Randomized Clinical Trial of Total Extraperitoneal Inguinal Hernioplasty vs Lichtenstein Repair^-www.drkeyurbhatt.in*

A Long-term Follow-up Study

Hasan H. Eker, MD; Hester R. Langeveld, MD; Pieter J. Klitsie, MD; Martijne van't Riet, MD, PhD;Laurents P. S. Stassen, MD, PhD; Wibo F. Weidema, MD, PhD; Ewout W. Steyerberg, PhD; Johan F. Lange, MD, PhD;Hendrik J. Bonjer, MD, PhD; Johannes Jeekel, MD, PhD 

Arch Surg. 2012;147(3):256-260. doi:10.1001/archsurg.2011.2023

Hypothesis  Mesh repair is generally preferred for surgical correction of inguinal hernia, although the merits of endoscopic techniques over open surgery are still debated. Herein, minimally invasive total extraperitoneal inguinal hernioplasty (TEP) was compared with Lichtenstein repair to determine if one is associated with less postoperative pain, hypoesthesia, and hernia recurrence.

Design  Prospective multicenter randomized clinical trial.

Setting  Academic research.

Patients  Six hundred sixty patients were randomized to TEP or Lichtenstein repair.

Main Outcome Measures  The primary outcome was postoperative pain. Secondary end points were hernia recurrence, operative complications, operating time, length of hospital stay, time to complete recovery, quality of life, chronic pain, and operative costs.

Results  At 5 years after surgery, TEP was associated with less chronic pain (P = .004). Impairment of inguinal sensibility was less frequently seen after TEP vs Lichtenstein repair (1% vs 22%, P < .001). Operative complications were more frequent after TEP vs Lichtenstein repair (6% vs 2%, P < .001), while no difference was noted in length of hospital stay. After TEP, patients had faster time to return to daily activities (P < .002) and less absence from work (P = .001). Although operative costs were higher for TEP, total costs were comparable for the 2 procedures, as were overall hernia recurrences at 5 years after surgery. However, among experienced surgeons, significantly lower hernia recurrence rates were seen after TEP (P < .001).

Conclusions  In the short term, TEP was associated with more operative complications, longer operating time, and higher operative costs; however, total costs were comparable for the 2 procedures. Chronic pain and impairment of inguinal sensibility were more frequent after Lichtenstein repair. Although overall hernia recurrence rates were comparable for both procedures, hernia recurrence rates among experienced surgeons were significantly lower after TEP. Patient satisfaction was also significantly higher after TEP. Therefore, TEP should be recommended in experienced hands.

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A Meta-Analysis of Surgical Morbidity and Recurrence After Laparoscopic and Open Repair of Primary Unilateral Inguinal Hernia^-www.drkeyurbhatt.in*

Annals of Surgery:

May 2012 - Volume 255 - Issue 5 - p 846–853

doi: 10.1097/SLA.0b013e31824e96cf

Meta-Analyses

O'Reilly, Elma A. MB, BCh; Burke, John P. PhD, MRCSI; O'Connell, P. Ronan MD, FRCSI

Abstract

Background: Laparoscopic inguinal hernia repair (LIHR), using a transabdominal preperitoneal (TAPP) or totally extraperitoneal (TEP) technique, is an alternative to conventional open inguinal hernia repair (OIHR). A consensus on outcomes of LIHR when compared with OIHR for primary, unilateral, inguinal hernia has not been reached.

Objectives: Perform a meta-analysis of all randomized controlled trials (RCTs) comparing OIHR and LIHR for primary unilateral inguinal hernia. Outcomes were hernia recurrence and surgery-related morbidity.

Methods: A comprehensive search for published RCTs comparing LIHR with OIHR for primary, unilateral, and inguinal hernia was performed. Reviews of each study were conducted and data were extracted. Random effect methods were used to combine data.

Results: Data were retrieved from 27 RCTs describing 7161 patients. An increased risk in hernia recurrence existed when LIHR was compared with OIHR (relative risk [RR] = 2.06, 95% confidence interval [CI] = 1.26–3.37, P = 0.004). TAPP had equivalent recurrence (RR = 1.14, 95% CI = 0.78–1.68, P = 0.491) but TEP had increased recurrence of risk (RR = 3.72, 95% CI = 1.66–8.35, P = 0.001) relative to OIHR. LIHR was associated with greater perioperative complication risk than OIHR (RR = 1.22, 95% CI = 1.04–1.42, P = 0.015). TAPP (RR = 1.47, 95% CI = 1.18–1.84, P < 0.001) but not TEP (RR = 1.05, 95% CI = 0.85–1.30, P = 0.667) was associated with this increased complication risk. LIHR was associated with reduced risk of chronic pain (RR = 0.66, 95% CI = 0.51–0.87, P = 0.003) and chronic numbness (RR = 0.27, 95% CI = 0.12–0.58, P < 0.001) relative to OIHR.

Conclusions: For primary unilateral inguinal hernia, TEP is associated with an increased risk of recurrence relative to OIHR but TAPP is not. TAPP is associated with increased risk of perioperative complications relative to OIHR. LIHR has a reduced risk of chronic pain and numbness relative to OIHR

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Should More Patients Continue Aspirin Therapy Perioperatively?: Clinical Impact of Aspirin Withdrawal Syndrome^-www.drkeyurbhatt.in*

Annals of Surgery:

May 2012 - Volume 255 - Issue 5 - p 811–819

doi: 10.1097/SLA.0b013e318250504e

Feature

Gerstein, Neal Stuart MD^*; Schulman, Peter Mark MD^¶; Gerstein, Wendy Hawks MD^†; Petersen, Timothy Randal PhD^‡,*; Tawil, Isaac MD^§

Abstract

Objective: To provide an evidence-based focused review of aspirin use in the perioperative period along with an in-depth discussion of the considerations and risks associated with its preoperative withdrawal.

