Determining the value of the abdominal core health quality collaborative to support regulatory decisions.

PURPOSE: The study objective is to document value created by real-world evidence from the Abdominal Core Health Quality Collaborative (ACHQC) for regulatory decisions. The ACHQC is a national effort that generates data on hernia repair techniques and devices. METHODS: Two retrospective cohort evaluations compared cost and time of ACHQC analyses to traditional postmarket studies. The first analysis was based on 25 reports submitted to the European Medicines Agency of 20 mesh products for post-market surveillance. A second analysis supported label expansion submitted to the Food and Drug Administration, Center for Devices and Radiological Health for a robotic-assisted surgery device to include ventral hernia repair. Estimated costs of counterfactual studies, defined as studies that might have been done if the registry had not been available, were derived from a model described in the literature. Return on investment, percentage of cost savings, and time savings were calculated. RESULTS: 45,010 patients contributed to the two analyses. The cost and time differences between individual 25 ACHQC analyses (41,112 patients) and traditional studies ranged from $1.3 to $2.2 million and from 3 to 4.8 years, both favoring use of the ACHQC. In the second label expansion analysis (3,898 patients), the estimated return on investment ranged from 11 to 461% with time savings of 5.1 years favoring use of the ACHQC. CONCLUSIONS: Compared to traditional postmarket studies, use of ACHQC data can result in cost and time savings when used for appropriate regulatory decisions in light of key assumptions.

Treatment of patients with screen-detected colorectal cancer is less strenuous: a nationwide cohort study with long-term follow-up.

OBJECTIVE: During the last two decades, organised colorectal cancer (CRC) screening has been widely implemented. It remains to be established if screen-detected CRC (SD-CRC) is associated with reduced long-term requirements for treatment as compared with patients with non-screen-detected CRC (NSD-CRC). STUDY DESIGN AND METHODS: This nationwide cohort study evaluated differences in treatment and healthcare contacts from the date of diagnosis to two years after comparing patients with SD-CRC and NSD-CRC. Data were collected from national healthcare registers, including patients aged 50-75 years and diagnosed with CRC between January 1st 2014 and March 31st 2018. Analyses were stratified into UICC stages and adjusted for sex, 5-year age groups, type of cancer (colonic/rectal), and Charlson comorbidity index score to address healthy user bias. RESULTS: In total, 12,040 patients were included, 4708 with SD-CRC and 7332 with NSD-CRC. In patients with SD-CRC, the duration of hospitalisation and rate of emergency surgery were reduced by 38 % (relative risk [RR] = 0.62) and 66 % (RR = 0.34), respectively. Moreover, this group was characterised by a 75 % reduction in oncological outpatient visits (RR = 0.35) and a reduced number of treatments with chemotherapy (RR = 0.57) and radiotherapy (RR = 0.50). There were no significant differences between the two populations in the rates of metastasectomy and the number of contacts with primary healthcare providers. CONCLUSION: Compared to patients with NSD-CRC, patients with SD-CRC experience less hospitalisation and treatment within the first two years after diagnosis.

Five-Year Follow-Up of a Slowly Resorbable Biosynthetic P4HB Mesh (Phasix) in VHWG Grade 3 Incisional Hernia Repair.

Objective: To assess the 5-year recurrence rate of incisional hernia repair in Ventral Hernia Working Group (VHWG) 3 hernia with a slowly resorbable mesh. Summary Background Data: Incisional hernia recurs frequently after initial repair. In potentially contaminated hernia, recurrences rise to 40%. Recently, the biosynthetic Phasix mesh has been developed that is resorbed in 12-18 months. Resorbable meshes might be a solution for incisional hernia repair to decrease short- and long-term (mesh) complications. However, long-term outcomes after resorption are scarce. Methods: Patients with VHWG grade 3 incisional midline hernia, who participated in the Phasix trial (Clinilcaltrials.gov: NCT02720042) were included by means of physical examination and computed tomography (CT). Primary outcome was hernia recurrence; secondary outcomes comprised of long-term mesh complications, reoperations, and abdominal wall pain [visual analogue score (VAS): 0-10]. Results: In total, 61/84 (72.6%) patients were seen. Median follow-up time was 60.0 [interquartile range (IQR): 55-64] months. CT scan was made in 39 patients (68.4%). A recurrence rate of 15.9% (95% confidence interval: 6.9-24.8) was calculated after 5 years. Four new recurrences (6.6%) were found between 2 and 5 years. Two were asymptomatic. In total, 13/84 recurrences were found. No long-term mesh complications and/or interventions occurred. VAS scores were 0 (IQR: 0-2). Conclusions: Hernia repair with Phasix mesh in high-risk patients (VHWG 3, body mass index >28) demonstrated a recurrence rate of 15.9%, low pain scores, no mesh-related complications or reoperations for chronic pain between the 2- and 5-year follow-up. Four new recurrences occurred, 2 were asymptomatic. The poly-4-hydroxybutyrate mesh is a safe mesh for hernia repair in VHWG 3 patients, which avoids long-term mesh complications like pain and mesh infection.

