New model shows usefulness of elective surgery for common symptomatic abdominal hernia cirrhosis Surgical scenario.
A team led by Nadim Mahmoud, MD, MSc, MSc Public Health, MSc, Department of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, identified optimal clinical thresholds for preferring surgical or non-surgical management of symptomatic abdominal hernias.
“With the increasing burden of cirrhosis in the United States,1 So is the volume of surgical treatments for cirrhosis.” “Preoperative risk stratification has been difficult due to the myriad of factors contributing to cirrhosis of surgical risk, such as poor structural function, malnutrition and impairment, portal hypertension, and dysfunctional hemostasis.”
Patients with cirrhosis of the liver often have an increased risk of death after surgery. While there are many models for risk estimation, current risk estimation scores cannot compare surgical risks with non-operational risks.
In the Markov Cohort Decision Analytical Modeling Study, researchers evaluated elective surgery and non-surgical management of symptomatic abdominal hernias in patients with cirrhosis. The team extracted transmission and facilities probabilities from the literature and data using the Liver Cirrhosis Cohort from the Veterans Health Administration.
Patients included in the analysis were referred to the surgery clinic for asymptomatic abdominal hernias and were diagnosed with cirrhosis between 2008-2018.
quality adjusted life years
The authors also estimated QALYs for each pathway and its frequency on the baseline model for end-stage liver disease-nadose (MELD-Na) scores ranging from 6 to 25 and cyclic Markov models over a 5-year time horizon.
The final analysis included 2,740 patients with cirrhosis with a mean age of 62 years. The number of patients was overwhelmingly male (n = 2699; 98.5%).
Each patient was referred to the surgery clinic for asymptomatic abdominal hernia, 63.9% (n = 1752) did not undergo surgery. There was a mean follow-up of 42.1 months.
The investigators estimated the risk of death in the surgical and non-surgical pathways, an initial MELD-Na limit of 21.3 points, below which surgery associated with maximum quality-adjusted life years was determined. In addition, nonsurgical management has been linked to 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 the increased time spent in resolving hernia associated with increased benefit.
The model results were also sensitive to the probability of hernia recurrence, hernia sequestration, and diminished utility in the case of symptomatic hernias.
The authors wrote: “This decision-making model study found that elective surgical treatment of symptomatic abdominal hernia was preferable even in the setting of relatively high MELD-Na scores.” “Patient symptoms, hernia-specific characteristics, and the experience of the surgeon and center may influence the optimal strategy, emphasizing the importance of joint decision making.”
the study, “Modeling optimal clinical thresholds for elective abdominal hernia repair in cirrhotic patients‘online at JAMA Network is open.