Optimization--BTK
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Speaker: [00:00:00] Welcome to Behind the Knife podcast. This is the OHSU hernia team. I'm Maggie Bosley, joined by my partner Sean Orenstein, our fellow Amber Sandoval, and our chief resident Peter Ferron. Today, we're here to talk about optimization This is something that every hernia surgeon wrestles with before thinking about doing a ventral hernia repair, general surgeons, anyone who closes holes.

And it sounds like a really straightforward thing, let's improve our patient preoperatively so that we can have better postoperative outcomes, but there's a lot of nuance that comes with this, and there's a lot of newer data that's coming out that potentially, um, goes against what we've traditionally thought was necessary in regards to BMI and smoking with the advent of minimally invasive techniques.

And so this is really a point of controversy right now in the hernia world and the literature, and so this is something that we really wanna dive into today. I [00:01:00] think before we kind of unpack what the data has to show and some of the things that we think about with optimization, let's kinda talk about why this even matters.

I think first we have to start with understanding the burden of hernia disease, which I think anybody who takes care of hernias knows that they are plentiful, and that there are tons of holes out there that need fixing. But we also are kind of starting to understand that hernias are a chronic disease.

It's not necessarily something that we fix once and then the patient never has a problem again. I mean, that's always our hope, but we're seeing patients who come back to us or come from elsewhere who are on their fifth or sixth hernia repair. And every time we have to go fix a hernia after a recurrence, s- each subsequent repair comes with a higher risk of complication, infection, and increased risk of recurrence.

And we even see this in the data. This was published now [00:02:00] 10 years ago in Jax, and we'll put the, um, paper in the show notes, but this has been shown that every subsequent hernia repair comes with an increased risk of recurrence and problems. And so what we need to do when we focus on doing these repairs is really trying to get it right the first time, and I think that's really at what the...

what is at the heart of optimization and part of what we want to, um, dive into today. But we also wanna recognize what the data actually shows and what we should do practically. And so how strict should we be? Peter, kinda tell us about some of the things that we need to think about from optimization, and what are even some of the factors that we should try to improve or maybe aren't even relevant.

Speaker 2: Yeah. So if we look at large data sets like NSQIP, the risk factors are pretty consistent. So s- looking at a study with over 25,000 ventral hernia repair patients, the authors found that surgical site infection [00:03:00] risk is higher with the following factors: BMI greater than 30, active smoking status, higher ASA class, open surgery, and longer operative times And they found that prolonged length of stay was affected by things such as poor functional status, low albumin, and comorbidities such as COPD or congestive heart failure So optimization really focuses on these modifiable risk factors, including high BMI, smoking status, poor functional status, and nutritional status.

Speaker: Yeah, I think you highlighted that there's a lot of things that can affect our outcomes, and some of the things we can address preoperatively and some of the things we're not gonna be able to move the needle on. Um, but this is where I think we can start to get into a little bit of nuance. So let's start by talking about diabetes and hyperglycemia and how that might affect our hernia repair and whether or not that even matters.

So Amber, can you kinda talk about that?

Speaker 3: [00:04:00] Absolutely, and I think this is really where the nuance of optimization starts because diabetes is probably one of the best examples of where our traditional dogma doesn't perfectly match the data. A lot of surgeons are familiar with the idea that we shouldn't offer elective hernia repair if the hemoglobin A1C is above eight.

Some centers are even stricter than that. The Carolinas CEDAR App uses a hemoglobin A1C cutoff of 7.2 as the threshold where risk of wound complication starts to rise. But when you really look at the hernia-specific literature, it's not quite that straightforward. There was an AHSQC study looking at ventral hernia patients above and below a hemoglobin A1C of eight, and they really didn't find significant differences in the short-term outcomes.

There was no difference in wound complications, readmissions, length of stay, or even quality of life at 30 days. And on the surface, this sounds like maybe hemoglobin A1C doesn't matter as much as we thought, but I think there are some important caveats there. First, these were [00:05:00] surgeon-reported outcomes, and second, they only looked at patients who actually made it to surgery, so we're not capturing the patients who may have been deferred because their diabetes was poorly controlled.

And honestly, for mesh-based hernia repair, 30-day data is probably not enough, uh, of a follow-up period. The CDC usually tracks deep surgical site infections out to 90 days for implanted mesh procedures because many of these complications simply show up later. So when we look at only 30-day outcomes, we may be underestimating the true impact of poor glycemic control.