Even minor alteration of plasma creatinine after open abdominal surgery is associated with 30-day mortality: A single-centre cohort study.

PURPOSE: Postoperative acute kidney injury is common and associated with increased length of hospital stay, costs and mortality. The impact from postoperative subclinical changes in plasma concentration of creatinine (p-creatinine) on postoperative mortality has received less attention. In this study, the association between the postoperative change of p-creatinine and all-cause mortality was investigated. METHODS: A single-centre register-based, retrospective study was conducted including patients ≥60 years undergoing open abdominal surgery from 2000 to 2013. Postoperative p-creatinine change was analysed for association with 30-day mortality following adjustment for age, gender, surgical setting and surgical procedure. Main findings A total of 3,460 patients were included in the study of whom 67.6% underwent emergency surgery. The 30-day mortality rate was 18.3%, and a given 10µmol/L daily postoperative increase in p-creatinine was associated with an increased mortality risk with an odds ratio (OR) of 2.67 (95% CI; 2.28-3.14, P<0.001). In patients undergoing emergency surgery, a daily 10µmol/L increase in p-creatinine increased the risk for a fatal outcome a 2.39 OR (CI 95%; 2.05-2.78), P<0.001). In patients undergoing elective surgery, a similar increase in p-creatinine increased risk of postoperative death with a 28.85 OR (CI 95%; 10.25-81.19). CONCLUSION: Even a minor postoperative p-creatinine increase following open abdominal surgery below the criteria for acute kidney injury was associated with increased 30-day mortality in patients aged 60 years or above.

Morphological alterations of the abdominal wall after open incisional hernia repair with endoscopic anterior and open posterior component separation.

PURPOSE: Effects of component separation (CS) on abdominal wall morphology have only been investigated in smaller case series or cadavers. This study aimed to compare abdominal wall alterations following endoscopic anterior CS (EACS) or open transverse abdominis release (TAR). METHODS: Computed tomography scans were evaluated in patients who had undergone open incisional hernia repair with EACS or TAR. Abdominal wall circumference, lateral abdominal wall muscle thickness, and displacement were compared with (1) preoperative images after bilateral CS and (2) the undivided side postoperatively after unilateral CS. RESULTS: In total, 105 patients were included. Fifty-five (52%) and 15 (14%) underwent bilateral and unilateral EACS, respectively. Five (5%) and 14 (13%) underwent bilateral and unilateral TAR, respectively. Sixteen (15%) underwent unilateral EACS and contralateral TAR. The external oblique and transverse abdominis muscles were significantly laterally displaced with a mean of 2.74 cm (95% CI 2.29-3.19 cm, P < 0.001) and 0.82 cm (0.07-1.57 cm, P = 0.032) after EACS and TAR, respectively. The combined thickness of the lateral muscles was significantly decreased after EACS (mean decrease 10.5% (5.8-15.6%, P < 0.001)) and insignificantly decreased after TAR (mean decrease 2.6% (- 4.8 to 9.5%, P = 0.50)). The abdominal wall circumference was unchanged after bilateral (mean reduction 0.90 cm (- 0.77 to 2.58 cm), P = 0.29) and unilateral CS (mean increase 0.03 cm (- 1.01 to 1.08 cm), P = 0.95). CONCLUSION: Postoperative changes in the lateral abdominal wall musculature were different following EACS and open TAR. Either technique seems not to compromise the overall integrity of the lateral abdominal wall.

The European Hernia Society Prehabilitation Project: A Systematic Review of Intra-Operative Prevention Strategies for Surgical Site Occurrences in Ventral Hernia Surgery.

