Value and patient appreciation of follow-up after endoscopic totally extraperitoneal (TEP) inguinal hernia repair.

PURPOSE: There is some consensus on inguinal hernia surgery follow-up in research settings. However, consensus on regular follow-up is lacking. Therefore, patients and surgeons are unnecessarily burdened and not cost-efficient. Moreover, the purpose of follow-up is barely questioned. This study aims to evaluate follow-up after inguinal hernia repair and determine patient satisfaction. METHODS: This prospective cohort study was executed in a high-volume specialized hernia clinic. All totally extraperitoneal (TEP) repair patients between July and October 2016 were included. Telephone follow-up was performed at 1 day, 6 weeks and 1 year postoperatively. One year postoperatively it was assessed whether patients visited other healthcare organizations, had remaining inguinal complaints, a Post-INguinal-repair-Questionnaire by telephone (PINQ-PHONE) was executed, and appreciation with follow-up was determined. RESULTS: Respectively, 6 weeks and 1 year postoperatively, 138 (79.3%) and 130 (74.7%) of 174 included patients were reached. One year postoperatively 15 patients (11.5%) had remaining inguinal complaints, of which only four patients (3.1%) had not already reported their symptoms. Nineteen patients (14.6%) presented with self-reported complaints between 6 weeks and 1 year, and no patients went to other hospitals. Respectively, 107 (82.3%), 61 (46.9%) and 117 (90.0%) patients considered follow-up useful at 6 weeks, 1 year and in general. One hundred nineteen patients (91.5%) preferred telephone follow-up to outpatient clinic appointments. CONCLUSION: TEP patients value a telephone follow-up time-point, however, long-term follow-up is not considered useful. Patients report postoperative complaints themselves, therefore performing follow-up serves no clinical purpose. The purpose of follow-up is patient satisfaction and registration for quality objectives.

Experience with the PINQ-PHONE telephone questionnaire for detection of recurrences after endoscopic inguinal hernia repair.

PURPOSE: The PINQ-PHONE is a 4-question telephone questionnaire designed and validated as a recurrence detection method after laparo-endoscopic inguinal hernia repair. The study aim was to evaluate the PINQ-PHONE by describing our experience with the questionnaire in a high-volume randomized-controlled trial. METHODS: The PINQ-PHONE was performed 5 years postoperatively after endoscopic totally extraperitoneal (TEP) repair. Positive PINQ-PHONE responses were compared with clinical assessments for a recurrence. An "experience with the PINQ-PHONE"-survey was conducted among the executing researchers. Furthermore, positive predictive values (PPV) for the separate questions and overall PINQ-PHONE were determined. RESULTS: Fifty-two of 769 responding patients (6.8%) had positive PINQ-PHONE responses and were invited to visit the outpatient clinic, thus preventing follow-up visits in 93.2% of included patients. Two recurrences were detected (0.3%). The overall PPV of the PINQ-PHONE was low (0.057). The PPV of question 1 (0.040) and 2 (0.100) was lower than that of question 3 (0.222) and 4 (0.286). The PPV of only question 3 and 4 combined was 0.183, and no recurrence would have been missed. The researcher survey unanimously produced that the PINQ-PHONE was user-friendly and executed in < 5 min, and questions 3 and 4 were considered adequate for recurrence detection. The majority found questions 1 and 2 to be inadequate questions. CONCLUSIONS: The PINQ-PHONE proved to be a valuable tool in TEP repair follow-up for recurrences. Enhancement of the PINQ-PHONE using only question 3 and 4 is recommended, since more patients refrain from outpatient clinic visits, and nevertheless, recurrences are safely detected.

Is young age a risk factor for chronic postoperative inguinal pain after endoscopic totally extraperitoneal (TEP) repair?