At the same time, if we zoom out beyond hernia-specific studies, the broader surgical literature is pretty consistent. The Endocrine Society guidelines and multiple meta-analyses have shown that higher preoperative hemoglobin A1C levels are associated with increased infections and postoperative complications, and that risk appears to rise progressively with each 1% increase in hemoglobin A1C.

And biologically, this makes sense. We know that hyperglycemia, particularly [00:06:00] glucose levels in the 180 to 200 range, impairs neutrophil chemotaxis and immune function, essentially preventing white blood cells from getting where they need to go to both fight infection and heal wounds, which is why we're so aggressive about our perioperative glycemic control.

So I think the takeaway here is not that diabetes or hemoglobin A1C doesn't matter. It absolutely does. But advocating for optimization doesn't have to mean rigidity enforcing arbitrary cutoffs. Really, it's about recognizing that risks exist along a spectrum, understanding the individual patient in front of you, and trying to improve these modifiable risk factors as much as realistically possible before surgery.

Speaker: I think you highlighted something important is that hyperglycemia is really the issue because it's going to impair our ability for our infection-fighting cells, our white blood cells, to get to our wound, help with healing, and fight any early infection. But in that same vein, the hemoglobin A1C is a surrogate [00:07:00] for hyperglycemia over time, and so it's a, it's a summary or a snapshot over several months.

And so a patient may be improving their hyperglycemia and getting this under control, and their hemoglobin A1C hasn't had, um, time to catch up and sh- and reflect some of the progress they've made in terms of their hyperglycemia management. And so I think that is part of where the nuance in some surgeons are really talking about whether or not this trajectory of their hemoglobin A1C also matters more.

And so I think it's something for us to study further and really figure out what that means for our patients. So I think there, there is a little bit of nuance and, and data coming from that perspective But I think we can all agree that hyperglycemia management is really important and something we can optimize.

But I think another area where some data is coming out that's maybe a little conflicting from traditional management is the idea of smoking and how much that impairs our wound [00:08:00] healing and, um, our outcomes in terms of hernia repair. So Dr. Orenstein, tell us a little bit about smoking, historical data, new data, and kinda where we should land.

Speaker 4: Well, you're right, Maggie, in that there is, um, perhaps mixed data and limited hernia-specific data with regards to smoking and tobacco sensation and, and risks for hernia repair, but there is, there is data out there. You know, Peter mentioned large NSQIP data that shows that smokers do in fact have higher rates of all, all kind of complications, mortality, wound complications, as well as pulmonary issues as well, ICU stay, things like that.

Um, other more recent data using the AHSQC shows that those differences aren't as profound as we had once thought. Um, while they did show that smokers did in fact have more wound morbidity, 12% versus 7%, there actually was no differences in major complications, reoperations, mesh, uh, explantation, et cetera.

Um, there are also some clear differences between these two categories in large database [00:09:00] studies. L- very, very large NSQIP database versus a QC, which is, is a, a ever-increasing size database that is surgeon-reported. Um, d- you know, timeframe, looking at a year versus 30 days, uh, or basically shorter term outcome, looking at with the QC data, um, as well as some other mixed data in those.

But that said, there are other studies that do demonstrate worse outcomes, uh, for hernia repair patients with active smoking, and those that have stopped smoking do have more favorable outcomes. Additionally, there's other data that we use to guide our decision-making that is more generalizable and not necessarily hernia-specific data.

Um, Sorensen is one of the world's experts at tobacco sensation with regards to wound healing. He has written, uh, and his team has written numerous randomized controlled and other trials reviewing wound healing as it pertains to tobacco use. And, uh, h- their data is, is pretty clear [00:10:00] in that they show, uh, worse wound-related, uh, outcomes, wound dehiscence, wound infection with active smoking, and that by stopping tobacco use for a minimum of four weeks prior to an elective operation, you can greatly reduce that risk.

And when, when folks ask, you know, how long to quit before an elective operation, the, the month or four weeks, this comes from Sorensen's data looking at those using randomized controlled trials for generalizable wounds Um, so, um, there certainly are big time benefits to having that patient stop smoking, not only from a wound standpoint but other perioperative, uh, risk and complications like pulmonary, uh, complications, ICU stay, et cetera.

Now, um, one of the other aspects that I think there is some confusion about, but there actually is some, uh, more concrete data, and that is on nicotine replacement therapy or NRT. There is sort of an old [00:11:00] school thought that because nicotine has some vasoconstricting properties, it is the culprit in poor wound healing, and the reality is that is not the case, and this is where Sorensen's data also pans out in that, um, nicotine is not the culprit.

