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Table of Contents
ORIGINAL ARTICLE
Year : 2020  |  Volume : 3  |  Issue : 4  |  Page : 128-137

Inguinal and femoral hernia repair in octogenarians and nonagenarians – A population-based analysis


1 University Hospital Basel; Department of Visceral Thorax and Vascular Surgery, Cantonal Hospital Olten, Switzerland
2 University Hospital Basel; Department of Surgery, Hospital Dornach, Switzerland
3 University Hospital Basel; Zweichirurgen Basel - Center for Hernia Surgery and Proctology, Basel, Switzerland
4 University Hospital Basel; Department of Visceral Surgery, University Centre for Gastrointestinal and Liver Diseases, Clarunis, Basel, Switzerland

Date of Submission23-Jul-2020
Date of Decision27-Jul-2020
Date of Acceptance19-Aug-2020
Date of Web Publication30-Nov-2020

Correspondence Address:
Dr. Philippe Glauser
Department of Surgery, Hospital Dornach, Basel
Switzerland
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijawhs.ijawhs_31_20

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  Abstract 


PURPOSE: Our primary aim was to evaluate the inhospital mortality (IHM) of elderly patients undergoing inguinal or femoral hernia repair (groin hernia repair GHR), since this growing population is associated with increased perioperative risks.
MATERIALS AND METHODS: Totally 179,806 patients undergoing GHR between 2005 and 2015 in Switzerland were divided into three cohorts: <80, 80–89, and ≥90 (years). IHM for each was compared and stratified according to: type of admission, hernia, surgical approach, and whether a bowel resection was performed. A multivariate analysis controlling for age, gender, type of hernia, admission, and comorbidities was performed.
RESULTS: The elderly (>80 years) represent 8.86% (n = 15,750) of our sample. The IHM for elective GHR in these patients is low (0.15% for octogenarians and 0.8% for nonagenarians). For emergency surgery, it increases substantially (4.1% and 7.5%, respectively). In emergency cases with a combined bowel resection (n = 755), the IHM has a fivefold increase for nonagenarians when compared to the younger population. The IHM was significantly higher with femoral hernia repair, especially in the elderly (4.75% – octogenarians and 11.4% – nonagenarians). When adjusting for other variables, there is a twofold risk of death with femoral hernia repair. Patients with a Charlson Comorbidity Index (CCI) ≥2 have a 7.5 times higher risk of dying after GHR. All of these results were statistically significant (P < 0.0001).
CONCLUSIONS: This retrospective analysis highlights the increased operative risk in emergency compared to elective GHR in the elderly. This should be considered when opting for watchful waiting in minimally symptomatic octo- and nonagenarians.

Keywords: Elderly, emergency, femoral hernia, inguinal hernia, nonagenarians, octogenarians


How to cite this article:
Pina-Vaz J, Glauser P, Hoffmann H, Kirchhoff P, Staerkle R, und Torney Mv. Inguinal and femoral hernia repair in octogenarians and nonagenarians – A population-based analysis. Int J Abdom Wall Hernia Surg 2020;3:128-37

How to cite this URL:
Pina-Vaz J, Glauser P, Hoffmann H, Kirchhoff P, Staerkle R, und Torney Mv. Inguinal and femoral hernia repair in octogenarians and nonagenarians – A population-based analysis. Int J Abdom Wall Hernia Surg [serial online] 2020 [cited 2021 Apr 20];3:128-37. Available from: http://www.herniasurgeryjournal.org/text.asp?2020/3/4/128/302026




  Introduction Top


Inguinal hernia repair is the most frequent elective surgical intervention in developed countries,[1] such as Switzerland, with the second highest life expectancy worldwide (83.4 years).[2] Its incidence increases with age due to physiological changes.[3]

The elderly present with unique health-care challenges due to bodily degeneration over time with attributes not present in younger patients.[4],[5]

Despite studies reporting an increase of operative mortality for patients older than 80 years, we still lack information regarding decision-making for inguinal or femoral hernia repair.[6],[7]

This study provides information to help decision-making, based on recent outcomes in a country with a relevant elder population.


