Inpatient Cost of Trauma Care Versus Repair of Elective Open Inguinal Hernias: Nationwide Trends Over Nearly a Decade

Purpose: Concerns exist regarding increased trauma activation fees at the expense of vulnerable patients. In contrast, elective open inguinal hernia repair (E-OIHR) has remained relatively fixed in terms of technique. This study aimed to examine health care costs for E-OIHR and trauma patients, hypothesizing trauma cost would increase from 2010 to 2018, while E-OIHR cost would remain unchanged. Methods: The Nationwide Inpatient Sample database was queried (2010-2018) for admitted patients undergoing unilateral E-OIHR or trauma-related admission. Health care costs per admission, total annual costs, and trends of E-OIHR and trauma admissions were also examined. Multiple linear regression was used to estimate the association of individual- and hospital-level variables with total costs. Results: Unilateral E-OIHR admission cost more than doubled per case in 2018. Trauma cost per admission also increased, however, only by 34%. Total costs for all E-OIHR admissions increased 26%, whereas trauma admission costs increased 32%. Both trauma admissions and unilateral E-OIHR admissions decreased; however, E-OIHR admissions decreased more. Multiple linear regression demonstrated compared to the cost of E-OIHR, trauma care decreased when adjusting for year, age, severity, hospital type, and length of stay (P < .001). Conclusion: The rate of increase in cost per unilateral E-OIHR admission exceeded that of trauma. However, the total economic burden for trauma care increased by billions of dollars due to a steady increase in per incidence cost and only slightly lower rates of trauma admissions. Increased focus on high-value care to curtail increasing costs of E-OIHR and especially trauma appears warranted.

Frailty is an independent predictor of postoperative rescue medication use after endoscopic sinus surgery

INTRODUCTION

The modified five-item frailty index (mFI-5) is a validated risk stratification tool with the ability to predict adverse outcomes following surgery. In this study, we sought to use mFI-5 to assess the potential relationship between unhealthy aging and postoperative endoscopic sinus surgery (ESS) outcomes.

METHODS

Patients who underwent sinus surgery at Vanderbilt between 2014 and 2018 were identified and assessed using the mFI-5, which is calculated based on the presence of five comorbidities: diabetes mellitus, hypertension requiring medication, chronic obstructive pulmonary disease, congestive heart failure, and non-independent functional status. Multivariate regression analyses were performed to quantify the association of mFI-5 score on need for rescue oral antibiotics, oral steroids, and antibiotic irrigations within 1 year following ESS, adjusting for relevant potential confounders.

RESULTS

Four hundred and three patients met inclusion criteria.  Within 6 months of surgery, 312 (77%) required rescue antibiotics, 243 (60%) required oral corticosteroids (OCS), and 31 (8%) initiated antibiotic irrigations. Increasing mFI-5 scores were significantly associated with higher postoperative use of rescue antibiotics (p < 0.0001), OCS (p = 0.032), and antibiotic irrigation (p < 0.0001). Frailty scores remained as an independent predictor of these outcomes after adjustment for age, polyp status, preoperative sinonasal outcomes test (SNOT-22) score, and revision surgery status.

CONCLUSIONS

Modified frailty scores may be a useful clinical tool to predict the need for postoperative rescue medication use after ESS.

УЛУЧШЕНИЕ РЕЗУЛЬТАТОВ ХИРУРГИЧЕСКОГО ЛЕЧЕНИЯ ГРЫЖ ПЕРЕДНЕЙ БРЮШНОЙ СТЕНКИ У ПАЦИЕНТОВ ПОЖИЛОГО ВОЗРАСТА

Tədqiqatın məqsədi qarnın ön divarının yırtığı olan, yüksək zəriflik indeksli yaşlı xəstələrin cərrahi müalicəsinin yaxşılaşdırılması məqsədilə yeni müalicə taktikasının effektivliynin öyrənilməsi olmuşdur. Kontrol qrupunda olan (n=43) xəstə ənənəvi qaydada əməliyyatdan sonrakı müalicə almışdır. Əsas qrup xəstələrdə (n=49) müəllifin təklif etdiyi üsulla müalicə aparılmışdır: bütün xəstələrə nazoqastral zond qoyulmuş, mərkəzi vena kateterizasiya edilmiş, genişspektrli antibiotik infuziyası, mərkəzi venoz təzyiqi və arterial təzyiqi stabilləşdirmək şərtilə vena daxilinə kolloid və kristalloid məhlulların infuziyası aparılmış və xəstələr 6 saat ərzində əməliyyata götürülmüşdür. Əməliyyatdan sonrakı erkən dövrdə intensiv terapiya şöbəsində tənəffüs gimnastikası, erkən per os qidalanma, ağrının idarə edilməsi üçün epidural kateter vasitəsilə ağrıkəsicilərin istifadəsi, erkən hərəkətə başlama və beynin funksional aktivliyinin artırılması üçün kognitiv məşqlər icra edilmişdir. Əsas və kontrol qruplarında alınmış nəticələrin müqayisəsi göstərmişdir ki, Clavien-Dindo klassifikasiyasına görə II və III sinif ağırlaşmalara kontrol qrupunda daha çox rast gəlinmişdir. Xəstələrin əməliyyatdan sonrakı hospitaldaxili vəziyyətləri əsas qrupda daha yaxşı olması ilə seçilmişdir. Təklif etdiyimiz yeni metodun effektivliyi qanda iltihab əlamətlərinin daha mülayim olması ilə öz təsdiqini tapmışdır.

