Outcome of incisional hernia repair in patients 80 years and older: results from the Herniamed-Registry

INTRODUCTION

More and more often complex abdominal surgeries are performed in the elderly. Together with the ageing population these patients are at risk for incisional hernias. We aimed on assessing outcomes following incisional hernia surgery in patients 80 years and older.

MATERIAL AND METHODS

Using the Herniamed-Registry, a prospective multi-institutional database, data on patients undergoing surgery for incisional hernias were retrospectively assessed. 46,040 patients were included and divided by age. Intraoperative-, general-, and postoperative complications as well as 1-year follow-up outcomes were assessed and compared between patients 80 years and older vs younger than 80 years.

RESULTS

Intra- (2.3% vs 1.5%; p < 0.001) and postoperative (8.6% vs 7.2%; p = 0.001) complications, general complications (5.5% vs 3.0%; p < 0.001), as well as reoperations (3.8% vs 3.0%; p = 0.007) were more likely to occur in elderly patients. By contrast, recurrences (3.6% vs 4.5%; p = 0.007), pain at rest (7.3% vs 10.1%; p < 0.001) and on exertion (11.3% vs 18.3%; p < 0.001), as well as pain requiring treatment (5.4% vs 7.7%; p < 0.001) was less likely in the group of patients aged ≥ 80 years.

CONCLUSION

Incisional hernia repair in patients 80 years and older is associated with a slightly higher complication risk but is quite acceptable and also have improved pain scores. The recurrence difference is also clinically unimportant.

Extended lymph node resection versus standard resection for pancreatic head and peri-ampullary adenocarcinoma: A systemic review

Objective

For patients with pancreatic and peri-ampullary adenocarcinoma, it has been hypothesized that extended lymphadenectomy may result in higher R0 resection rates and improved survival. As such, the objective of this systematic review was to compare the oncologic outcomes after pancreaticoduodenectomy (PD) with standard lymphadenectomy (SLA) versus PD with extended lymphadenectomy (ELA).

Methods

A Cochrane systematic review was conducted to identify all randomized controlled trials comparing PD with SLA versus PD with ELA for participants with periampullary or pancreatic cancer. The following electronic databases were reviewed: the Cochrane Central Register of Controlled Trials; MEDLINE; PubMed and EMBASE. The methodological quality of the included studies was assessed using the Cochrane risk of bias criteria and the quality of evidence for important outcomes using GRADE. Extended lymphadenectomy included the interaortocaval space, left side of the celiac trunk, and superior mesenteric artery.

Results

Seven randomized controlled trials were included with 843 patients (421 ELA and 422 SLA). No difference in overall survival (1- and 3-years after surgery) was seen between groups. Mortality and morbidity rates (including pancreatic fistula, delayed gastric emptying, and postoperative bleeding) were similar between the two groups. Operative time was significantly longer following extended resection (Mean Difference 50.1 min; 95% CI 19.2 to 81.1 min; P = 0.001). Total amount of blood loss during surgery was significantly increased following extended resection (Mean Difference 137 ml; 95% CI 12 to 263 ml; P = 0.03), as well as transfusion requirements (Mean Difference 0.15 units; 95% CI 0.13 to 0.17 units; P &lt; 0.00001).

More lymph nodes were retrieved during ELA (Mean Difference 11 nodes; 95% CI 7 to 15 nodes; P &lt; 0.00001). Incidence of positive resection margins was not different between groups.

Conclusion

There is no indication for extended lymphadenectomy in pancreatic head resection as a routine procedure.

Simple questionnaire for assessing core outcomes in inguinal hernia repair

Background

Patient-oriented questionnaires are indispensable in the assessment of surgical outcome. The psychometric properties of a brief multidimensional instrument were examined in patients with inguinal hernia undergoing surgery.

Methods

Fifty-one patients (mean(s.d.) age 50·6(17·4) years; 48 men) participated. The following questionnaire properties were assessed for the Core Outcome Measures Index adapted for patients with hernia (COMI-hernia) and the EuroQol: practicability, floor and ceiling effects, test–retest reliability (over 2 weeks), construct validity (by comparison with other relevant scales) and responsiveness 9 months after surgery as standardized response mean (SRM).

Results

The questionnaires were easy to implement and well accepted by the patients. Ceiling effects at baseline were 2 per cent for the COMI-hernia, 8 per cent for EuroQol—visual analogue scale (EQ-VAS) and 35 per cent for EuroQol—Five Dimensions (EQ-5D); no instrument showed floor effects. The reproducibility of individual COMI-hernia items was good, with test–retest differences within one grade ranging from 41 of 45 for ‘social/work disability’ to 44 of 45 for ‘general quality of life’. The intraclass correlation coefficients were moderately high for COMI-hernia (0·74) and EQ-VAS (0·77), but low for EQ-5D (0·43). COMI-hernia scores correlated in the expected manner with related scales (r = 0·42–0·72, P &lt; 0·050). COMI-hernia was the most responsive instrument (SRM 1·42).

Conclusion

The COMI-hernia and EQ-VAS general health scale represent reliable, valid and sensitive tools for assessing multidimensional outcome in patients with inguinal hernia undergoing surgical treatment.