  Materials and Methods Top


The analysis was based on the “Medical statistics of hospitals” (Medizinische Statistik der Krankenhäuser) of the Swiss Federal Statistical Office (BfS). This is a comprehensive irreversibly anonymized database including all inpatient admissions to Swiss hospitals including demographics, diagnosis (ICD-10 code), interventions or treatments performed (CHOP code), mode of admission, and type of discharge (home, nursing home, rehabilitation clinic, and death). All hospitals in Switzerland are required by law to collect this anonymized data and report it to the BfS, therefore, no informed consent is required, even though some hospitals do collect this consent at the time of admission anyway. The data were granted after a formal and peer-reviewed application process. A formal request to the ethical committee was, according to the said committee, not necessary since the data were anonymized and retrospective.

Patients with a main diagnosis of an inguinal or femoral hernia and submitted to surgical repair (groin hernia repair GHR) between 2005 and 2015 were included. Individuals were classified into age groups at the time of hospitalization: adults (18–79 years), octogenarians (80–89 years), and nonagenarians (≥90 years).

Data were summarized with frequencies and percentages for categorical data and medians and interquartile ranges (IQRs) for continuous data. Categorical variables were compared using Chi-square tests.

The main objective of this study was to quantify the difference in inhospital mortality (IHM) between these three age groups.

The secondary outcome measures were the influence on IHM by: the type of hernia (inguinal or femoral), type of episode (primary or recurrence), the surgical approach (open or laparoscopic), mode of admission (elective or emergency), and if, additionally to the hernia repair, a bowel resection had to be performed.

In addition, we investigated the specific postoperative morbidity, based on the coded surgical complications (ICD-10 code) available in the data set: these were postoperative hematoma, urinary retention, wound infection, other organ injuries (bladder or bowel), and testicular complications in men.[8]

A subgroup analysis was also performed to compare the differences in mortality on the open versus laparoscopic approach when performed in an elective and/or emergency situation. Four new subgroups were created (elective/open, elective/laparoscopic, emergency/open, and emergency/laparoscopic). The mortality of these subgroups was also stratified according to age and gender.

A multivariate logistic regression analysis for death and postoperative morbidity was performed controlling for age, gender, comorbidities using the Charlson Comorbidity Index (CCI),[9] mode of admission (emergency vs. elective), type of hernia (inguinal vs. femoral), insurance class (1° private, 2° semi-private, or 3° comprehensive), and expertise of the treating institution based on yearly hernia surgery caseload (high volume >100 hernia operations/year vs. low volume: <100 hernia operations/year). Results were presented with odds ratios and 95% confidence intervals. A Mann–Whitney test was performed to compare the CCI score of patients operated on elective or emergency situations.

We also decided to look into readmissions of the elder patients up to 3 months after the GHR and the reasons and outcomes of these readmissions.

In order to prevent a selection bias, we also analyzed the patients hospitalized with a main diagnosis of an inguinal or femoral hernia who were not submitted to surgery.

A secondary analysis was performed on the dead patients, dividing them in operated and nonoperated for inguinal hernia, in order to provide more information on what might influence the outcome of GHR.

P < 0.001 was considered statistically significant. All analyses were done with Stata version 15 (StataCorp, TX, USA).


  Results Top


A total of 179,806 patients hospitalized with a main diagnosis of inguinal or femoral hernia in Switzerland between 2005 and 2015 were identified. From these, 177,726 were submitted to groin hernia (inguinal or femoral) repair (GHR) [Figure 1]. The elderly (≥80 years) represent 8.86% (n = 15,750) of the overall study population [Table 1]a and 1b].
Figure 1: Selection of the study population

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The median length of stay was 2 days for the overall study population (IQR: 1–3), being longer for the elderly: 80–89 – 3 days (IQR: 2–5) and ≥90 – 4 days (IQR: 3–8). 42.8% of the Swiss hospitals treated more than 100 hernia patients in a given year during our study period.

