Network meta-analysis of urinary retention and mortality after Lichtenstein repair of inguinal hernia under local, regional or general anaesthesia

BACKGROUND

Urinary retention and mortality after open repair of inguinal hernia may depend on the type of anaesthesia. The aim of this study was to investigate possible differences in urinary retention and mortality in adults after Lichtenstein repair under different types of anaesthesia.

METHODS

Systematic searches were conducted in the Cochrane, PubMed and Embase databases, with the last search on 1 August 2018. Eligible studies included adult patients having elective unilateral inguinal hernia repair by the Lichtenstein technique under local, regional or general anaesthesia. Outcomes were urinary retention and mortality, which were compared between the three types of anaesthesia using meta-analyses and a network meta-analysis.

RESULTS

In total, 53 studies covering 11 683 patients were included. Crude rates of urinary retention were 0·1 (95 per cent c.i. 0 to 0·2) per cent for local anaesthesia, 8·6 (6·6 to 10·5) per cent for regional anaesthesia and 1·4 (0·6 to 2·2) per cent for general anaesthesia. No death related to the type of anaesthesia was reported. The network meta-analysis showed a higher risk of urinary retention after both regional (odds ratio (OR) 15·73, 95 per cent c.i. 5·85 to 42·32; P < 0·001) and general (OR 4·07, 1·07 to 15·48; P = 0·040) anaesthesia compared with local anaesthesia, and a higher risk after regional compared with general anaesthesia (OR 3·87, 1·10 to 13·60; P = 0·035). Meta-analyses showed a higher risk of urinary retention after regional compared with local anaesthesia (P < 0·001), but no difference between general and local anaesthesia (P = 0·08).

CONCLUSION

Local or general anaesthesia had significantly lower risks of urinary retention than regional anaesthesia. Differences in mortality could not be assessed as there were no deaths after elective Lichtenstein repair. Registration number: CRD42018087115 ( https://www.crd.york.ac.uk/prospero).

Characteristics of groin hernia repair in patients without a groin hernia: a nationwide cohort study

BACKGROUND

Sports hernia is a condition with longstanding groin pain without an obvious pathology. Even though no hernia is present, some of these patients have a groin hernia repair to relieve the pain. The aim of this study was to establish an overview of patient characteristics and surgical techniques in patients that have a groin hernia repair without a hernia present.

METHODS

This cohort study is based on nationwide data on hernia repairs from the Danish Hernia Database. Patients having a primary groin hernia repair without having a hernia between 1998 and 2011 were included and followed for minimum 4 years. We evaluated patient characteristics, type of surgery, and re-operation rates for laparoscopic and open surgeries.

RESULTS

Groin hernia repairs were performed in 1,028 groins where no hernia was present. The median follow-up after primary surgery was 11 years (range 4-17). Men represented 78% of the patients, and the mean age was 50 years (standard deviation 16.4). The most frequent type of surgery was the open Lichtenstein repair. The overall re-operation rate was 7% and this was evenly distributed across the different types of primary surgeries with no difference in neither the crude nor the cumulated re-operation rates. During re-operation, a groin hernia was found in 88% of the repairs.

CONCLUSION

Groin hernia repairs in groins without a hernia are performed at all ages and with the typical patient being a middle-aged man receiving an open mesh repair.

Functional outcomes from a randomized trial of early closure of temporary ileostomy after rectal excision for cancer

BACKGROUND

Low anterior resection syndrome (LARS) has a significant impact on postoperative quality of life. Although early closure of an ileostomy is safe in selected patients, functional outcomes have not been investigated. The aim was to compare bowel function and the prevalence of LARS in patients who underwent early or late closure of an ileostomy after rectal resection for cancer.

METHODS

Early closure (8-13 days) was compared with late closure (after 12 weeks) of the ileostomy following rectal cancer surgery in a multicentre RCT. Exclusion criteria were: signs of anastomotic leakage, diabetes mellitus, steroid treatment and postoperative complications. Bowel function was evaluated using the LARS score and the Memorial Sloan Kettering Cancer Center Bowel Function Instrument (BFI).

