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1.
Hernia ; 28(2): 621-628, 2024 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-38393496

RESUMO

INTRODUCTION: Since 2011, the German Hernia Society has developed the German Hernia School (GHS) as a standardized hernia surgery training program for younger surgeons, consisting of the Hernia Compact basic module. It is a standardized three day training program (cadaver workshop, ultrasound simulation training, and hands-on training). After 12 years of experience, a survey was conducted to evaluate the long term effect of this training. METHOD: Using an anonymous online-questionnaire, we contacted from September 2023 to October 2023 the Hernia Compact course participants via the congress organizer "Weitmeer" and the German Hernia Society. This online questionnaire contains 18 multiple choice questions regarding participants' age, gender, professional experience, participation in other modules of the German Hernia School, the effect of the course on their daily practice and their specific interest in hernia and abdominal wall surgery. RESULTS: A total of 146 participants responded to the anonymous online questionnaire. A majority of 132 of 146 participants (90.42%) responded that this course improved the quality of surgical and hernia training (n = 146, no missing data). 141 of 146 individuals (96.58%) recommended the course to surgical colleagues (n = 146, no missing data). There were 89.73% of participants, (n = 146, no missing data) that developed a specific interest in hernia and abdominal wall surgery after the course. For 78.08% (n = 146, no missing data) of participants hernia and abdominal wall surgery was one of the most important activities in their daily surgical practice. CONCLUSION: The standardized Hernia Compact basic course of the German Hernia School appears to have a huge impact on the quality of hernia surgery training in Germany and Austria. It might also help generate a specific interest in hernia surgery among participants.


Assuntos
Herniorrafia , Cirurgiões , Humanos , Herniorrafia/educação , Hérnia , Competência Clínica , Instituições Acadêmicas
2.
Hernia ; 28(1): 9-15, 2024 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-37843603

RESUMO

PURPOSE: The European Hernia Society guidelines of parastomal hernias, published in 2017, strongly recommend prophylactic synthetic non-absorbable mesh upon the construction of a permanent end colostomy to reduce the incidence of parastomal hernias. This study aims to evaluate the implementation of the guidelines in Germany. METHODS: This is a retrospective multicentric analysis conducted in December 2022 at the University Hospital Brandenburg an der Havel. Anonymous data on rectal resection without sphincter preservation in the period 2010-2020 were extracted from the German nationwide hospital discharge data set. Individuals with a hernia and < 18 years old were excluded. Another exclusion criterion was a performed colectomy or proctocolectomy with an ileoanal pouch and placement of an absorbable mesh. The primary endpoint was the annual rate of prophylactic parastomal mesh placement following rectal resection without sphincter preservation in Germany. Cases reporting both non-absorbable mesh placement and rectal resection without sphincter preservation were considered prophylactic mesh insertions. RESULTS: A total of 41,697 patients received a rectal resection without sphincter preservation and without non-absorbable mesh placement. Among these individuals, 27,089 were male and 14,608 were female. The rate of reoperations (3.1%) and the length of hospital stay (25.3 days ± 19.32) remained almost constant during these 10 years. The rate of prophylactic mesh placement was increasing from 0.2% (n = 8) in 2010 to 6.4% (n = 198) in 2020. CONCLUSIONS: Currently, only the minority of patients who have undergone rectal resection without sphincter preservation receive prophylactic mesh insertion.


Assuntos
Hérnia Incisional , Neoplasias Retais , Humanos , Masculino , Feminino , Adolescente , Telas Cirúrgicas , Estudos Retrospectivos , Alta do Paciente , Neoplasias Retais/cirurgia , Herniorrafia , Hérnia Incisional/cirurgia , Hospitais
3.
Ann Oncol ; 34(8): 660-669, 2023 08.
Artigo em Inglês | MEDLINE | ID: mdl-37201751