Background: Ventral hernia repair is one of the most commonly performed surgical procedures worldwide. To reduce the risk of complications, pre- and intra-operative strategies have received increasing focus in recent years. To assess possible preventive surgical strategies, this European Hernia Society endorsed project was launched. The aim of this review was to evaluate the current literature focusing on pre- and intra-operative strategies for surgical site occurrences (SSO) and specifically surgical site infection (SSI) in ventral hernia repair. Methods: A systematic review was conducted and reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Databases used were Pubmed and Web of Science. Original retrospective or prospective human adult studies describing at least one intra-operative intervention to reduce SSO after ventral hernia repair were considered eligible. Results: From a total of 4775 results, a total of 18 papers were considered suitable after full text reading. Prehospital chlorhexidine gluconate (CHG) scrub appears to increase the risk of SSO in patients undergoing ventral hernia repair, while there is no association between any type of surgical hat worn and the incidence of postoperative wound events. Intraoperative measures as prophylactic negative pressure therapy, surgical drain placement and the use of quilt sutures seem beneficial for decreasing the incidence of SSO and/or SSI. No positive effect has been shown for antibiotic soaking of a synthetic mesh, nor for the use of fibrin sealants. Conclusion: This review identified a limited amount of literature describing specific preventive measures and techniques during ventral hernia repair. An advantage of prophylactic negative pressure therapy in prevention of SSI was observed, but different tools to decrease SSIs and SSOs continuously further need our full attention to improve patient outcomes and to lower overall costs.

The European Hernia Society Prehabilitation Project: a systematic review of patient prehabilitation prior to ventral hernia surgery.

BACKGROUND: Ventral hernia repair is one of the most commonly performed surgical procedures worldwide. To reduce the risk of complications, patient prehabilitation has received increasing focus in recent years. To assess prehabilitation measures, this European Hernia Society endorsed project was launched. The aim of this systematic review was to evaluate the current literature on patient prehabilitation prior to ventral hernia repair. METHODS: The strategies examined were optimization of renal disease, obesity, nutrition, physical exercise, COPD, diabetes and smoking cessation. For each topic, a separate literature search was conducted, allowing for seven different sub-reviews. RESULTS: A limited amount of well-conducted research studies evaluating prehabilitation prior to ventral hernia surgery was found. The primary findings showed that smoking cessation and weight loss for obese patients led to reduced risks of complications after abdominal wall reconstruction. CONCLUSION: Prehabilitation prior to ventral hernia repair may be widely used; however, the literature supporting its use is limited. Future studies evaluating the impact of prehabilitation before ventral hernia surgery are warranted.

Open versus laparoscopic umbilical and epigastric hernia repair: nationwide data on short- and long-term outcomes.

BACKGROUND: It is unclear whether an open or laparoscopic approach results in the best outcomes for repair of umbilical and epigastric hernias. The aim of the study was to evaluate the rates of 90-day readmission and reoperation for complication, together with rate of operation for recurrence after either open or laparoscopic mesh repair for primary umbilical or epigastric hernias with defect widths above 1 cm. METHODS: A merge of data between the Danish Hernia Database and the National Patient Registry provided data from 2007 to 2018 on perioperative information, 90-day readmission, 90-day reoperation for complication, and long-term operation for hernia recurrence. RESULTS: A total of 6855 patients were included, of whom 4106 (59.9%) and 2749 (40.1%) patients had an open or laparoscopic repair, respectively. There were significantly more patients readmitted with a superficial surgical site infection 2.5% (102/4106) after open repair compared with laparoscopic repair (0.5% (15/2749), P < 0.001. The 90-day reoperation rate for complications was significantly higher for open repairs 5.0% (205/4106) compared with laparoscopic repairs 2.7% (75/2749), P < 0.001. The incidence of a reoperation for a severe condition was significantly increased after laparoscopic repair 1.5% (41/2749) compared with open repair 0.8% (34/4106), P = 0.010. The 4-year cumulative incidence of operation for hernia recurrence was 3.5% after open and 4.2% after laparoscopic repairs, P = 0.302. CONCLUSIONS: Recurrence rates were comparable between open and laparoscopic repair of umbilical and epigastric hernias. Open repair was associated with a significantly higher rate of readmission and reoperation due to surgical site infection, whereas the rate of reoperation due to a severe complication was significantly higher after laparoscopic repair.

Slowly resorbable biosynthetic mesh: 2-year results in VHWG grade 3 hernia repair.

