This RCT investigated the effect that complications have on patients' long-term quality of life (QoL) after curative colorectal cancer surgery using the the MRC-CLASICC trial (laparoscopic-assisted vs open surgery for colorectal cancer) cohort. A total of 614 of 794 CLASICC patients were suitable for inclusion. Complications occurred in 215 (35.0%) patients. Significant long-term differences in QoL between patients with and without complications were found for Physical and Social Function, Role Functioning, and Body Image on EORTC QLQ-C30/QLQ-CR38 analysis and Mobility, Self-care, and Pain/Discomfort on EQ5D analysis. No significant differences were seen for emotional/cognitive functioning, global QoL, financial difficulties, or future perspectives.
Ann Surg. 2013 Dec 26. [Epub ahead of print]
The use of low tidal volume (6-8ml/kg) ventilation with high positive end - expiratory pressures is accepted practice for patients with, or at risk of developing ARDS being ventilated on the intensive care unit. This simple and cost-free intervention has yet to be widely adopted, however, for intraoperative use in the at-risk patient population. In this multicentre, double-blind trial, 400 patients were randomised to receive either ‘non-protective’ (standard) ventilation with 10-12ml/kg tidal volumes and no PEEP or ‘Lung-protective’ ventilation with 6-8ml/kg tidal volumes, 6-8cm of PEEP and half-hourly recruitment manoeuvres. The primary outcome, which was a composite of major pulmonary and extrapulmonary complications, occurred in 10.5% of patients receiving lung-protective ventilation and 27.5% of those receiving standard ventilation (RR 0.4; 95% CI 0.24-0.68, P=0.01). Non-invasive or invasive ventilation was required within 7 days in 5.0% of the protective ventilation group and 17.0% in the non-protective group (RR 0.29; 95% CI 0.14-0.61, P=0.01). Duration of hospital stay was also non-significantly reduced in the lung-protective ventilation group. Given the significant reduction in morbidity, no additional cost to the healthcare provider and the robust nature of this study then lung-protective ventilation should be given serious consideration intra-operatively in this patient population, as well as on the intensive care unit.
New England Journal of Medicine 2013; 369(5):428-37
The effect of hospital volume on quality of recovery as measured by rates of successful discharge to home was investigated in this longitudinal analysis. The odds of discharge to home vs discharge to skilled facilities were significantly greater in high-volume hospitals compared with low-volume hospitals (odds ratio, 2.09; 95% CI, 1.70-2.56), with an absolute increase of 9%. For patients with postdischarge care needs, high-volume hospitals were less likely than low-volume hospitals to use skilled facilities rather than home health care (odds ratio, 0.35; 95% CI, 0.27-0.45), with an absolute difference of 10%.
JAMA Surg. 2014 Jan 15. doi: 10.1001/jamasurg.2013.3838. [Epub ahead of print]
This study assessed the long-term crossover (CO) rate in men undergoing watchful waiting (WW) as a primary treatment strategy for their asymptomatic or minimally symptomatic inguinal hernias. Eighty-one of the 254 men (31.9%) crossed over to surgical repair before the end of the original study, December 31, 2004, with a median follow-up of 3.2 (range: 2-4.5) years. The patients have now been followed for an additional 7 years with a maximum follow-up of 11.5 years. The estimated cumulative CO rates using Kaplan-Meier analysis was 68%. Men older than 65 years crossed over at a considerably higher rate than younger men (79% vs 62%). The most common reason for CO was pain (54.1%). A total of 3 patients have required an emergency operation, but there has been no mortality.
Ann Surg. 2013 Sep;258(3):508-15. doi: 10.1097/SLA.0b013e3182a19725.
This retrospective study compares the outcomes of patients who underwent lap ventral hernia repair (LVHR) with the outcomes of patients who underwent open ventral hernia repair (OVHR). There were 91 patients who underwent an LVHR and 167 patients who underwent an OVHR with mesh, with a median follow-up period of 56 months (range, 1-156 months). Seventy-nine patients with an LVHR were matched to 79 patients with an OVHR. No significant differences in demographic data or confounding factors were detected between the 2 groups. Compared with OVHR, LVHR was significantly associated with fewer SSIs (7.6% vs 34.1%; P < .01) but more clinical cases of bulging (21.5% vs 1.3%; P < .01) and port-site hernia (2.5% vs 0.0%). No differences in recurrence at the site of the hernia repair were observed (11.4% vs 11.4%; P = .99). Propensity score-matched multivariate analysis corroborated that LVHR is associated with more clinical cases of bulging but fewer SSIs.
JAMA Surg. 2013 Nov 1;148(11):1043-8. doi: 10.1001/jamasurg.2013.3587.
