The effects of a Virtual Fracture Care review protocol on secondary healthcare utilization in trauma patients requiring semi-acute surgery: a retrospective cohort study.

Purpose: The demand for trauma care in the Netherlands is increasing due to a rising incidence of injuries. To provide adequate trauma care amidst this increasing pressure, a Virtual Fracture Care (VFC) review protocol was introduced for treatment of musculoskeletal injuries to the extremities (MIE). This study aimed to assess the influence of the Dutch VFC review protocol on secondary healthcare utilization (i.e., follow-up appointments and imaging) in adult trauma patients (aged ≥18 years) who underwent semi-acute surgery (2-14 days after initial presentation) for MIE, compared to traditional workflows. We hypothesized utilization of VFC review would lead to reduced secondary healthcare utilization. Methods: This retrospective cohort study assessed the influence of VFC review on secondary healthcare utilization in adult trauma patients (aged ≥18 years) who underwent semi-acute surgery for a MIE. Patients treated before VFC review and the COVID-19 pandemic, from 1st of July 2018 to 31st of December 2019, formed a pre-VFC group. Patients treated after VFC review implementation from January 1st 2021 to June 30th 2022, partially during and after the COVID-19 pandemic (including distancing measures), formed a VFC group. Outcomes were follow-up appointments, radiographic imaging, time to surgery, emergency department reattendances, and complications. The study was approved by the local ethical research committee approved this study (WO 23.073). Results: In total, 2,682 patients were included, consisting of 1,277 pre-VFC patients, and 1,405 VFC patients. Following VFC review, the total number of follow-up appointments reduced by 21% and a shift from face-to-face towards telephone consultations occurred with 19% of follow-up appointments performed by telephone in the VFC group vs. 4% in the pre-VFC group. Additionally, VFC review resulted in a 7% reduction of radiographs, improved time scheduling of surgery, and a 56% reduction of emergency department reattendances. Registered complication rates remained similar. Conclusion: The utilization of VFC review for management of adult patients with a MIE requiring semi-acute surgery improves efficiency compared to traditional workflows. It results in a 21% follow-up appointment reduction, a shift from face-to-face to remote delivery of care, fewer radiographs, improved time scheduling of surgery, and reduces emergency department reattendances by 56%.

Complications and predictors associated with moderate to severe obstructive sleep apnoea in bariatric surgery: Evaluation of routine obstructive sleep apnoea screening.

PURPOSE: Obstructive sleep apnoea (OSA) is a breathing disorder resulting in blockage of airflow and hypo-oxygenation. The incidence of OSA in patients with class 2 or 3 obesity (Body Mass index, BMI >35) is 60-70%. Unfortunately, most bariatric patients are unaware they suffer from OSA. Untreated OSA can lead to perioperative cardiopulmonary complications. The aim of this study was to identify predictors associated with moderate to severe OSA and asses the incidence of OSA-related complications in a large cohort of patients who underwent OSA-screening and treatment if indicated before bariatric surgery. METHODS: All consecutive patients who underwent primary bariatric surgery between September 2013 and September 2019 were included. Univariable and multivariable logistic regression analysis was performed to identify potential predictors for moderate to severe OSA using sleep studies. RESULTS: A total of 2872 patients who underwent bariatric surgery were included for analysis. Overall, OSA was identified in 62.5% of all patients and moderate to severe OSA (AHI ≥15) in 28.6%. Independent predictors for moderate to severe OSA were male gender (p < 0.001), age (p < 0.001), preoperative BMI (p < 0.001), preoperative waist circumference (p < 0.001), hypertension (p < 0.001), and dyslipidaemia (p = 0.046). The incidence of OSA-related complications was low (0.8%) and not significantly different among the different OSA severity classes. CONCLUSION: This is the largest study to assess OSA presence and OSA-related complications in patients undergoing bariatric surgery. The incidence of potential OSA-related complications was low (0.8%). We believe focus could be shifted towards more cost-efficient strategies where OSA screening is omitted such as perioperative continuous monitoring.

Evaluation of CPAP adherence in bariatric patients diagnosed with obstructive sleep apnea: outcomes of a multicenter cohort study.