RESULTS

Following index surgery, 112 participants were randomized (55 early closure, 57 late closure). Bowel function was evaluated at a median of 49 months after stoma closure. Eighty-two of 93 eligible participants responded (12 had died and 7 had a permanent stoma). Rates of bowel dysfunction were higher in the late closure group, but this did not reach statistical significance (major LARS in 29 of 40 participants in late group and 25 of 42 in early group, P = 0·250; median BFI score 63 versus 71 respectively, P = 0·207). Participants in the late closure group had worse scores on the urgency/soiling subscale of the BFI (14 versus 17; P = 0·017). One participant in the early group and six in the late group had a permanent stoma (P = 0·054).

CONCLUSION

Patients undergoing early stoma closure had fewer problems with soiling and fewer had a permanent stoma, although reduced LARS was not demonstrated in this cohort. Dedicated prospective studies are required to evaluate definitively the association between temporary ileostomy, LARS and timing of closure.

Impact of contemporary patterns of chemotherapy utilization on survival in patients with advanced cancer of the urinary tract: a Retrospective International Study of Invasive/Advanced Cancer of the Urothelium (RISC)

Background

Cisplatin-based combination chemotherapy is the standard treatment of advanced urinary tract cancer (aUTC), but 50% of patients are ineligible for cisplatin according to recently published criteria. We used a multinational database to study patterns of chemotherapy utilization in patients with aUTC and determine their impact on survival.

Patients and methods

This was a retrospective study of patients with: UTC (bladder, renal pelvis, ureter or urethra); advanced disease (stages T4b and/or N+ and/or M+); urothelial, squamous or adenocarcinoma histology. Primary objective was overall survival (OS). Eligibility-for-cisplatin was defined by Eastern Cooperative Oncology Group performance status ≤ 1, creatinine clearance ≥ 60 ml/min, no hearing loss, no neuropathy and no heart failure. Cox regression multivariate analyses were used to establish independent associations of cisplatin versus noncisplatin-based chemotherapy on OS.

Results

1794 patients treated between 2000 and 2013 at 29 centers were analyzed. Median follow-up was 29.1 months. About 1333 patients (74%) received first-line chemotherapy: the use of first-line chemotherapy was associated with longer OS: [hazard ratio (HR): 1.91, 95% confidence interval (CI): 1.67-2.20]. Type of first-line chemotherapy received was: cisplatin-based 669 (50%), carboplatin-based 399 (30%) and other 265 (20%). Cisplatin use was an independent favorable prognostic factor (HR: 1.54, 95% CI: 1.35-1.77). This benefit was independent of baseline characteristics or comorbidities but was associated with eligibility-for-cisplatin: eligible patients treated with cisplatin lived longer than those who were not (HR: 1.74, 95% CI: 1.36-2.21), while such benefit was not observed among ineligible patients. About 26% of patients who did not receive cisplatin were eligible for this agent. Median OS of ineligible patients was poor irrespective of the chemotherapy used.

Conclusions

The importance of applying published criteria of eligibility-for-cisplatin was confirmed in a multinational, real-world setting in aUTC. The reasons for deviations from these criteria set targets to improve adherence. Effective therapies for cisplatin-ineligible patients are needed.

Uncertain diagnosis and prognosis in advanced melanoma: a qualitative study of the experiences of bereaved carers in a time of immune and targeted therapies

BACKGROUND

Recent advances in advanced melanoma therapies are associated with improved survival for some patients. However, how patients with diagnoses of advanced disease and their carers experience this expanding treatment paradigm is not well understood.

OBJECTIVES

To explore bereaved carers' accounts of the trajectory of advanced melanoma involving treatment by immune or targeted therapies, to build an understanding of their experiences of care relating to diagnosis and prognosis.

METHODS

A qualitative exploratory design, using methods drawn from grounded theory, was adopted. Analyses drew on in-depth interviews with 20 bereaved carers from three metropolitan melanoma treatment centres in Australia. A flexible interview guide and structured approach to concurrent data collection and analysis were applied.

RESULTS

Carers described qualities of the experience, including the shock of diagnosis after a sometimes-innocuous presentation with vague symptoms. They reported an unclear prognosis with complexity arising from interplay between an uncertain disease trajectory and often ambiguous expectations of outcomes of emerging immune and targeted therapies. Uncertainty dominated carers' experiences, increasing the complexity of care planning.

