Do postoperative complications correlate to chronic pain following inguinal hernia repair? A prospective cohort study from the Swedish Hernia Register.

PURPOSE: To analyse if postoperative complications constitute a predictor for the risk of developing long-term groin pain. METHODS: Population-based prospective cohort study of 30,659 patients operated for inguinal hernia 2015-2017 included in the Swedish Hernia Register. Registered post-operative complications were categorised into hematomas, surgical site infections, seromas, urinary tract complications, and acute post-operative pain. A questionnaire enquiring about groin pain was distributed to all patients 1 year after surgery. Multivariable logistic regression analysis was used to find any association between postoperative complications and reported level of pain 1 year after surgery. RESULTS: The response rate was 64.5%. In total 19,773 eligible participants responded to the questionnaire, whereof 73.4% had undergone open anterior mesh repair and 26.6% had undergone endo-laparoscopic mesh repair. Registered postoperative complications were: 750 hematomas (2.3%), 516 surgical site infections (1.6%), 395 seromas (1.2%), 1216 urinary tract complications (3.7%), and 520 hernia repairs with acute post-operative pain (1.6%). Among patients who had undergone open anterior mesh repair, an association between persistent pain and hematomas (OR 2.03, CI 1.30-3.18), surgical site infections (OR 2.18, CI 1.27-3.73) and acute post-operative pain (OR 7.46, CI 4.02-13.87) was seen. Analysis of patients with endo-laparoscopic repair showed an association between persistent pain and acute post-operative pain (OR 9.35, CI 3.18-27.48). CONCLUSION: Acute postoperative pain was a strong predictor for persistent pain following both open anterior and endo-laparoscopic hernia repair. Surgical site infection and hematoma were predictors for persistent pain following open anterior hernia repair, although the rate of reported postoperative complications was low.

Is out-of-hours cholecystectomy for acute cholecystitis associated with complications?

BACKGROUND: Existing data on the safety of out-of-hours cholecystectomy are conflicting. The aim of this study was to investigate whether out-of-hours cholecystectomy for acute cholecystitis is associated with a higher risk for complications compared with surgery during office hours. METHODS: This was a population-based cohort study. The Swedish Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography Register (GallRiks) was used to investigate the association between out-of-hours cholecystectomy for acute cholecystitis and complications developing within 30 days. Data from patients who underwent cholecystectomy between 2006 and 2017 were collected. Out-of-hours surgery was defined as surgery commencing between 19.00 and 07.00 hours on weekdays, or any time at weekends (Friday 19.00 hours to Monday 07.00 hours). Multivariable logistic regression analysis was used to assess the risk of complications, with time of procedure as independent variable. The proportion of open procedures and proportion of procedures exceeding 120 min were also analysed. Adjustments were made for sex, age, ASA grade, time between admission and surgery, and hospital-specific features. RESULTS: Of 11 153 procedures included, complications occurred within 30 days in 1573 patients (14·1 per cent). The adjusted odds ratio (OR) for complications for out-of-hours versus office-hours surgery was 1·12 (95 per cent c.i. 0·99 to 1·28). The adjusted OR for procedures completed as open surgery was 1·39 (1·25 to 1·54), and that for operating time exceeding 120 min was 0·63 (0·58 to 0·69). CONCLUSION: Out-of-hours complications may relate to patient factors and the higher proportion of open procedures.