INTRODUCTION: Information on the long-term performance of biosynthetic meshes is scarce. This study analyses the performance of biosynthetic mesh (Phasix™) over 24 months. METHODS: A prospective, international European multi-center trial is described. Adult patients with a Ventral Hernia Working Group (VHWG) grade 3 incisional hernia larger than 10 cm2, scheduled for elective repair, were included. Biosynthetic mesh was placed in sublay position. Short-term outcomes included 3-month surgical site occurrences (SSO), and long-term outcomes comprised hernia recurrence, reoperation, and quality of life assessments until 24 months. RESULTS: Eighty-four patients were treated with biosynthetic mesh. Twenty-two patients (26.2%) developed 34 SSOs, of which 32 occurred within 3 months (primary endpoint). Eight patients (11.0%) developed a hernia recurrence. In 13 patients (15.5%), 14 reoperations took place, of which 6 were performed for hernia recurrence (42.9%), 3 for mesh infection (21.4%), and in 7 of which the mesh was explanted (50%). Compared to baseline, quality of life outcomes showed no significant difference after 24 months. Despite theoretical resorption, 10.7% of patients reported presence of mesh sensation in daily life 24 months after surgery. CONCLUSION: After 2 years of follow-up, hernia repair with biosynthetic mesh shows manageable SSO rates and favorable recurrence rates in VHWG grade 3 patients. No statistically significant improvement in quality of life or reduction of pain was observed. Few patients report lasting presence of mesh sensation. Results of biosynthetic mesh after longer periods of follow-up on recurrences and remodeling will provide further valuable information to make clear recommendations. TRIAL REGISTRATION: Registered on clinicaltrials.gov (NCT02720042), March 25, 2016.

Changes in the abdominal wall after anterior, posterior, and combined component separation.

KEY MESSAGE: Knowledge of the changes that occur in the abdominal wall after component separation (CS) is essential for understanding the mechanisms of action of the various CS techniques, the changes observed on computed tomography images, and, perhaps most importantly, the anatomic and physiologic changes observed in patients who have undergone CS. Purpose Component separation (CS) techniques are essential adjuncts during most abdominal wall reconstructions. They allow the fulfillment of most modern abdominal wall reconstruction principles, especially primary closure of defects and linea alba restoration under physiologic tension. Knowledge of the post-CS abdominal wall changes is essential to understanding the mechanism of action of the various types of CS, the changes observed on computed tomographic images, and, perhaps most importantly, the anatomic and physiologic changes following CS techniques. Methods A systematic review of the literature was conducted using the PubMed database and other sources to identify articles describing abdominal wall changes after CS Results After excluding non-pertinent articles, 14 articles constituted the basis for this review.  Conclusions After reviewing the literature on post CS abdominal wall changes, we conclude the following: (1)The external oblique muscle is significantly displaced laterally after anterior CS, the transversus abdominis muscle shifts very little after posterior CS, and muscle trophism is generally maintained after both techniques. These findings are consistent for both open and minimally invasive CS. (2) The anatomy and physiology of abdominal wall muscles are preserved mainly by the muscles' overlapping function and their ability to undergo compensatory trophism after midline restoration (reloading). (3) Well-performed CS techniques have a low risk of producing bulging and semilunar line hernias. (4) Anterior and posterior CS techniques probably have different mechanisms of action. (5) Current studies on how the nutritional status and postoperative conditioning can alter abdominal wall changes after CS and the mechanisms of the actions involved in anterior and posterior CS are underway.

Visceral obesity is a predictor of surgical site occurrence and hernia recurrence after open abdominal wall reconstruction.

PURPOSE: High body mass index (BMI) increases the risk of postoperative complications and hernia recurrence after abdominal wall reconstruction (AWR). However, BMI does not provide specific information on the mass and distribution of adipose tissue. We hypothesized that visceral fat volume (VFV) was a better predictor than BMI for recurrence after AWR. METHODS: We included all patients undergoing AWR at our institution from November 2010 to December 2016. Data were collected from a prospective database and all patients were summoned for follow-up. VFV was calculated from preoperative CT. The primary and secondary outcomes were hernia recurrence and 30-day postoperative surgical site occurrences (SSO), respectively. RESULTS: We included a total of 154 patients. At follow-up, 42 (27.3%) patients had developed recurrence. The recurrence rate was significantly higher in patients with a VFV higher than the mean compared to a VFV lower than the mean, P = 0.004. After multivariable Cox-regression, VFV remained significantly predictive of recurrence (HR 1.09 per 0.5 L increase of VFV, P = 0.018). In contrary, BMI was not associated with hernia recurrence. There was no significant difference in the rate of SSO between patients with a VFV above and below the mean. A multivariable logistic regression model showed that VFV was significantly associated with development of SSO (OR 1.12 per 0.5 L increase, P = 0.009). CONCLUSION: VFV was significantly associated with recurrence and SSOs after AWR. This study suggests VFV as a risk assessment tool for patients undergoing AWR.