Представлены результаты исследования, проведенного с целью изучения эффективности новой тактики лечения, предложенного автором для улучшения хирургического лечения больных пожилого возраста с грыжами передней брюшной стенки с высоким индексом хрупкости. Больные контрольной группы (n=43) получали традиционное послеоперационное лечение. Основная группа больных (n=49) получили лечение предлагаемым автором способом, в которое входили: установление всем пациентам назогастрального зонда, катетеризация центральной вены, инфузия антибиотиков широкого спектра действия, внутривенное введение коллоидных и кристаллоидных растворов при условии стабилизации центрального венозного давления и артериального давления, а также 6 часов, в течение которых больного доставляют на операцию. В раннем послеоперационном периоде в отделении интенсивной терапии проводили дыхательную гимнастику, раннее пероральное питание, применение обезболивающих средств через эпидуральный катетер для купирования боли, раннюю двигательную и когнитивную гимнастику для повышения функциональной активности головного мозга. Сравнение результатов, полученных в основной (n=49) и контрольной (n=43) группах, показало, что по классификации Clavien-Dindo в контрольной группе чаще встречались осложнения II и III классов. Течение послеоперационого периода было лучше в основной группе. Эффективность предложенного нового метода подтверждена более хорошими показателями воспаления в анализах крови.

The aim was to study the effectiveness of new treatment tactics to improve the surgical treatment of elderly patients with hernias with a high frailty index. Patients in the control group (n=43) received traditional postoperative treatment. The main group of patients (n=49) received treatment using the method we proposed, which included: all patients had a nasogastric tube installed, central vein catheterization, infusion of broad-spectrum antibiotics, intravenous administration of colloid and crystalloid solutions, subject to stabilization of central venous pressure and blood pressure, as well as 6 hours, during which the patient is taken to surgery. In the early postoperative period in the intensive care unit, breathing exercises, early oral nutrition, the use of painkillers through an epidural catheter to relieve pain, and early motor and cognitive exercises to increase the functional activity of the brain were performed. A comparison of the results obtained in the main (n = 49) and control (n=43) groups, showed that according to the Clavien-Dindo classification, complications of classes II and III were more common in the control group. The course of the postoperative period was better in the main group. The effectiveness of our new method is confirmed by better indicators of inflammation in blood tests.

Transabdominal preperitoneal versus hybrid procedures for treating irreducible inguinal hernias: A retrospective controlled study

BACKGROUND

Inguinal hernia is a common condition; however, irreducible inguinal hernias are rare. In this retrospective study, two laparoscopic procedures for irreducible inguinal hernia were compared.

MATERIALS AND METHODS

The study cohort comprised 88 patients who had undergone laparoscopic repair of primary irreducible inguinal hernias between 1 June 2011 and 31 December 2019. The patients were retrospectively divided into Hybrid (Group H) and Standard Transabdominal Preperitoneal (TAPP) Groups (Group S). Patient characteristics, hernia details, and intraoperative and postoperative complications were compared between study groups.

RESULTS

There were no significant differences between the two groups in baseline characteristics, including age, sex, body mass index, hernia type, operation time, hospital stay, cost, and duration of follow-up. No recurrence or surgical site infection occurred in either group. There were no significant differences between the two groups in incidence of spermatic vessel injury (0% vs. 2.04%, P = 0.370), vas deferens injury (0% vs. 6.12%, P = 0.116), epigastric vessels injury (0% vs. 4.08%, P = 0.202), scrotal hematoma (7.69% vs. 2.04%, P = 0.206), dysuria (5.13% vs. 8.16%, P = 0.575), fever (17.95% vs. 16.32%, P = 0.841), seroma (25.64% vs. 32.65%, P = 0.474), chronic pain (0% vs. 2.04%, P = 0.370), sensation of a foreign body (2.56% vs. 2.04%, P = 0.870), or pain on ejaculation (0% vs. 2.04%, P = 0.370). The incidence of acute pain was higher in Group H than in Group S (43.59% vs. 8.16%, P = 0.000).