ANTECEDENTES: Los datos existentes sobre la seguridad de la colecistectomía fuera del horario laboral son discordantes. El objetivo de este estudio fue investigar si la colecistectomía para el tratamiento de la colecistitis aguda realizada fuera del horario laboral se asocia con un mayor riesgo de complicaciones en comparación con la cirugía efectuada durante el horario laboral. MÉTODOS: Se trata de un estudio de cohortes de base poblacional. Se utilizó el registro Swedish Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography Register (GallRiks) para examinar la asociación entre la colecistectomía por colecistitis aguda realizada fuera del horario laboral y las complicaciones a los 30 días. Se recogieron los datos de los pacientes en los que se realizó una colecistectomía entre 2006 y 2017. Se definió como cirugía fuera del horario laboral aquella realizada entre las 19:00 y las 07:00 de lunes a viernes y en cualquier momento durante los fines de semana (de viernes 19:00 a lunes 07:00) Se realizó un análisis de regresión logística multivariable para evaluar el riesgo de complicaciones, considerando la hora de la cirugía como variable independiente. También se analizó el porcentaje de intervenciones por vía abierta y el de aquellas cuya duración excedió de los 120 minutos. Se realizaron ajustes por sexo, edad, puntuación ASA, días desde el ingreso hasta la cirugía y características específicas del hospital. RESULTADOS: Se produjeron 1.573 (14,1%) complicaciones en las 11.153 intervenciones incluidas. La razón de oportunidades, odds ratio (OR) ajustada para las complicaciones comparando la cirugía fuera del horario laboral con la cirugía dentro del horario laboral, fue de 1,12 (i.c. del 95% 0,99-1,28). La OR ajustada para los procedimientos realizado por vía abierta fue de 1,39 (1,25-1,54). La OR ajustada para el tiempo operatorio > 120 minutos fue de 0,63 (0,58-0,69). CONCLUSIÓN: Las complicaciones que suceden en la cirugía efectuada fuera del horario laboral es más probable que se deban a factores relacionados con el paciente que con la hora del día en que se practica la cirugía. Debe tenerse en cuenta que las intervenciones realizadas por vía abierta fuera del horario laboral tienen una mayor morbilidad.

The Short-Form Inguinal Pain Questionnaire (sf-IPQ): An Instrument for Rating Groin Pain After Inguinal Hernia Surgery in Daily Clinical Practice.

BACKGROUND: The Inguinal Pain Questionnaire (IPQ) is a standardised and validated instrument for assessing persisting pain after groin hernia surgery. The IPQ is often perceived as being too extensive for routine use. The aim of this study was to develop and evaluate a condensed version of the IPQ in order to facilitate its use in daily clinical practice. METHODS: The condensed form, i.e. Short-Form Inguinal Pain Questionnaire (sf-IPQ), comprises two main items taken from the IPQ. Four hundred patients were recruited from the Swedish Hernia Register and were sent the IPQ, sf-IPQ and the Short-Form McGill Pain Questionnaire (SF-MPQ) three years after hernia repair. Ratings from the IPQ and the sf-IPQ were converted to a 12-point scale. The reported scores for the two shared items in the IPQ and sf-IPQ were compared using the Intraclass Correlation Coefficient (ICC), Cohen's kappa and McNemar's test. RESULTS: After two reminders, the response rate was 69.8% (n = 279/400). The ICC for the IPQ and sf-IPQ scores was 0.78 (95% confidence interval 0.73-0.82, p < 0.001). Cohen's kappa was 0.66 (95% confidence interval 0.55-0.77, p < 0.001). The sf-IPQ systematically indicated a higher pain score than the IPQ (p = 0.013). CONCLUSIONS: Despite the systematic difference in level of pain scored, correlation, consistency and agreement were seen between the IPQ and sf-IPQ. The forms appear to be interchangeable, though the sf-IPQ may be a more sensitive instrument. The condensed structure of the sf-IPQ is more user-friendly and shows promise as a useful tool in daily clinical practice.

Cyanoacrylate in nerve repair: transient cytotoxic effect.

Cyanoacrylate adhesive has been suggested as an alternative to suturing when repairing severed peripheral nerves. The authors examined the cytotoxic effect of ethyl-cyanoacrylate on the human neuroblastoma cell line SH-SY5Y and compared it with the effects of butyl-cyanoacrylate (Histoacryl), an adhesive approved for skin closure. Ethyl-cyanoacrylate or butyl-cyanoacrylate was applied in confluent SH-SY5Y cultures. Immediately, at 24h and at 7, 14, 21 and 28 days, cultures were photographed and analysed digitally. At corresponding intervals, cell death was quantified using a (51)Cr release assay. In cultures exposed to ethyl-cyanoacrylate or butyl-cyanoacrylate, cell death was observed predominantly in conjunction with the adhesive, causing a halo devoid of cells. Surviving cells showed neurodegenerative properties with loss of neuritis and reduction of body size up to 3 days post exposure. The inhibition halo diminished over time in both groups and at 28 days cells reached the margin of the adhesive in the ethyl-cyanoacrylate group. (51)Cr assay indicated significant cell death in exposed cultures, which rapidly decreased during the first 14 days. No significant differences were found between the adhesives. This study demonstrates that ethyl-cyanoacrylate and butyl-cyanoacrylate have a transient cytotoxic effect, which may explain the promising results when using cyanoacrylate for nerve repair.