PURPOSE: Obstructive sleep apnea (OSA) is highly prevalent but mostly undiagnosed in obese patients scheduled for bariatric surgery. To prevent cardiopulmonary complications, many clinics perform preoperative OSA screening. Consequently, adequate adherence to continuous positive airway pressure (CPAP) therapy is essential but challenging. We aimed to evaluate CPAP adherence and its influence on postoperative outcomes. METHODS: In a prospective multicenter cohort study, we compared different perioperative strategies for handling undiagnosed OSA in bariatric patients. In this subgroup analysis, patients newly diagnosed with OSA were compared to those with pre-existing OSA. We assessed inadequate CPAP adherence, defined as < 4 h/night, between the preoperative period and 6 months postoperative. Cardiopulmonary complications and (un)scheduled ICU admissions were also evaluated. RESULTS: In total, 272 patients with newly diagnosed OSA (67.4%) and 132 patients with pre-existing OSA (32.6%) were included. Before surgery, 41 newly diagnosed patients used CPAP inadequately, compared to 5 patients with pre-existing OSA (15% vs. 4%, p = 0.049). Six months after surgery, inadequate CPAP use increased to 73% for newly diagnosed patients and 39% for patients with pre-existing OSA, respectively (p < 0.001). Incidences of cardiopulmonary complications, scheduled, and unscheduled ICU admissions were similar in the two study groups (p = 0.600, p = 0.972, and p = 0.980, respectively). CONCLUSION: Inadequate CPAP adherence is higher in bariatric patients newly diagnosed with OSA when compared to patients with pre-existing OSA. Strategies to increase CPAP adherence may be valuable when considering routine OSA screening and CPAP therapy in patients undergoing bariatric surgery. Further studies are needed to improve current guidelines on perioperative OSA management of obese patients. TRIAL REGISTRATION: POPCORN study, registered at Netherlands Trial Register, https://www.trialregister.nl/trial/6805 . ID no: 6805.

Direct discharge of patients with simple stable musculoskeletal injuries as an alternative to routine follow-up: a systematic review of the current literature.

PURPOSE: There is growing evidence that patients with certain simple stable musculoskeletal injuries can be discharged directly from the Emergency Department (ED), without compromising patient outcome and experience. This study aims to review the literature on the effects of direct discharge (DD) of simple stable musculoskeletal injuries, regarding healthcare utilization, costs, patient outcome and experience. METHODS: A systematic review was performed in Medline, Embase, CINAHL, Cochrane Library and Web of Science using PRISMA guidelines. Comparative and non-comparative studies on DD of simple stable musculoskeletal injuries from the ED in an adult/paediatric/mixed population were included if reporting ≥ 1 of: (1) logistic outcomes: DD rate (proportion of patients discharged directly); number of follow-up appointments; DD return rate; (2) costs; (3) patient outcomes/experiences: functional outcome; treatment satisfaction; adverse outcomes; other. RESULTS: Twenty-six studies were included (92% conducted in the UK). Seven studies (27%) assessed functional outcome, nine (35%) treatment satisfaction, and ten (38%) adverse outcomes. A large proportion of studies defined DD eligibility criteria as injuries being minor/simple/stable, without further detail. ED DD rate was 26.7-59.5%. Mean number of follow-up appointments was 1.00-2.08 pre-DD, vs. 0.00-0.33 post-DD. Return rate was 0.0-19.4%. Costs per patient were reduced by €69-€210 (ranging from - 38.0 to - 96.6%) post-DD. Functional outcome and treatment satisfaction levels were 'equal' or 'better' (comparative studies), and 'high' (non-comparative studies), post-DD. Adverse outcomes were low and comparable. CONCLUSIONS: This systematic review supports the idea that DD of simple stable musculoskeletal injuries from the ED provides an opportunity to reduce healthcare utilization and costs without compromising patient outcomes/experiences. To improve comparability and facilitate implementation/external validation of DD, future studies should provide detailed DD eligibility criteria, and use a standard set of outcomes. Systematic review registration number: 120779, date of first registration: 12/02/2019.

Adoption of direct discharge of simple stable injuries amongst (orthopaedic) trauma surgeons.

