures and and how we should address these things. But certainly they're going to improve your outcomes if you can get some of these things into check. Uh, and then, you know, still, I think the question remains and what's the right thing to do? And folks that have had a significant history of S s, I s I know in my practice is particularly had a previous mesh infection. Um, I will counsel them, talk to them about not putting a permanent synthetic back in them. And that's where, uh, you know, by absorbable biologic, But my practice would be a, um inform or by away would be a better choice in that patients. All right, questions. Thank you dot com. Thank you for a very interesting talk on some of those sort of risk factors. I'm gonna start off with a couple of questions for you. Uh, vaping has obviously been a topic. Probably the last three or four years. Now, what are your sort of thoughts on whether patients are vaping pre op? Um, you know, we don't see a lot of that off, to be honest. Um I mean, in South Carolina, they just come right out, and they just they smoke cigarettes. I don't have a lot of vapors, so I wouldn't be the person to ask. I don't know Todd or Fish. See, a lot of that, Um, I know I've seen some stuff about, you know, the nicotine levels, um, arguably being higher and of a population. Um, I don't know if the cotinine test triggers. Um, if someone's vaping. Yeah, right. The problem. Mm, the same as but can you can you test for it, though? As well as you can with the nicotine and cigarettes tested for I think person when the tried for six months and 12. Yeah. Worse. Getting bigger, like just me too. Some sort of nicotine replaced. Inhale some. Yeah, a lot of it. Mhm and all just Well, Alex Matt, in the sense that the data, it's not the nicotine. This is so the sso census eyes it seems to be it's only everything else. The area lies tobacco. You know, when you smoke, because the source of data, the RCT basically, you know, wise risk when they were on nicotine replaced the transdermal patches. So probably not the nicotine. That's the causative factor. I mean, yeah, baby is not going to help. Yeah, but, I mean, I think that's the lesser Really. All of the most of we're the ones who were there. Like THC, right? Loyal. Hi. Maybe there's a good stuff. Seems to be at least relatively right. Well, this post wannabe, I guess we do this course in Colorado. We have to deal with, uh, marijuana spoken. Walk around? Yeah, Well, that's right. Last night we got a full of full of it, Dr Rose. Uh huh. With regard to final point there, Provide. Yes, it's already repaired that a durable so in your hands in most cases. So I mean, I reference the cobra data when I counsel patients. And so our two year recurrence was 17%, um, in that study, so it's not perfect, right? And correct, which was a couple of the recurrences. But, um, I think it's it's worth. I mean, yeah, it's not as good as your synthetic numbers, but it's It's certainly worth you know, that little bit of increase in recurrence versus a permanent mess. Infection. And so I know Todd got experience with cleaning these patients up and and making the choice based upon where you get them. And your recurrence rates are even better using by absorbing materials. Once you kind of get those modified risk factors. Absolutely. So, yeah, in those situations, I'll go in and just kind of clean everything out, rip out all the mesh, all the infected future tax, anything you can find. Um, don't really address the hernia at that time. Uh, and get the skin closed. I've not had anyone bust loose. You certainly put them on binders, but usually getting the skin closed. Um, you know that that's adequate. And they'll form a big old Ernie and I try to wait a year before I go back in. Um, I just actually just had a lady. I had to utilize pre avenue mode to get everything back inside because she had has lost domain by the time I got back to her. I have a question for you, sir. And since you brought up B m I do you have an absolute b m? I cut off, and sort of the bariatric surgeon in me says, Well, if my patient had b m i of 90 and they come down to a B m i 50 do I not offer them a hernia repair at that point? Um, so no, we don't have, and I certainly don't have any absolute cut offs. Um, you know, I think a lot of this whether it's smoking, cessation, weight loss, diabetes control, a lot of us is getting the patient to buy in. And, you know, as Todd mentioned, I mean having these conversations, if you sit down and formally show them the P. R o data that fish goes through or his cedar app and just kind of tell them and inform them, you know, I'm shocked at the number of folks you tell them, like, you know, the reason you've had all these recurrent hernias is because you've gotten infectious complications or whatnot from your smoking. They're like, no one's ever told me smoking impacts of a hernia. And they've had, like, eight previous repairs. Um, and so, you know, a lot of times educating these folks. And again, I'm in South Carolina, So education is always good. Um, but just kind of letting them know you know why they are where they are. And you're not just being a meanie. Um, you know, there's there's a reason for it. And so um, yes, if they can show any measurable if they lose a little bit of weight and you give them six weeks and say, Hey, how much weight you think you can lose in six weeks? Well, I'm quit drinking a gallon of Diet Coke every day like, Hey, that's a great start and just get out and walk to Todd's point. I mean, just show me something, come back and show me you lost £10 and we can start, you know, moving toward that now, the folks that gained weight, and then that's when I'll push them over and say, Look, we need to get some help and talk with geriatrics Published December 15, 2021 Created by