Impact of surgeon-performed ultrasound on diagnosis of abdominal pain.

BACKGROUND: A randomised study was performed to evaluate the diagnostic accuracy of surgeon-performed ultrasound in the emergency department for patients presenting with abdominal pain. METHODS: Surgeons responsible for the examination of study patients underwent 4 weeks of ultrasound training. 800 patients who were attending the emergency department for abdominal pain were randomised to undergo or not undergo surgeon-performed ultrasound as a complement to standard examination. The preliminary diagnosis made by the surgeon, with or without ultrasound, was compared with the final diagnosis made by a senior surgeon 6-8 weeks later. RESULTS: Diagnostic accuracy was significantly higher in the group examined with ultrasound (64.7% vs 56.8%, p = 0.027). Ultrasound proved to be helpful in making or confirming a correct diagnosis in 24.1% of cases receiving ultrasound and to contribute in 2.9%. In 22.3% of patients the diagnosis of non-specific pain was confirmed by normal findings. Ultrasound was misleading in 10.2% of cases and had no influence on the diagnosis in 40.0%. CONCLUSION: For patients with acute abdominal pain, higher diagnostic accuracy is achieved when surgeons use ultrasound as a diagnostic complement to standard examination. The use of bedside ultrasound should be considered in emergency departments.

Laser-induced shock wave endothelial cell injury.

BACKGROUND AND OBJECTIVE: Several laser procedures, extracorporeal lithotripsies (ESWL), and high-velocity missile trauma generate pressure transients that are transmitted through the tissues. Despite several publications demonstrating shock wave-induced tissue injury, little is known about its pathophysiology. This study introduces an in vitro model for studying shock wave effects on endothelial cell (EC) monolayers. STUDY DESIGN/MATERIALS AND METHODS: A Nd:YAG laser-driven flyer-plate technique was used to generate shock waves. Physical characteristics were determined with a pressure transducer, a high-speed video camera, and sequential photography. Biological effects were studied with phase contrast and lightfield microscopy, computerized morphometry, immunocytochemistry, spectrophotometry, and enzyme-linked immunosorbent assay (ELISA). RESULTS: The shock waves generated were highly reproducible. Cavitation was verified and quantified, and its extent could be varied in the vials. Exposed cultures exhibited areas with cell membrane damage and cell detachment. Release of LD was elevated (P < 0.01) in exposed vials. The EC lesions were larger (>P < 0.01) in cultures submitted to high vs. low extent of cavitation. CONCLUSION: The flyer-plate model can be used to subject cell monolayers to defined and reproducible shock waves causing immediate cell injury similar to the previously reported vascular lesions associated with ESWL, pulsed lasers, and blast trauma. With the flyer-plate model, such lesions may be further studied on the cellular and subcellular levels.

Hydrogen peroxide induces endothelial cell atypia and cytoskeleton depolymerization.

Reactive oxygen intermediates induce cell injury in a variety of pathophysiological conditions. Human umbilical cord vein endothelial cell (HUVEC) cultures were exposed to 1 or 200 microM H2O2 for 15 min, and observed after 15 min, or 1, 4, 24, or 120 h. Factor VIII and the cytoskeletal proteins vimentin and tubulin were visualized immunocytochemically. Release of lactate dehydrogenase (indices of cell membrane injury) did not increase after H2O2 exposure; nor was cellular expression of factor VIII affected. 200 microM H2O2 induced cell contraction after 15 min which disappeared after 1 and 4 h, but was evident again after 24 h. Immediately after exposure, the filamentous structure of vimentin and tubulin disappeared, but normalized after 1 h. After 120 h, the cytoskeleton filaments were coarsened and disorganized, and an abundance of multinucleated giant cells were observed. Catalase (150 U/ml) abolished all effects of H2O2. One microM H2O2 did not induce any changes in HUVEC. Thus, the present concentrations of H2O2 did not induce cell necrosis or altered expression of factor VIII. Early, reversible cell contraction and depolymerization of cytoskeletal proteins were observed, followed by a delayed contraction and cell atypia after 200 microM H2O2.