INTRODUCTION: The importance of routine follow-up of several relatively simple stable injuries (SSIs) is questionable. Multiple studies show that direct discharge (DD) of patients with SSIs from the Emergency Department results in patient outcomes and experiences comparable to 'standard care' with outpatient follow-up. The purpose of this study was to evaluate to which extent DD of SSIs has been adopted amongst trauma and orthopedic surgeons internationally, and to assess the variation in the management of these common injuries. METHODS: An online survey was sent to members of an international trauma- and orthopaedic surgery collaboration. Participants, all trauma- or orthopaedic surgeons, were presented with eleven hypothetical cases of patients with simple stable injuries in which they were asked to outline their treatment plan regarding number of follow-up appointments and radiographs, physiotherapy and when to start functional movement. The primary outcome was the proportion of surgeons selecting direct discharge (i.e. zero scheduled appointments), per injury. Secondary outcomes included clinical agreement (>80% of respondents answering similarly) on total number of follow-up appointments (0, 1 or ≥2), radiographs (0, 1 or ≥2), routine physiotherapy referral (yes/no) and when to start functional movement (weeks). RESULTS: 138 of 667 (20.7%) surgeons completed the survey. Adoption of direct discharge ranged from 4-45% of case examples. In 10 out of 11 cases, less than 25% of surgeons selected direct discharge. Clinical agreement regarding number of appointments and when to start functional movement was not reached for any of the injuries. There was clinical agreement on number of radiographs for one injury and for four injuries regarding routine referral to a physiotherapist. DISCUSSION: Despite available evidence, DD of SSIs has not been widely adopted worldwide. Practice variation still exists even for these common injuries. This variation suggests inefficiency and consequently unnecessarily high healthcare costs. (Orthopaedic) trauma surgeons are encouraged to evaluate their current treatment protocols of SSIs.

Correction to: Routine versus on demand removal of the syndesmotic screw; a protocol for an international randomised controlled trial (RODEO-trial).

An amendment to this paper has been published and can be accessed via the original article.

Feasibility of Postoperative Home Monitoring Using Video Consultation and Vital Sign Monitoring of Bariatric Patients.

RATIONALE: The length of hospital stay after bariatric surgery has decreased rapidly in recent years to an average of 1 day (one midnight). The transition from a controlled hospital environment to home environment may be a big step for patients. For these patients, home monitoring can be a substitute. METHODS: A pilot study of 84 morbidly obese patients undergoing either laparoscopic Roux-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (LGS) was performed. Home monitoring consisted of daily contact via video consultation and measurement of vital signs at home. The primary outcome was feasibility of home monitoring. Secondary outcomes were complications and patient satisfaction measured with a questionnaire (PSQ-18). RESULTS: In 77 of the 84 patients (92%), videoconference was possible on day 1, 74 patients (88%) on day 2 and 76 patients (90%) on day 3. Four patients (5%) were never reached. On day 1, 52 patients (62%) performed all instructed measurements, on day 2, 49 patients (58%) and on day 3, 63 patients (75%). Only 47 out of 84 patients (56%) measured the instructed amount of times on all 3 days. High satisfaction rates were reported in the patients receiving home monitoring. CONCLUSION: Our first experience with home monitoring was disappointing since home monitoring of vital signs had poor compliance and not all patients were able to use the application. Further refinement of the home monitoring tool is needed to increase compliance and utility of the tool.

Risk Factors Associated with Prolonged Hospital Stay and Readmission in Patients After Primary Bariatric Surgery.

INTRODUCTION: The introduction of enhanced recovery after surgery (ERAS) has resulted in a decrease in length of hospital stay of patients after bariatric surgery. The general length of hospital stay is 1 day. Some bariatric patients stay longer after an uncomplicated procedure or are readmitted for varying reasons. OBJECTIVES: The aim of the present study is to identify risk factors associated with prolonged hospital stay and readmissions. METHODS: A retrospective study of all patients who underwent a primary procedure (i.e. Roux-en-Y gastric bypass or sleeve gastrectomy) between January 2016 and January 2019 was performed. RESULTS: A total of 1669 patients who underwent primary laparoscopic Roux-en-Y gastric bypass (70.7%) or sleeve gastrectomy (29.3%) were included. The median length of stay was 1 day (range 1-69 days). In 138 patients (8.3%), a postoperative complication was diagnosed and 89 patients were readmitted (5.3%) within 30 days after discharge. Overall, 348 patients (20.9%) stayed longer than 1 day. Univariable analysis showed that depression, ASA III, sleeve gastrectomy and a perioperative and/or postoperative complication were significantly (p value < 0.05) associated with a prolonged stay. In the multivariable model depression, sleeve gastrectomy and postoperative complication were independent risk factors for prolonged stay. Univariable analysis of risk factors associated with readmission identified depression and perioperative and postoperative complications. Multivariable analysis for readmission demonstrated only presence of a postoperative complication was an independent risk factor. CONCLUSION: Depression, sleeve gastrectomy and postoperative complications were independent risk factors for prolonged stay. Postoperative complication was an independent risk factor for readmission.

The Influence of Body Contouring Surgery on Weight Control and Comorbidities in Patients After Bariatric Surgery.

