One-thousand consecutive inguinal hernia repairs under unmonitored local anesthesia.

UNLABELLED: To evaluate the feasibility and safety of unmonitored local anesthesia (ULA) for elective open inguinal hernia repair, we made a prospective, consecutive data collection from 1000 operations on primary and recurrent hernias. Follow-up consisted of a questionnaire 1 mo after surgery and retrieval from the electronic patient data management system. In 921 ASA Group I and II and 79 ASA Group III and IV patients, the median age was 60 yr (range, 18-95 yr). ULA was converted to general anesthesia in 5 of 1000 cases, and 961 patients were discharged on the day of surgery after 95 min (median; interquartile range, 75-150); 29 patients had complications requiring surgical intervention. Within the first month, three patients died of causes unrelated to hernia surgery, and six had cardiovascular or respiratory events. The questionnaire was returned by 940 patients; 124 were dissatisfied with local anesthesia, day-case setup, or both, primarily because of intraoperative pain (n = 74; 7.8%). We conclude that open inguinal hernia repair can be conducted under ULA, regardless of comorbidity, with a small rate of deviation from day-case setup and minimal morbidity. It provides a safe alternative to other anesthetic techniques with an acceptable rate of satisfaction, but intraoperative pain relief needs improvement. IMPLICATIONS: Inguinal hernia repair can be safely performed under unmonitored local anesthesia with infrequent postoperative morbidity and acceptable satisfaction, but intraoperative pain may be a problem.

[Incidence of adverse events in hospitals. A retrospective study of medical records]. / Forekomsten af utilsigtede haendelser på sygehuse. En retrospektiv gennemgang af journaler.

INTRODUCTION: Over the past decade a number of studies on the incidence and preventability of adverse events in the health care have been published in the US, Australia and the UK. So far no similar study has been performed in Denmark. In order to determine whether foreign findings could be generalised to Danish health care, a pilot study on adverse events was carried out in Danish acute care hospitals. METHOD: Chart reviews were carried out on 1.097 acute care hospital admissions, sampled from the central Danish National Patient Register. The sample was truly proportional with no over-sampling of high-risks groups. Chart reviews was done in 17 different acute care hospitals, reviewing between 20 and 204 admissions per hospital. Adverse events was identified using a three-step procedure: 1) Nurse screening by 18 criteria identifying high-risk groups. 2) Independent reviews by pairs of consultants. 3) In case of disagreement between second step consultants, two additional independent reviews was performed by new consultants (internist and surgeon) followed by conference. All chart reviews were performed independent of medical specialty. All nurses and doctors were senior and experienced clinicians. RESULTS: In 114 admissions 176 Adverse Events (AEs) were identified. The prevalence of admissions with adverse events were 9.0% of all admissions. Preventability of adverse events was found in 46 of admissions (40.4% of AEs). The adverse events caused on average a 7.0 days prolonged hospital stay. Most adverse events resulted in minor, transient disabilities. Permanent disability or death in relation to adverse event were recorded in 30 admissions. DISCUSSION: The findings from the Danish Adverse Event Study are similar to the results found in Australia, United Kingdom and the United States. It is therefore recommended that further Danish research, is directed towards high-risk groups focussing on narratives and intervention and towards research in primary health care.

[Peroperative "lavage" and primary anastomosis in acute left-sided colon ileus]. / Peroperativ "lavage" og primaer anastomose ved akut venstresidig colonileus.

AIM: A description of technique, course and results of operation for left-sided obstruction of the colon with primary resection, perioperative lavage of the colon and primary anastomosis. DESIGN: Retrospective examination of case records. MATERIAL: From January 1st 1994-December 31st 1997 eight operations were performed including primary resection, perioperative lavage and primary anastomosis. RESULTS: No anastomotic leaks were found. One patient died five days postoperatively due to cardiac complications. Three patients had postoperative cardiopulmonary complications treated medically. One patient had rupture of the fascia, was reoperated, experienced wound infection, transient serum elevation of liver enzymes and underwent ERCP with papillotomy and extraction of stones from the common bile duct two months postoperatively. CONCLUSION: In this small series the technique has appeared safe, thus confirming previous reports.

[Surgical treatment of stomach cancer at a university hospital. A retrospective survey of the period 1990-1995]. / Kirurgisk behandling af cancer ventriculi på et universitetshospital. En retrospektiv opgørelse for perioden 1990-1995.

