Hernia DOI 10.1007/s10029-013-1205-5
ORIGINAL ARTICLE
Strangulated groin hernia in octogenarians Y. Azari • Z. Perry • B. Kirshtein
Received: 23 June 2013 / Accepted: 12 December 2013 Ó Springer-Verlag France 2013
Abstract The aim of the study was to determine risk factors for morbidity and mortality in patients older than 80 years, compared to younger patients, who undergo emergency strangulated groin hernia repair. Methods This is a retrospective study of patients who underwent emergency surgery for strangulated groin hernia repair during 14 years. Patients were divided by age into three groups: younger than 59 (group A), 60–79 (group B), and older than 80 years (group C). Patient data included age, gender, hernia type, sac content, comorbidities, and surgical outcomes. Results Two hundred patients were included in the study. There was no difference between groups in sex, hernia localization, and the type of repair. More comorbidities were found in octogenarians compared to the younger patients [group C vs. D (A ? B)]. Small bowel resections and ICU admissions were more frequent in patients over 60 years compared to younger patients, 19.6 and 32.7 % vs. 1.7 and 0 %, respectively. Surgery was longer in group B. The rate of postoperative complications, repeated surgery, length of admission, and mortality were significantly higher in octogenarian (group C). Multivariate analysis found that age is a significant factor in the occurrence of
This study fulfilled part of the requirements for the MD degree of Y. Azari. Y. Azari Z. Perry B. Kirshtein Department of Surgery A, Soroka University Medical Center, Beersheba, Israel Y. Azari Z. Perry B. Kirshtein (&) Faculty of the Health Sciences, Ben Gurion University of the Negev, POB 151, 84101 Beersheba, Israel e-mail:
[email protected]
non-surgical postoperative complications, but not in surgical complications. Conclusion Emergency surgery for strangulated hernia repair in patients over 80 years is more complicated than in younger patients, mostly due to the existing comorbidities. In order to reduce the high morbidity and mortality rates in emergency surgery associated with this age group, elective hernia surgery in elderly should be considered in selected patients with severe symptoms affecting their daily life. Keywords Groin hernia Emergency surgery Strangulation Elderly Octogenarians Hernia repair
Introduction Long life nowadays leads to an increased number of various operations performed in elective or emergency settings in elderly patients. Hernia repair is a common operation, since inguinal hernia life risk is 27 % in men and 3 % in women [1]. Inguinal hernia is the most frequent and is usually fixed electively, while femoral hernia is relatively rare and is more frequently incarcerating, thus requiring urgent surgical intervention [2]. Elective hernia repair can be performed safely even in the presence of accompanying diseases, while emergency surgery hernia causes an increased risk of complications even without accompanying diseases [3]. Nowadays the tendency is to refrain from elective operations in patients over the age of 80 because their age alone is a risk factor. Only a few studies have focused on the risks in the repair of strangulated hernia in patients over the age of 80. The majority of researchers attribute age as a significant risk factor for hernia repair in this population. Martinez-Serranoet al. [4] showed that the major risk factors for mortality in emergency hernia repairs
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are resected bowel, ASA score (American Society of Anesthesiologists) Class III/IV, and age over 70 years. Up until now, a conclusive method in preventing strangulated hernia such as elective hernia repair has not been found in elderly patients or patients with severe comorbidities, although some studies showed that elective hernia surgery under local anesthesia is a good alternative option in this patient group [5, 6]. The favorite treatment with low risk for this group is still undetermined and therefore was the focus of the present study. In this study, we analyzed cases of strangulated groin hernia repair in various age groups to find risk factors for postoperative morbidity and mortality in octogenarians.
Patients and methods The study population included all patients who underwent strangulated groin hernia repair between 1997 and 2010 at the Department of Surgery A, Soroka University Medical Center in Beer-Sheva, Israel. After the study was approved by the local Helsinki Committee, patient data were gathered from the operating room database by ICD 9 codes (Z5321, Z5304, Z5302, Z5301). Data were collected from the medical charts and included demographics,
comorbidities, hernia type, surgery findings and outcomes, and length of ICU and hospital stay. Patients were divided into three groups: group A (aged 59 and younger), group B (60–79 years old), and group C (older than 80 years). Subgroup D (A ? B) included patients under the age of 80. Comparison was performed between three (A, B, and C) and two groups (D and C). Statistical analysis Data collected were coded for confidentiality of participants and retained in the database SPSS software (SPSS 17.0, SPSS, Chicago, IL). The data were processed initially using descriptive statistics and then inferential statistics by Parametric [t test uncorrelated (unpaired t test)] and non-parametric tests (Mann–Whitney and v2). Correlation test was done using parametric correlations and a-parametric correlations. Statistical significance was determined as p \ 0.05.