RESUMO

BACKGROUND: The multicenter, randomized, phase IV, intergroup AGO-B WSG PreCycle trial (NCT03220178) evaluated the impact of CANKADO-based electronic patient-reported outcome (ePRO) assessment on quality of life (QoL) in hormone receptor-positive, human epidermal growth factor receptor 2-negative locally advanced or metastatic breast cancer (MBC) patients receiving palbociclib and an aromatase inhibitor or palbociclib + fulvestrant. CANKADO PRO-React, a European Union-registered medical device, is an interactive autonomous application reacting to patient self-reported observations. PATIENTS AND METHODS: Between 2017 and 2021, 499 patients (median age 59 years) from 71 centers were randomized (2 : 1, stratified by therapy line) between an active version of CANKADO PRO-React (CANKADO-active arm) and a version with limited functionality (CANKADO-inform arm). A total of 412 patients (271 CANKADO-active; 141 CANKADO-inform) were available for analysis of the primary endpoint, time to deterioration (TTD) of QoL [10-point drop on the Functional Assessment of Cancer Therapy-General (FACT-G) score], using an Aalen-Johansen estimator for cumulative incidence function of TTD DQoL (QoL deterioration) with 95% pointwise confidence intervals (CIs). Secondary endpoints included progression-free survival (PFS), overall survival (OS), and DQoL. RESULTS: In all patients [intention-to-treat (ITT)-ePRO], cumulative incidence of DQoL was significantly more favorable (lower) in the CANKADO-active arm (hazard ratio 0.698, 95% CI 0.506-0.963). Among first-line patients (n = 295), the corresponding hazard ratio was 0.716 (0.484-1.060; P = 0.09), and in second-line patients (n = 117) it was 0.661 (0.374-1.168; P = 0.2). Absolute patient numbers declined in later visits; FACT-G completion rates were 80% and higher until about visit 30. Mean FACT-G scores showed a steady decline from baseline and an offset in favor of CANKADO-active. No significant differences in clinical outcome were observed between arms: median PFS (ITT population) was 21.4 (95% CI 19.4-23.7) (CANKADO-active) and 18.7 (15.1-23.5) months (CANKADO-inform); median OS was not reached (CANKADO-active) and 42.6 months (CANKADO-inform). CONCLUSIONS: PreCycle is the first multicenter randomized eHealth trial demonstrating a significant benefit for MBC patients receiving oral tumor therapy when using an interactive autonomous patient empowerment application.


Assuntos
Neoplasias da Mama , Humanos , Pessoa de Meia-Idade , Feminino , Neoplasias da Mama/patologia , Qualidade de Vida , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Piridinas/uso terapêutico , Receptor ErbB-2/metabolismo
4.
Chirurgie (Heidelb) ; 94(3): 230-236, 2023 Mar.
Artigo em Alemão | MEDLINE | ID: mdl-36786812

RESUMO

Inguinal hernia operations represent the most frequent operations overall with 300,000 interventions annually in Germany, Austria and Switzerland (DACH region). Despite the announced political willingness and the increasing pressure from the legislator to avoid costly inpatient treatment by carrying out as many outpatient operations as possible, outpatient treatment has so far played a subordinate role in the DACH region. The Boards of the specialist societies the German Hernia Society (DHG), the Surgical Working Group Hernia (CAH of the DHG), the Austrian Hernia Society (ÖHG) and the Swiss Working Group Hernia Surgery (SAHC) make inroads into this problem, describe the initial position and assess the current situation.


Assuntos
Hérnia Inguinal , Humanos , Hérnia Inguinal/cirurgia , Pacientes Ambulatoriais , Alemanha , Herniorrafia
5.
Nat Commun ; 13(1): 7505, 2022 12 13.
Artigo em Inglês | MEDLINE | ID: mdl-36513637