Background: For patients with established cardiovascular disease, taking aspirin is considered a critical therapy. The cessation of aspirin can cause a platelet rebound phenomenon and prothrombotic state leading to major adverse cardiovascular events. Despite the risks of aspirin withdrawal, which are exacerbated during the perioperative period, standard practice has been to stop aspirin before elective surgery for fear of excessive bleeding. Mounting evidence suggests that this practice should be abandoned.

Methods: We performed a PubMed and Medline literature search using the keywords aspirin, withdrawal, and perioperative. We manually reviewed relevant citations for inclusion.

Results/Conclusions: Clinicians should employ a patient-specific strategy for perioperative aspirin management that weighs the risks of stopping aspirin with those associated with its continuation. Most patients, especially those taking aspirin for secondary cardiovascular prevention, should have their aspirin continued throughout the perioperative period. When aspirin is held preoperatively, the aspirin withdrawal syndrome may significantly increase the risk of a major thromboembolic complication. For many operative procedures, the risk of perioperative bleeding while continuing aspirin is minimal, as compared with the concomitant thromboembolic risks associated with aspirin withdrawal. Those cases where aspirin should be stopped include patients undergoing intracranial, middle ear, posterior eye, intramedullary spine, and possibly transurethral prostatectomy surgery.

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CASE: RECURRENT FECAL FISTULA^-www.drkeyurbhatt.in*

Old aged male with h/o trauma 8 months back and operated for resection of 3.5 feets of ileum due to mesenteric tare..developed low level fistula from wound....discharging pus...

Was not subsided even after 6 months of surgery...worked up again and fistulogram suggested communication with bowel..taken up Unfortunately scrapping...and biopsy...and some resection was done (exact data not available)  Bx was sent from the fistula site: s/o tuberculosis!!

Following this surgery presented after 20 days of hospital stay with bile discharging from main wound

TLC:  22,000 , And hypotension with tachycardia and distension

CECT : plain and oral contrast demonstrated leak near terminal ileum....

surgery: exploration and removal of of dead omentum, lump, debridment of obscess, Rt quarter colectomy and ileostomy and mucus fistula...wound healed and pt discharged on POD 7 to home.

on exploration, with chronic fistulous tracts and dirty abscesses...

after clearing , lavage and resection...the relatively healthy looking bowel

HPE: s/o  atypical tuberculosis with granuloma p/o M. Kansasi

pt now started on COMBINATION AKT.

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Timing of Cholecystectomy After Mild Biliary Pancreatitis: A Systematic Review^-www.drkeyurbhatt.in*

Annals of Surgery:

May 2012 - Volume 255 - Issue 5 - p 860–866

doi: 10.1097/SLA.0b013e3182507646

Reviews

van Baal, Mark C. MD^*; Besselink, Marc G. MD, PhD^†; Bakker, Olaf J. MD^†; van Santvoort, Hjalmar C. MD, PhD^†; Schaapherder, Alexander F. MD, PhD^‡; Nieuwenhuijs, Vincent B. MD, PhD^§; Gooszen, Hein G. MD, PhD^*; van Ramshorst, Bert MD, PhD^‖; Boerma, Djamila MD, PhD^‖; for the Dutch Pancreatitis Study Group

Abstract

Objectives: To determine the risk of recurrent biliary events in the period after mild biliary pancreatitis but before interval cholecystectomy and to determine the safety of cholecystectomy during the index admission.

Background: Although current guidelines recommend performing cholecystectomy early after mild biliary pancreatitis, consensus on the definition of early (ie, during index admission or within the first weeks after hospital discharge) is lacking.

Methods: We performed a systematic search in PubMed, Embase, and Cochrane for studies published from January 1992 to July 2010. Included were cohort studies of patients with mild biliary pancreatitis reporting on the timing of cholecystectomy, number of readmissions for recurrent biliary events before cholecystectomy, operative complications (eg, bile duct injury, bleeding), and mortality. Study quality and risks of bias were assessed.

Results: After screening 2413 studies, 8 cohort studies and 1 randomized trial describing 998 patients were included. Cholecystectomy was performed during index admission in 483 patients (48%) without any reported readmissions. Interval cholecystectomy was performed in 515 patients (52%) after 40 days (median; interquartile range: 19–58 days). Before interval cholecystectomy, 95 patients (18%) were readmitted for recurrent biliary events (0% vs 18%,P < 0.0001). These included recurrent biliary pancreatitis (n = 43, 8%), acute cholecystitis (n = 17), and biliary colics (n = 35). Patients who had an endoscopic retrograde cholangiopancreatography had fewer recurrent biliary events (10% vs 24%, P = 0.001), especially less recurrent biliary pancreatitis (1% vs 9%). There were no differences in operative complications, conversion rate (7%), and mortality (0%) between index and interval cholecystectomy. Because baseline characteristics were only reported in 26% of patients, study populations could not be compared.

Conclusions: Interval cholecystectomy after mild biliary pancreatitis is associated with a high risk of readmission for recurrent biliary events, especially recurrent biliary pancreatitis. Cholecystectomy during index admission for mild biliary pancreatitis appears safe, but selection bias could not be excluded.

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