Page 14 - International guidelines for groin hernia management

Hernia

safe, symptoms will likely progress and an operation may WW policy was instituted in the United Kingdom for those
be needed. A follow-up cost analysis has yet to be reported. with asymptomatic IHs. Outcomes of approximately 1000
Another 2006 study randomized 160 men over the age patients before, and 1000 patients after, the policy’s
of 55 with asymptomatic IHs to either WW (80 patients) or inception were compared retrospectively. The period fol-
surgery (80 patients). 136 The primary outcome was pain at lowing the policy change saw a 59% rise in the incidence
1 year as measured by the SF-36. Cost was a secondary of emergent hernia repair (3.6 vs 5.5%). Emergent repair
outcome. At 6 months, improvement—in most SF-36 was also associated with significantly more adverse events
dimensions—was observed in the surgery group compared (4.7 vs 18.5%). Mortality spiked from 0.1 to 5.4%. How-
with the WW group. This effect had dissipated at ever, this was a retrospective study and did not report on
12 months and there were no significant inter-group dif- the prior histories of those requiring emergent herniorrha-
ferences in visual analogue pain scores at rest or with phies. Therefore, conclusions should be made with caution.
activity. Analgesic use between groups did not differ. The
only notable inter-group difference at 12 months was in a Discussion, consensus and clarification of grading
single SF-36 item indicating perceived change in health. The initial results of a WW strategy in men with asymp-
The 1-year crossover rate from surgery to WW was 10 and tomatic or minimally symptomatic IHs were promising.
19% from WW to surgery. A single hernia incarceration Complications occurred uncommonly and WW seemed
occurred at 574 days. Primary surgical repair added 407.9 cost effective in the short term. However, a longer-term
GBP in costs per patient (approximately $591 US). view revealed high crossover rates due to symptom
138
Long-term follow-up data were published in 2011. At development, mostly pain. Whether WW is ultimately cost
5 years, 54% had crossed over from WW to surgery and an effective remains to be determined.
estimated 72% crossed over at 7.5 years. The most com- Observational studies have shown that emergent
mon crossover reason was pain. The estimated median time herniorrhaphy is associated with increased morbidity and
between randomization and crossover was 4.6 years. In mortality. Unfortunately, it is not possible currently to
7.5 years, two patients required emergent hernia repair. accurately predict which WW patients will develop
The study’s authors concluded that a WW strategy is of symptoms or suffer a hernia complication. This fore-
little value since the majority of WW patients will require knowledge would of course allow more tailored
surgery in the near term. management.
Two systematic reviews have appraised primary repair Because of the increased morbidity and mortality asso-
versus WW for minimally symptomatic or asymptomatic ciated with emergent herniorrhaphy, the expert group
139, 140
IHs in men. Both reviews included mostly obser- advises that each patient with an asymptomatic or mini-
vational studies and pooled data on morbidity and mor- mally symptomatic inguinal hernia be informed about the
tality. Morbidity and mortality after elective repair was 8 expected natural history of their condition, the timing, and
and 0.2–0.5%, respectively, versus 32 and 4–5.5% fol- the risks of emergency hernia surgery. Although robust
lowing emergent repair (a 10- to 20-fold increase in mor- support for a WW strategy and timing of surgery is not to
tality). Risk factors for the observed increased morbidity be found in the present medical literature the expert group
and mortality include: age greater than 49 years, symptom has upgraded its recommendation on this subject. This is
duration, the presence of a femoral hernia, ASA class over because patient health-related, life style and social factors
two and nonviable bowel. Incarceration/strangulation risk should all influence the shared decision-making process
factors are: symptom duration, age and hernia site leading up to hernia management.
(femoral). However, the reviews acknowledge that the
incarceration/strangulation risk is low and that watchful
waiting may be justified in selected patients.
Notably, both systematic reviews were published prior Chapter 6
to the long-term RCTs cited above demonstrating
symptom development over time in most men with
minimally symptomatic or asymptomatic IHs. Symptom Surgical treatment of inguinal hernias
development (primarily pain) will prompt surgery. While
it is true that incarcerations rarely occur in the WW Th. J. Aufenacker, F. Berrevoet, R. Bittner, D. C. Chen, J.
group and are associated with defined risk factors, Conze, F. Kockerling, J. F. Kukleta, M. Miserez, M.
morbidity and mortality rates increase alarmingly when C. Misra, M. P. Simons, H. M. Tran, S. Tumtavitikul
an IH strangulates.
A 2014 study reported on clinical consequences after the
inception of a watchful waiting strategy. 141 Regionally, a

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