Listen in as Dr. Salvatore Docimo discusses the incidence of obesity and hernia, how obesity alters hernia outcomes, and utilizing bariatric procedures to optimize outcomes.
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ACCME
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Target Audience: primary care, internal medicine, surgical oncology groups without a hernia/obesity focus, urology practices, GYN-oncology groups
Release Date: 12/6/2022
Expiration Date: 12/6/2023
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Salvatore Docimo, Jr, DO: Consultant for Boston Scientific and Medtronic.
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Selected Podcast
Complex Hernia Repair and Obesity: Optimizing Outcomes with Bariatric Surgery
Featuring:
Salvatore Docimo, D.O.
Salvatore Docimo, D.O. is an Associate Professor of Surgery.
Transcription:
Scott Webb: Treating complex hernias in obese patients often requires bariatric surgery, so these patients can lose weight and ultimately improve outcomes for hernia repair. And joining me today to discuss the importance of weight loss and how it relates directly to complex hernia repair is Dr. Salvatore Docimo. He's a general surgeon with Tampa General and an Associate Professor of Surgery with the University of South Florida. I'm Scott Webb and welcome to MD cast by Tampa general hospital. I go to listening location for specialized physician to position content and a valuable learning tool for world-class healthcare.
and doctor,thanks for your time. We're going to talk about complex hernias as it relates to obese patients. So as we get rolling here, what is the incidence of obese patients with complex hernias?
Dr. Salvatore Docimo: So, you know, we do know that in the United States, the incidence of obesity throughout the US is, approaching approximately 40% now. And if you look at the United States alone, we perform on average 350,000 abdominal wall hernias per year. So if we look at how many hernias are being performed annually on top of the fact that 40% of adults in the United States are obese, that number of hernia repairs being performed in obese patients is unfortunately becoming more and more common.
Scott Webb: Yeah, it sure sounds that way. And I had no idea that 40% of adults in America are considered obese and that number just seems so high to me. And it seems like we should have another conversation some other time about what do we do about that. But for today, why does obesity cause poor outcomes in hernia patients?
Dr. Salvatore Docimo: So as we've been doing more and more studies of obesity and just adipose tissue in general, you know, we've been focusing on the effects on wound healing and that obviously becomes a big factor in terms of outcomes for surgical repair. So we've seen that in some Benz studies, obesity itself is a strong indicator of inflammation itself. It is an inflammatory marker. So certainly, as individuals become more and more obese and we're making wounds through the adipose tissue, you know, the incidence of wound site infections and poor wound healing is obviously increased. So when we look at abdominal wall reconstruction in fixing of these complex hernias, obviously wound healing is of extreme importance. So anytime we have a factor such as obesity, that's going to inhibit wound healing, obviously that carries a significant amount of worry on our part.
And then, you know, when we studied specifically obesity and hernia itself, I mean, the studies have been pretty obvious that patients who undergo complex hernia repairs, and who are also obese, the outcomes are pretty lousy to be honest. And these are some studies that I've worked on and I published myself. And we found that a BMI of 35 or higher creates a risk factor for the development of wound site infections, skin site breakdowns, wound dehiscence, et cetera, and all of these lead to a hernia recurrence in itself. So obviously, there's something to be concerned about there.
And we do know from a bariatric surgery standpoint, that those patients who have a BMI of 40 or higher are candidates for weight loss surgery. And if you have a BMI of 35 to 40 with some type of comorbidity, then you're also a candidate for bariatric surgery as well. So that kind of goes hand in hand. That BMI cutoff of 35 is something that I personally use. So if a patient comes in with a BMI above 35, who has a complex hernia, you know, the first thing we're talking about is not how to fix this hernia, but how are we going to get you to lose the weight so we can reduce some of these significant risk factors.
Scott Webb: Yeah. And so, as you mentioned there, the bariatric surgery for those that are 35 or higher is a great option. So why or how did the hernia outcomes improve after bariatric surgery? Is it simply just the weight loss?