RESUMO

Dust devils (convective vortices loaded with dust) are common at the surface of Mars, particularly at Jezero crater, the landing site of the Perseverance rover. They are indicators of atmospheric turbulence and are an important lifting mechanism for the Martian dust cycle. Improving our understanding of dust lifting and atmospheric transport is key for accurate simulation of the dust cycle and for the prediction of dust storms, in addition to being important for future space exploration as grain impacts are implicated in the degradation of hardware on the surface of Mars. Here we describe the sound of a Martian dust devil as recorded by the SuperCam instrument on the Perseverance rover. The dust devil encounter was also simultaneously imaged by the Perseverance rover's Navigation Camera and observed by several sensors in the Mars Environmental Dynamics Analyzer instrument. Combining these unique multi-sensorial data with modelling, we show that the dust devil was around 25 m large, at least 118 m tall, and passed directly over the rover travelling at approximately 5 m s-1. Acoustic signals of grain impacts recorded during the vortex encounter provide quantitative information about the number density of particles in the vortex. The sound of a Martian dust devil was inaccessible until SuperCam microphone recordings. This chance dust devil encounter demonstrates the potential of acoustic data for resolving the rapid wind structure of the Martian atmosphere and for directly quantifying wind-blown grain fluxes on Mars.


Assuntos
Meio Ambiente Extraterreno , Marte , Poeira/análise , Vento , Atmosfera
6.
Science ; 378(6618): 412-417, 2022 10 28.
Artigo em Inglês | MEDLINE | ID: mdl-36302013

RESUMO

Two >130-meter-diameter impact craters formed on Mars during the later half of 2021. These are the two largest fresh impact craters discovered by the Mars Reconnaissance Orbiter since operations started 16 years ago. The impacts created two of the largest seismic events (magnitudes greater than 4) recorded by InSight during its 3-year mission. The combination of orbital imagery and seismic ground motion enables the investigation of subsurface and atmospheric energy partitioning of the impact process on a planet with a thin atmosphere and the first direct test of martian deep-interior seismic models with known event distances. The impact at 35°N excavated blocks of water ice, which is the lowest latitude at which ice has been directly observed on Mars.

8.
Nature ; 605(7911): 653-658, 2022 05.
Artigo em Inglês | MEDLINE | ID: mdl-35364602

RESUMO

Before the Perseverance rover landing, the acoustic environment of Mars was unknown. Models predicted that: (1) atmospheric turbulence changes at centimetre scales or smaller at the point where molecular viscosity converts kinetic energy into heat1, (2) the speed of sound varies at the surface with frequency2,3 and (3) high-frequency waves are strongly attenuated with distance in CO2 (refs. 2-4). However, theoretical models were uncertain because of a lack of experimental data at low pressure and the difficulty to characterize turbulence or attenuation in a closed environment. Here, using Perseverance microphone recordings, we present the first characterization of the acoustic environment on Mars and pressure fluctuations in the audible range and beyond, from 20 Hz to 50 kHz. We find that atmospheric sounds extend measurements of pressure variations down to 1,000 times smaller scales than ever observed before, showing a dissipative regime extending over five orders of magnitude in energy. Using point sources of sound (Ingenuity rotorcraft, laser-induced sparks), we highlight two distinct values for the speed of sound that are about 10 m s-1 apart below and above 240 Hz, a unique characteristic of low-pressure CO2-dominated atmosphere. We also provide the acoustic attenuation with distance above 2 kHz, allowing us to explain the large contribution of the CO2 vibrational relaxation in the audible range. These results establish a ground truth for the modelling of acoustic processes, which is critical for studies in atmospheres such as those of Mars and Venus.

9.
J Geophys Res Planets ; 127(12): e2022JE007523, 2022 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-37033152

RESUMO

Wind speeds measured by the Mars 2020 Perseverance rover in Jezero crater were fitted as a Weibull distribution. InSight wind data acquired in Elysium Planitia were also used to contextualize observations. Jezero winds were found to be much calmer on average than in previous landing sites, despite the intense aeolian activity observed. However, a great influence of turbulence and wave activity was observed in the wind speed variations, thus driving the probability of reaching the highest wind speeds at Jezero, instead of sustained winds driven by local, regional, or large-scale circulation. The power spectral density of wind speed fluctuations follows a power-law, whose slope deviates depending on the time of day from that predicted considering homogeneous and isotropic turbulence. Daytime wave activity is related to convection cells and smaller eddies in the boundary layer, advected over the crater. The signature of convection cells was also found during dust storm conditions, when prevailing winds were consistent with a tidal drive. Nighttime fluctuations were also intense, suggesting strong mechanical turbulence. Convective vortices were usually involved in rapid wind fluctuations and extreme winds, with variations peaking at 9.2 times the background winds. Transient high wind events by vortex-passages, turbulence, and wave activity could be driving aeolian activity at Jezero. We report the detection of a strong dust cloud of 0.75-1.5 km in length passing over the rover. The observed aeolian activity had major implications for instrumentation, with the wind sensor suffering damage throughout the mission, probably due to flying debris advected by winds.