CONCLUSION

The hybrid TAPP procedure is a safe and feasible means of treating irreducible inguinal hernias. Though it is associated with a higher incidence of postoperative acute pain than the standard TAPP procedure, it may have advantages in avoiding injuries to the vas deferens and spermatic vessels.

Comparison of transumbilical single-incision laparoscopic TAPP versus conventional laparoscopic TAPP in the elderly: A retrospective analysis

BACKGROUND

To analyze and compare the clinical efficacy of transumbilical single-incision laparoscopic surgery TAPP(SILS-TAPP) and conventional laparoscopic TAPP(CL-TAPP) in the treatment of senile inguinal hernia.

METHODS

From January 2019 to June 2021, a total of 221 elderly patients (≥60 years old) with inguinal hernia received SILS-TAPP and CL-TAPP in General Surgery Department of Affiliated Hospital of Nantong University. The perioperative indicators, postoperative complications and follow-up of the two groups were compared to explore the feasibility and superiority of SILS-TAPP in the treatment of inguinal hernia in the elderly.

RESULTS

There was no difference in demographic characteristics between the two groups. The mean operation time (28.6 ± 4.2 min vs 28.2 ± 5.3 min) in the SILS-TAPP group was not significantly different from that in the CL-TAPP group (Ρ = 0.623), and there was no significant increase in hospital costs(Ρ = 0.748). The intraoperative blood loss (7.4 ± 3.4 ml), VAS score on the postoperative day (2.2 ± 0.7), mean time of resuming activity (8.2 ± 1.9 h) and mean postoperative hospital stay (0.8 ± 0.2 d) in the SILS-TAPP group were better than those in the CL-TAPP group (Ρ < 0. 05).There was no statistical difference in the overall incidence of intraoperative (Ρ = 0.128) and postoperative complications (Ρ = 0.125) between the two groups.

CONCLUSION

Single-incision laparoscopic surgery TAPP (SILS-TAPP) is feasible and effective in elderly patients, providing a new alternative surgical method for patients who can tolerate general anesthesia.

Outcomes of Emergency Groin Hernia Repair in the Elderly: A Systematic Review

Introduction: The number of surgeries for groin hernia (GH) among the elderly follows the increase in life expectancy of the population. The greater number and severity of comorbidities in this group increases the surgical risk, promoting discussion regarding the indication of elective surgery and the benefits of watchful waiting approach (WWA). The aim of the present study was to evaluate the outcomes of emergency hernia surgery among the elderly population. Materials and methods: A systematic review was performed in Pubmed and Scielo databases for the past early 10 years, until July 2022. The subject was groin hernia in the emergency setting focusing the elderly population. The PRISMA statement was followed and the classification of elderly was based on the World Health Organization's definition. Results: A total of 1,037 results were returned and we ended with nine original articles with emphasis in groin hernia in the emergency among the elderly population. In these subjects, the complications rate ranged between 21.2% and 28.9% and the mortality rate ranged between 1.2% and 6%. Cardiopulmonary disease, high ASA and Charlson's scales were associated with greater risk of complications and death. Conclusion: Emergency GH surgery in the elderly population carries an increased risk of complications and mortality. GH surgery is safe or, at least, less harmful when done electively. The risk and benefits of WWA and upfront surgery needs to be assessed and exposed to the patients. Our review sugest that elective surgery should be the option over WWA in this patient population.

Short-Term Outcomes of Inguinal Hernia Repair in Older Patients: A Retrospective Review at a Tertiary Center

Objectives

Although inguinal hernia (IH) repair is low-risk surgery, older patients are occasionally offered watchful waiting because of their functional status and comorbidities. This study reviewed the surgical outcomes of IH repair in older patients in comparison with outcomes in younger patients.

Methods

This retrospective study included all patients who had IH repair from 2010 to 2020. The primary outcomes of interest were postoperative complications and recurrence.

Results

A total of 262 patients underwent IH repair during the study period; 40% were ≥60 years old. One patient had a recurrence. Among the 8% of patients who had postoperative complications, groin pain was the most common one (1.9%). Female patients had a significantly higher rate of complications than male patients did (38.5% female versus 6.4% male, p<0.001). The rate of complications was also higher for emergency surgery than for elective surgery (22.6% emergency versus 6.1% elective, p<0.001), as well for patients who needed concomitant bowel resection compared with those who did not. Patients who had emergency surgery or postoperative complications had a prolonged hospital stay. 