Results The study included 200 patients [135 (67.5 %) males and 65 (32.5 %) females], who underwent emergency strangulated hernia repair: 58 in group A, 76 in group B, and 66
Table 1 Patient data
Group A B59
Group B 60–79
Group C C80
p
Number of patients (%)
58 (29)
76 (38)
66 (33)
Age (mean)
43.7
70.9
86.5
Female, n (%)
19 (32.8)
21 (27.6)
25 (37.9)
0.429
Mesh repair, n (%) Hernia sac content, n (%)
43 (74.1)
57 (75)
43 (65.2)
0.375
Small bowel
8 (14.8)
26 (36.1)
34 (53.1)
\0.001
Large bowel
5 (9.3)
23 (31.9)
9 (14.1)
Small and large bowel
0 (0)
3 (4.2)
2 (3.1)
Omentum
21 (38.9)
6 (8.3)
4 (6.3)
Other
20 (37)
14 (19.4)
15 (23.4)
Comorbidities, n (%) \0.001
Ischemic heart disease
1 (1.7)
23 (30.3)
32 (48.5)
Diabetes mellitus
1 (1.7)
13 (17.1)
11 (16.7)
0.013
Hypertension
2 (3.4)
35 (46.1)
32 (48.5)
\0.001
Chronic obstructive pulmonary disease
1 (1.7)
13 (17.1)
11 (16.7)
0.013
Chronic renal failure
0 (0)
11 (14.5)
16 (24.2)
\0.001
Indirect inguinal
29 (50.0)
36 (47.4)
24 (36.3)
0.685
Direct inguinal
18 (31.0)
25 (32.9)
24 (36.3)
11 (19.0)
15 (19.7)
16 (24.2)
Right
29 (50.0)
38 (50.0)
38 (57)
Left
26 (44.8)
36 (47.4)
26 (39.3)
Hernia type
Femoral Hernia side
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0.613
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in group C. Background characteristics were compared between the groups (Table 1). There was no difference between the groups in gender, and location and side of the hernia. Omentum or other content was frequently found in the hernia sac in group A, while small and large intestines were often present in groups B and C (p \ 0.001). On the other hand, small bowel was frequent in octogenarians (group C) compared to the younger patients (group D) (p = 0.003). Ischemic heart disease, diabetes, hypertension, chronic obstructive pulmonary disease, and chronic renal failure were the most recent comorbidities. Octogenarians had significantly more additional pathologies in all variables compared to younger patients in groups A and B. Comparison of groups D and C revealed significant difference in coronary heart disease, hypertension, and chronic renal failure. Also, repeated surgery was more common in the elderly in the three and two groups comparison due to additional laparotomies for anastomotic leaks (p = 0.035, p = 0.047, respectively). Surgery outcomes are summarized in Table 2. The overall postoperative surgical complication rate was significantly higher in octogenarians compared to three and
two groups (p = 0.015, p = 0.013, respectively). Three groups comparison found wound infection and sepsis as prevalent significant surgical complications, as well as cardiac (p = 0.011) and respiratory complications (p = 0.012), and death related to surgery (p = 0.017), in patients in group C. Comparison of groups C and D did not find any difference in the occurrence of postoperative complications. Examining the factors that influenced the existence of surgical and non-surgical complications, we found that hypertension, age, duration of surgery, and length of hospitalization are the factors affecting surgical complications. Conversely, factors leading to non-surgical complications are gender, type of repair, and duration of hospitalization when age was not a significant factor. Surgery was longer in group B (p = 0.002). Analysis of variables affecting surgery length found that incision enlargement (p = 0.026) and bowel resection with anastomosis (p = 0.016) prolonged the surgery time, when the model predicted the result by 21.4 %. Age was not a significant prognostic factor in this model. Postoperative admissions to the intensive care unit were more frequent in octogenarians when we compared the