Mortality after GHR was rare: the crude IHM in the overall study population was found to be 0.14% (n = 240). It was significantly (P < 0.000) higher but still rare in the elderly (<80 – 0.04%, n = 65; 80–89 – 0.85%, n = 121; and ≥90 – 3.7%, n = 54) [Table 2].
Table 2: Inhospital mortality of groin hernia repair

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From the 15,575 elderly patients who survived after GHR, 2,934 had a further hospitalization within 3 months of the operation (readmission rate, 18.8%). Two hundred and five of them died in a subsequent hospitalization. The most common causes of readmission were cardiovascular disease, musculoskeletal disorders, trauma, and neoplasia [Graph 1 on Supplemental Content Digital File (SCDF)].

Type of hernia

Patients were predominantly male (88%, n = 143,874), and inguinal hernia was more prevalent in this group (89.2%, n = 153,654).

Although women only represent 12% (n = 19,780) of our population, 3 out of 4 femoral hernias occurred in females (75.6%, n = 4,126). However, inguinal hernia is still the most common type of hernia in both males (99.1%, n = 153,654) and females (81.8%, n = 18,614). The proportion of femoral hernias in relation to inguinal hernias increased with age (<80 – 2.8%, 80–89 – 5.7%, and ≥90 – 11%). Women tend to be operated later in life than men (<80 – 12%, 80–89 – 20.5%, and ≥90 –30%).

There was a prevalence of inguinal hernias (97%, n = 174,151), and the IHM was lower (0.1%) than for patients with a femoral hernia (1.3%). This difference was found to be more relevant in the octogenarians (0.6% for inguinal and 4.75% for femoral) and nonagenarians (2.6% for inguinal and 11.4% for femoral).

43.6% (n = 2,381) of the treated femoral hernias were classified as incarcerated, with or without gangrene, whereas only 6.6% (n = 11,413) of the inguinal hernias fell into this category. Furthermore, 33.4% (n = 1,825) of the femoral hernias treated during our study period were admitted as an emergency. This situation was much more frequent in women (76.8%, n = 1,402).

From the 72 patients with a femoral hernia who died after surgery, 66 had been admitted as an emergency.

Mode of admission

Ninety-five percent (n = 156,227) of all procedures were performed in an elective setting. The IHM in this case was 0.03% and significantly (P < 0.000) higher in the elderly (80–89 – 0.15% and ≥90 – 0.8%).

In the emergency setting, the IHM increased (1.9%), especially in the nonagenarians being 7.5%.

Technique

Open surgery was the preferred surgical approach on each mode of admission: 73.5% of the elective and 85.6% of the emergency procedures. Although, 25.8% (n = 45,799) of the procedures were performed laparoscopically. Graph 2 on SCDF shows an increasing trend on minimally invasive hernia surgery in the last years in Switzerland.

Compared to the overall study population, IHM after laparoscopic GHR was 0.01% in younger adults, 0.48% in octogenarians, and 2.65% in nonagenarians [Table 2].

The remaining 74.2% (n = 131,927) were open surgeries. In this group, we registered a higher overall IHM (0.17%) with a significant increase with age (<80 – 0.05%, 80–89 – 0.9%, and ≥90 – 3.64%) (P < 0.0001).

A subgroup analysis was conducted to compare the IHM between the surgical approaches according to the mode of admission. This means that four new groups were created (elective/open, elective/laparoscopic, emergency/open, and emergency/laparoscopic) and stratified according to age and gender.

The IHM followed the same trend as already referred for our cohorts: it was significantly higher in emergencies and open procedures and it increased with age [Table 3]. On the nonagenarians operated electively and laparoscopically, we registered an IHM of 0% on the 72 procedures performed during our study period. Women had a higher IHM on each of the 4 subgroups, except on elective laparoscopies, where the IHM was also 0% on a total of 5,116 procedures [Table 4].
Table 3: Subgroup analysis with cohort distribution and inhospital mortality when crossing the mode of admission with the surgical approach

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Table 4: Subgroup analysis with population distribution and inhospital mortality for each gender when crossing the mode of admission with the surgical approach

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Bowel resection

Nine hundred and seventeen patients (0.5%) needed a concomitant bowel resection, and the IHM was 8.4% (n = 77) in the overall study population, compared to 0.1% when no bowel was resected. Between the three cohorts, IHM increased from 3.96% (n = 20) in younger adults to 11.2% (n = 38) in octogenarians and 25.7% (n = 19) in nonagenarians.