Reporting guideline for interventional trials of primary and incisional ventral hernia repair.

BACKGROUND: Primary and incisional ventral hernia trials collect unstandardized inconsistent data, limiting data interpretation and comparison. This study aimed to create two minimum data sets for primary and incisional ventral hernia interventional trials to standardize data collection and improve trial comparison. To support these data sets, standardized patient-reported outcome measures and trial methodology criteria were created. METHODS: To construct these data sets, nominal group technique methodology was employed, involving 15 internationally recognized abdominal wall surgeons and two patient representatives. Initially a maximum data set was created from previous systematic and panellist reviews. Thereafter, three stages of voting took place: stage 1, selection of the number of variables for data set inclusion; stage 2, selection of variables to be included; and stage 3, selection of variable definitions and detection methods. A steering committee interpreted and analysed the data. RESULTS: The maximum data set contained 245 variables. The three stages of voting commenced in October 2019 and had been completed by July 2020. The final primary ventral hernia data set included 32 variables, the incisional ventral hernia data set included 40 variables, the patient-reported outcome measures tool contained 25 questions, and 40 methodological criteria were chosen. The best known variable definitions were selected for accurate variable description. CT was selected as the optimal preoperative descriptor of hernia morphology. Standardized follow-up at 30 days, 1 year, and 5 years was selected. CONCLUSION: These minimum data sets, patient-reported outcome measures, and methodological criteria have allowed creation of a manual for investigators aiming to undertake primary ventral hernia or incisional ventral hernia interventional trials. Adopting these data sets will improve trial methods and comparisons.

Histopathological risk factors for lymph node metastases in T1 colorectal cancer: meta-analysis.

BACKGROUND: National screening programmes increase the proportion of T1 colorectal cancers. Local excision may be possible, but the risk of lymph node metastases (LNMs) could jeopardize long-term outcomes. The aim of the present study was to review the association between histopathological findings and LNMs in T1 colorectal cancer. METHODS: A systematic literature search was conducted using PubMed,Embase, and Cochrane online databases. Studies investigating the association between one or more histopathological factors and LNMs in patients who underwent resection for T1 colorectal cancer were included. RESULTS: Sixteen observational studies were included in the meta-analysis, including a total of 10 181 patients, of whom 1 307 had LNMs. Lymphovascular invasion (odds ratio (OR) 7.42; P < 0.001), tumour budding (OR 4.00; P < 0.001), depth of submucosal invasion, whether measured as at least 1000 µm (OR 3.53; P < 0.001) or Sm2-3 (OR 2.12; P = 0.020), high tumour grade (OR 3.75; P < 0.001), polypoid growth pattern (OR 1.59; P = 0.040), and rectal location of tumour (OR 1.36; P = 0.003) were associated with LNMs. CONCLUSION: Distinct histopathological factors associated with nodal metastases in T1 colorectal cancer can aid selection of patients for local excision or major excisional surgery.

Open versus laparoscopic incisional hernia repair: nationwide database study.

BACKGROUND: Although laparoscopic repair of incisional hernias decreases the incidence of wound complications compared with open repair, there has been rising concern related to intraperitoneal mesh placement. The aim of this study was to examine outcomes after open or laparoscopic elective incisional hernia mesh repair on a nationwide basis. METHODS: This study analysed merged data from the Danish Hernia Database and the National Patient Registry on perioperative information, 90-day readmission, 90-day reoperation for complication, and long-term operation for hernia recurrence among patients who underwent primary repair of an incisional hernia between 2007 and 2018. RESULTS: A total of 3090 (57.5 per cent) and 2288 (42.5 per cent) patients had surgery by a laparoscopic and open approach respectively. The defect was closed in 865 of 3090 laparoscopic procedures (28.0 per cent). The median follow-up time was 4.0 (i.q.r. 1.8-6.8) years. Rates of readmission (502 of 3090 (16.2 per cent) versus 442 of 2288 (19.3 per cent); P = 0.003) and reoperation for complication (216 of 3090 (7.0 per cent) versus 288 of 2288 (12.5 per cent); P < 0.001) were significantly lower for laparoscopic than open repairs. Reoperation for bowel obstruction or bowel resection was twice as common after laparoscopic repair compared with open repair (20 of 3090 (0.6 per cent) versus 6 of 2288 (0.3 per cent); P = 0.044). Patients were significantly less likely to undergo repair of recurrence following laparoscopic compared with open repair of defect widths 2-6 cm (P = 0.002). CONCLUSION: Laparoscopic intraperitoneal mesh repair for incisional hernia should still be considered for fascial defects between 2 and 6 cm, because of decreased rates of early complications and repair of hernia recurrence compared with open repair.