It's all the other, uh, byproducts and metabolites in tobacco use that, uh, cause poor wound healing, uh, limited, uh, oxygenation of tissues, uh, et cetera. And, um, um, there might even be some anti-inflammatory benefits to nicotine. And so in our practice, we're very strong, um, advocates to have our patients, uh, cease all tobacco use a minimum of thirty days prior to their planned elective operation, and we're okay with NRT, uh, a variety of nicotine replacement therapy such as gum, patch, lozenge, uh, or, or other things to help them out.

And there is a way to test these patients also. It's a common question that we get asked that how can you [00:12:00] tell if they're taking, say, a nicotine patch versus actively smoking cigarettes? And if you do want to test these patients, you need to order... It's a urine test with nicotine and metabolites, and you need to be very specific with the lab while you're ordering this because, uh, some of the metabolites like cotinine and hydroxycotinine can be found in both nicotine as well as in um, or sorry, tobacco products and nicotine replacement therapy.

However, one of the, uh, metabolites called anabasine, uh, with an A, anabasine is found in tobacco, uh, usage. It is not found in nicotine replacement therapy. So there are ways to measure and determine if a patient is actively smoking versus only taking nicotine replacement therapy, which again can be a useful adjunct to help them get off a smoking cessation.

Bottom line, though, is with these patients, it involves counseling, uh, letting them know why they put themselves at risk with [00:13:00] active tobacco use, why we need to stop their, uh, cigarette and other tobacco use, and also it's important to, to help them along that process, whether it be counseling them on nicotine replacement therapy or get them whatever counseling they need to get them off to help improve their outcomes following surgery.

Speaker: Great. So thanks for sharing that Dr. Orenstein. I think as you highlighted, often when I talk to patients or even other providers, there's a lot of misinformation around NRT, and I think, um, it can be really helpful because quitting smoking or getting your patients, um, across the finish line from that perspective is really difficult, and, um, if they can use NRT, it may help them be able to quit and, and make, make it to the operating room.

I think another thing that everybody talks about a lot in terms of optimization and probably one of the most focused on things is BMI. And I think certainly this has come into focus more as we begin to do more robotic repairs, more [00:14:00] robotic abdominal wall reconstruction. I think the, um, limits are being pushed on terms of BMI and who we're operating on and who we're offering surgery to, and this has come into focus more.

When we look at the data, we do see that as BMI increases, the risk of recurrent hernia does go up. And I think a general consensus, if you talk to people and surgeons talking about definitive hernia repair, once you're approaching BMI close to fifty, in the high forties, that is prohibitive to doing a hernia repair, and the data shows that.

But when you're talking about BMIs lower than that, what's really the cutoff and what does the data show and what makes sense? I think traditionally when we're talking about experience at OHSU, and as you can tell, we're all-- we're very passionate about optimization, so you may be getting a slightly biased report here in terms of, of what we think and feel in the data.

But we typically shoot [00:15:00] for a BMI of thirty-five. But I think when you dive into the data, what we also see, and this was highlighted by the WashU group a couple years ago, they presented this work at SAGES, and it was published in Surgical Endoscopy, about, um, weight trajectory. And I think we all understand this intuitively, but they actually showed it in the data that patients who lost weight preoperatively had lower risk of wound complications and-- postoperatively and complications in general, compared to those patients with the same BMI who had not lost any weight at all And I think it makes a lot of sense.

If you have somebody on a downward trajectory, it's basically, um, like a tissue expander that we get rid of, right? So they have a lot better abdominal wall compliance, and there's reduced tension on our closure, and also we do see in the data that their wound complications are lower. [00:16:00] And so if you have a patient that comes to your clinic and they have a BMI of 60, it's probably a pipe dream to think that you're gonna get them down to a BMI of 35 before you ever offer them an operation.

But if you can get them to lose weight significantly and drop their BMI, and now you have a patient that has a, a BMI of 40 and they started at a BMI of 60, that's likely gonna be a big deal for them, and you're gonna be able to, um, perform a very durable repair for them. That makes a lot of sense if you take somebody who started at a BMI of 30 and went up to b- a BMI of 40 compared to a patient who started at 60 and then made their way down to 40.

Those are two very different patients in terms of hernia repair and what you're gonna be dealing with in the operating room and afterwards. So I think when it comes to BMI, what we're seeing in the data and what we're seeing in practice is that the trajectory really matters. But [00:17:00] even so, that doesn't mean that we can totally ignore our optimization targets.