Dr. Salvatore Docimo: Well, it's not just the weight loss itself, there's a whole multitude of factors. I mean, obviously the weight loss plays a role in it. So let's say you do a hernia repair, and the outcome looks great initially in the postoperative period. We do know that patients who have BMI, even in the lower ends like 33, but then they go up to, you know, some of the patients have been polished, they go up to a BMI of 38, they run a 2.6 times increased risk of recurrence at a BMI of 33. If they go up to the BMI of 38, they have a 4.2 increased risk of recurrence. So that's pretty significant, I think, from our standpoint.
So when we talk about weight loss surgery itself, you know, we want to obviously get them to get down to these markers in terms of their BMI. So anybody who comes in who are obese, who has a complex hernia. You know, we have a couple options for them. They can undergo either a bariatric surgical procedure. That's one way that we perform it or they can go into weight loss management options as well. In terms of looking at the better outcomes after bariatric surgery like we mentioned, you know, anybody who has a BMI of 35 or higher, they're at an increased risk of surgical site infections, of complications, morbidity, so we want to perform bariatric surgery in order for them to get down below that BMI of 35 cutoff.
And then also, if you look at it more global in nature as well, right? So it's not just, like we mentioned, it's not just the BMI, it's not just the obesity, obese patients have a lot of other issues or underlying factors that go along with this. If they're morbidly obese, they're not going to ambulate as well. Obviously, that's going to cause issues in the postoperative period because they're not going to be walking. They're going to have issues with breathing. They are not going to be breathing as well because they're a little bit more bedbound. And then also, they're also at a really high risk of having other complications, even like developing DVTs, pulmonary embolisms. So all these other factors that are related to obesity in the post-operative period, obviously they translate over if you're doing a complex abdominal wall reconstruction, and it obviously puts the patients at an unnecessary risk from our standpoint.
Scott Webb: Yeah. And just thinking about the interventions, whether it's bariatric surgery or just weight loss approaches in general, how long can folks hold out if they have a hernia, but they really do need to lose the weight in order to have the most, you know, positive or effective outcomes? How long can they hold out with that hernia?
Dr. Salvatore Docimo: You know, we'll watch them very closely, even in the postoperative period. And, from my perspective, you know, one of my areas of research and clinical interest is obviously in these complex hernias in the obese patients. So in our practice, these are a good proportion of my personal patients. So in the postoperative period, we do watch them very closely. You know, they're going to come for their standard bariatric followups, but then in the back of our minds, we're obviously well aware that they have this complex hernia. So if any other issues arise such as increasing abdominal pain, any change in their physical examination, then obviously we're going to appropriately work them up for the most part. And we want to make sure that they don't have the normal complications from having this complex hernia such as incarceration or strangulation. So all these things are on our radar, so we're watching them very closely.
On average, from the moment someone has their bariatric surgery until they get their complex ab wall reconstruction, it's about 12 months. In some studies that are published, it's a range of 12 months to 24 months. So it is a long process. We call this a two-stage approach where they'll have their weight loss surgery first. And then after about 12 months, once they get down to the appropriate BMI level, then we'll get them ready to have their abdominal wall reconstruction performed. For the most part, like we said, the studies that have used this two-stage approach, the outcomes are much more improved. There's less complication, less morbidity risk and, obviously, there's less hernia recurrence as well.
Scott Webb: Yeah, it does seem like the outcomes are much better with the two-stage approach. I didn't realize it would be such a long process. But as you say, you know, it could be 12 to 24 months. So everybody just kind of needs to do their part and be patient and hang in there and, you know, monitor patients along the way. So really interesting. What are some of the endobariatric options for these patients?
Dr. Salvatore Docimo: The surgical procedures most commonly performed, you have two options, one is going to be sleeve gastrectomy, second is going to be a Roux-en-Y gastric bypass. Me personally, if someone has a complex hernia, I try to stay away from a bypass. I believe a sleeve gastrectomy is going to be the most optimal option for them, because obviously if you do a Roux-en-Y gastric bypass and they have some issues in the postop period with hernia incarceration or strangulation, that puts the patient at a much higher risk of having a major complication in the long run. So I try to steer them more towards a sleeve gastrectomy in order to get them to appropriate weight loss.