Causes of prolonged hospitalization after open incisional hernia repair: an observational single-center retrospective study of a prospective database.

PURPOSE: Enhanced recovery after surgery (ERAS) is a well-known approach to optimize the recovery after surgery. Little is known about specific causes of prolonged hospitalization despite enhanced recovery after open incisional hernia repair (OIHR). The purpose of this study was to identify the causes of continued hospitalization on each of the first 5 postoperative days (PODs) after OIHR. METHODS: This was a retrospective study of consecutive patients undergoing open AWR at a regional academic hernia center from 2008 to 2018. Patient charts were evaluated using predefined potential causes of continued hospitalization on each of the first five PODs. RESULTS: A total of 388 patients (mean age 60.9 years, 54.6% male, mean BMI 27.9 kg/m2) were included in the study. Mesh placement was either preperitoneal/intraperitoneal (20%) or retromuscular (80%) and 61% of the patients had an epidural catheter. The median length of stay (LOS) in the cohort was four [IQR 2-6] days. On PODs 4 and 5, causes of continued hospital stay were absent bowel function (2% on POD 4, 1% on POD 5), pain (7% on POD 3, 2% on POD 4), lack of mobilization (1% on POD 4, 1% on POD 5), and other causes (urinary retention, high drain output, and complications to the surgery). CONCLUSION: Causes for prolonged hospitalization after OIHR were possibly reducible. Future efforts to improve the ERAS regime and reduce LOS after OIHR should focus on pain treatment- and prevention, alternatives to epidural treatment, and well-defined, evidence-based discharge criteria.

Factors affecting patient adherence to publicly funded colorectal cancer screening programmes: a systematic review.

OBJECTIVES: Colorectal cancer (CRC) is the third most common cancer. Many countries in Europe have already implemented systematic screening programmes as per the recommendations by the European Union. The impact of screening is highly dependent on participation rates. The aim of the study was to identify barriers, facilitators and modifiers to participation in systematised, stool sample-based, publicly financed CRC screening programmes. STUDY DESIGN: Systematic review. METHODS: A systematic search in PubMed, Embase, MEDLINE, CINAHL, Cochrane CENTRAL, Google Scholar and PsycINFO was undertaken. We included both qualitative and quantitative studies reporting on barriers and facilitators (excluding sociodemographic variables) to participation in stool sample-based CRC screening. Barriers and facilitators to participation were summarised and analysed. RESULTS: The inclusion criteria were met in 21 studies. Reported barriers and facilitators were categorised into the following seven themes (examples): psychology (fear of cancer), religion (believing cancer is the will of God), logistics (not knowing how to conduct the test), health-related factors (mental health), knowledge and awareness (lack of knowledge about the test), role of the general practitioner (being supported in taking the test by the general practitioner), and environmental factors (knowing someone who has participated in a screening programme). Six studies reported that non-participation was not due to a negative attitude towards screening for CRC. CONCLUSION: Many barriers to screening were found. It is important to work with peoples' fear of screening. Moreover, this review suggests that it might be possible to increase participation rates, if the population-wide awareness and knowledge of potential health benefits of CRC screening are increased and proper logistical support is provided.

Preoperative Hypoalbuminemia Predicts Early Mortality Following Open Abdominal Surgery in Patients Above 60 Years of Age.