We still see that, um, recurrence rates and complications are higher in our higher BMI patients So as we've seen, um, optimization is not binary, and the data is showing that. It's not just are you optimized or are you not optimized. There's be- there's nuance in that, and it's really treating the patient in front of you.

And I think in that vein, we are starting to see more concern and more data come out around the idea of disparities and whether or not we're gatekeeping operations for our patients and preventing them from ever receiving care. And so Amber, talk to us a little bit about that and what that looks like in real life and what that looks like in the data.

Speaker 3: Yeah. I think that's a really important point, uh, because once we start viewing optimization as risk modification along a spectrum or a continuum, [00:18:00] not just a binary optimized versus not optimized, we also have to recognize how these principles can impact patient access to care. And paying attention to this is paramount because strict optimization criteria can unintentionally create barriers.

Uh, Mansoor and colleagues looked at this directly and found that patients who did not meet common elective cutoffs, things like BMI less than forty, no active smoking, or a hemoglobin A1C less than eight percent, were about fifty percent less likely to ever undergo hernia repair. And importantly, the patients who were less likely to meet those cutoffs were disproportionately female, Black, or from socioeconomically distressed communities.

So the concern here is very real. Are we actually improving outcomes, or are we limiting access to care for already vulnerable populations? And I think that's where this conversation can become uncomfortable because there's truth on both sides. On one hand, we know these risk factors matter. Higher BMI, smoking, poorly controlled [00:19:00] diabetes, these are associated with more wound complications, infections, recurrence, and reoperation.

But on the other hand, if optimization simply becomes a gatekeeping tool where patients are told, "Come back when you've lost weight," or, "Come back when your hemoglobin A1C is better," without giving them the resources to actually get there, then we may just be widening disparities unintentionally. At the same time, I don't think the answer is to completely abandon optimization either because operating on higher-risk patients without support may actually worsen disparities in a different way.

Complications are harder to recover from when patients have fewer financial resources, limited social support, transportation barriers, or difficulty accessing follow-up care. So the solution probably isn't rigid cutoffs, but it also isn't ignoring risk. It's recognizing barriers and investing in helping patients overcome them.

And I actually think these studies help identify the populations we should be focusing on our resources the most aggressively That means building [00:20:00] systems around optimization, not just expecting patients to do it on their own. Things like smoking cessation programs, nutritional support with dieticians, diabetic management with multidisciplinary groups, weight loss resources, and even social work involvement when needed because optimization works best when it's collaborative, not just you're not optimized enough s- for surgery, but rather how can we help you get there safely?

Speaker: Yeah, I think that's an important point. There are, um, some smaller studies that have, um, evaluated optimization programs and have concluded that they're not very successful in getting patients across the finish line, further, um, fueling the debate about whether or not this is a worthwhile venture. I think the devil is in the details here, and it really matters how you optimize the patients.

We're really lucky here at OHSU that we have a lot of resources to optimize our patients But I think a big part of it is not saying [00:21:00] lose 50 pounds and come back and see us later when you make that happen. There has to be a lot of accountability, and it's very time intensive. We meet with these patients very regularly and have, um, a lot of resources and plug them in where they need to be seen, and we don't just send them out into the atmosphere.

Th- that's easier to do at a, a large academic institution with a lot of resources, and I think it can be more difficult in a community setting where you don't have as many, um, resources at your disposal. Amber, you're gonna be going out into the real world potentially with less resources available to you.

How are you going to facilitate optimization for these people?

Speaker 3: Yeah. I think one of the things that I've found really valuable during my time in fellowship here is having appropriate follow-up for these patients, and I think that likely comes in the flavor of having support staff who can facilitate that.

Um, if you're not able to have [00:22:00] patients have interval follow-up in your clinic, specifically having a dedicated APP or even a nurse who's calling patients to follow up and track their progress, I think really helps with that accountability piece and gives patients a touchpoint to know that they're still invested in this as they move forward in their optimization goals.

Speaker: All right. Peter, tell us a little bit more about some of the upsides of optimization that I think we don't talk about as much. W- what are some of like the long-term benefits, and is this even something that will be sustained after we do our hernia repair? Do we get patients to lose weight or quit smoking and then post-op day one, um, they return to smoking and gain all their weight back?

What, what does that really look like in the real world?

Speaker 2: Yeah. So optimization actually isn't just about the surgery, but it has the potential to lead to durable long-term health improvements. The Carolinas group actually just recently published a study, um, a series of papers showing [00:23:00] patients who lost weight before a complex abdominal wall reconstruction maintained that weight loss long term.