10.
J Geophys Res Planets ; 127(12): e2022JE007605, 2022 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-37033154

RESUMO

Martian atmospheric dust is a major driver of weather, with feedback between atmospheric dust distribution, circulation changes from radiative heating and cooling driven by this dust, and winds that mobilize surface dust and distribute it in the atmosphere. Wind-driven mobilization of surface dust is a poorly understood process due to significant uncertainty about minimum wind stress and whether the saltation of sand particles is required. This study utilizes video of six Ingenuity helicopter flights to measure dust lifting during helicopter ascents, traverses, and descents. Dust mobilization persisted on takeoff until the helicopter exceeded 3 m altitude, with dust advecting at 4-6 m/s. During landing, dust mobilization initiated at 2.3-3.6 m altitude. Extensive dust mobilization occurred during traverses at 5.1-5.7 m altitude. Dust mobilization threshold friction velocity of rotor-induced winds during landing is modeled at 0.4-0.6 m/s (factor of two uncertainty in this estimate), with higher winds required when the helicopter was over undisturbed terrain. Modeling dust mobilization from >5 m cruising altitude indicates mobilization by 0.3 m/s winds, suggesting nonsaltation mechanisms such as mobilization and destruction of dust aggregates. No dependence on background winds was seen for the initiation of dust lifting but one case of takeoff in 7 m/s winds created a track of darkened terrain downwind of the helicopter, which may have been a saltation cluster. When the helicopter was cruising at 5-6 m altitude, recirculation was seen in the dust clouds.

11.
Hernia ; 26(1): 201-215, 2022 02.
Artigo em Inglês | MEDLINE | ID: mdl-33895891

RESUMO

INTRODUCTION: Using registry analyses, a large number of influencing factors on the perioperative outcome of groin hernia repair has been identified. The interactions between several influencing factors and differences in the influencing value have to date been inadequately investigated. METHODS: This retrospective analysis of prospectively collected data from the Herniamed Registry included all fully documented cases with minimum age of 16 years and groin hernia repair. Patients were assigned to the risk groups unilateral, bilateral, recurrent and emergency groin hernia repair. Multivariable analysis was performed to investigate the influence of confirmatory defined patient- and procedure-related characteristics on the outcome parameters intraoperative, postoperative general and postoperative surgical complications, complication-related reoperation and total perioperative complications. RESULTS: A highly significantly unfavorable association with the total perioperative complication rate was identified for emergency groin hernia repair, scrotal hernia, anticoagulant medication and coagulopathy. A significantly unfavorable relation with the total perioperative complication rate was found for recurrence procedure, bilateral repair, high age, ASA score III/IV, femoral hernia, antithrombotic medication, smoking, COPD and corticosteroid medication. A significantly favorable correlation with the total perioperative complication rate was observed for the laparo-endoscopic techniques, smaller defects, female gender, normal weight and medial hernia. CONCLUSION: Both the number of potential influencing factors and their influencing value on the perioperative outcome should be considered when estimating the individual risk of a patient with groin hernia repair.


