Search

Introduction and Purpose of the Study: Small bowel obstruction (SBO) accounts for a substantial proportion of emergency surgical admissions. Malignancy is a common cause of obstruction, either due to a primary tumour or intra-abdominal metastases. However, little is known regarding the current treatment or outcomes of patients with malignant SBO. This study aimed to characterise the treatment of malignant SBO and identify areas for potential improvement and compare overall survival of patients with malignant SBO to patients with non-malignant SBO., Materials and Methods: This was a subgroup analysis of a multicentre observational study of patients admitted with SBO. Details regarding these patients' diagnoses, treatments, and outcomes up to 1-year after admission were recorded. The primary outcome was overall survival in patients with malignant SBO., Results: A total of 316 patients with small bowel obstruction were included, of whom 33 (10.4%) had malignant SBO. Out of the 33 patients with malignant SBO, 20 patients (60.6%) were treated with palliative intent although only 7 patients were seen by a palliative team during admission. Nutritional assessments were performed on 12 patients, and 11 of these patients received parenteral nutrition. 23 patients underwent surgery, with the most common surgical interventions being loop ileostomies (9 patients) and gastrointestinal bypasses (9 patients). 4 patients underwent right hemicolectomies, with a primary anastomosis formed and 1 patient had a right hemicolectomy with a terminal ileostomy. Median survival was 114 days, and no difference was seen in survival between patients treated with or without palliative intent., Conclusion: Malignant SBO is associated with significant risks of short-term complications and a poor prognosis. Consideration should be given to the early involvement of senior decision-makers upon patient admission is essential for optimal management and setting expectation for a realistic outcome., (© 2024. The Author(s).)

Background: A trial of initial non-operative management is recommended in stable patients with adhesional small bowel obstruction. However, recent retrospective studies have suggested that early operative management may be of benefit in reducing subsequent recurrences. This study aimed to compare recurrence rates and survival in patients with adhesional small bowel obstruction treated operatively or non-operatively., Methods: This was a prospective cohort study conducted at six acute hospitals in Denmark, including consecutive patients admitted with adhesional small bowel obstruction over a 4-month interval. Patients were stratified into two groups according to their treatment (operative versus non-operative) and followed up for 1 year after their index admission. Primary outcomes were recurrence of small bowel obstruction and overall survival within 1 year of index admission., Results: A total of 201 patients were included, 118 (58.7 per cent) of whom were treated operatively during their index admission. Patients undergoing operative treatment had significantly better 1-year recurrence-free survival compared with patients managed non-operatively (operative 92.5 per cent versus non-operative 66.6 per cent, P <0.001). However, when the length of index admission was taken into account, patients treated non-operatively spent significantly less time admitted to hospital in the first year (median 3 days non-operative versus 6 days operative, P <0.001). On multivariable analysis, operative treatment was associated with decreased risks of recurrence (HR 0.22 (95 per cent c.i. 0.10-0.48), P <0.001) but an increased all-cause mortality rate (HR 2.48 (95 per cent c.i. 1.13-5.46), P = 0.024)., Conclusion: Operative treatment of adhesional small bowel obstruction is associated with reduced risks of recurrence but increased risk of death in the first year after admission., Registration Number: NCT04750811 (http://www.clinicaltrials.gov).prior (registration date: 11 February 2021)., (© The Author(s) 2023. Published by Oxford University Press on behalf of BJS Society Ltd.)

Purpose: Small bowel obstruction (SBO) is a common surgical emergency. Previous studies have shown the value computed tomography (CT) scanning in both confirming this diagnosis and identifying indications for urgent surgical intervention, such as strangulated bowel or closed loop obstructions. However, most of the literature is based on retrospective expert review of previous imaging and little data regarding the real-time accuracy of CT reporting is available. Here, we investigated the real-world accuracy of CT reporting in patients admitted with SBO., Methods: This was a multicentre prospective study including consecutive patients admitted with SBO. The primary outcomes were the sensitivity and specificity of CT scanning for bowel obstruction with ischaemia and closed loop obstruction. Data were retrieved from the original CT reports written by on-call radiologists and compared with operative findings., Results: One hundred seventy-six patients were included, all of whom underwent CT scanning with intravenous contrast followed by operative management of SBO. Bowel obstruction with ischaemia was noted in 20 patients, with a sensitivity and specificity of CT scanning of 40.0% and 85.5%, respectively. Closed loop obstructions were noted in 26 patients, with a sensitivity and specificity of CT scanning of 23.1% and 98.0%, respectively., Conclusions: The real-world accuracy of CT scanning appears to be lower than previously reported in the literature. Strategies to address this could include the development of standardised reporting schemas and to increase the surgeon's own familiarity with relevant CT features in patients admitted with SBO., (© 2023. The Author(s).)

