Suture fixation versus self-gripping mesh for open inguinal hernia repair: a systematic review with meta-analysis and trial sequential analysis.

INTRODUCTION: Morbidity following open inguinal hernia repair is mainly related to chronic pain. ProGrip™ is a self-gripping mesh which aims to reduce rates of chronic pain. The aim of this study is to perform an update meta-analysis to consolidate the non-superiority hypothesis in terms of postoperative pain and recurrence and perform a trial sequential analysis. METHODS: Systematic review of randomised controlled trials performed according to PRISMA guidelines. Pooled odds ratios with 95% confidence intervals (CI) were calculated using the Mantel-Haenszel (M-H) method. The primary outcome measure was postoperative pain and secondary outcomes were recurrence, operative time, wound complications, length of stay, re-operation rate, and cost. Trial sequential analysis was performed. RESULTS: There were 14 studies included in the quantitative analysis with 3180 patients randomised to self-gripping mesh (1585) or standard mesh (1595). At all follow-up time points, there was no significant difference in the rates of chronic pain between the self-gripping and standard mesh (risk ratio, RR 1.10, 95% confidence interval, CI 0.83-1.46). There were no significant differences in recurrence rates (RR 1.13, CI 0.84-2.04). The mean operating time was significantly shorted in the ProGrip™ mesh group (MD - 7.32 min, CI - 10.21 to - 4.44). Trial sequential analysis suggests findings are conclusive. CONCLUSION: This meta-analysis has confirmed no benefit of a ProGrip™ mesh when compared to a standard sutured mesh for open inguinal hernia repair in terms of chronic pain or recurrence. No further trials are required to address this clinical question.

Systematic review and meta-analysis of incisional hernia post-reversal of ileostomy.

PURPOSE: Incisional hernia following closure of loop ileostomy is a common problem. Assessment of the proportion of this complication is limited by small sample size and inconsistent reporting. The aim of this review was to provide an estimate of the proportion of incisional hernia following closure of loop ileostomy according to clinical and radiological diagnostic criteria and to investigate the association of bibliometric and study quality parameters with reported proportion. METHODS: A systematic review of PubMed, Embase, CENTRAL, ISRCTN Registry and Open Grey from 2000 onwards was performed according to PRISMA standards. Reporting on the type of stoma and mesh reinforcement after closure was mandatory for inclusion, whereas studies on paediatric populations were excluded. Fixed effect or random effects models were used to calculate pooled proportion estimates. Meta-regression models were formed to explore potential heterogeneity. RESULTS: 42 studies with 7166 patients were included. The pooled estimate of the proportion of incisional hernia after ileostomy closure was 6.1% (95% confidence interval, CI 4.4-8.3%). Proportion estimates for higher quality studies and studies reporting on incisional hernia as primary outcome were 9.0% (95% CI 6.3-12.7%) and 13.1% (95% CI 8.8-19.1%). Significant between-study heterogeneity was identified (P < 0.001, I2 = 87%) and the likelihood of publication bias was high (P = 0.028). Mixed effects regression showed that both year of publication (P = 0.034, Q = 4.484, df = 1.000) and defining hernia as a primary outcome (Q = 20.298, P < 0.001) were related to effect size. Method of follow-up and quality of the studies affected the proportion. CONCLUSION: The proportion of incisional hernia at ileostomy closure site is estimated at 6.1%. Reporting incisional hernia as primary or secondary outcome, the method of diagnosis, the year of publication and methodological quality are associated with reported proportion.

Open versus laparoscopic mesh repair of primary unilateral uncomplicated inguinal hernia: a systematic review with meta-analysis and trial sequential analysis.

