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08-03-2023 | Original Article

Impact of a multidisciplinary team discussion on planned ICU admissions after complex abdominal wall reconstruction

Authors: J. A. Wegdam, D. L. C. de Jong, M. J.C.A.M. Gielen, S. W. Nienhuijs, A. F. M. Füsers, N. D. Bouvy, T. S. de Vries Reilingh

Published in: Hernia | Issue 3/2023

Abstract

Background

Patients often need admission at an Intensive Care Unit (ICU), immediately after complex abdominal wall reconstruction (CAWR). Lack of ICU resources requires adequate patient selection for a planned postoperative ICU admission. Risk stratification tools like Fischer score and Hernia Patient Wound (HPW) classification may improve patient selection. This study evaluates the decision-making process in a multidisciplinary team (MDT) on justified ICU admissions for patients after CAWR.

Methods

A pre-Covid-19 pandemic cohort of patients, discussed in a MDT and subsequently underwent CAWR between 2016 and 2019, was analyzed. A justified ICU admission was defined by any intervention within the first 24 h postoperatively, considered not suitable for a nursing ward. The Fischer score predicts postoperative respiratory failure by eight parameters and a high score (> 2) warrants ICU admission. The HPW classification ranks complexity of hernia (size), patient (comorbidities) and wound (infected surgical field) in four stages, with increasing risk for postoperative complications. Stages II–IV point to ICU admission. Accuracy of the MDT decision and (modifications of) risk-stratification tools on justified ICU admissions were analyzed by backward stepwise multivariate logistic regression analysis.

Results

Pre-operatively, the MDT decided a planned ICU admission in 38% of all 232 CAWR patients. Intra-operative events changed the MDT decision in 15% of all CAWR patients. MDT overestimated ICU need in 45% of ICU planned patients and underestimated in 10% of nursing ward planned patients. Ultimately, 42% went to the ICU and 27% of all 232 CAWR patients were justified ICU patients. MDT accuracy was higher than the Fischer score, HPW classification or any modification of these risk stratification tools.

Conclusion

A MDT’s decision for a planned ICU admission after complex abdominal wall reconstruction was more accurate than any of the other risk-stratifying tools. Fifteen percent of the patients experienced unexpected operative events that changed the MDT decision. This study demonstrated the added value of a MDT in the care pathway of patients with complex abdominal wall hernias.

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Bosanquet DC, Ansell J, Abdelrahman T, Cornish J, Harries R, Stimpson A, Davies L, Glasbey JC, Frewer KA, Frewer NC, Russell D, Russell I, Torkington J (2015) Systematic review and meta-regression of factors affecting midline incisional hernia rates: analysis of 14,618 patients. PloS one, 10(9): e0138745. https://doi.org/10.1371/journal.pone.0138745

Rhemtulla IA, Hsu JY, Broach RB, Mauch JT, Serletti JM, DeMatteo RP, Fischer JP (2021) The incisional hernia epidemic: evaluation of outcomes, recurrence, and expenses using the healthcare cost and utilization project (HCUP) datasets. Hernia 25(6):1667–1675. https://doi.org/10.1007/s10029-021-02405-9CrossRefPubMed

Shubinets V, Fox JP, Lanni MA, Tecce MG, Pauli EM, Hope WW, Kovach SJ, Fischer JP (2018) Incisional Hernia in the United States: trends in hospital encounters and corresponding healthcare charges. Am Surg 84(1):118–125CrossRefPubMed

Rios-Diaz AJ, Morris MP, Christopher AN, Patel V, Broach RB, Heniford BT, Hsu JY, Fischer JP (2022) National epidemiologic trends (2008–2018) in the United States for the incidence and expenditures associated with incisional hernia in relation to abdominal surgery. Hernia 26(5):1355–1368. https://doi.org/10.1007/s10029-022-02644-4CrossRefPubMed

Grove, T. N., Kontovounisios, C., Montgomery A, Heniford BT, Windsor ACJ, Warren OJ, AWR Europe Collaborative (2021). Perioperative optimization in complex abdominal wall hernias: Delphi consensus statement. BJS open, 5(5): zrab082. https://doi.org/10.1093/bjsopen/zrab082