Introduction: Inter-hospital variation in the management of small bowel obstruction (SBO) has been described in other countries, but the extent to which similar variations exist in Denmark remains unknown. This study aimed to compare the management of SBO between hospitals in Denmark and identify potential areas for improvement METHODS. This was a multicentre prospective study performed at six emergency hospitals. Patients aged ≥ 18 years with a diagnosis of SBO were eligible for inclusion. The primary study endpoints were the proportion of patients undergoing operative versus non-operative management, laparoscopic surgery versus open surgery and the success rate of non-operative management., Results: A total of 316 patients were included. No differences were noted in diagnostic pathways or operative versus non-operative management. However, variations were noted in compliance with peri-operative care bundles, ranging from 63.2% to 95.8%. The surgical approach also varied, with the use of laparoscopic surgery ranging from 20.7% to 71.0% (p less-than 0.001). Variations were also noted in duration of surgery (63-124 minutes, p less-than 0.001), time to re-introduction of normal diet and length of hospital stay (3-8.5 days, p less-than 0.001). No differences were observed in 30-day or 90-day mortality rates., Conclusion: The management of SBO in Denmark is relatively standardised. Future efforts should focus on improving adherence to multidisciplinary peri-operative protocols, optimising patient selection for laparoscopic surgery and standardising nutritional therapy., Funding: None., Trial Registration: NCT04750811., (Articles published in the DMJ are “open access”. This means that the articles are distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits any non-commercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.)

Aims: The optimal management of small bowel obstruction (SBO) remains a matter of debate and treatment varies internationally. In Denmark, a more surgically aggressive strategy has traditionally been used, but to what extent patient outcomes differ from international reports is unknown. This study aimed to describe the current management and outcomes of patients admitted with SBO in Denmark., Methods: This was a prospective cohort study conducted at six acute hospitals in Denmark over a 4-month period. Patients aged ≥ 18 years with a clinical or radiological diagnosis of SBO were eligible. Primary outcomes were 30 day morbidity and mortality rates., Results: 316 patients were included during the study period. The median age was 72 years and 56% were female. Diagnosis was made by computed tomography (CT) in 313 patients (99.1%), with the remaining three diagnosed clinically. Non-operative management was the initial strategy in 152 patients (48.1%) and successful in 119 (78.3%). Urgent surgery was performed in the remaining 164 (51.9%), with a laparoscopic approach used in 84 patients (51.2%). The entire cohort had a 30 day mortality rate of 7.3% and a 30 day morbidity rate of 17.1%., Conclusions: The management of SBO in Denmark differs markedly to previous international reports, with an almost ubiquitous use of CT for diagnosis and a high proportion of patients undergoing urgent surgery. Despite higher rates of surgery, patient outcomes are broadly similar to reports of more conservative strategies, perhaps due to a reduction in delayed operations., Trial Registration: Trial registration number: NCT04750811. Trial registration date: 11/02/2021., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Introduction: This is a systematic review of existing literature on the diagnostic modalities and treatment of traumatic abdominal wall hernia caused by bicycle handlebar injury in children. 
METHODS: A systematic literature search was conducted covering incidents involving children below 17 years of age. Data were extracted regarding gender, age, diagnostic modality, timing of surgery, location of hernia, associated injuries, management and recurrence of hernia.
 RESULTS: A total of 62 cases of handlebar hernia were included in the systematic review. CT scan was the most frequently used final diagnostic modality (52%) followed by 
ultrasonography (13%), explorative laparotomy (5%) and diagnostic laparoscopy (5%). Coexisting intraabdominal injuries were present in 57% of all hernias located in the upper abdomen. Open surgical repair was the preferred treatment of choice (85%). Laparoscopic suturing was performed in one study. Six cases of handlebar hernia were treated conservatively. No cases of recurrence of hernia were reported in any of the cases. 
CONCLUSIONS: Traumatic abdominal wall hernia can be visualized by ultrasonography, but CT scan is often used as the final diagnostic modality because of the risk of associated intra-abdominal injuries. Open surgical repair in layers or laparoscopic suturing during diagnostic laparoscopy may be appropriate in managing traumatic abdominal wall hernias in children. Non-surgical management has been described, but available data do not support a general recommendation for a non-surgical approach., (Articles published in the DMJ are “open access”. This means that the articles are distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits any non-commercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.)