Of the combined bowel resections, 82.3% (n = 755) were emergencies; from these patients, 77 died (IHM: 8.4%) (P = 0.000). This mortality increased with age (<80 – 3.96%, n = 20; 80–89 – 11.24%, n = 38; and ≥90 – 25.68%, n = 19).

Four hundred and seventy (51.3%) of these operations were performed in females, and 423 (90%) of them on an emergency context, representing 2.1% of all the GHR performed in women. For the men, the 447 (48.7%) additional bowel resections represented 0.3% of their GHR and 332 (74.3%) of these were emergencies.

Recurrence

The vast majority of hernias treated during the study period in Switzerland were primary hernias (95% n = 168,633), while 5% (n = 9,093) were recurrences. The incidence of recurrence increased with age (<80 – 5%, 80–89 – 7%, and ≥90 – 7.3%).

The IHM was slightly the same for primary or recurrent hernias (0.14% and 0.11%, respectively), with P = 0.504.

Postoperative morbidity

The postoperative morbidity in the overall study population as defined above was 3.7% (n = 6,512). It was higher in the elderly (octogenarians – 7.1% and nonagenarians – 8.4%) [Table 5]. In detail, the most common postoperative surgical complications were as follows: testicular complications 1.6% (<80 – 1.5%, 80–90 – 2.5%, and 90 – 3.5%), hematoma 1.1% (<80 – 0.9%, 80–89 – 2.6%, and ≥90 – 2.7%), and urinary retention 0.9% (<80 – 0.8%, 80–89 – 2.1%, and ≥90 – 2.7%).
Table 5: Postoperative morbidity

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Influence of comorbidities on the outcome

After adjusting for relevant confounders (age, gender, CCI, mode of admission, type of hernia, insurance class, and expertise of the treating institution), age remains an independent risk factor for IHM, with an odds ratio of 4.8 and 9.1 for octogenarians and nonagenarians, respectively. Patients undergoing femoral hernia repair had a 2.3 times higher risk of IHM. Patients with a CCI ≥ 2 have a 7.5 times higher postoperative mortality compared to patients with a CCI of 0–1. The relationship between CCI and mode of admission (emergency vs. emergency) was looked into in more detail with a Wilcoxon rank-sum test. It shows a significant difference between the two groups, being so that patients operated electively have a trend toward a lower CCI. Nevertheless, the overall median CCI in both groups remains marginally low (median 0 in both groups).

Emergency procedures carry a 20.9 times higher risk of IHM compared to elective interventions. Gender is not an independent risk factor for IHM (odds ratio OR: 0.99 for females, P = 0.904) [Table 6] and [Table 7].
Tables 6: Multivariable logistic regression models for the association of death and postoperative morbidity

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Tables 7: Multivariable logistic regression models for the association of death and postoperative morbidity

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For females, the relative risk for postoperative morbidity is significantly lower (OR: 0.42), mainly based on the significantly lower frequency of urinary retention. The type of health insurance (private vs. compulsory) or the expertise of the treating institutions did not show an influence on IHM with the given cutoffs in our sample.