BACKGROUND: One standard repair technique for groin hernias does not exist. The objective of this study is to perform an update meta-analysis and trial sequential analysis to investigate if there is a difference in terms of recurrence between laparoscopic and open primary unilateral uncomplicated inguinal hernia repair. METHODS: The reporting methodology conforms to PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. Randomised controlled trials only were included. The intervention was laparoscopic mesh repair (transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP)). The control group was Lichtenstein repair. The primary outcome was recurrence rate and secondary outcomes were acute and chronic post-operative pain, morbidity and quality of life. RESULTS: This study included 12 randomised controlled trials with 3966 patients randomised to Lichtenstein repair (n = 1926) or laparoscopic repair (n = 2040). There were no significant differences in recurrence rates between the laparoscopic and open groups (odds ratio (OR) 1.14, 95% CI 0.51-2.55, p = 0.76). Laparoscopic repair was associated with reduced rate of acute pain compared to open repair (mean difference 1.19, CI - 1.86, - 0.51, p ≤ 0.0006) and reduced odds of chronic pain compared to open (OR 0.41, CI 0.30-0.56, p ≤ 0.00001). The included trials were, however, of variable methodological quality. Trial sequential analysis reported that further studies are unlikely to demonstrate a statistically significant difference between the two techniques. CONCLUSION: This meta-analysis and trial sequential analysis report no difference in recurrence rates between laparoscopic and open primary unilateral inguinal hernia repairs. Rates of acute and chronic pain are significantly less in the laparoscopic group.

What interval between colorectal cancer resection and first surveillance colonoscopy? An audit of practice and yield.

AIM: Colonoscopic follow-up after colorectal cancer resection (CRC) is recommended to screen for anastomotic recurrence and metachronous neoplasia, although guidelines vary in the timings of the first investigation. We aimed to quantify current practice and yield of neoplasia at first colonoscopy in relation to time from original resection. METHOD: We conducted a retrospective case note study of all CRCs treated with curative intent within our hospital between two time periods: 2001-2003 and 2006-2007. Variables collected were the extent of preoperative luminal imaging, tumour site, procedure, timing and findings of initial colonoscopy, postoperative CT findings and mortality. The first follow-up colonoscopy findings including neoplasia formation and recurrence rates were matched with rates of complete preoperative luminal imaging. Two-year and 5-year outcomes were sought. RESULTS: A total of 863 patients underwent CRC with curative intent within these two time periods (518 vs 345). Colonoscopic follow-up rates by 2 years were 32.8%vs 54.1%. Within the first cohort 63.5% of patients underwent colonoscopy by 5 years. Significant volumes of neoplasia and resectable recurrences were found before 2 years within these groups. Earlier detection of recurrent malignancy was associated with an improved patient outcome. Complete preoperative screening of the bowel was not associated with a lower incidence of neoplasia at first postoperative colonoscopy. CONCLUSION: Our study demonstrates significant colonoscopic detection rates of neoplasia within 2 years of CRC. Patient outcomes were improved with earlier detection. We would therefore suggest an interval of no more than 2 years between resection and first surveillance colonoscopy.

How do you measure performance as a colonoscopist?

AIM: The aim of this study was to describe an easy and reproducible method of measuring clinical performance in colonoscopy. METHOD: Data from all endoscopy procedures performed within the main endoscopy unit at Derriford Hospital between January and December 2007 were analysed. Points were allocated for given procedures. A local health economic analysis revealed that at least 8 points (or four colonoscopies) must be performed to meet list costs. The clinical performance was described as a capability index of crude Caecal Intubation Rate (CIR) vs the mean Points Performed/Endoscopy List (points/list). RESULTS: Overall, 3884 colonoscopies were performed, with a mean crude CIR of 89.6% and 8.3 points/List. Only 7/23 endoscopists consistently met the Joint Advisory Group on Gastrointestinal Endoscopy (JAG) standard in a cost-effective way. An annual colonoscopy rate of ≥ 150 cases was associated with higher points per list (points/list) (P = 0.003). Endoscopists offering ≥ 15% of cases as training cases had significantly higher crude CIRs and points/list (P = 0.051; P = 0.017). CONCLUSIONS: Clinical performance is a function of quality provided in a cost-effective way. Our capability index is an effective and reproducible way of measuring clinical performance. Training was not associated with reduced volume.

Defining localities for health planning: a GIS approach.

The National Health Service in Britain is undergoing far-reaching changes. While District and Regional Health Authorities are currently merging, professionals agree that primary health care is most efficiently managed at the local level. This paper uses geographical information systems (GIS) capabilities to identify a nested hierarchy of localities for the management of primary health care in West Sussex, England. GIS coverages were developed which contained key criteria for defining local areas, including nodes or focal points of service provision, edges which act as physical or psychological barriers to movement, districts such as official administrative areas and interaction criteria such as journey to work, school and family doctor (GP) surgeries. Central to the derivation of the localities was a large matrix of patient to GP flows based on postcoded data. Once managed, these data revealed clear geographical patterns of patient to GP allegiance. A large-scale field survey obtained supporting information on the perception of areas from local residents.