Persistent postsurgical pain: risk factors and prevention

Glucagon-like peptide 1 (GLP-1) is a 30-amino acid peptide hormone produced in the intestinal epithelial endocrine L-cells by differential processing of proglucagon, the gene which is expressed in ...

The Physiology of Glucagon-like Peptide 1

Accurate assessment is required to assess current and changing physical activity levels, and to evaluate the effectiveness of interventions designed to increase activity levels. This study systematically reviewed the literature to determine the extent of agreement between subjectively (self-report e.g. questionnaire, diary) and objectively (directly measured; e.g. accelerometry, doubly labeled water) assessed physical activity in adults. Eight electronic databases were searched to identify observational and experimental studies of adult populations. Searching identified 4,463 potential articles. Initial screening found that 293 examined the relationship between self-reported and directly measured physical activity and met the eligibility criteria. Data abstraction was completed for 187 articles, which described comparable data and/or comparisons, while 76 articles lacked comparable data or comparisons, and a further 30 did not meet the review's eligibility requirements. A risk of bias assessment was conducted for all articles from which data was abstracted. Correlations between self-report and direct measures were generally low-to-moderate and ranged from -0.71 to 0.96. No clear pattern emerged for the mean differences between self-report and direct measures of physical activity. Trends differed by measure of physical activity employed, level of physical activity measured, and the gender of participants. Results of the risk of bias assessment indicated that 38% of the studies had lower quality scores. The findings suggest that the measurement method may have a significant impact on the observed levels of physical activity. Self-report measures of physical activity were both higher and lower than directly measured levels of physical activity, which poses a problem for both reliance on self-report measures and for attempts to correct for self-report – direct measure differences. This review reveals the need for valid, accurate and reliable measures of physical activity in evaluating current and changing physical activity levels, physical activity interventions, and the relationships between physical activity and health outcomes.

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A comparison of direct versus self-report measures for assessing physical activity in adults: a systematic review

Objective: To evaluate the effect of modifying perioperative care in noncardiac surgical patients on morbidity, mortality, and other outcome measures. Background: New approaches in pain control, introduction of techniques that reduce the perioperative stress response, and the more frequent use of minimal invasive surgical access have been introduced over the past decade. The impact of these interventions, either alone or in combination, on perioperative outcome was evaluated. Methods: We searched Medline for the period of 1980 to the present using the key terms fast track surgery, accelerated care programs, postoperative complications and preoperative patient preparation; and we examined and discussed the articles that were identified to include in this review. This information was supplemented with our own research on the mediators of the stress response in surgical patients, the use of epidural anesthesia in elective operations, and pilot studies of fast track surgical procedures using the multimodality approach. Results: The introduction of newer approaches to perioperative care has reduced both morbidity and mortality in surgical patients. In the future, most elective operations will become day surgical procedures or require only 1 to 2 days of postoperative hospitalization. Reorganization of the perioperative team (anesthesiologists, surgeons, nurses, and physical therapists) will be essential to achieve successful fast track surgical programs. Conclusions: Understanding perioperative pathophysiology and implementation of care regimes to reduce the stress of an operation, will continue to accelerate rehabilitation associated with decreased hospitalization and increased satisfaction and safety after discharge. Developments and improvements of multimodal interventions within the context of "fast track" surgery programs represents the major challenge for the medical professionals working to achieve a "pain and risk free" perioperative course.

Multimodal strategies to improve surgical outcome.

The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm

Umbilical and epigastric hernia repairs are minor, but are commonly conducted surgical procedures. Long-term results have only been sparsely investigated. Our objective was to investigate the risk of chronic complaints after a simple sutured repair for small umbilical and epigastric hernias. A retrospective cohort study with a 5-year questionnaire and clinical follow-up was conducted. Patients undergoing primary elective, open non-mesh umbilical or epigastric sutured hernia repair were included. Patients completed a structured questionnaire regarding chronic complaints during work and leisure activities using a verbal rating scale. The primary outcome was chronic complaints. A total of 295 patients were included for analysis after a median of 5.0-year (range 2.8–8.0) follow-up period. Follow-up results were achieved from 262 of the included patients (90 % response rate). Up till 5.8 % of the patients reported moderate or severe pain and discomfort. Work and leisure activities were restricted in 8.5 and 10.0 % of patients, respectively. Patients with chronic complaints had a higher incidence of recurrence (clinical and reoperation), than patients with none or mild complaints (78.6 vs. 22.2 % (P < 0.001)). The recurrence rate was significantly higher after a repair with absorbable suture (20.1 %) compared with non-absorbable suture repair (4.2 %) (P < 0.001). We found that chronic complaints after a simple sutured umbilical or epigastric repair was in the level of 5.5 % and could in part be explained by recurrence. Furthermore, absorbable suture should be omitted to reduce risk of recurrence.

