Outcomes of Emergency Groin Hernia Repair in the Elderly: A Systematic Review.

Introduction: The number of surgeries for groin hernia (GH) among the elderly follows the increase in life expectancy of the population. The greater number and severity of comorbidities in this group increases the surgical risk, promoting discussion regarding the indication of elective surgery and the benefits of watchful waiting approach (WWA). The aim of the present study was to evaluate the outcomes of emergency hernia surgery among the elderly population. Materials and methods: A systematic review was performed in Pubmed and Scielo databases for the past early 10 years, until July 2022. The subject was groin hernia in the emergency setting focusing the elderly population. The PRISMA statement was followed and the classification of elderly was based on the World Health Organization's definition. Results: A total of 1,037 results were returned and we ended with nine original articles with emphasis in groin hernia in the emergency among the elderly population. In these subjects, the complications rate ranged between 21.2% and 28.9% and the mortality rate ranged between 1.2% and 6%. Cardiopulmonary disease, high ASA and Charlson's scales were associated with greater risk of complications and death. Conclusion: Emergency GH surgery in the elderly population carries an increased risk of complications and mortality. GH surgery is safe or, at least, less harmful when done electively. The risk and benefits of WWA and upfront surgery needs to be assessed and exposed to the patients. Our review sugest that elective surgery should be the option over WWA in this patient population.

Cohort cholecystectomies in the Brazilian public system: is access to laparoscopy universal after three decades?

OBJECTIVE: videosurgery in Brazil started in 1990 with the performance of laparoscopic cholecystectomy, being included by the public health system in 2008. We evaluated the current situation of the use of this technology in the Unified Health System (SUS - Sistema Único de Saúde). METHODS: from 2013 to 2019, 1,406,654 patients registered at the SUS Informatics Department (DATASUS) were analyzed to calculate the rate of laparoscopic cholecystectomies (LC) in relation to open cholecystectomies (OC). Patient characteristics, disease presentation and postoperative mortality were evaluated. RESULTS: the LC rate reached 41.5% (growth of 68%) with no decrease in the absolute number of OC. In University Hospitals (UH), the LC rate reached 91.96%. The open technique in emergencies was more associated with male patients, aged 60 years or older, with prolonged hospitalization and in the ICU. Those undergoing LC were less predisposed to postoperative death, both electively (OR 0.49; 95% CI 0.42 - 0.56; NNT=20) and urgently (OR 0.23; 95% CI 0.20 - 0.25; NNT ≅1), providing a protective effect. CONCLUSION: despite the increase in the indication of LC, the open technique during the years studied remained stable and the most used in the public health system in Brazil. The effectiveness of public health policies to shorten the complete implementation of videosurgery in SUS needs to be investigated in future epidemiological studies, as well as its impact on postoperative morbidity and mortality.

Cohort cholecystectomies in the Brazilian public system: is access to laparoscopy universal after three decades? / Colecistectomias em coorte no sistema público brasileiro: o acesso à laparoscopia é universal após três décadas?

ABSTRACT Objective: videosurgery in Brazil started in 1990 with the performance of laparoscopic cholecystectomy, being included by the public health system in 2008. We evaluated the current situation of the use of this technology in the Unified Health System (SUS - Sistema Único de Saúde). Methods: from 2013 to 2019, 1,406,654 patients registered at the SUS Informatics Department (DATASUS) were analyzed to calculate the rate of laparoscopic cholecystectomies (LC) in relation to open cholecystectomies (OC). Patient characteristics, disease presentation and postoperative mortality were evaluated. Results: the LC rate reached 41.5% (growth of 68%) with no decrease in the absolute number of OC. In University Hospitals (UH), the LC rate reached 91.96%. The open technique in emergencies was more associated with male patients, aged 60 years or older, with prolonged hospitalization and in the ICU. Those undergoing LC were less predisposed to postoperative death, both electively (OR 0.49; 95% CI 0.42 - 0.56; NNT=20) and urgently (OR 0.23; 95% CI 0.20 - 0.25; NNT ≅1), providing a protective effect. Conclusion: despite the increase in the indication of LC, the open technique during the years studied remained stable and the most used in the public health system in Brazil. The effectiveness of public health policies to shorten the complete implementation of videosurgery in SUS needs to be investigated in future epidemiological studies, as well as its impact on postoperative morbidity and mortality.

RESUMO Introdução: a videocirurgia no Brasil iniciou em 1990 com a realização da colecistectomia laparoscópica, sendo incluída pelo sistema público de saúde em 2008. Avaliamos a situação atual do emprego desta tecnologia no Sistema Único de Saúde (SUS). Métodos: de 2013 a 2019, 1.406.654 pacientes registrados no Departamento de Informática do SUS (DATASUS) foram analisados para calcular a taxa de colecistectomias laparoscópicas (CL) em relação a colecistectomias abertas (CA). Avaliaram-se características dos pacientes, apresentação da doença e mortalidade pós-operatória. Resultados: a taxa de CL atingiu 41,5%, com crescimento de 68%, sem ocorrer diminuição do número absoluto de CA. Já em Hospitais Universitários (HUs) a taxa de CL chegou a 91,96%. A técnica aberta em urgências esteve mais associada a pacientes masculinos, com 60 anos ou mais, à internação prolongada e em UTI. Aqueles submetidos à CL estiveram menos predispostos à morte pós-operatória, tanto em caráter eletivo (OR 0,49; IC 95% 0,42 - 0,56; NNT = 20) como na urgência (OR 0,23; IC 95% 0,20 - 0,25; NNT ≅ 1), conferindo efeito protetor. Conclusão: apesar do aumento da indicação da CL, a cirurgia aberta durante os anos estudados se manteve estável e a técnica mais utilizada no sistema público de saúde do Brasil. A efetividade de políticas de saúde pública para abreviar a completa implementação da videocirurgia no SUS necessita ser investigada em estudos epidemiológicos futuros, assim como seu impacto na morbimortalidade pós-operatória.