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Risk Stratification of Incisional Hernia After Bariatric Surgery: Guiding Patient Selection for Prophylactic Mesh Augmentation Based Upon 2,161 Operations
Marten N. Basta, MD1, Michael N. Mirzabeigi, MD2, Valeriy Shubinets, MD2, Jeffrey A. Drebin, MD, PhD2, Joseph M. Serletti, MD2, Stephen J. Kovach, MD2, John P. Fischer, MD, MPH2.
1Brown University, Rhode Island Hospital, Providence, RI, USA, 2University of Pennsylvania Health System, Philadelphia, PA, USA.

PURPOSE:
Incisional hernia (IH) is a persisting cause of morbidity, diminished quality of life, and healthcare costs. Literature suggests prophylactic mesh reduces IH risk in bariatric surgery but no predictive models are available. This study aimed to identify factors associated with IH after bariatric surgery to develop a clinically-actionable risk stratification tool to optimize outcomes and mitigate healthcare costs after bariatric surgery.
METHODS:
Patients undergoing open or laparoscopic bariatric surgery from 1/1/2005-
6/1/2013 at one institution were identified. Comorbidities and operative characteristics were assessed. The primary outcome was surgically treated IH following index procedures. Patients with prior hernia, <1 year follow-up, or BMI<40 were excluded. Cox hazard regression modeling with bootstrapped validation, risk factor stratification, and assessment of model performance were conducted.
RESULTS:
2,161 bariatric patients were included, 2.4% developed a surgically-treated IH (follow-up 28.3 +/- 25.4 months). Predictors for IH included open approach (HR=10.3), malnutrition (HR=3.10), prior abdominal surgery (HR=2.89), and BMI>60 kg/m2 (HR=2.60). Patients were stratified into low-, moderate-, and high-risk groups for IH. 15.2% of high-risk patients developed IH vs. 0.6% of low-risk patients (C-statistic=0.85). IH and associated complications exceeded \.5 million in costs.
CONCLUSION:
Bariatric surgery conferred a 2.4% incisional hernia risk, which led to more readmissions, complications, and substantially greater healthcare resource utilization. This risk tool allows identification of candidates for prophylactic mesh augmentation to optimize outcomes and mitigate costs.


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