Chronic complaints after simple sutured repair for umbilical or epigastric hernias may be related to recurrence

The optimal treatment of patients with malignant colorectal polyps is unsettled. The surgical dilemma following polypectomy is selecting between watchful waiting (WW) and subsequent bowel resection (SBR), but the long-term survival outcomes have not been established yet. This nationwide study compared survival of patients after WW or SBR. Danish nationwide study with 100% follow-up of all patients with malignant colorectal polyps (the Danish Colorectal Cancer Group database) in a 10-year period from 2001 to 2011. All patients’ charts and histological reports were individually reviewed. Survival rates were calculated with Cox proportional hazard model after propensity score matching. A total of 692 patients were included (WW, 424 (61.3%), SBR, 268 (38.7%)) with a mean follow-up of 7.5 years (3–188 months). Following propensity score matching, there was no significant difference in overall or disease-free survival (p = 0.344 and p = 0.184) or rate of local recurrence (WW, 7.2%, SBR, 2%, p = 0.052) or distant metastases (WW, 3.3%, SBR, 4.6%, p = 0.77). In the SBR group, there was no residual tumor or lymph node metastases in the resected specimen in 82.5% of the patients. Subsequent bowel resection may not be superior to endoscopic polypectomy and watchful waiting with regard to overall and disease-free survival in patients with malignant colorectal polyps.

Malignant colorectal polyps: endoscopic polypectomy and watchful waiting is not inferior to subsequent bowel resection. A nationwide propensity score-based analysis.

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. 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. 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. 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.

Convalescence after laparoscopic inguinal hernia repair: a qualitative systematic review

Patient-related outcome measures (PROM) such as quality of life (QoL) after hernia repair are important to monitor, since QoL is an important indication of a hernia repair. Carolinas Comfort Scale (CCS) is a hernia-specific questionnaire regarding health-related QoL after a mesh hernia repair. The primary objective of this study was to monitor changes in health-related QoL over time after different mesh hernia repair procedures using the CCS.
 We performed a prospective study with an exploratory, intraobserver design enrolling consecutive patients who were to undergo elective mesh hernia repair. Four different hernia repair techniques were included and analyzed specifically for each surgical group. Patients scored themselves using CCS preoperatively and at several fixed times postoperatively. Since no gold standard exists for either hernia-specific QoL questionnaires or change of scores on PROMs as a function of time after hernia repair, we compared the CCS scores with the visual analog scale (VAS) scores reflecting the subdomains of the CCS. A total of 166 patients completed the study. CCS scores for QoL, pain, sensation of mesh, and activity limitations changed significantly with time during the 90-day study period. Furthermore, CCS and VAS showed significant agreement and correlation (ρ = 0.52–0.82, P < 0.001). The present study is the first to demonstrate significant changes over time in health-related QoL using the CCS after four different types of hernia repair with mesh.

Health-related Quality of Life Scores Changes Significantly within the First Three Months After Hernia Mesh Repair

Large-scale data for the optimal inguinal hernia repair in younger men with an indirect hernia is not available. We analysed nationwide data for risk of reoperation in younger men after a primary repair using a Lichtenstein operation or a conventional non-mesh hernia repair. Prospective recording of all inguinal hernia repairs from 1 January 1998 to 31 December 2005 in the national Danish Hernia Database, using reoperation rate as a proxy for recurrence. We included only men between the age of 18 and 30 years with a primary repair of a primary indirect inguinal hernia. A primary sutured repair was performed in 1,120 men (median age 23 years, range 18–30) and a Lichtenstein mesh repair in 2,061 young men (24 years, range 18–30) (total 3,181 patients). The observation time after conventional hernia repair was median 62 months (range 0–96) and 41 months (range 0–96) after a Lichtenstein repair. The cumulative incidence of reoperation at 5 years was 1.6% (Lichtenstein) versus 3.9% (sutured repair), while overall reoperation rates were almost three-fold as high after a sutured repair (39 reoperations, overall reoperation rate = 3.5%) compared to a Lichtenstein repair (24 reoperations, overall reoperation rate = 1.2%; P = 0.0003). Lichtenstein repair for an indirect inguinal hernia reduces the risk of recurrence in young men between the age of 18 and 30 years compared with a sutured repair. The use of a Lichtenstein mesh repair in young males must be balanced against the risk of chronic pain.

Thue Bisgaard

Papers

Chronic complaints after simple sutured repair for umbilical or epigastric hernias may be related to recurrence

Malignant colorectal polyps: endoscopic polypectomy and watchful waiting is not inferior to subsequent bowel resection. A nationwide propensity score-based analysis.

Convalescence after laparoscopic inguinal hernia repair: a qualitative systematic review

Health-related Quality of Life Scores Changes Significantly within the First Three Months After Hernia Mesh Repair

Groin hernia repair in young males: mesh or sutured repair?