Assuntos
Hérnia Inguinal , Laparoscopia , Adolescente , Feminino , Virilha/cirurgia , Hérnia Inguinal/complicações , Hérnia Inguinal/cirurgia , Herniorrafia/efeitos adversos , Herniorrafia/métodos , Humanos , Laparoscopia/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Recidiva , Estudos Retrospectivos , Fatores de Risco
12.
Hernia ; 26(3): 809-821, 2022 06.
Artigo em Inglês | MEDLINE | ID: mdl-34532811

RESUMO

INTRODUCTION: Groin hernia repair is performed increasingly more often as an outpatient procedure across the world. However, the rates are extremely different and vary between below 10% and above 90%. The outpatient procedure appears to negatively impact the proportion of laparo-endoscopic repairs. To date, only very few studies have compared inpatient vs outpatient groin hernia repair. METHODS: All outpatient and inpatient primary elective unilateral groin hernia repairs performed between 2010 and 2019 were identified in the Herniamed Registry and their treatment and outcomes compared. RESULTS: The 737 participating hospitals/surgeons performed a total of 342,072 primary elective unilateral groin hernia repairs from 2010 to 2019. The proportion of outpatient repairs was 20.2% in 2013 and 14.3% in 2019. Whereas the proportion of laparo-endoscopic repairs among the inpatient cases was 71.9% in 2019, the last year for which data are available, it was only 34.3%.for outpatient repairs. In outpatient groin hernia repairs, the rates of patients aged ≥ 60 years, with ASA score III and IV and risk factors were highly significantly lower. Given this rigorous patient selection for outpatient groin hernia repair, a more favorable perioperative outcome was achieved. At 1-year follow-up there were no significant differences in the pain and recurrence rates. CONCLUSION: With an appropriate patient selection, outpatient primary elective unilateral groin hernia repair can be performed with acceptable risks and good outcomes. Since to date no studies have compared inpatient vs outpatient groin hernia repair, the impact of a higher rate of outpatient groin hernia repair cannot currently be evaluated.


Assuntos
Hérnia Inguinal , Herniorrafia , Virilha/cirurgia , Hérnia Inguinal/complicações , Hérnia Inguinal/cirurgia , Herniorrafia/efeitos adversos , Herniorrafia/métodos , Humanos , Pacientes Internados , Pacientes Ambulatoriais , Complicações Pós-Operatórias/etiologia , Recidiva , Sistema de Registros
13.
Hernia ; 25(4): 891-903, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-34319466

RESUMO

INTRODUCTION: Rectus abdominis diastasis (RAD) ± concomitant hernia is a complex hernia entity of growing significance in everyday clinical practice. Due to a multitude of described surgical techniques, a so far missing universally accepted classification and hardly existing comparative studies, there are no clear recommendations in guidelines. Therefore, "RAD ± concomitant hernia" will be documented as a separate hernia entity in the Herniamed Registry in the future. For this purpose, an appropriate case report form will be developed on the basis of the existing literature. METHODS: A systematic search of the available literature was performed in March 2021 using Medline, PubMed, Google Scholar, Scopus, Embase, Springer Link, and the Cochrane Library. 93 publications were identified as relevant for this topic. RESULTS: In total 45 different surgical techniques for the repair of RAD ± concomitant hernia were identified in the surgical literature. RAD ± concomitant hernia is predominantly repaired by plastic but also by general surgeons. Classification of RAD ± concomitant hernia is based on a proposal of the German Hernia Society and the International Endohernia Society. Surgical techniques are summarized as groups subject to certain aspects: Techniques with abdominoplasty, open techniques, mini-less-open and endoscopic sublay techniques, mini-less-open and endoscopic subcutaneous/preaponeurotic techniques and laparoscopic techniques. Additional data impacting the outcome are also recorded as is the case for other hernia entities. Despite the complexity of this topic, documentation of RAD ± concomitant hernia has not proved to be any more cumbersome than for any of the other hernia entities when using this classification. CONCLUSION: Using the case report form described here, the complex hernia entity RAD ± concomitant hernia can be recorded in a registry for proper analysis of comparative treatment options.