Background: Duration of convalescence after inguinal hernia repair is of major socio-economic interest and an often reported outcome measure. The primary aim was to perform a critical analysis of duration of convalescence from work and activity and secondary to identify risk factors for unexpected prolonged convalescence after laparoscopic inguinal hernia repair., Methods: A qualitative systematic review was conducted. PubMed, Embase and the Cochrane database were searched for trials reporting convalescence after laparoscopic inguinal hernia repair in the period from January 1990 to January 2016. Furthermore, snowball search was performed in reference lists of identified articles. Randomized controlled trials and prospective comparative or non-comparative trials of high quality were included. Trials with ≥100 patients, >18 years of age and manuscripts in English were included. Scoring systems were used for assessment of quality., Results: The literature search identified 1039 papers. Thirty-four trials were included in the final review including 14,273 patients. There was overall a large variation in duration of convalescence. Trials using non-restrictive recommendations of 1-2 days or "as soon as possible to return to all activities" reported overall a shorter duration of convalescence compared with trials not using recommendations for convalescence. Strenuous physical activity at work, strenuous leisure activity and patients with expectations of a prolonged period of convalescence may be risk factors for prolonged convalescence extending more than a few days after laparoscopic inguinal hernia repair., Conclusions: Patients should be recommended a duration of 1-2 days of convalescence after laparoscopic inguinal hernia repair. Short and non-restrictive recommendations may reduce duration of convalescence without increasing risk of pain, complications or recurrence rate.

Background: Sexual life may be impaired by pain during sexual activity in patients with inguinal hernia. On the other hand, inguinal hernia repair has also been reported to cause sexual dysfunction in terms of pain during sexual activity and ejaculation. The primary aim of this study was to estimate the prevalence of pain during sexual activity before and after laparoscopic inguinal hernia repair, and the secondary, to describe pain location, frequency of pain during sexual activity, and to which degree sexual life was affected by the pain. Furthermore, to examine whether preoperative pain during sexual activity was a risk factor for postoperative pain during sexual activity., Methods: A prospective questionnaire study before and 6 months after hernia repair was conducted. Men (age 18-85 years) undergoing laparoscopic inguinal hernia repair were included., Results: In total, 160 men were included. Overall, 23% of patients complained preoperatively of pain during sexual activity. Sexual life was affected in moderate-to-severe degree in 17%. Ten percent had pain during sexual activity 6 months after hernia repair. The prevalence of men with pain during sexual activity was not increased after hernia repair (p = 0.080). Instead, there was a trend toward a reduction. Both before and after hernia repair sexually related pain was primarily located in the groin area and in the scrotum. Patients with preoperative pain during sexual activity had a higher risk of postoperative pain during sexual activity compared with patients without pain preoperatively (p = 0.0007)., Conclusion: Having an inguinal hernia may be related to pain during sexual activity before operation. We did not find an increase in sexually related pain after operation. On the contrary, there was a trend toward decreased pain related to sexual activity after laparoscopic inguinal hernia repair. Preoperative pain during sexual activity predisposed to postoperative pain during sexual activity.

Background: Preliminary studies have indicated clinical advantages of mesh fixation using fibrin glue in transabdominal preperitoneal groin hernia repair (TAPP) compared with tack fixation. The aim of this randomized double-blinded, controlled, clinical trial is to compare fibrin glue with tacks fixation of mesh during TAPP., Methods: One hundred and twelve men with unilateral inguinal hernia were enrolled. Primary outcome was pain during coughing on postoperative day 1. Secondary outcomes were postoperative scores of pain at rest, discomfort, and fatigue (day 1 and cumulated day 0-3), incidence of moderate/severe nausea and/or vomiting, foreign-body sensation, and recurrence after 6 months. Outcome measures were assessed by visual analogue scale (VAS, 0-100 mm), verbal rating scale (no, light, moderate or severe) and numerical rating scales (NRS, 1-10)., Results: One hundred patients were available for analysis. The fibrin group (n = 50) had significantly less pain during coughing on day 1 compared with the tacks group (n = 50) [median 23 (range 0-80) vs 35 (2-100) mm] (p = 0.020). Moreover, day 1 scores and all cumulated scores of pain during rest, discomfort, and fatigue were significantly lower in the fibrin group compared with the tacks group (all p-values ≤ 0.02). There was no significant difference in the incidence of nausea and/or vomiting (p > 0.05) or recurrence (fibrin glue n = 2, tacks n = 0, p = 0.241). Incidence of foreign-body sensation was significantly lower in the fibrin group at 1 month (p = 0.006)., Conclusions: Fibrin glue compared with tacks fixation improved the early postoperative outcome after TAPP. The trial was registered at clinicaltrials.gov NCT01000116.