AIM: A retrospective study of 69 cases of gastric cancer seen during the period from 1/1-1990 to 31/12-1994 treated in a University Hospital. The aim of the study was to describe morbidity, mortality and identify independent prognostic variables for mortality. METHOD: Patient data were recovered from the hospital's central database. Mortality was chosen as end-parameter. Univariate log-rank-test identified statistically significant variables which were then analysed by Cox backward stepwise regressional analysis. MATERIAL: Sixty-nine patients were available for analysis, median age 73 years. Fifty-one patients underwent operation. Eighteen patients did not have a surgical procedure due to disseminated disease. The overall postoperative morbidity was 25% and postoperative mortality 10%. The overall five-year survival rate was 8%, 12% for operated patients, 35% after radical and 0% after non-radical or omitted surgery. Age, radicality of operation, type of operation, Borrmann's tumour classification, and degree of depth of local infiltration were identified as significant factors for survival. Cox's analysis identified type of operation (p = 0.0002) and Borrmann's tumour classification (p = 0.001) as independent variables. DISCUSSION: The overall five-year survival is low and has not changed over two decades in Denmark, whereas mortality and morbidity rates have improved. It should be recommended that: The treatment of gastric cancer must be centralised in order to develop preoperative examinations, operative technique and the necessary routine for the surgeons. All gastric ulcers must be considered malignant and biopsies taken accordingly.

Methods for assessment of future demand of medical doctors in Denmark.

BACKGROUND: Whereas supply prognoses is mainly a matter of establishing mathematical scenarios with ongoing adjustments of variables, reliable demand prognoses are more difficult and complex to establish. However, optimum use of human and educational resources and--on the other hand--sufficient supply of medical doctors calls for reliable supply as well as demand prognoses. METHODS: Based on a number of technical and political considerations the first demand prognosis was based on three different methods; 1. Changes in demand due to demographic changes. 2. An evaluation made by the owners of the hospitals. 3. An evaluation made by the scientific medical societies. RESULTS: The demand prognosis was found to be hampered by a number of limitations. Demographic changes beyond the next 10 years was found to be unreliable. Moreover, the demand observed during the last 20 years was only to a very limited extent explained by demographic changes. The owners of the hospitals could only prognosticate for an election period, i.e. for about 5 years,--and only in very general terms that were difficult to interpretate. From some counties the answers did only seem to be based on rather superficial analysis and gave very little information. Each of the Scientific Medical Societies claimed increasing demands for the next 25 years, despite marked expectations for diagnostic and therapeutic advantageous technological developments. The overall conclusion from the combined weighed analysis was an expected increase in the demand of medical doctors of about 1% per year in the short as well as in the long term (25 years). This should be compared to the observed development during the last 10 years, i.e. an annual increase of 1.7-1.8%.

Dimensioning of the postgraduate educational training in Denmark.

BACKGROUND: Postgraduate medical training in Denmark consists of basic training, offered to all medical doctors, followed by specialist training. The National Board of Health is responsible for the overall frame of medical training in Denmark and determines the number of trainee positions for each of the 42 specialities available. The total number of positions and their distribution between specialities are based on demand, supply and demographic considerations. Approximately 85% of medical doctors finalise specialist training. METHODS: Denmark is divided into three educational regions: North, South and East. Each region consists of counties, with their own administration. The National Board of Health approves each position for postgraduate training. All new positions and changes of existing positions are evaluated before approval by The National Board of Health. An updated version of the list of educational positions is available on the internet. CONCLUSION: The Danish governmental authorities have an efficient tool to control the dimensioning of the postgraduate medical education and thereby the production of specialists. Medical doctors can easily get information about where to obtain trainee positions. The majority of hospital departments improve their recruitment potential by participating in medical training. A number of structural changes, for instance establishing of medical centres and corporations within larger entities across an extended geographic area, specialisation between hospitals and reduced number of hospitals, calls for decentralisation of the administration in order to improve flexibility in the organisation of postgraduate medical training. However, the National Board of Health will still co-ordinate at the national level.

Feasibility of local infiltration anaesthesia for recurrent groin hernia repair.