And similarly, people who optimize their hemoglobin A1C or quit smoking preoperatively maintained those changes postoperatively. So in some ways, hernia surgery actually becomes an opportunity or a carrot to improve overall health beyond just surgically repairing the hernia, and this has the potential to majorly impact our patient's overall long-term health

Speaker: Thanks for that, Peter.

I think this is an, uh, opportunity for us as surgeons to really impact, uh, the health of our patients. You know, when a patient meets with their primary care doctor, and their PCP is encouraging them to quit smoking, there's not much motivation besides hopefully wanting to improve their health long term.

But us, as surgeons, we're in a really unique position to have something to encourage patients to work towards that, and I think that's not something that we should [00:24:00] ignore But I think the, um, counterpoint to optimization is whether or not this is something that's safe to do. If we send all these patients out and have them work on their weight or their diabetes or quitting smoking or, you know, strength training prior to a big operation, what's the chance one of these patients comes back in an emergency fashion through our ED and needs an urgent operation at this unoptimized state?

So Dr. Orenstein, tell us some of your thoughts on watchful waiting and what the data looks like around that.

Speaker 4: Yeah. Well, watchful waiting can be a safe and effective strategy. There's a couple studies specifically looking at watchful waiting in the, in the hernia world for, uh, for patients, and, uh, basically the, the, the crossover was about 4 to 7% between these two studies of patient that crossed over from watchful waiting that did end up needing some type of [00:25:00] urgent or emergent repair.

So, you know, when we watchful wait, whether it be for n- for non-optimization or for other reasons that have nothing to do with optimization, many of those patients will do well, but there will be a small set of s- small subset of patients that may require some form of intervention sooner than later. So the conclusion of these studies was that while watchful waiting is a safe and effective strategy for the vast majority of patients, it does come at a cost, and that cost is quality of life, meaning these patients are gonna be waiting for some time to optimize, and they will still continue to have their symptomatic disease of their hernia, pain, bulging, uh, uh, obstructive symptoms, et cetera.

Um, now that said, if somebody is demonstrating signs and symptoms of impending obstruction, strangulation, or escalating symptoms, frequent recor- or re- frequent returning visits to the emergency department and admissions, um, the, the, the patient's body is saying it is time to go to the OR. Uh, it does not mean you need to commit [00:26:00] to a big abdominal wall reconstruction.

There's a variety of ways to temporize that hernia and get them through that acute episode, but the bottom line is watchful waiting can be a safe and effective strategy for many of our patients.

Speaker: I think you also highlight an important part thinking about what kind of symptoms the patient is presenting with to your clinic, what their hernia to neck ratio looks like on their CT scan.

There's a lot of indicators that can tell you, you may need to think about operative intervention sooner rather than later, or it's something safe to continue to watch and work towards optimization. We've talked about a lot of different data. Dr. Orenstein, give us kind of the 30,000 foot view, kind of what are the c- conclusions and takeaways from our optimization talk today?

Speaker 4: Well, bottom line is that preoptima- preoperative optimization, uh, uh, does benefit our patients. That said, there's controversy around this, controversy over the data, the robustness of the data, and can we apply it directly to our patients, or are we just generalizing for all, uh, elective [00:27:00] operations? Um, uh, you know, some of these cutoffs that we have discussed are rigid and, and arbitrary.

Um, we've talked that access to care does matter. Um, but at the same time, the, the bigger picture is harder to ignore. Complications lead to recurrence. Recurrence leads to operation. Uh, and that, uh, leads to the vicious cycle which we really try to avoid or try to crack that so we don't g- go downward spiral of, uh, impending vicious cycle.

But one of the things that's important about this is when, when it comes to decision-making, it's about risk reduction. That's what we're doing here with a lot of our decision-making, uh, within surgery, but especially for preoperative optimization. It's about risk reduction. We can never get the risk to zero.

Even in the healthiest of patients, there will be risk. But when patients have factors that need optimization, those patients are at much higher risk, so by optimizing our patients, we can greatly reduce that risk. Uh, [00:28:00] and, you know, and, and a couple percentage points down of each of these categories that we discussed, by continuing to reduce this risk, we benefit our patients for the short term as well as the long term.

And for many of these complex abdominal wall hernias, um, you know, we're playing the long game with this, not short-term benefits. We really wanna try to get them to a state of health where we can really maximize long-term outcomes with them.

Speaker: Well, thanks, everyone, for joining us today on this talk on optimization, and dominate the day.