The aim of this meta-analysis of RCTs was to comparatively evaluate the outcomes of laparoscopic transabdominal preperitoneal inguinal hernia repair and totally extraperitoneal repair. Seven studies comprising 516 patients with 538 inguinal hernia defects were identified. A shorter recovery time (P = .02) was found for totally extraperitoneal repair in comparison with transabdominal preperitoneal inguinal hernia repair (weighted mean difference = -.29; 95% confidence interval [CI], -.71 to .07) although the length of hospitalization (P = .89) was similar in the 2 treatment arms (weighted mean difference = .01; 95% CI, -.13 to .15). Operative morbidity (P = .004) was higher for the preperitoneal approach (odds ratio = 2.15; 95% CI, 1.29 to 3.61). No differences were found with regard to the incidence of recurrence, long-term neuralgia, and operative time.
Am J Surg. 2013 Aug;206(2):245-252.e1. doi: 10.1016/j.amjsurg.2012.10.041. Epub 2013 Jun 12.
This retrospective study compared predictors of chronic groin discomfort following laparoscopic totally extraperitoneal (TEP) inguinal hernia repairs. There were 691 patients (71%) who provided complete responses to the questionnaire. Median follow-up was 5.7 years (range 0 to 14.4 years). The majority (n = 543, 79%) denied any symptoms of mesh sensation, pain, or movement limitation. In the remaining 148 (21%) patients, symptoms were most often mild (n = 108), followed by mild but bothersome (n = 25), and 15 patients (2%) had moderate or severe symptoms. Symptomatic patients were younger (median age 52 vs 57 years, p = 0.002) and were more likely to have had the TEP repair for recurrent hernias (24% vs 17%, p = 0.035). Operative diagnosis, bilateral exploration, mesh fixation techniques, perioperative complications, American Society of Anesthesiologists grade, and length of hospital stay were not associated with chronic groin discomfort.
J Am Coll Surg. 2013 Jul;217(1):72-8; discussion 78-80. doi: 10.1016/j.jamcollsurg.2013.03.005. Epub 2013 Apr 30.
The aim of this 10 year retrospective study was to evaluate the incidence, indications, and predictive factors of hospital readmission after open ventral hernia repair. Of the 888 patients, 75 (8%) were readmitted between 1 and 30 days, 97 (11%) between 1 and 90 days, and 78 (9%) between 91 and 365 days. Unplanned readmissions related to the surgery constituted the majority of 1-day to 30-day and 1-day to 90-day readmissions (82% and 74%, respectively) but not between 91 and 365 days (32%). Prior superficial or deep surgical-site infection (odds ratio, 2.39; 95% confidence interval, 1.32 to 4.32) and duration of surgery (odds ratio, 1.35; 95% confidence interval, 1.05 to 1.73) were associated with 30-day readmission.
Am J Surg. 2013 Dec;206(6):942-9. doi: 10.1016/j.amjsurg.2013.08.022. Epub 2013 Oct 18.
The purpose of this retrospective study was to evaluate and compare the incidence of wound complications after laparoscopic component separation (LCS) vs open component separation (OCS) in patients with complex abdominal wall hernias. A total of 44 patients underwent LCS (n = 18) or OCS (n = 26). There was no statistically significant difference between categoric variables. Multivariate analysis using wound complications as the dependent variable showed a statistically significantly lower rate of wound complications in the LCS group.
Am J Surg. 2013 Dec;206(6):869-75. doi: 10.1016/j.amjsurg.2013.08.005. Epub 2013 Oct 7.
This study aimed to evaluate the clinical outcomes of 2 institutions' experience implanting lightweight polypropylene synthetic mesh in clean-contaminated and contaminated ventral hernias. One hundred patients (50 male, 50 female) with a mean age of 60 ± 13 years and a mean body mass index (calculated as kg/m(2)) of 32 ± 9.3 met inclusion criteria. There were 42 clean-contaminated and 58 contaminated cases. The incidence of surgical site occurrence was 26.2% in clean-contaminated cases and 34% in contaminated cases. The 30-day surgical site infection rate was 7.1% for clean-contaminated cases and 19.0% for contaminated cases. There were a total of 7 recurrences with a mean follow-up of 10.8 ± 9.9 months (range 1 to 63 months). Mesh removal was required in 4 patients: 2 due to early anastomotic leaks, 1 due to stomal disruption and retraction in a morbidly obese patient, and 1 from a long-term enterocutaneous fistula.
J Am Coll Surg. 2013 Dec;217(6):991-8. doi: 10.1016/j.jamcollsurg.2013.07.382. Epub 2013 Sep 14.
The aim of this study was to investigate the improvement in pain and QoL after open inguinal hernia repair, and the economic impact. Of 225 patients who began the study, 184 completed follow-up at 12 months. Some 77·2 per cent reported improvement in pain and 5·4 per cent reported increased pain after surgery. Significant improvement in SF-36® scores, pain scores measured on a visual analogue scale (VAS), and symptoms were found in the majority of patients, even those with mild symptoms before surgery. For the whole group, the bodily pain score increased from 56·4 before surgery to 82·6 at 12 months after hernia repair (P < 0·050), and the VAS score decreased from a median of 4 to 0 (P < 0·050). The return on investment was positive for all groups of patients, including those with mild symptoms.
Br J Surg. 2013 Oct;100(11):1483-8. doi: 10.1002/bjs.9232.
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