OBJECTIVE: To describe the the feasibility of and patients' satisfaction with day case repair of recurrent inguinal hernias under unmonitored local anaesthesia. DESIGN: Prospective study. SETTING: Public service university hospital, Denmark. SUBJECTS: All patients with a reducible recurrent inguinal or femoral hernia unselectedly referred for elective repair during the 4-year period 1 September 1994 to 31 August 1998. INTERVENTIONS: Data were collected prospectively and consecutively from standardised, detailed files, a questionnaire 4 weeks postoperatively, and the Copenhagen Hospitals electronic patient data management system. MAIN OUTCOME MEASURES: Feasibility of local anaesthesia in the day case setting, patient satisfaction and morbidity. RESULTS: 215 consecutive operations for recurrent hernias were performed under unmonitored local anaesthesia. No conversion to general anaesthesia took place and no patients developed urinary retention. After 207 operations, the patients were discharged on the day of operation (96%), and the median time from the end of operation to discharge was 90 minutes (IQR 75-140). After 6 operations (3%), patients had complications that required surgical intervention. The 4-week questionnaire was returned after 208 operations (97%). 30 patients were dissatisfied, mainly because of intraoperative pain (17 patients, 8%). No mortality or cardiopulmonary morbidity was recorded during the first 30 days postoperatively. CONCLUSIONS: Open day-case repair of recurrent inguinal hernias can safely be conducted under unmonitored local anaesthesia with minimal morbidity. Intraoperative pain is the main topic that requires improvement.

[Patient satisfaction and duration of breast feeding]. / Patienttilfredshed og ammevarighed.

INTRODUCTION: Only two out of three Danish women follow the recommendations for duration of breast-feeding given by The Danish National Board of Health, which recommend it as the sole source of nutrition for at least the first four months of life. The present study was carried out to investigate the influence of patient satisfaction on the duration of breast-feeding. MATERIAL AND METHODS: Based on an earlier investigation into the satisfaction of primiparas with the public health service during pregnancy, delivery, and the puerperium, 145 women were interviewed by telephone about the period in which their child was fed solely by mother's milk. Mothers of twins and those who had had an elective caesarean or whose child had been transferred to the neonatal care unit were excluded. Data from the patient satisfaction study and data on the delivery retrieved from a local obstetric database were related to the duration of breast-feeding. RESULTS: The mean duration of breast-feeding only was four months with no association to the women's satisfaction with the public health service in general. There was, however, an association between the period of breast-feeding only and satisfaction with issues dealing specifically with breast-feeding. In women who had had an oxytocin infusion breast-feeding was more often well-established. No other event during labour related to the initiation or duration of breast-feeding. There was an insignificant trend towards more use of a pacifier or formula supplementation in the first days in women, who did not initiate breast-feeding. It is unknown whether this is a cause or a consequence. DISCUSSION: The initiation of breast-feeding is influenced by the woman's satisfaction with the public service in matters relating to breastfeeding. In other ways, it is a process that is difficult to disturb.

Prospective study of chronic pain after groin hernia repair.

BACKGROUND: The aim was to provide a detailed description of any residual pain 1 year after elective day-case open groin hernia repair under local anaesthesia. METHODS: This was a prospective consecutive case series study by questionnaire of 500 consecutive operations in 466 unselected adult patients 1 year after surgery. Pain was scored (none, mild, moderate or severe) at rest, while coughing and during mobilization, and compared with similar data collected 1 and 4 weeks after operation. RESULTS: Some 419 questionnaires were returned (response rate 93 per cent); 20 patients had died within the year and 30 data sets from patients who had a subsequent operation during the study were excluded. Eighty patients (19 per cent) reported some degree of pain, and 25 (6 per cent) had moderate or severe pain. Pain restricted daily function in 24 patients (6 per cent). The incidence of moderate or severe pain was higher after repair of recurrent than primary hernias (14 versus 3 per cent; P < 0.001). The risk of developing moderate or severe pain was increased in patients who had a high pain score 1 week after operation (9 versus 3 per cent; P < 0.05) and also in patients who had moderate or severe pain 4 weeks after operation (24 versus 3 per cent; P < 0.001). CONCLUSION: Chronic pain is a significant problem after open groin hernia repair. It may be worse after surgery for a recurrent hernia and may be predicted by the intensity of early postoperative pain.

Levobupivacaine vs bupivacaine as infiltration anaesthesia in inguinal herniorrhaphy.

