K. Bernardi1, O. A. Olavarria1, J. L. Holihan1, D. V. Cherla1, D. H. Berger2, T. C. Ko1, L. S. Kao1, M. K. Liang1 1McGovern Medical School at UT Health,General Surgery,Houston, TX, USA 2Baylor College Of Medicine,General Surgery,Houston, TX, USA
Introduction: Obesity and poor fitness are associated with complications following ventral hernia repair (VHR). We previously presented the early outcomes of a randomized controlled trial (RCT) comparing prehabilitation and standard care among obese patients seeking VHR. Prehabilitation, or preoperative nutritional counseling and exercise, was associated with higher percentage of patients who lost weight, achieved preoperative weight loss goals, and underwent VHR. Also, patients in the prehabilitation group had a lower percentage of wound complications and were more likely to be hernia-free and complication-free up to 7 months post randomization. We hypothesized that prehabilitation in obese patients with VHR results in more hernia- and complication-free patients at 2 years post randomization.?
Methods: This was a blinded RCT at a safety-net academic institution. Obese patients (BMI 30-40) seeking VHR were randomized to prehabilitation versus standard counseling. Prehabilitation included a multi-disciplinary approach with nutritional counseling, physical therapy sessions, and weekly meetings. Standard counseling consisted of a standardized script discussed during preoperative appointments. Elective VHR was performed once preoperative requirements were met: 7% total body weight loss or 6 months of counseling and no weight gain. Primary outcome was percentage of hernia-free and complication-free patients at 2 years post randomization. Complications included recurrence, need for re-operation, and mesh complications (such as mesh infection). ?
Results: A total of 118 patients were randomized, 110 (93.2%) completed a median (range) follow-up of 26.6 (19.1- 35.6) months. Baseline BMI (mean±SD) was similar between the two groups (36.8±2.6 in prehabilitation and 37.0±2.6 in standard counseling). At late follow-up, there was no difference in the percentage of patients who were hernia-free and complication-free (75.0% versus 68.5%, p=0.527) (Table). Almost half of all patients, 44.2% in prehabilitation and 43.2% in standard counseling, gained weight over their baseline and 14.5% of patients (5 with prehabilitation, 10 with standard counseling) sought hernia repair elsewhere. ?
Conclusion: While prehabilitation compared to standard care resulted in a higher percentage of patients who were hernia- and complication-free in the short-term, there is no difference in long-term results. This may be because patients often regain the weight they lost or seek VHR elsewhere if they fail to meet preoperative requirements. Continuing diet and exercise programs even after VHR along with establishing national guidelines and changes in compensation may be important components of tackling VHR in obese patients. ?