Assuntos
Hérnia Ventral , Laparoscopia , Hérnia Ventral/cirurgia , Herniorrafia , Humanos , Reto do Abdome/cirurgia , Sistema de Registros
14.
Toxicology ; 456: 152783, 2021 05 30.
Artigo em Inglês | MEDLINE | ID: mdl-33872731

RESUMO

Our understanding of the etiology of cancer has developed significantly over the past fifty years, beginning with a single-hit linear no-threshold (LNT) conceptual model based on early studies conducted in Drosophila. Over the past several decades, multiple lines of evidence have accumulated to support a contemporary model of chemical carcinogenesis: a multi-hit model involving a prolonged stress environment that over time may drive the mutation of multiple cells into an injured state that ultimately could lead to uncontrolled proliferation via clonal expansion of mutation-carrying daughter cells. Arsenic carcinogenicity offers a useful case study for further exploration of advanced conceptual models for chemical carcinogenesis. A threshold for arsenic carcinogenicity is supported by its mode of action, characterized by repeating cycles of cytotoxicity and cellular regeneration. Furthermore, preliminary meta-analyses of epidemiology dose-response data for inorganic arsenic (iAs) and bladder cancer, correlated to dose-response data measured in vitro, support a threshold of effect in humans on the order of 50-100 µg/L in drinking water. In light of recent developments in our understanding of cancer etiology, we urge strong consideration of the existing mode-of-action evidence supporting a threshold of effect for arsenic carcinogenicity, as well as consideration of the potential methodological pitfalls in evaluating epidemiology dose-response data that could potentially bias in the direction of low-dose linearity.


Assuntos
Arsênio/toxicidade , Carcinogênese/induzido quimicamente , Carcinogênese/genética , Carcinógenos/toxicidade , Proliferação de Células/efeitos dos fármacos , DNA/genética , Animais , Carcinogênese/metabolismo , Proliferação de Células/fisiologia , DNA/metabolismo , Água Potável/efeitos adversos , Exposição Ambiental/efeitos adversos , Humanos
15.
Hernia ; 25(4): 1083-1094, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-33837884

RESUMO

INTRODUCTION: The proportion of epigastric hernias in the total collective of all operated abdominal wall hernias is 3.6-6.9%. The recently published guidelines for treatment of epigastric hernias of the European Hernia Society and the Americas Hernia Society recommend the use of a mesh for defect size of ≥ 1 cm, i.e., a preperitoneal flat mesh technique for sizes 1-4 cm, and laparoscopic IPOM technique for defects > 4 cm and/or obesity. Against that background, this analysis of data from the Herniamed Registry now aims to explore trends in epigastric hernia repair. METHODS: To detect trends, the perioperative outcome was calculated separately for the years 2010 to 2019 and the 1-year follow-up for the years 2010 to 2018 and significant differences were identified. Analysis was based on 25,518 primary elective epigastric hernia repairs. The rates of postoperative surgical complications, pain at rest, pain on exertion, chronic pain requiring treatment and recurrence associated with the various surgical techniques were calculated separately for each year. Fisher's exact test for unadjusted analysis between years was applied with Bonferroni adjustment for multiple testing. RESULTS: The proportion of laparoscopic IPOM repairs declined from 26.0% in 2013 to 18.2% in 2019 (p < 0.001). Instead, the proportion of open sublay repairs rose from 16.5% to 21.8% (p < 0.001). That was also true for innovative techniques such as the EMILOS, MILOS, eTEP and preperitoneal flat mesh technique (8.3% vs 15.3%; p < 0.001). This change in indication for the various surgical techniques led to a significant improvement in the postoperative surgical complication rate (3.8% vs 1.9%; p < 0.001). CONCLUSION: The trend is for epigastric hernia repair to be performed less often in laparoscopic IPOM technique and instead more often in open sublay technique or the new innovative techniques.


Assuntos
Dor Crônica , Hérnia Abdominal , Hérnia Abdominal/epidemiologia , Hérnia Abdominal/cirurgia , Herniorrafia/efeitos adversos , Humanos , Sistema de Registros , Telas Cirúrgicas
16.
Urologe A ; 60(4): 465-471, 2021 Apr.
Artigo em Alemão | MEDLINE | ID: mdl-33666669