We have compared the anaesthetic and analgesic efficacy of levobupivacaine with that of racemic bupivacaine in 66 male patients undergoing ambulatory primary inguinal herniorrhaphy. Patients were allocated randomly in a double-blind manner to local infiltration anaesthesia (0.25% w/v 50 ml) with either racemic bupivacaine (n = 33) or levobupivacaine (n = 33). Scores for intraoperative pain and satisfaction with anaesthesia were recorded, together with perception of postoperative pain and need for supplementary postoperative analgesic medications in the first 48 h after operation. Intraoperative satisfaction with the infiltration anaesthesia was similar, with median scores of 77 (levobupivacaine) and 80 (bupivacaine) (VAS; 100 mm = extremely satisfied). Time averaged postoperative pain scores (48 h) were 8 (levobupivacaine) and 10 (bupivacaine) in the supine position, 13 (levobupivacaine) and 12 (bupivacaine) while rising from the supine position to sitting, and 9 (levobupivacaine) and 13 (bupivacaine) while walking (VAS; 100 mm = worst pain imaginable) (ns). There was no difference in the use of peroral postoperative analgesics between the two groups. We conclude that racemic bupivacaine and its S-enantiomer levobupivacaine had similar efficacy when used as local infiltration anaesthesia in inguinal herniorrhaphy.

Short convalescence after inguinal herniorrhaphy with standardised recommendations: duration and reasons for delayed return to work.

OBJECTIVE: To provide a detailed description of post-herniorrhaphy convalescence. DESIGN: Prospective, descriptive, consecutive questionnaire case series. SETTING: Public university hospital, Denmark. PATIENTS: 100 consecutive patients treated for inguinal hernia. INTERVENTION: Elective open inguinal herniorrhaphy under local anaesthesia. One day convalescence for light/moderate and three weeks for strenuous physical activity was recommended. MAIN OUTCOME MEASURE: Duration of absence from work or main recreational activity. RESULTS: Overall median absence (including the day of operation) was 6 days (interquartile range 1-16). For unemployed patients it was 1 day (0-7), for patients with a light or moderate workload 6 days (3-12), and for those with a heavy workload 25 days (21-37). Among the 64 patients, who did not follow the recommendations, pain was contributory in 33 and advice from the general practitioner in 12. Pain was the main cause of impairment of activities of daily living. CONCLUSION: Well-defined recommendations for convalescence may, together with improved management of postoperative pain, shorten convalescence; they are essential in the evaluation of effects of different surgical techniques of herniorrhaphy on convalescence.

Pain after primary inguinal herniorrhaphy: influence of surgical technique.

BACKGROUND: Pain is an important problem after ambulatory hernia repair. To assess the influence of the surgical technique on postoperative pain, two separate randomized, patient-blinded, controlled trials were performed in men with an indirect inguinal hernia. STUDY DESIGN: In study A, 48 patients with an internal inguinal ring smaller than 1.5 cm were randomly allocated to either simple extirpation of the hernial sac or extirpation plus annulorrhaphy. In study B, 84 patients with an internal inguinal ring wider than 1.5 cm were randomly allocated to extirpation plus annulorrhaphy or extirpation plus Lichtenstein mesh repair (modified). All operations were performed under unmonitored local anesthesia with standardized perioperative analgesia using methadone and tenoxicam. Pain was scored daily for the first postoperative week and after 4 weeks on a four-point verbal-rank scale (no, light, moderate, or severe pain) during rest, while coughing, and during mobilization (rising to the sitting position). Use of supplementary analgesics (paracetamol) was recorded. Cumulative daily pain scores for the first postoperative week and the number of patients who used supplementary analgesics were the main outcome measures. RESULTS: There were no significant differences in cumulative pain scores or use of supplementary analgesics between the treatment groups in either study. Cumulative pain scores were significantly higher during coughing and mobilization than during rest in both studies. CONCLUSIONS: Choice of surgical technique for open repair of a primary indirect inguinal hernia has no influence on postoperative pain.

Cryoanalgesia: effect on postherniorrhaphy pain.