CONCLUSIONS

Effective communication of an advanced melanoma diagnosis and prognosis is critical. Recognition of the uncertainty inherent in the benefit of immune and targeted therapies in a constructive manner may facilitate more timely and effective care-planning conversations between patients, carers and medical specialists.

Dealing with the round ligament of uterus in laparoscopic groin hernia repair: a nationwide survey among experienced surgeons

PURPOSE

Our aim was to investigate how often a national cohort of experienced groin hernia surgeons transected the round ligament of uterus in laparoscopic groin hernia repair. Furthermore, we wished to explore the surgeons' personal opinions and knowledge on the function and importance of the ligament.

METHODS

An electronic questionnaire was sent to all surgeons in Denmark performing laparoscopic groin hernia repair on a regular basis. The questionnaire consisted of demographic details, estimated incidence of transection of the round ligament of uterus, information about transection to the patients, documentation of transection in the medical records, and the surgeons' personal opinions and knowledge of the importance of the ligament.

RESULTS

A total of 71 surgeons met our eligibility criteria and 61 (86%) provided complete responses. We estimated that the round ligament of uterus was transected in 395 of 813 (49%) herniorrhaphies during the past 12 months. Personal opinions and knowledge on the function of the ligament and the importance of preserving it varied greatly among the surgeons.

CONCLUSIONS

Transection of the round ligament of uterus in laparoscopic groin hernia repair is common. The consequences of transecting the round ligament of uterus are not well described, and opinions and knowledge on the issue vary widely among experienced hernia surgeons.

Long-Term Complications of Appendectomy: A Systematic Review

BACKGROUND AND AIMS

Appendectomy is a common surgical procedure, but no overview of the long-term consequences exists. Our aim was to systematically review the long-term complications of appendectomy for acute appendicitis.

MATERIALS AND METHODS

This systematic review was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A protocol was registered on PROSPERO (CRD42017064662). The databases PubMed and EMBASE were searched for original reports on appendectomy with n ≥ 500 and follow-up >30 days. The surgical outcomes were ileus and incisional hernia; other outcomes were inflammatory bowel disease, cancer, fertility, and mortality.

RESULTS

We included 37 studies. The pooled estimate of the ileus prevalence was 1.0% over a follow-up period of 4.6 (range, 0.5-15) years. Regarding incisional hernia, we found a pooled estimate of 0.7% prevalence within a follow-up period of 6.5 (range, 1.9-10) years. Ulcerative colitis had a pooled estimate of 0.15% prevalence in the appendectomy group and 0.19% in controls. The opposite pattern was found regarding Crohn's disease with a pooled estimate of 0.20% prevalence in the appendectomy group and 0.12% in controls. No clear pattern was found regarding most of the examined cancers in appendectomy groups compared with background populations. Pregnancy rates increased after appendicitis compared with controls in most studies. Mortality was low after appendectomy.

CONCLUSION

Appendectomy had a low prevalence of long-term surgical complications. We did not find any significant other long-term complications, though the prevalence of Crohn's disease was higher and the prevalence of ulcerative colitis was lower after appendectomy than in controls. Appendectomy did not impair fertility.

Two-year results of the randomized clinical trial DILALA comparing laparoscopic lavage with resection as treatment for perforated diverticulitis

Background

Traditionally, perforated diverticulitis with purulent peritonitis was treated with resection and colostomy (Hartmann's procedure), with inherent complications and risk of a permanent stoma. The DILALA (DIverticulitis – LAparoscopic LAvage versus resection (Hartmann's procedure) for acute diverticulitis with peritonitis) and other randomized trials found laparoscopic lavage to be a feasible and safe alternative. The medium‐term follow‐up results of DILALA are reported here.

Methods

Patients were randomized during surgery after being diagnosed with Hinchey grade III perforated diverticulitis at diagnostic laparoscopy. The primary outcome was the proportion of patients with one or more secondary operations from 0 to 24 months after the index procedure in the laparoscopic lavage versus Hartmann's procedure groups. The trial was registered as ISRCTN82208287.