INTRODUCTION: A considerable number of patients experience some long-term weight regain after bariatric surgery. Body contouring surgery (BCS) is thought to strengthen post-bariatric surgery patients in their weight control and maintenance of achieved improvements in comorbidities. OBJECTIVES: To examine the impact of BCS on long-term weight control and comorbidities after bariatric surgery. METHODS: We performed a retrospective study in a prospective database. All patients who underwent primary Roux-en-Y gastric bypass (RYGB) and presented for preoperative consultation of BCS in the same hospital were included in the study. Linear and logistic mixed-effect model analyses were used to evaluate the longitudinal relationships between patients who were accepted or rejected for BCS and their weight loss outcomes or changes in comorbidities. RESULTS: Of the 1150 patients who underwent primary RYGB between January 2010 and December 2014, 258 patients (22.4%) presented for preoperative consultation of BCS. Of these patients, 126 patients eventually underwent BCS (48.8%). Patients who were accepted for BCS demonstrated significant better ∆body mass index (BMI) on average over time (- 1.31 kg/m2/year, 95% confidence interval (CI) -2.52 - -0.10, p = 0.034) and percent total weight loss (%TWL) was significantly different at 36 months (5.79, 95%CI 1.22 - 10.37, p = 0.013) and 48 months (6.78, 95%CI 0.93 - 12.63, p = 0.023) after body contouring consultation. Patients who were accepted or rejected did not differ significantly in the maintenance of achieved improvements in comorbidities. CONCLUSION: BCS could not be associated with the maintenance of achieved improvements in comorbidities after bariatric surgery, whereas it could be associated with improved weight loss maintenance at 36 and 48 months after body contouring consultation. This association should be further explored in a large longitudinal study.

Trocar port scar quality in morbidly obese patients after bariatric surgery.

BACKGROUND: Patient satisfaction of scar quality and their influence on health-related quality of life (HRQoL) have never been investigated in morbidly obese patients. OBJECTIVES: Our objectives were (1) to assess scar quality 1 year post laparoscopic bariatric surgery by means of the Patient and Observer Scar Assessment Scale (POSAS), and (2) to examine the influence of patients' perception of scar quality on patients' HRQoL. SETTING: A large Bariatric Center of Excellence in the Netherlands. METHODS: This was a descriptive pilot study of patients who underwent primary laparoscopic bariatric surgery. One year after surgery, patients and 2 observers completed the POSAS. HRQoL was assessed by using the RAND-36. Agreement of POSAS scores between patients and observers was calculated with intraclass correlation coefficient. Correlations between POSAS scores and HRQoL scores were calculated with Spearman's rho. RESULTS: A total of 50 patients were included. Patients scored their scar quality worse than observers (21 versus 15-16), particularly on visual parameters (4-5 versus 2-3). Patients and observers showed poor agreement on all POSAS items (intraclass correlation coefficient = .16-.32). No significant correlations were detected between POSAS and HRQoL scores. CONCLUSION: While patient scar quality satisfaction was relatively low after bariatric surgery, these outcomes were not correlated with HRQoL. Bariatric surgeons should be aware that patients could have a different view on scar quality compared with them. This realization is important to manage patient expectations regarding scar quality after bariatric surgery. Effective communication may improve patient satisfaction as an outcome.

Routine versus on demand removal of the syndesmotic screw; a protocol for an international randomised controlled trial (RODEO-trial).

BACKGROUND: Syndesmotic injuries are common and their incidence is rising. In case of surgical fixation of the syndesmosis a metal syndesmotic screw is used most often. It is however unclear whether this screw needs to be removed routinely after the syndesmosis has healed. Traditionally the screw is removed after six to 12 weeks as it is thought to hamper ankle functional and to be a source of pain. Some studies however suggest this is only the case in a minority of patients. We therefore aim to investigate the effect of retaining the syndesmotic screw on functional outcome. DESIGN: This is a pragmatic international multicentre randomised controlled trial in patients with an acute syndesmotic injury for which a metallic syndesmotic screw was placed. Patients will be randomised to either routine removal of the syndesmotic screw or removal on demand. Primary outcome is functional recovery at 12 months measured with the Olerud-Molander Score. Secondary outcomes are quality of life, pain and costs. In total 194 patients will be needed to demonstrate non-inferiority between the two interventions at 80% power and a significance level of 0.025 including 15% loss to follow-up. DISCUSSION: If removal on demand of the syndesmotic screw is non-inferior to routine removal in terms of functional outcome, this will offer a strong argument to adopt this as standard practice of care. This means that patients will not have to undergo a secondary procedure, leading to less complications and subsequent lower costs. TRIAL REGISTRATION: This study was registered at the Netherlands Trial Register (NTR5965), Clinicaltrials.gov ( NCT02896998 ) on July 15th 2016.