For that subset of patients who can't tolerate a bariatric procedure itself, the other option that they may have is also an endoscopic bariatric procedure. So all these procedures are obviously done endoscopically, that avoids performing any intraabdominal surgery. And one option they have are weight loss balloons, where either the balloon will be swallowed or be placed endoscopically. And they're placed for on average about six months. And then at the end of the six months, once they've reached their weight loss goals, the balloons are then removed endoscopically. Again, these endogastric balloons are better option for patients who are closer to their weight loss goals. Let's say a BMI of 38, 40 or so, they would have a strong option for the endoscopic bariatric procedure.
One other option that's coming down the pipeline here as well is a procedure called an endoscopic sleeve gastroplasty, where we literally go down with suturing device at the end of an endoscope and we endoscopically plicate the lumen of the stomach to mimic a sleeve gastrectomy. But again, we're not going into the abdomen. We're not placing suture lines. We're not removing any of the stomach at all. It's all done endoscopically.
The short-term results thus far of some of the studies have been published, the results themselves are actually comparable to a sleeve gastrectomy. So it's pretty exciting from our standpoint, we're still waiting on the long-term data on this. But again, I think this is going to be a really solid option for those patients who are obese, who have very complex abdominal hernias and they're simply not a candidate for a bariatric surgical procedure. So this gives them another option with a little bit less risks than a true bariatric surgical procedure.
Scott Webb: Yeah, it does sound like there are a lot of options and always good to know that, this is what's so great about science and technology in medicine, there's always something really cool coming down the pipeline. So doctor, thanks so much for your time and expertise today and you stay well.
Dr. Salvatore Docimo: All right. Thank you so much. Appreciate it.
Scott Webb: That's Dr. Salvatore Docimo, general surgeon and Associate Professor of Surgery.
Scott Webb (Host): And thank you for listening to MD cast by Tampa general hospital, which is available on all major streaming services for free to collect your CME. Please click on the link in the description for other CME opportunities, including live webinars on demand videos and local events offered by Tampa general hospital.
Please visit cme.tgh.org. Thanks for listening. I'm Scott Webb stay well.
Scott Webb: Treating complex hernias in obese patients often requires bariatric surgery, so these patients can lose weight and ultimately improve outcomes for hernia repair. And joining me today to discuss the importance of weight loss and how it relates directly to complex hernia repair is Dr. Salvatore Docimo. He's a general surgeon with Tampa General and an Associate Professor of Surgery with the University of South Florida. I'm Scott Webb and welcome to MD cast by Tampa general hospital. I go to listening location for specialized physician to position content and a valuable learning tool for world-class healthcare.
and doctor,thanks for your time. We're going to talk about complex hernias as it relates to obese patients. So as we get rolling here, what is the incidence of obese patients with complex hernias?
Dr. Salvatore Docimo: So, you know, we do know that in the United States, the incidence of obesity throughout the US is, approaching approximately 40% now. And if you look at the United States alone, we perform on average 350,000 abdominal wall hernias per year. So if we look at how many hernias are being performed annually on top of the fact that 40% of adults in the United States are obese, that number of hernia repairs being performed in obese patients is unfortunately becoming more and more common.
Scott Webb: Yeah, it sure sounds that way. And I had no idea that 40% of adults in America are considered obese and that number just seems so high to me. And it seems like we should have another conversation some other time about what do we do about that. But for today, why does obesity cause poor outcomes in hernia patients?