Bittner R, Bain K, Bansal VK, Berrevoet F, Bingener-Casey J, Chen D, Chen J, Chowbey P, Dietz UA., de Beaux A, Ferzli G, Fortelny R, Hoffmann H, Iskander M, Ji Z, Jorgensen LN, Khullar R, Kirchhoff P, Köckerling F, Kukleta J, Yao Q (2019). Update of Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias (International Endohernia Society (IEHS))-Part A. Surgical endoscopy, 33(10), 3069–3139. https://doi.org/10.1007/s00464-019-06907-7

Timmer AS, Claessen JJM and Boermeester MA (2022) Risk Factor-Driven Prehabilitation Prior to Abdominal Wall Reconstruction to Improve Postoperative Outcome. A Narrative Review. J. of Abdom. Wall Surg. 1:10722. doi: https://doi.org/10.3389/jaws.2022.10722

Slater NJ, Montgomery A, Berrevoet F, Carbonell AM, Chang A, Franklin M, Kercher KW, Lammers BJ, Parra-Davilla E, Roll S, Towfigh S, van Geffen E, Conze J, van Goor H (2014) Criteria for definition of a complex abdominal wall hernia. Hernia 18(1):7–17. https://doi.org/10.1007/s10029-013-1168-6CrossRefPubMed

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(2):217–228. https://doi.org/10.1016/j.jamcollsurg.2012.10.013CrossRefPubMed

10.

Deerenberg EB, Timmermans L, Hogerzeil DP, Slieker JC, Eilers PH, Jeekel J, Lange JF (2015) A systematic review of the surgical treatment of large incisional hernia. Hernia 19(1):89–101. https://doi.org/10.1007/s10029-014-1321-xCrossRefPubMed

11.

Blatnik JA, Krpata DM, Pesa NL, Will P, Harth KC, Novitsky YW, Rowbottom JR, Rosen MJ (2012) Predicting severe postoperative respiratory complications following abdominal wall reconstruction. Plast Reconstr Surg 130(4):836–841. https://doi.org/10.1097/PRS.0b013e318262f160CrossRefPubMed

12.

Fischer JP, Shang EK, Butler CE, Nelson JA, Braslow BM, Serletti JM, Kovach SJ (2013) Validated model for predicting postoperative respiratory failure: analysis of 1706 abdominal wall reconstructions. Plast Reconstr Surg 132(5):826e–835e. https://doi.org/10.1097/PRS.0b013e3182a4c442CrossRefPubMed

13.

Docimo S Jr, Spaniolas K, Altieri M, Bates A, Talamini M, Pryor A (2019) Pre-operative characteristics and their role in prolonged intubation following abdominal wall reconstruction. Surg Endosc 33(7):2345–2348. https://doi.org/10.1007/s00464-018-6536-yCrossRefPubMed

14.

Sood RF, Lipira AB, Neligan PC, Louie O, Wright AS, Gibran NS (2019) Respiratory Failure following Abdominal Wall Reconstruction: An Analysis of the Nationwide Inpatient Sample. Plast Reconstr Surg 143(1):165e–171e. https://doi.org/10.1097/PRS.0000000000005115CrossRefPubMed

15.

Schlosser KA, Maloney SR, Prasad T, Colavita PD, Augenstein VA, Heniford BT (2020) Too big to breathe: predictors of respiratory failure and insufficiency after open ventral hernia repair. Surg Endosc 34(9):4131–4139. https://doi.org/10.1007/s00464-019-07181-3CrossRefPubMed

16.

Said S, Thomas J, Montelione K, Fafaj A, Beffa L, Krpata D, Prabhu A, Rosen M, Petro C (2022) Tanaka score predicts surgical intensive care admission following abdominal wall reconstruction. Hernia 26(3):873–880. https://doi.org/10.1007/s10029-022-02605-xCrossRefPubMed

17.