Unexplained abdominal pain in morbidly obese patients after bariatric surgery.

BACKGROUND: There is an overall complication rate of 6.3%-10% after bariatric surgery. After ruling out anatomic/physical causes, there is a substantial group of patients who develop unexplained postsurgical abdominal pain. OBJECTIVES: To inventory the prevalence of unexplained abdominal pain after laparoscopic Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy and to determine predictive factors for unexplained abdominal pain. SETTING: Obesity Center Amsterdam, Amsterdam, the Netherlands. METHODS: A retrospective study in a prospective database was performed. Baseline characteristics and postoperative course were evaluated. RESULTS: A total of 1788 patients underwent laparoscopic Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy between November 2007 and April 2015. The average follow-up consisted of 33.5 months, without loss to follow-up. Abdominal pain was presented in 387 patients (21.6%). The study population consisted of 337 women (87.1%) and 50 men (12.9%); the mean age was 43.3 years (standard deviation 10.1) and the median preoperative body mass index was 43.7 kg/m². An explanation for abdominal pain was found in 246 of 387 patients (63.6%), whereas no explanation was found in 133 patients (34.4%). Revisional surgery was a significant predictor for unexplained pain (odds ratio 1.7; confidence interval 1.0-2.8; P = 0.037). CONCLUSION: A total of 133 patients (7.4%) experienced unexplained abdominal pain after laparoscopic bariatric surgery. Revisional surgery was found to be a significant predictive factor for this outcome. Present study results suggest that postoperative unexplained abdominal pain is a significant morbidity and should be part of the informed consent. More research is needed regarding further diagnosis and management and treatment.

Less negative appendectomies due to imaging in patients with suspected appendicitis.

BACKGROUND: The optimal diagnostics and treatment of acute appendicitis continues to be a challenge. We evaluated the implementation of the guideline "diagnostics and treatment in acute appendicitis" in 2010. This guideline states that, in every patient with clinically suspected acute appendicitis, an ultrasonography or CT scan is advised to confirm the diagnosis before surgery. PATIENTS AND METHODS: We selected all consecutive patients with acute appendicitis in our hospital in the years 2008 and 2011. We compared the use of imaging and the operation results in both years. RESULTS: In 2008, 228 patients were treated for acute appendicitis. In 43 %, imaging was performed. In 2011, 238 patients were treated; in 99 % of the cases, imaging was performed. A decrease in patients with negative appendectomy was seen from 19 % in 2008 to 5 % in 2011. Financial analysis showed a reduction in costs favoring 2011. CONCLUSIONS: The increased use of pre-operative imaging in patients with suspected acute appendicitis resulted in a cost-effective way to decrease the number of patients with negative appendectomies.

Adhesion prevention during laparotomy: long-term follow-up of a randomized clinical trial.

OBJECTIVE: The objective of the study was to determine the long-term effect of the use of a hyaluronic acid-carboxymethylcellulose membrane (Seprafilm) on the incidence of adhesions and subsequent small-bowel obstruction and chronic abdominal complaints after colorectal surgery (Hartmann's procedure). BACKGROUND: Adhesions occur frequently after abdominal surgery and are the most common cause of bowel obstruction, chronic abdominal pain, and infertility. The risk for adhesion-related readmission in the first 10 years after colorectal surgery is as high as 30%. To reduce the formation of adhesions, a mechanical barrier composed of hyaluronic acid and carboxymethylcellulose was developed, to prevent adherence of tissues after abdominal surgery. Long-term results concerning the incidence of small-bowel obstruction and chronic abdominal pain are lacking. METHODS: Between April 1996 and September 1998, 71 patients requiring Hartmann's procedure for sigmoid diverticulitis or obstructed rectosigmoid were randomized to either intraperitoneal placement of Seprafilm under the midline and in the pelvis or as a control. Direct visual evaluation of the incidence and severity of adhesions was performed laparoscopically in 42 patients at second-stage surgery for restoration of the continuity of the colon. The results of this study were published in 2002. In 2006, the patients' general practitioners were interviewed by means of a questionnaire concerning their patients' health. The patients who were still alive were interviewed and asked to fill out 2 questionnaires concerning pain and quality of life (VAS-pain score, EQ-5D, and SF-36). In 2009, the medical records of the patients were evaluated for adhesion-related hospital re-admissions. RESULTS: Of the 42 evaluated patients, 35 (16 in the Seprafilm group, 19 in the control group) could be enrolled in the long-term follow-up. Median follow-up was 126 months (range 41-148) for the Seprafilm group and 128 months (range 49-149) months for the control group. Incidence of chronic (3 months or longer existing) abdominal complaints was significantly lower in the Seprafilm group compared with controls (35.3% vs. 77.8%, respectively; P = 0.018). Incidence of small-bowel obstruction showed no significant difference in favor of the Seprafilm group; no small-bowel obstructions occurred in the Seprafilm group, whereas in the control group 2 cases of small-bowel obstruction were found to have occurred. Evaluation of the quality of life questionnaires did not reveal significant differences between the 2 groups. CONCLUSIONS: In Hartmann's procedure, Seprafilm placement does not provide protection against small-bowel obstruction. Incidence of chronic abdominal complaints is significantly lower after use of Seprafilm.

