Emergency inguinal hernioplasties in a tertiary public Hospital in Athens Greece, during the economic crisis.

BACKGROUND: Although the effect of the recent Greek economic crisis and austerity on the population's health and the health system effectiveness have been discussed a lot recently, data on common surgical conditions affecting large part of the population are missing. Using inguinal hernia as a model we investigated possible changes of citizens' attitude regarding the time of referral, the perioperative details and the intraoperative findings of the emergency hernioplasties. METHODS: The present retrospective study was conducted by a Department of Surgery in a tertiary public hospital of the Greek capital. We reviewed the records of all hernioplasties performed during two 5-year periods: 2005-2009 and 2012-2016, i.e. before and during the crisis focusing on the emergency ones (either incarcerated or strangulated). RESULTS: An equal number of hernioplasties was performed in both periods. During the crisis however, an emergency hernioplasty was significantly more probable (HR 1.269, 95% CI 1.108-1.1454, p = 0.001), at a younger age (p = 0.04), mainly in patients younger than 75 years old (p = 0.0013). More patients presented with intestinal ischemia (7 vs 18, p = 0.002), requiring longer hospitalization (5.2 vs 9.6 days, p = 0.04), with higher cost (560 ± 262.4€ vs 2125 ± 1180.8€ p < 0.001). In contrast the percentage of patients with intestinal resection, their hospitalization length and treatment-cost remained unchanged. During the crisis there was a non-significant increase of emergency patients requiring ICU postoperatively (0 vs 4, p = 0.07) and a non-significant 60% increase of emergency operations in migrants/refugees population (3.5% vs 5.8%, p = 0.28). Epidural anesthesia was significantly more frequent during the crisis. CONCLUSION: During the crisis: (i) the emergency hernioplasties increased significantly, (ii) more patients (exclusively Greek) presented with intestinal ischemia requiring longer hospitalization and higher treatment cost, (iii) the mean age of the urgently treated patients decreased significantly (iv) regional (epidural) anesthesia was more frequent. Although a direct causal relation could not be proven by the present study most observations can be explained by an increase of the patients who delayed the elective treatment of their hernia, and by a redistribution of the surgical workload towards big central hospitals. This can be prevented by adequately supporting the small district hospitals.

Long-term assessment of surgical and quality-of-life outcomes between lightweight and standard (heavyweight) three-dimensional contoured mesh in laparoscopic inguinal hernia repair.

BACKGROUND: Mesh weight is a possible contributor to quality-of-life outcomes after inguinal hernia repair. This study compares lightweight mesh versus heavyweight mesh in laparoscopic inguinal hernia repair. METHODS: A prospective, single-center, hernia-specific database was queried for all adult laparoscopic inguinal hernia repair with three-dimensional contoured mesh (3-D Max, Bard, Inc, New Providence, NJ) from 1999 to June 2016. Demographics and outcomes were analyzed. Quality of life was evaluated preoperatively and after 2 weeks, 4 weeks, 6 months, 12 months, and 24 months, using the Carolinas Comfort Scale. Univariate analysis and multivariate logistic regression were performed. RESULTS: A total of 1,424 laparoscopic inguinal hernia repair were performed with three-dimensional contoured mesh, with 804 patients receiving lightweight mesh and 620 receiving heavyweight mesh. Patients receiving lightweight mesh were somewhat younger (52.6 ± 14.8 years vs 56.3 ± 13.7 years, P < .0001), with slightly lower body mass indices (26.4 ± 9.9 vs 27.1 ± 4.3, P < .0001). Lightweight mesh was used less often in incarcerated hernias (12.5% vs 16.8%, P = .02). There were a total of 3 surgical site infections. There were no differences in complications between groups except for seroma. Although on univariate analysis, seromas appeared to occur more frequently with heavyweight mesh (21.5% vs 7.9%). On multivariate analysis, heavyweight mesh was not independently associated with seroma formation. Average follow-up was 20 months. Recurrence rates were similar between lightweight mesh and heavyweight mesh (0.7 vs 0.6% P > .05). At all points of follow-up (4 week to 3 years), quality-of-life outcomes of discomfort, mesh sensation, and movement limitation scores were similar between lightweight mesh and heavyweight mesh. CONCLUSION: Contoured lightweight mesh and heavyweight mesh in laparoscopic inguinal hernia repair yield excellent recurrence rates and no difference in postoperative complications or quality of life. Considering the lack of outcome difference with long-term follow-up, heavyweight mesh may be considered for use in laparoscopic inguinal hernia repair patients.

Prospective study of pain, quality of life and the economic impact of open inguinal hernia repair.