Table 2 Surgery outcomes
Group A B59
Group B 60–79
Group C C80
p
Mean surgery time (±SD), min
49.57 (19.3)
64.67 (35.8)
50.8 (24.6)
0.002
Mean hospital stay (±SD), days
2.95 (1.2)
4.71 (2.8)
5.53 (4.7)
0.000
Mean ICU stay(±SD), days Additional laparotomy at primary surgery, n (%)
0 (0) 0 (0)
0.89 (3.6) 2 (2.6)
1.03 (3.8) 2 (3)
0.142 0.428
Small bowel resection, n (%)
1 (1.7)
8 (10.5)
6 (9.1)
0.133
Repeated surgery, n (%)
0 (0)
6 (8)
7 (10.6)
0.047
30-day readmission, n (%)
2 (3.4)
4 (5.3)
6 (9.1)
0.399
Postoperative ICU admissions, n (%)
0 (0)
11 (14.5)
12 (18.2)
0.004
Intraoperative complications, n (%) Bladder injury n (%)
0 (0)
1 (1.3)
2 (3)
0.378
Postoperative complications, overall, n (%)
4 (6.9)
20 (26.3)
28 (42.4)
0.000 0.015
Surgical
4 (6.9)
11 (14.5)
17 (25.8)
Wound infection
4 (6.9)
5 (6.6)
9 (13.6)
0.274
Sac seroma, hematoma
1 (1.7)
1 (1.3)
1 (1.5)
0.982
Paralytic ileus
0 (0)
1 (1.3)
0 (0)
0.44
Small bowel obstruction
0 (0)
3 (3.9)
1 (1.5)
0.255
Sepsis
0 (0)
3 (3.9)
7 (10.6)
0.022
0 (0) 0 (0)
2 (2.6) 5 (6.6)
7 (10.6) 9 (13.6)
0.011 0.012
Non-surgical Cardiac Pulmonary Urinary UTI Acute urinary obstruction Pulmonary emboli Mortality, n (%)
0 (0)
2 (2.6)
5 (7.6)
0.063
0 (0)
1 (1.3)
3 (4.5)
0.17
0 (0)
1 (1.3)
2 (3)
0.378
0 (0)
1 (1.3)
1 (1.5)
0.657
0 (0)
4 (5.3)
8 (12.1)
0.017
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three groups (p = 0.004) and the two groups (p = 0.002). However, the length of stay in the intensive care unit was not statistically different. A multivariate analysis revealed that comorbidities, repeated surgery, and duration of surgery are the main causes leading to ICU admissions after surgery, when age was not a prognostic factor. Analysis of variables affecting the length of ICU stay found that laparotomy, repeated surgery, organ failure, intestinal obstruction, repeated admissions, pulmonary complications, urinary complications, sepsis, and gender predicted the results by 77 %. Even in this model age by itself was not a significant prognostic factor. Hospital stay was significantly longer in octogenarians (p \ 0.001). We built a model explaining prolonged hospital admission in this group. We created a linear regression model that predicted by 58.7 % the length of hospitalization. In this model, we found that hypertension, diabetes, hospitalization in ICU, wound infection, paralytic ileus, multiple organ failure, damage to the bladder during surgery, thromboembolic or respiratory complications, surgical complications, and duration of surgery were the factors that affect the length of hospitalization. However, age was not a significant predictive factor. Logistic regression model for predictors of mortality found that the bowel resection significantly affected mortality (p \ 0.001). Other variables (age, sex, duration of surgery, and diseases) were not significant predictors.