Results

Forty‐three patients were randomized to laparoscopic lavage and 40 to Hartmann's procedure. Patients in the lavage group had a 45 per cent reduced risk of undergoing one or more operations within 24 months (relative risk 0·55, 95 per cent c.i. 0·36 to 0·84; P = 0·012) and had fewer operations (ratio 0·51, 95 per cent c.i. 0·31 to 0·87; P = 0·024) compared with those in the Hartmann's group. No difference was found in mean number of readmissions (1·37 versus 1·50; P = 0·221) or mortality between patients randomized to laparoscopic lavage or Hartmann's procedure. Three patients in the lavage group and nine in the Hartmann's group had a colostomy at 24 months.

Conclusion

Laparoscopic lavage is a better option for perforated diverticulitis with purulent peritonitis than open resection and colostomy.

Laparoscopic lavage still an option

Pouch failures following ileal pouch-anal anastomosis for ulcerative colitis

AIM

Ileal pouch-anal anastomosis is a procedure offered to patients with ulcerative colitis who opt for restoration of bowel continuity. The aim of this study was to determine the risk of pouch failure and ascertain the risk factors associated with failure.

METHOD

The study included 1991 patients with ulcerative colitis who underwent ileal pouch-anal anastomosis in Denmark in the period 1980-2013. Pouch failure was defined as excision of the pouch or presence of an unreversed stoma within 1 year after its creation. We used Cox proportional hazards regression to explore the association between pouch failure and age, gender, synchronous colectomy, primary faecal diversion, annual hospital volume (very low, 1-5 cases per year; low, 6-10; intermediate 11-20; high > 20), calendar year, laparoscopy and primary sclerosing cholangitis.

RESULTS

Over a median 11.4 years, 295 failures occurred, corresponding to 5-, 10- and 20-year cumulative risks of 9.1%, 12.1% and 18.2%, respectively. The risk of failure was higher for women [adjusted hazard ratio (aHR) 1.39, 95% CI 1.10-1.75]. Primary non-diversion (aHR 1.63, 95% CI 1.11-2.41) and a low hospital volume (aHR, very low volume vs high volume 2.30, 95% CI 1.26-4.20) were also associated with a higher risk of failure. The risk of failure was not associated with calendar year, primary sclerosing cholangitis, synchronous colectomy or laparoscopy.

CONCLUSION

In a cohort of patients from Denmark (where pouch surgery is centralized) with ulcerative colitis and ileal pouch-anal anastomosis, women had a higher risk of pouch failure. Of modifiable factors, low hospital volume and non-diversion were associated with a higher risk of pouch failure.

Optimal Timing for Laparoscopic Cholecystectomy After Endoscopic Retrograde Cholangiopancreatography: A Systematic Review

Background and Aims:

Endoscopic retrograde cholangiopancreatography followed by laparoscopic cholecystectomy is often used as definitive treatment for common bile duct stones. The aim of this study was to investigate the optimal time interval between endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy.

Materials and Methods:

PubMed and Embase were searched for studies comparing different time delays between endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy. Observational studies and randomized controlled trials were included. Primary outcome was conversion rate from laparoscopic to open cholecystectomy and secondary outcomes were complications, mortality, operating time, and length of stay.

Results:

A total of 14 studies with a total of 1930 patients were included. The pooled estimate revealed an increase from a 4.2% conversion rate when laparoscopic cholecystectomy was performed within 24 h of endoscopic retrograde cholangiopancreatography to 7.6% for 24–72 h delay to 12.3% when performed within 2 weeks, to 12.3% for 2–6 weeks, and to a 14% conversion rate when operation was delayed more than 6 weeks.

Conclusion:

According to this systematic review, it is preferable to perform cholecystectomy within 24 h of endoscopic retrograde cholangiopancreatography to reduce conversion rate. Early laparoscopic cholecystectomy does not increase mortality, perioperative complications, or length of stay and on the contrary it reduces the risk of reoccurrence and progression of disease in the delay between endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy.

Systematic review and network meta-analysis of methods of mesh fixation during laparoscopic ventral hernia repair

BACKGROUND

Ventral hernia repairs are common and have high recurrence rates. They are usually repaired laparoscopically with an intraperitoneal mesh, which can be fixed in various ways. The aim was to evaluate the recurrence rates for the different fixation techniques.