BACKGROUND: Major abdominal surgery in older and frail patients is associated with considerable morbidity and mortality. Plasma albumin is routinely measured in the clinic and has been proposed as an indicator of frailty. This study aimed to investigate if plasma albumin is a predictor of mortality in older patients undergoing open abdominal surgery. MATERIALS AND METHODS: We conducted a single-center, register-based retrospective study of patients, aged ⩾60 years who underwent one of 81 open abdominal surgical procedures. Patients operated on during the period from January 1st, 2000 to May 31st, 2013 were consecutively identified in the Danish National Patient Registry. Plasma albumin was measured within 30 days prior to surgery and the primary endpoint was 30-day postoperative mortality. RESULTS: 3,639 patients were included of whom 68.2% underwent emergency surgery. The rate of severe hypoalbuminemia (plasma albumin < 28 g/L) was 43.4%. Preoperative plasma albumin was lower in patients with a fatal 30-day outcome (mean 20.6 g/L vs 30.1 g/L in survivors, p < 0.0001). Other independent predictive parameters of 30-day mortality were age, male sex, and emergency surgery. We present an algorithm including these four variables for the prediction of 30-day mortality for patients aged ⩾60 years undergoing open abdominal surgery. CONCLUSION: Preoperative plasma albumin is a predictor of 30-day mortality in patients above 60 years of age following open abdominal surgery. Assessment of plasma albumin in conjunction with other risk factors such as age, sex, and surgical priority may improve preoperative decision-making.

Mesh versus suture in elective repair of umbilical hernia: systematic review and meta-analysis.

BACKGROUND: Mesh repair of umbilical hernia has been associated with a reduced recurrence rate compared with suture closure, but potentially at the expense of increased postoperative complications and chronic pain. The objective of this systematic review and meta-analysis was to examine the outcomes after elective open mesh and suture repair for umbilical hernia in adults. METHODS: A literature search was conducted to identify studies presenting original data on elective open mesh and suture repair of umbilical hernia. The primary outcome was hernia recurrence. Secondary outcomes included surgical-site infection (SSI), seroma, haematoma and chronic pain. Meta-analyses were undertaken. RESULTS: The search resulted in 5353 hits and led to 14 studies being included (6 RCTs and 8 observational studies) describing a total of 2361 patients. Compared with suture, mesh repair was associated with a lower risk of recurrence (risk ratio (RR) 0·48, 95 per cent c.i. 0·30 to 0·77), with number needed to treat 19 (95 per cent c.i. 14 to 31). Mesh repair was associated with a higher risk of seroma (RR 2·37, 1·45 to 3·87), with number needed to harm 30 (17 to 86). There was no significant difference in the risk of SSI, haematoma or chronic pain. CONCLUSION: The use of mesh in elective repair of umbilical hernia reduced the risk of recurrence compared with suture closure without altering the risk of chronic pain.

ANTECEDENTES: La reparación con malla de la hernia umbilical se ha asociado con una tasa menor de recidivas en comparación con el cierre con suturas, pero potencialmente a expensas de un aumento de complicaciones postoperatorias y dolor crónico. El objetivo de esta revisión sistemática y metaanálisis fue examinar los resultados después de reparación abierta electiva con malla o suturas para la reparación de una hernia umbilical en adultos. MÉTODOS: Se llevó a cabo una búsqueda en la literatura para identificar estudios que presentaban datos originales sobre la reparación abierta electiva con malla y sutura de la hernia umbilical. El resultado primario fue la recidiva herniaria. Los resultados secundarios incluyeron la infección del sitio quirúrgico (surgical site infection, SSI), seroma, hematoma y dolor crónico. Se realizaron metaanálisis. RESULTADOS: En la búsqueda identificaron 5.353 documentos, incluyéndose 14 estudios (6 ensayos clínicos aleatorizados, 8 estudios observacionales) que presentaban datos de un total de 2.361 pacientes. En comparación con la sutura, la reparación con malla se asoció con un menor riesgo de recidiva (tasa de riesgo, risk ratio, RR 0,48, i.c. del 95% 0,30 a 0,77) y número necesario para tratar de 19 (i.c. del 95% 14 a 31). La reparación con malla se asoció con un mayor riesgo de seroma (RR 2,37, i.c. del 95% 1,45 a 3,87) y número necesario para provocar daño de 30 (i.c. del 95% 17 a 86). No hubo diferencia significativa en el riesgo de SSI, hematoma o dolor crónico. CONCLUSIÓN: El uso de malla en la reparación electiva de la hernia umbilical redujo el riesgo de recidiva en comparación con el cierre con sutura, sin modificar el riesgo de dolor crónico.