BACKGROUND: There are variations in quality of life (QoL) and reported risk of chronic pain after inguinal hernia repair. The aim of this study was to investigate the improvement in pain and QoL after open inguinal hernia repair, and the economic impact. METHODS: Patients undergoing open mesh repair of a primary unilateral inguinal hernia were stratified depending on preoperative levels of symptoms and pain. Short Form 36 (SF-36®) and EQ-5D™ questionnaires were filled in before, and at 3 and 12 months after surgery. EQ-5D™ data, together with information on the mean value of a quality-adjusted life-year and the societal cost of hernia repair, were used to calculate the monetary value of QoL gained and the mean return on investment. RESULTS: Of 225 patients who began the study, 184 completed follow-up at 12 months. Some 77·2 per cent reported improvement in pain and 5·4 per cent reported increased pain after surgery. Significant improvement in SF-36® scores, pain scores measured on a visual analogue scale (VAS), and symptoms were found in the majority of patients, even those with mild symptoms before surgery. For the whole group, the bodily pain score increased from 56·4 before surgery to 82·6 at 12 months after hernia repair (P < 0·050), and the VAS score decreased from a median of 4 to 0 (P < 0·050). The return on investment was positive for all groups of patients, including those with mild symptoms. CONCLUSION: QoL improves after open inguinal hernia repair, with a good return on investment independent of symptom severity.

Waiting for elective general surgery: impact on health related quality of life and psychosocial consequences.

BACKGROUND: Long waiting times for elective surgical treatment threaten timely care provision in several countries. The purpose of this study was to assess the impact of waiting for elective general surgery on the quality of life and psychosocial health of patients. METHODS: A cross-sectional questionnaire study with postoperative follow-up was performed among patients on waiting lists for surgical treatment of varicose veins (n = 176), inguinal hernia (n = 201), and gallstones (n = 128) in 27 hospitals. RESULTS: In each group the waiting period involved worse general health perceptions (GHPQ), more problems in quality of life (EuroQoL), and raised levels of anxiety (STAI) as compared to after surgery (all differences: p < 0.05). Quality of life was not affected in 19-36% of patients. Emotional reactions to waiting were most negative among patients with gallstones. Prior information about the duration of the wait reduced the negativity of these reactions (p < 0.05). Social activities were affected in 39% to 48% of the patients and 18%-23% of employed patients reported problems with work during the wait. Having waited a longer time was associated with worse quality of life among patients with inguinal hernia. Longer waited times also engendered more negative reactions to waiting among patients with inguinal hernia and gallstones (multilevel regression analysis, p < 0.01). CONCLUSION: Waiting for general surgery mainly involves a prolonged period of decreased health and an affected psychological and social life of the patient in waiting. Variation in the severity of these consequences across patients indicates that the prioritisation of patients could reduce the overall burden of waiting. Early information about the duration of the delay could further promote a patient's acceptance of waiting.

Quality of life assessment in patients with inguinal hernia.

BACKGROUND: The natural history of untreated inguinal hernia (IH) is poorly understood. Whether a delay in operative repair of IH leads to excessive physical suffering or significant psychosocial impairment is not known. This study attempts to quantify the morbidity of patients with IH by assessing their quality of life (QOL) while on a waiting list for IH surgery. METHODS: QOL was measured in adult patients with IH who were on the waiting list using a standardized SF-36 questionnaire. Scores were compared with a sample of age-, sex- and comorbidity-matched controls. RESULTS: A total of 143 patients were identified, of which 106 were included in the study. Patients with IH had significantly impaired QOL compared with comorbidity- and demographic-matched controls across all of the domains measured. Subgroup analysis showed an inverse relationship between the size of the IH and the QOL and patients employed in manual work tended to have lower QOL compared with those with sedentary vocations. CONCLUSIONS: In conclusion, we showed that the SF-36 score is a good measure of QOL in this patient group. Those patients on the elective waiting list for repair of IH have a significantly impaired QOL compared with age-, sex- and comorbidity-matched controls.

Assessment of patient functional status after surgery.

BACKGROUND: Improvement in day-to-day functioning is a valued outcome of surgical intervention. A new functional status assessment instrument, the Activities Assessment Scale (AAS), was designed for a randomized clinical trial evaluating laparoscopic versus open hernia repair procedures. STUDY DESIGN: The study data set included 2,164 patients at baseline and 1,562 patients at 3-month followup. Only male patients were enrolled in the trial. The psychometric characteristics of the AAS were examined in statistical analyses of cross-sectional and longitudinal data from the trial. Correlational analyses, factor analyses, and t-tests were used to evaluate scale performance. RESULTS: We found that the AAS was a reliable measure (Cronbach's Coefficient Alpha =0.85) in the patient population studied. Factor analyses identified three subscales (sedentary activities; ambulatory activities; work and exercise activities). Construct validity was demonstrated by a correlation of 0.65 between the AAS and the physical functioning (PF) dimension of the SF-36 (p < 0.001); comparisons between clinical subgroups further confirmed its validity (p < 0.001). Patients reporting improvement on the physical functioning dimension after surgery showed an effect size of 1.20 for preoperative-postoperative change in their AAS scores. CONCLUSIONS: The AAS has been demonstrated to be a reliable, valid, and clinically responsive instrument that can be used to evaluate patient functioning after hernia surgery. It is easy to administer and requires less than 5 minutes of patient time to complete. This measurement system may prove useful in assessing surgical outcomes in both research and office practice settings.