Discussion The older population is increasing all the time due to changes in the length of life. According to statistics, in 2030 there will be about 19 million people over the age of 85 in the USA [7]. Emergency surgeries are more complicated in the elderly due to risk factors such as age itself and age-related diseases, as well as by the fact that emergency surgery itself is more complex. Our study showed a prevalence of coronary heart disease, hypertension, and chronic renal failure in octogenarians. Even the National Institute on Aging (NIA) found that the higher the age, the greater the likelihood of developing chronic diseases such as diabetes, respiratory disease, cardiac disease, hypertension [8]. For this reason, older patients are not candidates for elective surgery and most surgeons try to avoid elective operations in elderly patients due to age and comorbidities. Rorbaek-Madsen described the complication rate in elderly patients after elective hernia surgery as 5 % and after emergency surgery as 57 % [3]. Our results demonstrated significantly higher rates of postoperative morbidity and mortality in octogenarians. Several studies have shown the relationship between advanced age, multiple comorbidities, complications, and
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mortality in emergency hernia surgery. Martinez-Serrano et al. [4] showed that age over 70 years and a high ASA score are risk factors for death in strangulated abdominal wall hernia surgery. Alvarez et al. [9] found comorbidities and ASA score as risk factors in strangulated inguinal hernia surgery. Recent studies considered the safety of elective surgery in the elderly despite their having significant comorbidities [5, 6]. According to the data, we can decide that age itself is not a risk factor for morbidity and mortality, but is affected by the comorbidities often accompanying the elderly. Urgent surgery and high level of stress can worsen comorbidities during surgery and after it. Bowel as a common hernia sac content is a risk for strangulation and necrosis. Coronary heart disease, diabetes, and other chronic diseases aggravate the blood supply to the affected part of intestine and result in rapid necrosis in these patients. Correlation between high ASA score and bowel resection with a poor outcome of surgery in the elderly is probably due to anastomotic leaks; sepsis was demonstrated in the literature [10]. Sepsis and cardiac events were more common complications in patients over 60 years of age. In addition, this population has longer hospital admissions after the surgery. We assume a correlation between prolonged admission and high bowel resection and anastomotic leakage rate. Ruggiero et al. [11] showed that localization of the anastomosis is a risk factor for leakage, and colorectal anastomosis is prone to leakage. A relation between anastomosis leakage and comorbidities such as diabetes, chronic renal failure, and chronic obstructive pulmonary disease was also found [12, 13]. Other risk factors are poor blood supply to the anastomosis area, bowel obstruction, and the use of corticosteroids [12]. Early relaparotomy and revision of anastomosis can help in diagnosis of a leak and improve surgical outcome. Bellows et al. [14] reported that respiratory or neurological findings are the earliest markers for anastomotic leaks. Another means for early detection of complications is using exploratory laparoscopy for early detection of life-threatening complication after open surgery [15]. It allows visualization of anastomotic leak, diverting the leaking bowel, and preventing severe sepsis and wound complications. Complications of elective surgery are significantly lower in the elderly compared with emergency hernia surgery [3]. In our opinion, this is the reason that elective surgery should be considered in patients over the age of 80. Chronic constipation, medications, prostate hyperplasia, and weakness of the muscles of the abdominal wall are common risk factors for hernia and incarceration in advanced age. Colorectal tumors are often the cause of progressive constipation in this age group and should be excluded prior to elective surgery. Careful preoperative preparation, operative, and postoperative risk prediction,
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and appropriate follow-up after surgery decrease morbidity and mortality. Elective surgery allows more options for advanced resources in anesthesiology as well as a surgical team of experienced senior surgeons. Our study found more frequent ICU admissions in octogenarians. Ozkan et al. [16] found a correlation between the ASA score and hospitalization in intensive care after abdominal surgery in the elderly Therefore, this difference can be attributed to background disease in the older group. Necmi et al. found predictors for bowel resection in strangulated inguinal hernia in elderly patients [17]. Delay in the approach to medical care after the onset of symptoms, often due to disability, dementia, etc., and altered blood supply followed by rapid bowel necrosis are probably the causes of intestinal resections. Small sample size was the reason that our study did not show a difference between age groups in bowel resections. Information collected in the context of intraoperative complications included only damage to the bladder, which showed no significant difference. The main reason for bladder injury is a sliding hernia and difficulty in identifying the hernia sac due to thickening and edema of the sac and changing anatomy of large hernias. Early detection of bladder damage and repair of the lesion with two layers of absorbable sutures and a catheter for 7–10 days is usually sufficient for the treatment of this complication. Later detection of urine leakage into the abdomen is dangerous and can lead to death in older patients.
Study limitations This work is retrospective and therefore limited information was collected from patients’ charts. Other data such as time of disease before hospital admission were not available. We do not have enough data about the level of surgical experience of the surgeon (resident, chief resident, senior), which can greatly affect the surgery outcome.
Conclusions Emergency surgery for strangulated hernia repair in octogenarians is more complicated than in younger patients, mostly due to the existing comorbidities. Watchful waiting is safe in asymptomatic groin hernias, even in elderly patients. Elective hernia surgery with subsequent preoperative investigation and preparation can be considered in
elderly patients with symptomatic hernias severely affecting their daily life. Conflict of interest YA declares no conflict of interest, ZP declares no conflict of interest, BK declares no conflict of interest.
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