Bowel Lengthening Procedures in Children with Short Bowel Syndrome: A Systematic Review.

INTRODUCTION: The aims of the study are to systematically assess and critically appraise the evidence concerning two surgical techniques to lengthen the bowel in children with short bowel syndrome (SBS), namely, the longitudinal intestinal lengthening and tailoring (LILT) and serial transverse enteroplasty (STEP), and to identify patient characteristics associated with a favorable outcome. MATERIALS AND METHODS: MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) databases were searched from inception till December 2019. No language restriction was used. RESULTS: In all, 2,390 articles were found, of which 40 were included, discussing 782 patients. The median age of the patients at the primary bowel lengthening procedure was 16 months (range: 1-84 months). Meta-analysis could not be performed due to the incomparability of the groups, due to heterogeneous definitions and outcome reporting. After STEP, 46% of patients weaned off parenteral nutrition (PN) versus 52% after LILT. Mortality was 7% for STEP and 26% for LILT. Patient characteristics predictive for success (weaning or survival) were discussed in nine studies showing differing results. Quality of reporting was considered poor to fair. CONCLUSION: LILT and STEP are both valuable treatment strategies used in the management of pediatric SBS. However, currently it is not possible to advise surgeons on accurate patient selection and to predict the result of either intervention. Homogenous, prospective, outcome reporting is necessary, for which an international network is needed.

Emergency repair of inguinal hernia in the premature infant is associated with high direct medical costs.

PURPOSE: Inguinal hernia repair is frequently performed in premature infants. Evidence on optimal management and timing of repair, as well as related medical costs is still lacking. The objective of this study was to determine the direct medical costs of inguinal hernia, distinguishing between premature infants who had to undergo an emergency procedure and those who underwent elective inguinal hernia repair. METHODS: This cohort study based on medical records concerned premature infants with inguinal hernia who underwent surgical repair within 3 months after birth in a tertiary academic children's hospital between January 2010 and December 2013. Two groups were distinguished: patients with incarcerated inguinal hernia requiring emergency repair and patients who underwent elective repair. Real medical costs were calculated by multiplying the volumes of healthcare use with corresponding unit prices. Nonparametric bootstrap techniques were used to derive a 95 % confidence interval (CI) for the difference in mean costs. RESULTS: A total of 132 premature infants were included in the analysis. Emergency surgery was performed in 29 %. Costs of hospitalization comprised 65 % of all costs. The total direct medical costs amounted to €7418 per premature infant in the emergency repair group versus €4693 in the elective repair group. Multivariate analysis showed a difference in costs of €1183 (95 % CI -1196; 3044) in favor of elective repair after correction for potential risk factors. CONCLUSION: Emergency repair of inguinal hernia in premature infants is more expensive than elective repair, even after correction for multiple confounders. This deserves to be taken into account in the debate on timing of inguinal hernia repair in premature infants.

Prognostic value of age for chronic postoperative inguinal pain.

PURPOSE: Chronic postoperative inguinal pain (CPIP) is considered the most common and serious long-term problem after inguinal hernia repair. Young age has been described as a risk factor for developing chronic pain after several surgical procedures. Our aim was to assess if age has prognostic value on CPIP. METHODS: The database of a randomized trial; the LEVEL trial, 669 patients, TEP versus Lichtenstein, was used for analysis. Data on incidence and intensity of preoperative pain, postoperative pain and CPIP at 1 year were collected. The association of age with incidence and intensity of pain was assessed with regression analysis. Further, hernia type and surgical technique were studied in combination with age and CPIP as possible risk factors on CPIP over age alone. RESULTS: Younger patients (18-40 years) presented more often with CPIP than middle-aged patients (40-60 years) and elderly (>60 years); 43 vs. 29 vs. 19 %; overall 27 %. Younger and middle-aged patients had more frequently preoperative pain; 54 vs. 55 vs. 41 % and intensity of pain was higher during the first three postoperative days (VAS on day 1: 5.5 vs. 4.5 vs. 3.9 and on day 3: 3.8 vs. 2.9 vs. 2.6). Indirect-type hernias were seen more often in younger patients (77 vs. 51 vs. 48 %) and were not related to CPIP or with surgical technique. CONCLUSIONS: Almost one out of three patients experiences CPIP. The younger the patient, the higher the risk of CPIP. Hernia type and surgical technique did not influence CPIP.

Open or endoscopic total extraperitoneal inguinal hernia repair? A systematic review.

BACKGROUND: Although a large number of surgeons currently perform endoscopic hernia surgery using a total extraperitoneal (TEP) approach, reviews published to date are based mainly on trials that compare laparoscopic transabdominal preperitoneal (TAPP) repair with various types of open inguinal hernia repair. METHODS: A qualitative analysis of randomized trials comparing TEP with open mesh or sutured repair. RESULTS: In this review, 4,231 patients were included in 23 trials. In 10 of 15 trials, TEP repair was associated with longer surgery time than open repair. A shorter postoperative hospital stay after TEP repair than after open repair was reported in 6 of 11 trials. In 8 of 9 trials, the time until return to work was significantly shorter after TEP repair. Hospital costs were significantly higher for TEP than for open repair in all four trials that included an economic evaluation. Most trials (n = 14) reported no differences in subsequent recurrence rates between TEP and open repair. CONCLUSIONS: The findings showed that endoscopic TEP repair is associated with longer surgery time, shorter postoperative hospital stay, earlier return to work, and recurrence rates similar to those for open inguinal hernia repair. The procedure involves greater expenses for hospitals, but appears to be cost effective from a societal perspective. The TEP technique is a serious option for mesh repair of primary hernias.

Costs and quality of life after endoscopic repair of inguinal hernia vs open tension-free repair: a review.

BACKGROUND: The ongoing debate about the relative merits of endoscopic (EH) vs open mesh herniorrhaphy (OH) prompts the need for comparisons of outcome measures other than recurrence. Therefore, we reviewed data on the costs, time to return to work, quality of life (QoL), and pain associated with EH and OH. METHODS: Studies comparing EH to OH and explicitly involving costs or QoL were identified and reviewed. RESULTS: Eighteen studies were included. Direct in-hospital costs were higher for unilateral EH. Direct out-of-hospital costs were lower after EH in some studies. Indirect costs were lower for EH. Total costs were higher for EH in three studies and lower in one study. With EH, QoL was better, pain was less, operating time was longer, and time return to work and other activities was shorter. CONCLUSION: From a societal perspective, EH entails costs similar to OH but offers extra benefits to the patient in terms of QoL and pain.