Patients not submitted to surgery

Two thousand and eighty (1.16%) of the patients hospitalized with an inguinal or femoral hernia between 2005 and 2015 were not submitted to surgical treatment. Four hundred and two (19.3%) of these patients were over 80 years old, 74.3% (1546) of them were men, the majority of the hernias were classified as inguinal (90.5% n = 1883), 24% (500) of the cases were admitted through the emergency department, the median CCI score of these patients was 0 (IQR: 0–14), and 44 of them died within this hospitalization (2.12%) [Table 8].
Table 8: Characteristics of the patients not submitted to inguinal or femoral hernia repair

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Dead patients

From the 284 patients who died in the hospital with a groin hernia, 240 had been surgically treated. These patients were mainly octogenarians and males. Almost a fourth (27.8%) had a femoral hernia and most of them were admitted through the emergency department (80.6%). The length of stay was longer for the operated patients 7 days (3–13), in comparison to 2.5 (1–6) for the treated conservatively. The operation was performed in a mean of 9 days (0–24) after admission. The mean CCI score of the conservatively treated patients was slightly lower than the operated ones: 1 (0–2) and 2 (1–4), respectively [Table 9].
Table 9: Characteristics of dead patients hospitalized with a groin hernia according to surgical repair

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We do not have data on the causes of death, but we looked into the secondary diagnosis of the dead patients in our sample. The most common diagnoses were bowel-related conditions such as ileus or adhesions or bowel ischemia (26.5% n = 72). Thirteen percent of these patients had cardiovascular (myocardial infarct and arrhythmias) or respiratory events (pneumonia and respiratory failure) [Graph 2 in SCDF].


  Discussion Top


This study has significant strengths including a large sample size and a nationwide population-based analysis.

Most of the studies published are based in specific hernia registries, which have a high risk of selection bias, since some cases are not registered for various reasons: patient consent is required; patients with cognitive impairment are usually excluded; and in an emergency context, there is no time to gather the patient's information and consent for the registry, so some data might get lost.

With the growing aging population of Switzerland and one of the highest life expectancies in the world, the Swiss health-care system offers the unique opportunity to evaluate the outcomes of hernia surgery in a large and comprehensive cohort of truly elderly patients.[2]

The definition of elderly is subjective and controversial in the literature. Previous investigations on outcomes of hernia surgery in the elderly used a cutoff of over 65 years, as this is the age of retirement in many countries.[10],[11] However, nowadays, in Western countries, a 70-year-old patient would have higher chances of being healthy or having well-controlled comorbidities. A competing concept with higher clinical relevance is frailty: “an increased susceptibility to stressors as a result of age- and disease-related declines in function throughout several domains.”[12],[13] It, therefore, seems to be reasonable to consider patients aged 80 years or older as “elderly” for any population-based investigation on surgical outcomes.[14]

The established goals of elective hernia repair in symptomatic patients are the relief of pain and bulging symptoms as well as the prevention of acute surgical emergencies, such as incarceration and strangulation. Emergency repair is known to carry significantly higher rates of morbidity and mortality, especially among the elderly.[15],[16] Factors such as dehydration, subnutrition, decreased cardiopulmonary reserve, and immunodeficiency and cognitive impairment also expose these patients to a higher risk of postoperative complications, such as infections, cardiovascular and thromboembolic events, or delirium.[17],[18],[19]

The question is how to balance the risk of an elective intervention in a possibly highly comorbid patient against the risk of an emergency intervention in case of ongoing conservative management.[20]

Inguinal and femoral hernia repair is considered a low risk procedure, performed both open and laparoscopically.[21],[22] Although the IHM after inguinal and femoral hernia repair increases with age, the overall frequency and numbers remain low.

In this large population-based study on GHR in octo- and nonagenarians, we find an acceptably low mortality and morbidity in the elective setting. In contrast, emergency operations came with a very high risk for these frail patients.

This has been previously reported in other studies. A nonmetric regression analysis from the Herniamed Registry of 24,571 adult patients with endoscopic treatment over 3.5 years showed a rising risk for postoperative complications above the age of 80 years.[23] In 2011, the NSQIP database was analyzed and compared older adults between the ages of 65 and 79 with patients over 80 years of age and concluded that postoperative mortality and morbidity increase with age but remain acceptably low in elective cases (0.34% for octogenarians and 3% for nonagenarians). On the other hand, the authors found clinically relevant increased morbidity and mortality in the emergency setting (4.2% for octogenarians and 18.5% for nonagenarians).[24] The present Swiss analysis does support these previous findings in a large aging population. Nevertheless, the magnitude of the difference between elective and emergency interventions in our study outnumbered previous reports: our real-world data show the high risk of emergency hernia repair in the elderly with a 20 times higher IHM compared to elective cases.