Long-term follow-up evaluation of chronic pain after endoscopic total extraperitoneal repair of primary and recurrent inguinal hernia.

BACKGROUND: Long-term data on chronic pain after endoscopic total extraperitoneal (TEP) hernia repair are hardly available. METHODS: Between January 1997 and December 1998, 416 patients with consecutive primary and recurrent inguinal hernia underwent endoscopic TEP hernia repair. Long-term follow-up evaluation was carried out from June 2007 to June 2008. The primary outcome measure was persistent pain and discomfort interfering with daily activity. RESULTS: The overall response rate was 66% (273 of 416 patients). Of the 416 patients, 85 (20%) had died of causes unrelated to hernia repair and 58 (14%) were lost to follow-up. A total of 177 patients were physically examined in the outpatient clinic. Because 96 patients were not able to visit the outpatient' clinic, they completed the survey by telephone. The median follow-up period was 10 years (range, 9-11 years). After TEP repair, 16 patients (6%) reported chronic groin pain, and 10 patients (4%) still experience pain at this writing after the 10-year follow-up period. One of the patients has experienced persistent pain and discomfort interfering with daily activity. Patients with preoperative pain have reported significantly more chronic pain (P = 0.03). CONCLUSIONS: Chronic groin pain after TEP repair of primary and recurrent inguinal hernia seems to have a low incidence after a 10-year follow-up period.

A 10-year follow-up study on endoscopic total extraperitoneal repair of primary and recurrent inguinal hernia.

BACKGROUND: To determine whether endoscopic repair is favorable in the long term, follow-up recurrence rates after 10 years need to be assessed. METHODS: Between January 1995 and January 1996, 306 consecutive patients underwent total extraperitoneal (TEP) inguinal hernia repair. Long-term follow-up assessment occurred from January 2006 to May 2006. RESULTS: After a 10-year follow-up period, six (4%) recurrences were found in the primary inguinal hernia group and three recurrences (11%) in the recurrent inguinal hernia group. Age, experience, hospital stay, and operating time were not significantly correlated with recurrences. CONCLUSION: The long-term results of TEP primary inguinal hernia repair demonstrate it to be an effective and safe procedure with an acceptable recurrence rate. Recurrence rates may be underestimated because the findings show that recurrences continue to occur for as long as 10 years.

Long-term follow-up of a randomized clinical trial of non-mesh versus mesh repair of primary inguinal hernia.

BACKGROUND: Prospective studies and meta-analyses have indicated that non-mesh repair is inferior to mesh repair based on recurrence rates in inguinal hernia. The only reliable way to evaluate recurrence rates after hernia surgery is by long-term follow-up. METHODS: Between September 1993 and January 1996, a multicentre clinical trial was performed, in which 300 patients with unilateral primary inguinal hernia were randomized to non-mesh or mesh repair. Long-term follow-up was carried out from June 2005 to January 2006. RESULTS: Median follow-up was 128 months for non-mesh and 129 months for mesh repair. The 10-year cumulative hernia recurrence rates were 17 and 1 per cent respectively (P = 0.005). Half of the recurrences developed after 3 years' follow-up. There was no significant correlation between hernia recurrence and age, level of expertise of the surgeon, contralateral hernia, obesity, history of pulmonary disease, constipation or prostate disease. CONCLUSION: After 10 years mesh repair is still superior to non-mesh hernia repair. Recurrence rates may be underestimated as recurrences continue to develop for up to 10 years after surgery.