RESUMO

BACKGROUND: In accordance with legal requirements, the Federal Joint Committee (German: Gemeinsamer Bundesausschuss, G­BA) decides based on the best available evidence which new diagnostic and treatment methods are reimbursed by statutory health insurance. If the benefit is proven with sufficient certainty, statutory health insurance providers pay for the new method, otherwise a trial study must be conducted. OBJECTIVES: To present the G­BA's decision-making options even in the case of insufficient evidence in the field of urology. MATERIALS AND METHODS: A document search was conducted on the homepage of the G­BA for the decisions about method evaluation and quality assurance in the field of urology of the last 10 years. The respective decisions are presented in the light of the decision options available in each case. RESULTS: Using the example of the debate on low-dose rate brachytherapy for localised prostate cancer, the years-long, ultimately futile, effort to increase the evidence base for an innovative method is presented. CONCLUSION: Compared to the development of guidelines, for example, the G­BA can only make dichotomous yes/no decisions and has to accept the often insufficient evidence situation, or (has to) try to increase the evidence base by initiating its own study. The latter is particularly difficult when specific methods are already established in routine care. A particular challenge is posed by new, especially invasive methods in the hospital sector, which has to be evaluated (benefit assessment) and, if necessary, tested by the G­BA with a trial study. To what extent this will succeed in the future is not yet foreseeable.


Assuntos
Medicina Baseada em Evidências , Programas Nacionais de Saúde , Alemanha , Humanos
17.
Hernia ; 25(5): 1199-1207, 2021 10.
Artigo em Inglês | MEDLINE | ID: mdl-33502639

RESUMO

INTRODUCTION: For many years the Shouldice technique was the gold standard for inguinal hernia repair. Nowadays mesh repair has been proven to entail better results in randomized trials. Since the first publication 1953 the Repair has been described in detail in many textbooks, articles and You Tube videos. It appears that the original technique is used almost exclusively in the Shouldice Hospital in Thornhill/ Canada and despite the success of the Shouldice Hospital many surgeons inexplicably modify this original technique in their daily practice. In the last couple of years there appears to be an increasing interest in pure tissue repairs for various reasons, often fear of mesh-related pain. The aim of the study was to review the current evidence and to define an updated standard with key principles of the Shouldice repair. METHODS: Because of unpublished evidence regarding many operative details the organizing group decided to create a technical update via a consensus meeting with 13 international designated hernia surgeons from six countries. In preparation of the meeting a review of the current literature regarding Shouldice repair was done by the organizing group. A questionnaire was prepared and sent to all participants before the meeting to get an independent answer on all critical aspects. RESULTS: All questions regarding a detailed standard of the operation technique could be outlined. As result of the consensus meeting the participants have formulated all key-points of preparation/dissection and repair of the Shouldice technique. For 5 of 6 critical technical surgical steps a strong consensus could be defined in the group. There was no consensus among the group regarding the cremaster resection and the ideal indication for Shouldice repair. CONCLUSION: After a 75-year history of the Shouldice repair the technique should continue to merit consideration by all hernia surgeons. After this consensus meeting a clear binding standard of the Shouldice technique for all interested surgeons is proposed.


Assuntos
Hérnia Inguinal , Herniorrafia , Consenso , Dissecação , Hérnia Inguinal/cirurgia , Humanos , Recidiva , Telas Cirúrgicas
19.
Hernia ; 25(3): 605-617, 2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-33237505