In the past, some studies reported high mortality rates for GHR in patients over 90 years of age, regardless of the mode of admission (elective or emergency),[25] so that several guidelines on groin hernia management recommend only offering surgery to symptomatic patients, and following a watchful waiting strategy for patients with smaller and asymptomatic hernia.[26] There are still no reliable data that would help predict which patients are at risk to develop complications from an asymptomatic or light symptomatic hernia or when these might happen. However, recent data on more recent outcomes, especially with nowadays state of the art technology and expertise on groin hernia surgical repair, raise the question whether, although asymptomatic/light symptomatic, elderly patients could profit from an elective surgical repair, instead of the previously recommended watchful waiting.[27] Our data support this recommendation, since the IHM for elective GHR in the nonagenarians remains low in this large Swiss cohort.

Recently, a randomized trial compared the outcomes between elective hernia repair and watchful waiting in men older than 50 years over the period of 24 months, and although the conservative method was reasonably safe, the elective surgical treatment had better results in terms of pain management and quality of life.[28]

Furthermore, broadening the indication for elective repair will not necessarily mean an increase in the IHM, as patients would be operated while younger and fitter and not present later with the known complications and associated health status decompensation. Of course, this is a decision that should be individualized: taken together with the patient and taking into account their health profiles.[27]

Our data also show that the IHM is much higher when a bowel resection is needed during the GHR. Most of the bowel resections associated to GHR are performed in an emergency, which could suggest that the need for bowel resection might be a contributor for the high mortality in the emergency setting. This has also been suggested in 2017 by Wu et al., as they registered a 30-day postoperative mortality of 18.25% for patients over 80 years of age.[29]

An emergency surgery rate of 6% might seem high in comparison with the 0.5% rate of bowel resection. In Switzerland, when a patient is admitted through the emergency department with a symptomatic hernia, even if not incarcerated, if the symptoms are too strong, usually it will be operated within the same hospitalization. The infrastructures available (minimally invasive surgery is also available on an emergency), the short waiting lists, the quick patient turnover between surgeries, might be factors that allow more procedures per day, allowing short time between diagnosis and surgery.

Furthermore, when a patient is admitted with an incarcerated hernia, even if it is reducible, it will be operated right away, to minimize pain, length of stay and costs. This way a bowel resection is often prevented if the incarceration is reversed before the onset of ischemia.

Another alarming result is the much higher mortality associated with femoral hernias, reaching 4.75% and 11.4% in our two elderly groups. In addition, those with a femoral hernia were almost twice as likely to die as those with inguinal hernias [Table 6] and [Table 7]. A third (33.4% n = 1,893) of all the femoral hernias diagnosed in our study period were operated in an emergency setting, from these 69 patients (3.65%) died, which might also make this type of hernia a contributor to a worse outcome in an emergency setting. This can be explained by the higher risk and incidence of incarceration with this kind of hernia and also by the fact that it is clinically more challenging to diagnose a femoral hernia either pre- or intraoperatively, especially in open surgery with an inguinal access. This might explain why the first presentation of a femoral hernia is often in an emergency/complicated setting.[30] Current guidelines suggest the use of ultrasound preoperatively in order to allow a better operative planning/performance, especially in females, as this type of hernia is more prevalent in this population. A more aggressive diagnostic approach to elderly female patients complaining of groin pain might help to prevent these dangerous emergency interventions. Nevertheless, this aspect still requires future research to understand the reasons and find ways to reduce this number, either more sensitive diagnostic or different surgical techniques/training.

On our multivariable analysis, when adjusting for the referred confounders, gender was not significantly associated with risk of death (P = 0.720), although females had more femoral hernias and more emergency procedures and they tend to be operated later in life than men.