Laparoscopic inguinal hernia repair (TAPP) has gained increasing popularity because of less post-operative pain and a shorter duration of convalescence compared with open hernia repair technique (Lichtenstein). However, investigation of duration of convalescence with non-restrictive recommendations, and a procedure-specific characterization of the early clinical outcomes after TAPP was lacking. Furthermore, optimization of the post-operative period with fibrin sealant versus tacks for fixation of mesh, and the glucocorticoid dexamethasone versus placebo needed to be investigated in randomized clinical trials. The objective of this PhD thesis was to characterize the early clinical outcomes after TAPP and optimize the post-operative period. The four studies included in this thesis have investigated duration of convalescence and procedure-specific post-operative pain and other early clinical outcomes after TAPP. Furthermore, it has been shown that fibrin sealant can improve the early post-operative period compared with tacks, while dexamethasone showed no advantages apart from reduced use of antiemetics compared with placebo. Based on these findings, and the existing knowledge, 3-5 days of convalescence should be expected when 1 day of convalescence is recommended and future studies should focus on reducing intraabdominal pain after TAPP. Fibrin sealant can optimize the early clinical outcomes but the risk of hernia recurrence and chronic pain needs to be evaluated. Dexamethasone should be investigated in higher doses.

Purpose: Female gender is a risk factor for early pain after several specific surgical procedures but has not been studied in detail after laparoscopic groin hernia repair. The aim of this study was to compare early postoperative pain, discomfort, fatigue, and nausea and vomiting between genders undergoing laparoscopic groin hernia repair., Methods: Prospective consecutive enrollment of women and age-matched (± 1 year) and uni-/bilateral hernia-matched male patients undergoing elective transabdominal preperitoneal hernia repair (TAPP). Patients in the two groups received a similar anesthetic, surgical, and analgesic treatment protocol., Results: Between August 2009 and August 2010, 25 women and 25 men undergoing elective TAPP were prospectively included in the analysis (n = 50) with no significant difference between groups in psychological status regarding anxiety, depression, and catastrophizing. On day 0, women had significantly more pain during rest (p = 0.015) and coughing (p = 0.012), discomfort (p = 0.001), and fatigue (0.020) compared with men. Additionally, cumulative overall postoperative pain during coughing, discomfort, and fatigue on day 0-3 was significantly higher in women compared with men (all p values < 0.05). Women required significantly more opioids (p = 0.015) and had a significantly higher incidence of vomiting on days 0 and 1 (p = 0.002)., Conclusions: Women experienced more pain, discomfort, and fatigue compared with men after laparoscopic groin hernia repair., Trial Registration: Registration number NCT00962338 ( www.clinicaltrials.gov ).

Background: The effect of dexamethasone on recovery and length of convalescence has not been evaluated in patients after laparoscopic groin hernia repair. It was hypothesized that preoperative intravenous dexamethasone would reduce postoperative pain., Methods: Men undergoing transabdominal preperitoneal (TAPP) inguinal hernia repair were randomized to receive either a single intravenous dose of 8 mg dexamethasone or placebo (saline) 30-60 min before operation in a randomized double-blind trial. Patients in the two groups received similar standardized anaesthesia and analgesic regimens. The primary outcome measure was pain during coughing on postoperative day 1. Secondary outcomes were postoperative discomfort, fatigue and length of convalescence. Pain scores, discomfort and fatigue were recorded before surgery and daily on postoperative days 0-3 in a standard manner using visual analogue, verbal rating and numerical rating scales. The use of analgesics and antiemetics on the day of operation was recorded. The duration of time away from work and leisure activities was registered., Results: The study enrolled 80 patients. No significant differences were found between the groups regarding postoperative pain, need for analgesia, discomfort, fatigue, nausea, vomiting or length of convalescence. Patients who received placebo used significantly more antiemetics in the postanaesthesia care unit (PACU) than patients in the dexamethasone group (P = 0.026)., Conclusion: A single preoperative dose of 8 mg dexamethasone before laparoscopic groin hernia repair had no clinical effect on early postoperative pain, discomfort or fatigue after TAPP inguinal hernia repair, but resulted in a significantly lower use of antiemetics in the PACU., (Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.)