METHODS

This systematic review included studies with human adults with a ventral hernia repaired with an intraperitoneal onlay mesh. The outcome was recurrence at least 6 months after operation. Cohort studies with 50 or more participants and all RCTs were included. PubMed, Embase and the Cochrane Library were searched on 22 September 2016. RCTs were assessed with the Cochrane risk-of-bias assessment tool and cohort studies with the Newcastle-Ottawa scale. Studies comparing fixation techniques were included in a network meta-analysis, which allowed comparison of more than two fixation techniques.

RESULTS

Fifty-one studies with a total of 6553 participants were included. The overall crude recurrence rates with the various fixation techniques were: absorbable tacks, 17·5 per cent (2 treatment groups); absorbable tacks with sutures, 0·7 per cent (3); permanent tacks, 7·7 per cent (20); permanent tacks with sutures, 6·0 per cent (25); and sutures, 1·5 per cent (6). Six studies were included in a network meta-analysis, which favoured fixation with sutures. Although statistical significance was not achieved, there was a 93 per cent chance of sutures being better than one of the other methods.

CONCLUSION

Both crude recurrence rates and the network meta-analysis favoured fixation with sutures during laparoscopic ventral hernia repair.

Quality of life in a randomized trial of early closure of temporary ileostomy after rectal resection for cancer (EASY trial)

Background

A temporary ileostomy may reduce symptoms from anastomotic leakage after rectal cancer resection. Earlier results of the EASY trial showed that early closure of the temporary ileostomy was associated with significantly fewer postoperative complications. The aim of the present study was to compare health‐related quality of life (HRQOL) following early versus late closure of a temporary ileostomy.

Methods

Early closure of a temporary ileostomy (at 8–13 days) was compared with late closure (at more than 12 weeks) in a multicentre RCT (EASY) that included patients who underwent rectal resection for cancer. Inclusion of participants was made after index surgery. Exclusion criteria were signs of anastomotic leakage, diabetes mellitus, steroid treatment, and signs of postoperative complications at clinical evaluation 1–4 days after rectal resection. HRQOL was evaluated at 3, 6 and 12 months after resection using the European Organisation for Research and Treatment of Cancer (EORTC) questionnaires QLQ‐C30 and QLQ‐CR29 and Short Form 36 (SF‐36®).

Results

There were 112 patients available for analysis. Response rates of the questionnaires were 82–95 per cent, except for EORTC QLQ‐C30 at 12 months, to which only 54–55 per cent of the patients responded owing to an error in questionnaire distribution. There were no clinically significant differences in any questionnaire scores between the groups at 3, 6 or 12 months.

Conclusion

Although the randomized study found that early closure of the temporary ileostomy was associated with significantly fewer complications, this clinical advantage had no effect on the patients' HRQOL. Registration number: NCT01287637 (https://www.clinicaltrials.gov).

No different after early ileostomy closure

Validation of subjective rating scales for assessment of surgical workspace during laparoscopy

BACKGROUND

Recently, studies have focused on how to optimize laparoscopic surgical workspace by changes in intra-abdominal pressure, level of muscle relaxation or body position, typically evaluated by surgeons using subjective rating scales. We aimed to validate two rating scales by having surgeons assess surgical workspace in video sequences recorded during laparoscopic surgery.

METHOD

Video sequences were obtained from laparoscopic procedures. Eight experienced surgeons assessed the video sequences on a categorical 5-point scale and a numerical 10-point rating scale. Intraclass correlations coefficients (ICC) and 95% confidence intervals (CI) were calculated for intra- and inter-rater reliability.

RESULTS

The 5-point rating scale had an intra-rater ICC of 0.76 (0.69; 0.83) and an inter-rater ICC of 0.57 (0.45; 0.68), corresponding to excellent and fair reliability, respectively. The 10-point scale had an intra-rater ICC of 0.86 (0.82; 0.89) and an inter-rater ICC of 0.54 (0.39; 0.68), corresponding to excellent and fair as well. All surgeons used the full range of the 5-point scale, but only one surgeon used the full range of the 10-point scale.

CONCLUSION

In conclusion, both scales showed excellent intra-rater and fair inter-rater reliability for assessing surgical workspace in laparoscopy. The 5-point surgical rating scale had all categories employed by all surgeons.