The postoperative morbidity is, as expected,[23],[31] higher in the elderly, who have a more fragile general condition to withstand surgery. The postoperative hematoma is probably more frequent in this population as in the younger group, due to the higher prevalence of oral anticoagulation or antiplatelet therapy. In addition, the more elevated rate of urinary retention could be explained by the higher incidence of neuropathy and/or prostatic hyperplasia in men. This was also consistent with the results of our multivariable analysis, which showed a significantly lower postoperative morbidity. Since the postoperative complications of GHR, such as urinary retention and testicular complications, affect mainly men, this result is no surprise.

Analysis of secondary diagnoses in patients who died during a hospitalization for GHR suggests that a relevant proportion presented with a complication related to the hernia, such as incarceration, major adhesions, concomitant ileus or bowel ischemia (26.5% n = 72), or major cardiorespiratory events (13%). Both being easier to prevent or respectively to control in an elective rather than emergency setting.

Relevant comorbidities (CCI score ≥2) increase IHM 7.5 times. The risk of any postoperative morbidity is almost double for CCI >1. This suggests that, for the decision-making process, might be more relevant to consider the patient's health status, rather than age.

These results are consistent with previous studies, like the retrospective multicenter study conducted by Martinez-Serrano et al. stated that older age (>70 years), associated bowel resection at the time of hernia repair, and American Society of Anesthesiologists (ASA) score are independent factors significantly associated with postoperative mortality.[32]

The fact that the IHM is much lower for elective and/or laparoscopic procedures (IHM for nonagenarians after elective laparoscopic surgery was 0%) might represent a surgical indication bias, since it is possible that this procedure might be tried only on the healthiest, less complicated cases. The same argument might be applied to explain the low mortality of emergency laparoscopic hernia treatments. Nonetheless, these are promising results in favor of minimally invasive GHR. Hafner et al. demonstrated already in 2003, in a single-center, observational study including 124 patients over the age of 85 years, with moderate to higher anesthesiological risk (68.5% – ASA II and 28.2% – ASA III), submitted to laparoscopic GHR between 1993 and 2001, that a general anesthesia with standard intraoperative monitoring is sufficient for safe laparoscopic hernia surgery, and age or comorbidities should not be an argument against this surgical approach.[33]

Limitations

Although our results are encouraging for surgeons to propose elective hernia repair to older patients, we unfortunately still need more studies and data that help us select these patients more accurately, taking into consideration their health status, rather than solely their age.

In general, the use of routine administrative data bears the risk of under- or overreporting of particular conditions or complications. Since only inhospital data were available, no long-term follow-up of the patients was possible. This means that postdischarge death and out-of-hospital long-term morbidity could not be assessed.

Although we do not have data about the out-of-hospital mortality, we followed the elderly submitted to a GHR during our study period and noticed that 2,934 (18.8%) had been readmitted within 3 months after surgery. The causes of admission were not related to the expected postoperative surgical complications.

We also have no data on outpatient surgery for GHR. However, unlike most other Western health-care systems, outpatient surgery for GHR only played a very limited role in Switzerland. Due to reimbursement issues, GHR was traditionally performed in the inpatient setting until 2017.

Unfortunately, we were lacking data on patients that were treated successfully with a watch-and-wait strategy as they were unlikely to be admitted to a hospital.

We feel though, that this large and complete national cohort offers a unique opportunity to identify, even minor effects on the outcomes of GHR in the elderly. It also counters common beliefs that are not backed up by comprehensive population-based date, but mainly individual experiences or smaller case series with relevant risks of selection bias.


  Conclusions Top


The IHM of elective GHR in elderly patients (≥80 years) is low. In contrast, emergency GHR in octogenarians and nonagenarians carries an increased risk of IHM.

Therewith, prevention of emergency GHR in the elderly population by early elective surgical repair should be considered before opting for watchful waiting in light symptomatic of even asymptomatic octo- and nonagenarians, especially if they do not bare a long list of comorbidities, or these are well manageable. The results we present in such a large population with good representation of the modern and still fit enough elders open the path to solve this dilemma.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.





 
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    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]



 

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