UNLABELLED: Cryoanalgesia versus sham treatment was applied to the ilioinguinal and iliohypogastric nerves after mesh repair of an inguinal hernia under local anesthesia in 48 male patients in a prospective, randomized, and observer- and patient-blinded trial. Pain was scored daily during rest, while coughing, and during mobilization to the sitting position for 1 wk and weekly for 8 wk on a four-point verbal rank scale. Use of supplementary analgesics and sensory disturbances were recorded. Assessments were made for allodynia, hyperalgesia, and mechanical pain detection thresholds 8 wk postoperatively. Cumulative pain scores for the first postoperative week were equal in the two groups, as was the use of analgesics. Eight weeks postoperatively, three cases of hyperalgesia to pinprick were detected in the cryoanalgesia group, and 10 patients in the cryoanalgesia group versus 5 in the sham-treatment group reported disturbed sensibility. We conclude that cryoanalgesia of the iliohypogastrical and ilioinguinal nerve does not decrease postherniorrhaphy pain. IMPLICATIONS: Does freezing of sensory nerves in the groin reduce pain after hernia repair? Extreme cold (-60 degrees C) was applied in a double-blind, randomized study. No difference in pain scores was found. Sensory disturbances were seen in treatment and control patients. Freezing cannot be recommended for pain relief after hernia repair.

Pain after groin hernia repair.

BACKGROUND: The purpose of the study was to provide a detailed description of postoperative pain after elective day-case open inguinal hernia repair under local anaesthesia. METHODS: This was a prospective consecutive case series study. After 500 hernia operations in 466 unselected patients aged 18-90 years, pain was scored (none, light, moderate or severe) at rest, while coughing and during mobilization, daily for the first postoperative week and after 4 weeks. Pain scores were added together over the first postoperative week. RESULTS: On days 1, 6 and 28, 66, 33 and 11 per cent respectively had moderate or severe pain while coughing or mobilizing. Total pain scores were higher while coughing or mobilizing than at rest (P < 0.001). Younger patients had higher total pain scores than older patients while coughing or mobilizing (P0< 0.01), but not at rest. No significant differences were found between types of surgery or hernia. CONCLUSION: Pain remained a problem despite the pre-emptive use of opioids, non-steroidal anti-inflammatory drugs and local anaesthesia, irrespective of surgical technique.

The feasibility, safety and cost of infiltration anaesthesia for hernia repair. Hvidovre Hospital Hernia Group.

Data from 400 consecutive elective ambulatory operations for inguinal hernia under unmonitored local anaesthesia with limited pre-operative testing were prospectively obtained by the use of standardised files and questionnaires to assess the feasibility, patient satisfaction and potential cost reductions for such a technique. The median age of the patients was 59 years, and 29 operations were performed in ASA group III patients. The median postoperative hospital stay was 85 min. Conversion to general anaesthesia was necessary only in two cases, and nine patients needed overnight admission. One week postoperative morbidity was low with one case of transient cerebral ischaemia and one case of pneumonia, but no case of urinary retention. On follow-up, 88% were satisfied with the procedure, including unmonitored local anaesthesia. The cost reduction was at least 160 Pounds per patient compared with general/regional anaesthesia. We conclude that elective inguinal herniorrhaphy may be performed routinely under unmonitored local anaesthesia with a low postoperative morbidity, a high satisfaction rate and significant cost reductions.

[Organization and results of ambulatory surgery for inguinal hernia]. / Organisation og resultater af ambulant kirurgi for hernia inguinalis.

The results of a reorganization of surgery for inguinal hernias within a department of surgical gastroenterology were assessed concerning staff simplifications, feasibility, patient satisfaction, safety, complications and resources. Five hundred consecutive, elective, open operations for unilateral reducible inguinal hernias were performed in 466 patients under local anaesthesia in an ambulatory setup. One hundred and fourteen of the operations were for a recurrent hernia. The median age was 60 years (44-74 years as 25% and 75% quartiles). Two of the operations were converted to general anaesthesia. The patients were discharged 85 min (median) post-operatively, but 12 patients were not discharged on the same day. Bleeding or wound infections in need of treatment were seen postoperatively in 1.6% and 1.6%, respectively. All patients were given a postoperative questionnaires with a response rate of 95%, 89% of the respondents were satisfied with the whole procedure, 11% were dissatisfied. A reorganization of surgery for inguinal hernias to a standardized ambulatory setup induced staff simplifications and saved resources with a preserved high patient satisfaction, safety and a low complication rate.