Dr. Salvatore Docimo: So as we've been doing more and more studies of obesity and just adipose tissue in general, you know, we've been focusing on the effects on wound healing and that obviously becomes a big factor in terms of outcomes for surgical repair. So we've seen that in some Benz studies, obesity itself is a strong indicator of inflammation itself. It is an inflammatory marker. So certainly, as individuals become more and more obese and we're making wounds through the adipose tissue, you know, the incidence of wound site infections and poor wound healing is obviously increased. So when we look at abdominal wall reconstruction in fixing of these complex hernias, obviously wound healing is of extreme importance. So anytime we have a factor such as obesity, that's going to inhibit wound healing, obviously that carries a significant amount of worry on our part.
And then, you know, when we studied specifically obesity and hernia itself, I mean, the studies have been pretty obvious that patients who undergo complex hernia repairs, and who are also obese, the outcomes are pretty lousy to be honest. And these are some studies that I've worked on and I published myself. And we found that a BMI of 35 or higher creates a risk factor for the development of wound site infections, skin site breakdowns, wound dehiscence, et cetera, and all of these lead to a hernia recurrence in itself. So obviously, there's something to be concerned about there.
And we do know from a bariatric surgery standpoint, that those patients who have a BMI of 40 or higher are candidates for weight loss surgery. And if you have a BMI of 35 to 40 with some type of comorbidity, then you're also a candidate for bariatric surgery as well. So that kind of goes hand in hand. That BMI cutoff of 35 is something that I personally use. So if a patient comes in with a BMI above 35, who has a complex hernia, you know, the first thing we're talking about is not how to fix this hernia, but how are we going to get you to lose the weight so we can reduce some of these significant risk factors.
Scott Webb: Yeah. And so, as you mentioned there, the bariatric surgery for those that are 35 or higher is a great option. So why or how did the hernia outcomes improve after bariatric surgery? Is it simply just the weight loss?
Dr. Salvatore Docimo: Well, it's not just the weight loss itself, there's a whole multitude of factors. I mean, obviously the weight loss plays a role in it. So let's say you do a hernia repair, and the outcome looks great initially in the postoperative period. We do know that patients who have BMI, even in the lower ends like 33, but then they go up to, you know, some of the patients have been polished, they go up to a BMI of 38, they run a 2.6 times increased risk of recurrence at a BMI of 33. If they go up to the BMI of 38, they have a 4.2 increased risk of recurrence. So that's pretty significant, I think, from our standpoint.
So when we talk about weight loss surgery itself, you know, we want to obviously get them to get down to these markers in terms of their BMI. So anybody who comes in who are obese, who has a complex hernia. You know, we have a couple options for them. They can undergo either a bariatric surgical procedure. That's one way that we perform it or they can go into weight loss management options as well. In terms of looking at the better outcomes after bariatric surgery like we mentioned, you know, anybody who has a BMI of 35 or higher, they're at an increased risk of surgical site infections, of complications, morbidity, so we want to perform bariatric surgery in order for them to get down below that BMI of 35 cutoff.
And then also, if you look at it more global in nature as well, right? So it's not just, like we mentioned, it's not just the BMI, it's not just the obesity, obese patients have a lot of other issues or underlying factors that go along with this. If they're morbidly obese, they're not going to ambulate as well. Obviously, that's going to cause issues in the postoperative period because they're not going to be walking. They're going to have issues with breathing. They are not going to be breathing as well because they're a little bit more bedbound. And then also, they're also at a really high risk of having other complications, even like developing DVTs, pulmonary embolisms. So all these other factors that are related to obesity in the post-operative period, obviously they translate over if you're doing a complex abdominal wall reconstruction, and it obviously puts the patients at an unnecessary risk from our standpoint.
Scott Webb: Yeah. And just thinking about the interventions, whether it's bariatric surgery or just weight loss approaches in general, how long can folks hold out if they have a hernia, but they really do need to lose the weight in order to have the most, you know, positive or effective outcomes? How long can they hold out with that hernia?