Background: Early post-operative pain after laparoscopic groin hernia repair may, as in other laparoscopic operations, have its own individual pain pattern and patient-related predictors of early pain. The purpose of this review was to characterise pain within the first post-operative week after transabdominal pre-peritoneal repair (TAPP) and total extraperitoneal repair (TEP), and to identify patient-related predictors of early pain., Methods: A qualitative systematic review was conducted. Pubmed, Embase, CINAHL, and the Cochrane database were searched for studies on early pain (first week) after TAPP or TEP., Results: We included 71 eligible studies with 14,023 patients. Post-operative pain is most severe on day 0 and mainly on a level of 13-58 mm on a visual analogue scale and decreases to low levels on day 3. There seems to be no difference in pain intensity and duration when TEP and TAPP are compared. Deep abdominal pain (i.e. groin pain/visceral pain) dominates over superficial pain (i.e. somatic pain) and shoulder pain (i.e. referred pain) after TAPP. Predictors of early pain are young age and pre-operative high pain response to experimental heat stimulation. Furthermore, evidence supported early pain intensity as a predictive risk factor of chronic pain after laparoscopic groin hernia repair., Conclusion: Early pain within the first week after TAPP and TEP is most severe on the first post-operative day, and the pain pattern is dominated by deep abdominal pain. Early post-operative pain is most intense in younger patients and can be predicted by pre-operative high pain response to experimental heat stimulation., (© 2012 The Authors. Acta Anaesthesiologica Scandinavica © 2012 The Acta Anaesthesiologica Scandinavica Foundation.)

Background: Evidence-based recommendations for the expected duration of convalescence after laparoscopic groin hernia repair are not available, and objective reasons for prolonged convalescence are not clear. Our main aim was to establish the expected duration of convalescence using preoperative recommendations to the patient and to identify the limiting factors for early (postoperative) resumption of normal activities after laparoscopic transabdominal preperitoneal inguinal herniorraphy (TAPP)., Methods: This was a single-center prospective study. The intervention (the recommendation to the patient) was 1 day for convalescence. Several predefined factors were investigated for their influence on the duration of convalescence and the risk of early postoperative pain. Predefined, clinically justified reasons for not resuming normal activities within the first 3 postoperative days were also registered., Results: Between August 2009 and August 2010, 185 consecutive male patients with groin hernia were enrolled prospectively, and 162 patients were available for analysis. Convalescences from work and leisure activities were a median of 5 days (range, 1-40) and 3 days (range, 1-49), respectively (P = .34). Preoperative expectations of convalescence from work (the number of days) was the only factor to explain prolonged convalescence from work (P < .001). Postoperative, self-registered planned sick leave, and complaints of pain and fatigue were the dominant reasons for not resuming normal activities within the first 3 days after operation. Younger age was the only factor found to explain the intensity of postoperative pain (P < .001)., Conclusion: Postoperative convalescence (return to work or normal activities) was between 3 and 5 days after TAPP in patients who were counseled about a 1-day expected convalescence. The expectation of convalescence from work was an important reason for delayed convalescence beyond 1 day., (Copyright © 2012 Mosby, Inc. All rights reserved.)

Background: Previous studies have shown different pain characteristics in different types of laparoscopic operations, but pain pattern has not been studied in detail after laparoscopic inguinal hernia repair. To optimise preoperative patient information and postoperative analgesic treatment the present study investigated postoperative pain in terms of time course, pain intensity and individual pain components during the first 4 days after transabdominal preperitoneal hernia repair (TAPP)., Methods: The study was a single-centre prospective trial including 50 consecutive male patients with primary or recurrent inguinal and/or femoral hernia undergoing elective repair. Several pain components (visceral pain, incisional pain and shoulder pain) were studied as well as pain at the three different trocar incisions. Pain was recorded before operation and on a daily basis during the first four postoperative days using a visual analogue and a verbal rating scale. We used 1 × 12 and 2 × 5 mm trocars for TAPP., Results: A total of 46 patients were available for analyses (age median 58 years, range 27-69 years). Visceral pain dominated significantly compared with incisional pain (P < 0.01), which again dominated over shoulder pain intensity and incidence (P < 0.01). Pain intensity did not significantly differ between different trocar incisions (5 and 12 mm) (P > 0.05). The overall pain intensity (a conglomerate of the different pain components) was most intense 3 h after TAPP and declined to preoperative levels on day 3 (P > 0.5)., Conclusion: Pain was most intense 3 h after the operation and declined to low levels within the first 3 days. Visceral pain was by far the dominating pain component compared with incisional and shoulder pain.