RESUMO

INTRODUCTION: Based on meta-analyses and registry data, the European Hernia Society and the Americas Hernia Society have published guidelines for the treatment of umbilical hernias. These recommend that umbilical hernia should generally be treated by placing a non-absorbable (permanent) flat mesh into the preperitoneal space with an overlap of the hernia defect of 3 cm. Suture repair should only be considered for small hernia defects of less than 1 cm. Hence, the use of a mesh in general is subject to controversial debate particularly for small (< 2 cm) umbilical hernias. This analysis of data from the Herniamed Registry now presents data on the treatment of small (< 2 cm) umbilical hernias over the past 10 years. METHODS: Herniamed is an Internet-based hernia registry in which hospitals and surgical centers in Germany, Austria and Switzerland can voluntarily enter data on their routine hernia operations. Between 2010 and 2019, data were entered into the Herniamed Registry by 737 hospitals/surgery centers on a total of 111,765 patients with primary elective umbilical hernia repair. The prospective data were analyzed retrospectively for each year and statistically compared. Due to a higher number of cases, the years 2013 and 2019 were compared for the perioperative outcome and the years 2013 and 2018 for 1-year follow-up. Fisher's exact test was applied for unadjusted analyses between the years, using a significance level of alpha = 5%. For post hoc tests of single categories, a Bonferroni adjustment for multiple testing was implemented. RESULTS: A mesh technique was used to treat 45.4% of all umbilical hernias. The proportion of small (< 2 cm) umbilical hernias in the total collective of umbilical hernias was 55.6%. Suture repair was used consistently over the 10-year period to treat around 75% of all small (< 2 cm) umbilical hernias. Preperitoneal mesh placement as recommended in the guidelines was used only in 1.8% of cases. Between 2013 and 2019, stable values of 2 and 0.7% were observed for the postoperative complications and complication-related reoperations, respectively, with no relevant effect identified for the surgical technique. At 1-year follow-up, significantly higher rates of pain at rest (2.6 vs. 3.3), pain on exertion (5.7 vs. 6.6), and recurrences (1.3 vs. 1.8) (all p < 0.05) were identified for 2018 compared with 2013. CONCLUSIONS: A suture technique is still used to treat 75% of patients with small (< 2 cm) umbilical hernias. The pain and recurrence rates are significantly less favorable for 2018 compared with 2013.


Assuntos
Hérnia Umbilical , Hérnia Umbilical/epidemiologia , Hérnia Umbilical/cirurgia , Herniorrafia/efeitos adversos , Humanos , Complicações Pós-Operatórias , Estudos Prospectivos , Recidiva , Sistema de Registros , Estudos Retrospectivos , Telas Cirúrgicas
20.
Hernia ; 25(1): 183-192, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-32157505

RESUMO

INTRODUCTION: Inguinal hernias are among the most common surgical diseases in Africa. The current International HerniaSurge Guidelines recommend mesh-based surgical techniques in Low Resource Settings (LRS). This recommendation is currently unachievable in large parts of Africa due to the unaffordability of mesh and lack of appropriate training of the few available surgeons. There is, therefore, a need for formal training in mesh surgery. There is an experience in Hernia Repair for the Underserved in Central and South America, however, inadequate evidence of structured training in Africa. MATERIAL AND METHODS: Since 2016, the aid Organizations, Surgeons for Africa and Operation Hernia have developed and employed a structured hernia surgical training program for postgraduate surgical trainees and medical doctors in Rwanda. This course consists of lectures on relevant aspects of hernia surgery and hands-on training in operating theatres. The lectures emphasize anatomy and surgical technique. All parts of the training were evaluated. Formal pre-course evaluation was conducted to assess the personal surgical experience of the trainees. RESULTS: Over a 3-year period, a structured hernia training programme was employed to train a total of 36 surgical trainees in both mesh and also non mesh hernia surgery. The key principle in this course is the continuous competence assessment and feedback. Evidence is provided to demonstrate improvement in surgical skills as well as knowledge of surgical anatomy which is essential to acquiring surgical competency. With self-assessment, expressed on a Likert scale, the participants could improve the theoretical knowledge about hernias from median 4.4 (on a scale of 1-10) before training to 8.4 after the training. The specific knowledge about anatomy could be improved in the same assessment from 4.8 before training to 8.1. after the training. After training course 12 of the 36 participants (33.33%) were able to carry out both suture- and mesh-based operations of simple inguinal hernias completely and independently. 20 of the 36 participants (55.55%) required only minimal supervision and only four participants (11.11%) required surgical supervision even after the completion of the course. CONCLUSION: We have demonstrated that, medical personnel in Africa can be trained in mesh and non-mesh hernia surgery using a structured training programme.


Assuntos
Educação de Pós-Graduação em Medicina , Cirurgia Geral/educação , Hérnia Inguinal , Herniorrafia/educação , Currículo/normas , Educação de Pós-Graduação em Medicina/normas , Hérnia Inguinal/cirurgia , Herniorrafia/normas , Humanos , Internato e Residência/normas , Ruanda , Telas Cirúrgicas
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