Dr. Salvatore Docimo: You know, we'll watch them very closely, even in the postoperative period. And, from my perspective, you know, one of my areas of research and clinical interest is obviously in these complex hernias in the obese patients. So in our practice, these are a good proportion of my personal patients. So in the postoperative period, we do watch them very closely. You know, they're going to come for their standard bariatric followups, but then in the back of our minds, we're obviously well aware that they have this complex hernia. So if any other issues arise such as increasing abdominal pain, any change in their physical examination, then obviously we're going to appropriately work them up for the most part. And we want to make sure that they don't have the normal complications from having this complex hernia such as incarceration or strangulation. So all these things are on our radar, so we're watching them very closely.
On average, from the moment someone has their bariatric surgery until they get their complex ab wall reconstruction, it's about 12 months. In some studies that are published, it's a range of 12 months to 24 months. So it is a long process. We call this a two-stage approach where they'll have their weight loss surgery first. And then after about 12 months, once they get down to the appropriate BMI level, then we'll get them ready to have their abdominal wall reconstruction performed. For the most part, like we said, the studies that have used this two-stage approach, the outcomes are much more improved. There's less complication, less morbidity risk and, obviously, there's less hernia recurrence as well.
Scott Webb: Yeah, it does seem like the outcomes are much better with the two-stage approach. I didn't realize it would be such a long process. But as you say, you know, it could be 12 to 24 months. So everybody just kind of needs to do their part and be patient and hang in there and, you know, monitor patients along the way. So really interesting. What are some of the endobariatric options for these patients?
Dr. Salvatore Docimo: The surgical procedures most commonly performed, you have two options, one is going to be sleeve gastrectomy, second is going to be a Roux-en-Y gastric bypass. Me personally, if someone has a complex hernia, I try to stay away from a bypass. I believe a sleeve gastrectomy is going to be the most optimal option for them, because obviously if you do a Roux-en-Y gastric bypass and they have some issues in the postop period with hernia incarceration or strangulation, that puts the patient at a much higher risk of having a major complication in the long run. So I try to steer them more towards a sleeve gastrectomy in order to get them to appropriate weight loss.
For that subset of patients who can't tolerate a bariatric procedure itself, the other option that they may have is also an endoscopic bariatric procedure. So all these procedures are obviously done endoscopically, that avoids performing any intraabdominal surgery. And one option they have are weight loss balloons, where either the balloon will be swallowed or be placed endoscopically. And they're placed for on average about six months. And then at the end of the six months, once they've reached their weight loss goals, the balloons are then removed endoscopically. Again, these endogastric balloons are better option for patients who are closer to their weight loss goals. Let's say a BMI of 38, 40 or so, they would have a strong option for the endoscopic bariatric procedure.
One other option that's coming down the pipeline here as well is a procedure called an endoscopic sleeve gastroplasty, where we literally go down with suturing device at the end of an endoscope and we endoscopically plicate the lumen of the stomach to mimic a sleeve gastrectomy. But again, we're not going into the abdomen. We're not placing suture lines. We're not removing any of the stomach at all. It's all done endoscopically.
The short-term results thus far of some of the studies have been published, the results themselves are actually comparable to a sleeve gastrectomy. So it's pretty exciting from our standpoint, we're still waiting on the long-term data on this. But again, I think this is going to be a really solid option for those patients who are obese, who have very complex abdominal hernias and they're simply not a candidate for a bariatric surgical procedure. So this gives them another option with a little bit less risks than a true bariatric surgical procedure.
Scott Webb: Yeah, it does sound like there are a lot of options and always good to know that, this is what's so great about science and technology in medicine, there's always something really cool coming down the pipeline. So doctor, thanks so much for your time and expertise today and you stay well.
Dr. Salvatore Docimo: All right. Thank you so much. Appreciate it.
Scott Webb: That's Dr. Salvatore Docimo, general surgeon and Associate Professor of Surgery.
Scott Webb (Host): And thank you for listening to MD cast by Tampa general hospital, which is available on all major streaming services for free to collect your CME. Please click on the link in the description for other CME opportunities, including live webinars on demand videos and local events offered by Tampa general hospital.
Please visit cme.tgh.org. Thanks for listening. I'm Scott Webb stay well.