PURPOSE: A generally known risk factor for developing chronic postoperative inguinal pain after inguinal hernia repair is young age. However, studies discussing young age as a risk factor are mainly based on open repairs. The aim of this study was to determine if young adults (age 18-30) are also more prone to experience chronic postoperative inguinal pain after totally extraperitoneal (TEP) inguinal hernia repair, compared to older adults (age ≥ 31). METHODS: A prospective study was conducted in a high-volume TEP hernia clinic in 919 patients. Patients were assessed using the Numeric (Pain) Rating Scale, Inguinal Pain Questionnaire and Carolina Comfort Scale preoperatively, at 3 months, 1 year and 2 years after TEP mesh repair. The primary outcome was clinically relevant pain in young adults compared to older adults at 3 months follow-up. Secondary outcomes were pain 1 and 2 years postoperatively, the impact of pain on daily living, foreign body feeling and testicular pain. Furthermore, age categories were analyzed to determine potential age-dependent risk factors. RESULTS: Follow-up was completed in 867 patients. No significant difference was found between young adults and older adults for clinically relevant pain at 3 months follow-up (p = 0.723). At all follow-up time points, no significant differences were found for clinically relevant pain, any pain, mean pain scores, the Inguinal Pain Questionnaire and the Carolina Comfort Scale. The subgroup analyses showed no age-dependent risk factor. CONCLUSIONS: Young age is not associated with a higher risk of chronic postoperative inguinal pain after endoscopic TEP hernia repair.

Atypical E2Fs inhibit tumor angiogenesis.

Atypical E2F transcription factors (E2F7 and E2F8) function as key regulators of cell cycle progression and their inactivation leads to spontaneous cancer formation in mice. However, the mechanism of the tumor suppressor functions of E2F7/8 remain obscure. In this study we discovered that atypical E2Fs control tumor angiogenesis, one of the hallmarks of cancer. We genetically inactivated atypical E2Fs in epithelial and mesenchymal neoplasm and analyzed blood vessel formation in three different animal models of cancer. Tumor formation was either induced by application of 7,12-Dimethylbenz(a)anthracene/12-O-Tetradecanoylphorbol-13-acetate or by Myc/Ras overexpression. To our surprise, atypical E2Fs suppressed tumor angiogenesis in all three cancer models, which is in a sharp contrast to previous findings showing that atypical E2Fs promote angiogenesis during fetal development in mice and zebrafish. Real-time imaging in zebrafish displayed that fluorescent-labeled blood vessels showed enhanced intratumoral branching in xenografted E2f7/8-deficient neoplasms compared with E2f7/8-proficient neoplasms. DLL4 expression, a key negative inhibitor of vascular branching, was decreased in E2f7/8-deficient neoplastic cells, indicating that E2F7/8 might inhibit intratumoral vessel branching via induction of DLL4.

Athletes with inguinal disruption benefit from endoscopic totally extraperitoneal (TEP) repair.

PURPOSE: Inguinal disruption, a common condition in athletes, is a diagnostic and therapeutic challenge. The aim of this study was to evaluate the effect of endoscopic totally extraperitoneal (TEP) repair in athletes with inguinal disruption, selected through a multidisciplinary, systematic work-up. METHODS: An observational, prospective cohort study was conducted in 32 athletes with inguinal disruption. Athletes were assessed by a sports medicine physician, radiologist and hernia surgeon and underwent subsequent endoscopic TEP repair with placement of polypropylene mesh. The primary outcome was pain reduction during exercise on the numeric rating scale (NRS) 3 months postoperatively. Secondary outcomes were sports resumption, physical functioning and long-term pain intensity. Patients were assessed preoperatively, 3 months postoperatively and after a median follow-up of 19 months. RESULTS: Follow-up was completed in 30 patients (94%). The median pain score decreased from 8 [interquartile range (IQR) 7-8] preoperatively to 2 (IQR 0-5) 3 months postoperatively (p < 0.001). At long-term follow-up, the median pain score was 0 (IQR 0-3) (p < 0.001). At 3 months, 60% of patients were able to complete a full training and match. The median intensity of sport was 50% (IQR 20-70) preoperatively, 95% (IQR 70-100) 3 months postoperatively (p < 0.001), and 100% (IQR 90-100) at long-term follow-up (p < 0.001). The median frequency of sport was 4 (IQR 3-5) times per week before development of symptoms and 3 (IQR 3-4) times per week 3 months postoperatively (p = 0.025). Three months postoperatively, improvement was shown on all physical functioning subscales. CONCLUSIONS: Athletes with inguinal disruption, selected through a multidisciplinary, systematic work-up, benefit from TEP repair.