Harji, D., Thomas, C., Antoniou, S. A., Chandraratan, H., Griffiths, B., Henniford, B. T., Horgan, L., Köckerling, F., López-Cano, M., Massey, L., Miserez, M., Montgomery, A., Muysoms, F., Poulose, B. K., Reinpold, W., Smart, N., & NoSTRA HarMoNY (2021). A systematic review of outcome reporting in incisional hernia surgery. BJS open, 5(2), zrab006. https://doi.org/10.1093/bjsopen/zrab006

18.

Basta MN, Fischer JP, Wink JD, Kovach SJ (2016) Mortality after inpatient open ventral hernia repair: developing a risk stratification tool based on 55,760 operations. Am J Surg 211(6):1047–1057. https://doi.org/10.1016/j.amjsurg.2015.03.009CrossRefPubMed

19.

Goldberg A, Straus SE, Hamid JS, Wong CL (2015) Room transfers and the risk of delirium incidence amongst hospitalized elderly medical patients: a case-control study. BMC Geriatr 15:69. https://doi.org/10.1186/s12877-015-0070-8CrossRefPubMedPubMedCentral

20.

Alasad, J. A., Abu Tabar, N., & Ahmad, M. M. (2015). Patients' experience of being in intensive care units. Journal of critical care, 30(4), . https://doi.org/10.1016/j.jcrc.2015.03.021

21.

Bittner E, Ueland W, Nisiewicz MJ, Siddiqi H, Plymale MA, Davenport DL, Roth JS (2021) Ventral hernia patient outcomes postoperatively housed on surgical vs non-surgical units. Surg Endosc 35(7):4003–4007. https://doi.org/10.1007/s00464-020-07829-5CrossRefPubMed

22.

Muirhead LJ, Shaw AV, Kontovounisios C, Warren OJ (2019) Establishing a robust multidisciplinary team process in complex abdominal wall reconstruction within a colorectal surgical unit. Tech Coloproctol 23(4):379–383. https://doi.org/10.1007/s10151-019-01965-4CrossRefPubMedPubMedCentral

23.

Schlosser KA, Arnold MR, Kao AM, Augenstein VA, Heniford BT (2018) Building a Multidisciplinary Hospital-Based Abdominal Wall Reconstruction Program: Nuts and Bolts. Plast Reconstr Surg 142(3 Suppl):201S-208S. https://doi.org/10.1097/PRS.0000000000004879CrossRefPubMed

24.

Wegdam JA, de Jong DLC, de Vries Reilingh TS, Schipper EE, Bouvy ND, Nienhuijs SW (2022) Assessing Textbook Outcome After Implementation of Transversus Abdominis Release in a Regional Hospital. J of Abdom Wall Surg 1:10517. https://doi.org/10.3389/jaws.2022.10517CrossRef

25.

Novitsky YW (2016). Classification of Hernias. In: Novitsky, YW, (ed) Hernia Surgery Current Principles. 1 edn: Springer.

26.

Muysoms FE, Miserez M, Berrevoet F, Campanelli G, Champault GG, Chelala E, Dietz UA, Eker HH, El Nakadi I, Hauters P, Hidalgo Pascual M, Hoeferlin A, Klinge U, Montgomery A, Simmermacher RK, Simons MP, Smietański M, Sommeling C, Tollens T, Vierendeels T, Kingsnorth A (2009) Classification of primary and incisional abdominal wall hernias. Hernia 13(4), 407–414. https://doi.org/10.1007/s10029-009-0518-x

27.

Al Sadairi AR, Durtette-Guzylack J, Renard A, Durot C, Thierry A, Kianmanesh R, Passot G, Renard Y (2022) A simplified method to evaluate the loss of domain. Hernia 26(3):927–936. https://doi.org/10.1007/s10029-021-02474-wCrossRefPubMed

28.

Weber CK, Miglioranza MH, Moraes MA, Sant’anna RT, Rover MM, Kalil RA, Leiria TL (2014) The five-point Likert scale for dyspnea can properly assess the degree of pulmonary congestion and predict adverse events in heart failure outpatients. Clinics (Sao Paulo, Brazil) 69(5):341–346. https://doi.org/10.6061/clinics/2014(05)08CrossRefPubMed

29.