Conclusions

IH repair in older patients is low-risk surgery, comparable to that in younger patients. In this study, emergency surgery was more common in older than in younger patients and posed a higher risk of complications. We recommend offering elective hernia repair to older patients to avoid the higher complication rate associated with emergency repair.

Loss of independence after emergency inguinal hernia repair in elderly patients: How aggressive should we be?

BACKGROUND

Loss of independence (LOI) assesses patient quality of life after surgery and is associated with increased readmission and death. This paper compares LOI among the elderly who received elective versus emergent inguinal hernia repair.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Participant User Files from 2015 to 2017 were reviewed for inguinal hernia repairs in patients 70-years-old or older. Chi-square analysis, Student t-test, and backwards multivariate logistic analysis were performed appropriately.

RESULTS

Patients undergoing elective open or laparoscopic repair were less likely to experience LOI (OR 0.061, CI 0.035-0.106) and (OR 0.052 CI 0.024-0.113), respectively, and they were less likely to experience mortality (OR 0.07, CI 0.026-0.185) and (OR 0.059, CI 0.015-0.229), respectively.

CONCLUSIONS

Significant debility occurs following emergency inguinal hernia repair in elderly patients. Elective surgery may be indicated more often in order to reduce emergencies and LOI in elderly patients.

Laparoscopy Versus Open Incarcerated Inguinal Hernia Repair in Octogenarians: Single-Center Experience With World Review

OBJECTIVES

The clinical study is aiming to discuss the therapeutic benefit of laparoscopic hernia (LH) repair with comparing conventional open hernia (OH) repair in incarcerated hernia in octogenarians.

MATERIALS AND METHODS

The clinical data of 29 octogenarian incarcerated hernia patients who underwent hernia repair from November 2013 to March 2017 were retrospectively analyzed. The variables analyzed include baseline, operation characteristics, and clinical outcomes. The patients were divided into LH and OH according to the surgical approach and their clinical parameters were compared. Descriptive statistics were calculated, and outcomes were compared using the Fisher exact test and the student t test, a P≤0.05 was considered significant.

RESULTS

Of reported 18 octogenarian patients, 7 patients underwent LH, whereas the remaining 11 patients underwent OH. The median age of the patients was 86 (81 to 97). All patients in LH group and 3 patients in OH group underwent nonmesh repair. In total, 8 patients in OH group underwent mesh repair. Simultaneous intestinal resection was needed in 4 patients (2 in LH, 2 in OH) due to the necrotic bowel. No mortality was observed in all subjects. The results showed significantly shorter operation time (50±5 vs. 110±3 min; P=0.000), hospital stay (6±1 vs. 12±3 d; P=0.04). There were no noteworthy postoperative complications and during the follow-up period, no patient experienced recurrent hernia in both groups.

CONCLUSIONS

LH nonmesh repair has not increased the morbidity and mortality but showed shorter hospital stay and fast recovery and no recurrence in octogenarian incarcerated hernia patients. Therefore, LH in octogenarian incarcerated hernia patients might be preferred approach in sophisticated hands with acceptable outcomes.

Evaluation of Ultrasound-guided Genitofemoral Nerve Block Combined with Ilioinguinal/iliohypogastric Nerve Block during Inguinal Hernia Repair in the Elderly

To evaluate the anesthetic effect of ultrasound-guided (USG) ilioinguinal/iliohypogastric nerve (II/IHN) block combined with genital branch of genitofemoral nerve (GFN) block in the elderly undergoing inguinal hernia repair, 54 old patients (aged 60-96years, ASA I-III) with indirect hernia were enrolled and scheduled for unilateral tension-free herniorrhaphy. Patients were grouped randomly to receive either USG II/IHN plus GFN block (Group G) or USG II/IHN block alone (Group I). The intraoperative visual analogue scale (VAS) scores were recorded at skin incision, at spermatic cord/round ligament traction and at sac ligation. The resting and dynamic VAS scores were recorded postoperatively. The requirements of extra sedatives and analgesics for intra- and postoperative analgesia were assessed. Occurrence of complications of the block, postoperative nausea and vomiting and femoral nerve palsy was also reported. Both groups showed similar sensory block. When stretching spermatic cord/round ligament, the patients in group G had significantly lower VAS scores than in group I. And group G used much fewer adjuvant sedatives and analgesics to achieve adequate anaesthesia. In addition, group G was presented with better intraoperative anaesthesia and lower postoperative dynamic VAS scores at all time points tested. No significant difference was found in the postoperative requirement of rescue medication. Both groups showed no complications related to the block and group G reported no femoral nerve palsy. The addition of GFN block to II/IHN block improves the quality of perioperative anesthesia and analgesia in the elderly and reduces the consumption of extra sedatives and analgesics during the surgery.