Ainsworth BE, Haskell WL, Whitt MC, Irwin ML, Swartz AM, Strath SJ, O’Brien WL, Bassett DR Jr, Schmitz KH, Emplaincourt PO, Jacobs DR Jr, Leon AS (2000) Compendium of physical activities: an update of activity codes and MET intensities. Med Sci Sports Exerc 32(9 Suppl):S498–S504. https://doi.org/10.1097/00005768-200009001-00009CrossRefPubMed

30.

Licari L, Viola S, Salamone G (2022) TAP block prior to open ventral hernia repair improves surgical outcome. World J Surg 46(6):1383–1388. https://doi.org/10.1007/s00268-022-06508-xCrossRefPubMedPubMedCentral

31.

Kirchhoff S, Ladurner R, Kirchhoff C, Mussack T, Reiser MF, Lienemann A (2010) Detection of recurrent hernia and intraabdominal adhesions following incisional hernia repair: a functional cine MRI-study. Abdom Imaging 35(2):224–231. https://doi.org/10.1007/s00261-009-9505-zCrossRefPubMed

32.

Bernardi K, Adrales GL, Hope WW, Keith J, Kuhlens H, Martindale RG, Melin AA, Orenstein SB, Roth JS, Shah SK, Tsuda S, Liang MK, Ventral Hernia Outcomes Collaborative Writing Group (2018). Abdominal wall reconstruction risk stratification tools: a systematic review of the literature. Plastic and reconstructive surgery, 142(3 Suppl): 9S–20S. https://doi.org/10.1097/PRS.0000000000004833

33.

Fligor, J. E., Lanier, S. T., & Dumanian, G. A. (2017). Current Risk Stratification Systems Are Not Generalizable across Surgical Technique in Midline Ventral Hernia Repair. Plastic and reconstructive surgery. Global open, 5(3), e1206. https://doi.org/10.1097/GOX.0000000000001206

34.

Parker SG, Wood CPJ, Butterworth JW, Boulton RW, Plumb AAO, Mallett S, Halligan S, Windsor ACJ (2018) A systematic methodological review of reported perioperative variables, postoperative outcomes and hernia recurrence from randomised controlled trials of elective ventral hernia repair: clear definitions and standardised datasets are needed. Hernia 22(2):215–226. https://doi.org/10.1007/s10029-017-1718-4CrossRefPubMed

35.

Smith O, MacLeod T, Lim P, Chitsabesan P, Chintapatla S (2021) A structured pathway for developing your complex abdominal hernia service: our York pathway. Hernia 25(2):267–275. https://doi.org/10.1007/s10029-020-02354-9CrossRefPubMedPubMedCentral

36.

Kollias V, Reid J, Udayasiri D, Granger J, Karatassas A, Hensman I, Maddern G (2022) Towards a complete cycle of care: a multidisciplinary pathway to improve outcomes in complex abdominal wall hernia repair. ANZ J Surg 92(9):2025–2036. https://doi.org/10.1111/ans.17765CrossRefPubMed

37.

Ramshaw B (2020) Applying systems and complexity science to real patient care. J Eval Clin Pract 26(5):1559–1563. https://doi.org/10.1111/jep.13442CrossRefPubMed

Title: Impact of a multidisciplinary team discussion on planned ICU admissions after complex abdominal wall reconstruction
Authors: J. A. Wegdam
D. L. C. de Jong
M. J.C.A.M. Gielen
S. W. Nienhuijs
A. F. M. Füsers
N. D. Bouvy
T. S. de Vries Reilingh
Publication date: 08-03-2023
Publisher: Springer Paris
Published in: Hernia / Issue 3/2023
Print ISSN: 1265-4906
Electronic ISSN: 1248-9204
DOI: https://doi.org/10.1007/s10029-023-02762-7

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Impact of a multidisciplinary team discussion on planned ICU admissions after complex abdominal wall reconstruction

Abstract

Background

Methods

Results

Conclusion

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Methods

Results

Conclusion

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