Optimal timing for inguinal hernia repair in premature infants: a systematic review and meta-analysis

BackgroundThe optimal timing of repair for inguinal hernia in premature infants remains a controversial topic. Our objective was to assess the clinical effects of inguinal hernia repair done before or after neonatal intensive care unit (NICU) discharge.MethodsMEDLINE, Embase, CINAHL, and CENTRAL were searched in July 2018. Publications comparing clinical outcomes of the premature infants with inguinal hernia repair before (early) and after (delayed) NICU discharge were identified. Two reviewers independently screened studies, extracted data, and assessed for quality. Results were pooled using random effects meta-analysis.ResultsOf 640 publications identified, six comparative studies assessing a total of 1761 premature infants were included. Meta-analysis indicated no statistically significant difference in incarceration rate (odds ratio (OR) 2.15, 95% confidence interval (CI) 0.83–5.58, I² = 0%), surgical complications (OR 2.36, 95% CI 0.66–8.41, I² = 0%) and other secondary complications. However, the odds of recurrence and respiratory difficulty was significantly increase in the early group compared to delayed (OR 4.12, 95% CI 1.17–14.45, I² = 0%; OR 3.59, 95% CI 1.10–11.75, I² = 42%).ConclusionsRepair of inguinal hernia in premature infants before NICU discharge may increase the odds of recurrence, but not incarceration or surgical complications.Level of evidenceLevel III     

Costs and recurrence of inguinal hernia repair in premature infants during neonatal admission

BackgroundTiming of inguinal hernia repair (IHR) in premature infants remains variable, yet the impact of IHR timing on procedure costs and recurrence is unclear. We sought to compare cost and recurrence rates of IHR in premature infants based on timing of repair.MethodsWe performed a retrospective cohort study using MarketScan insurance claims data from 2007 to 2018 to evaluate IHR occurring within 365 days of birth in preterm infants (gestational age [GA]<37 weeks at birth). Patients were stratified based on timing of IHR: those occurring during and after neonatal discharge. Hernia recurrences within one year following IHR were identified. Patient demographic characteristics and costs were compared between groups. Time to recurrence and cumulative recurrence hazards were estimated using Kaplan Meier analysis and Cox proportional hazards regression.ResultsWe identified 3,662 preterm infants with IHR within 365 days of birth; 1,054(28.8%) occurred early. Infants with IHR during NICU stay were more likely to have GA at birth≤32 weeks (74.7% vs. 37.2%; p<0.01) and birthweight<1500 g (83.0% vs. 40.3%; p<0.01) compared to post-NICU IHR. The hernia recurrence rate was higher and total procedure costs lower in early IHR. Early IHR (HR:1.86, 95% CI: 1.56–2.22), incarcerated/strangulated hernia (HR:1.86, 95% CI:1.49–2.32), GA≤32 weeks (HR: 1.40, 95% CI: 1.19–1.65), and congenital anomalies (HR: 1.32, 95% CI: 1.12–1.57) were predictors of hernia recurrence.ConclusionUsing insurance claims data, IHR performed during initial neonatal admission was associated with lower cost, but higher recurrence rate, when compared to delayed repairs in preterm infants.Type of StudyRetrospective studyLevel of EvidenceLevel III     

Systematic review and meta-analysis of published randomized controlled trials comparing the role of self-gripping mesh against suture mesh fixation in patients undergoing open inguinal hernia repair

The objective of this article is to analyze systematically the randomized, controlled trials comparing the use of self-gripping mesh (SGM) versus suture mesh fixation (SMF) in patients undergoing open inguinal hernia repair. Randomized, controlled trials comparing the use of SGM versus SMF in patients undergoing open inguinal hernia repair were analyzed using RevMan^®, and combined outcomes were expressed as odds ratio (OR) and standardized mean difference (SMD). Four randomized, controlled trials recruiting 1,115 patients undergoing open inguinal hernia repair using SGM versus SMF were retrieved from the search of medical electronic databases. There were 553 patients in the SGM group and 562 patients in the SMF group. The incidence of chronic groin pain (OR 1.04; 95 % CI 0.72, 1.49; z = 0.21; p = 0.83), recurrence (OR 0.76; 95 % CI 0.14, 4.08; z = 0.32; p = 0.75), postoperative complications and length of hospital stay were similar in SGM and SMF groups. The duration of operation (SMD ?0.36; 95 % CI ?0.47, ?0.24; z = 5.88; p < 0.00001) was shorter following the use of SGM in open inguinal hernia repair. SGM failed to demonstrate the reduced incidence of postoperative groin pain following open inguinal hernia repair. In addition, hernia recurrence, postoperative complications and length of stay was also unchanged. However, SGM was associated with overall shorter operative time.     

Factors associated with inguinal hernia repair in premature infants during neonatal admission

IntroductionTiming of inguinal hernia repair (IHR) in premature infants is variable and influenced by surgeon preference and complication profile. The purpose of this study was to evaluate factors related to early IHR, defined as hernia repair during initial neonatal admission, in premature infants.MethodsNeonatal hospitalizations of premature infants (gestational age at birth < 37 weeks and ≤ 28 days old at admission), with a diagnosis of inguinal hernia from 2010 to 2017 in HCUP National Inpatient Sample and Kid's Inpatient Sample databases were evaluated. Multivariable Cox proportional hazard models was used to estimate associations between demographics, additional procedures, hospital characteristics, and early IHR.ResultsOverall, 30,298 neonatal hospitalizations of premature infants with inguinal hernia were identified; 13,228 (43.3%) underwent early IHR. Early IHR was more likely with older gestational age at birth (35–36 weeks vs < 24 weeks, HR 6.05, 95% CI 4.17, 8.79), female sex (HR 1.20, 95% CI 1.07, 1.34), and undergoing concomitant gastrostomy (HR 2.51, 95% CI 1.72, 3.66). Non-Hispanic Black infants (HR 0.84, 95% CI 0.75, 0.95), infants at urban non-teaching hospitals (HR 0.15, 95% CI 0.07, 0.33), and infants at rural hospitals (HR 0.81, 95% CI 0.70, 0.97) were less likely to undergo early IHR.ConclusionsUsing a nationally representative database, early IHR in premature neonates was more commonly performed in non-Hispanic White, female neonates and at urban teaching hospitals. Patient race and hospital type were determinants of early IHR in premature neonates. There is a need to further evaluate the impact of race and socioeconomic factors on outcomes of common pediatric operations like inguinal hernia repairs.Level of EvidenceLevel III.     

Local anaesthesia versus spinal anaesthesia in inguinal hernia repair: A systematic review and meta-analysis

Background

Inguinal hernias are a significant cause of morbidity. The purpose of this systematic review and meta-analysis is to determine the totality of evidence regarding the effectiveness of local anaesthesia when compared to spinal anaesthesia in individuals undergoing open inguinal hernia repair.

Postoperative outcomes in older surgical patients with preoperative cognitive impairment: A systematic review and meta-analysis

Study objectiveTo determine the effect of cognitive impairment (CI) and dementia on adverse outcomes in older surgical patients.DesignA systematic review and meta-analysis of observational studies and randomized controlled trials (RCTs). Various databases were searched from their inception dates to March 8, 2021.SettingPreoperative assessment.PatientsOlder patients (≥ 60 years) undergoing non-cardiac surgery.MeasurementsOutcomes included postoperative delirium, mortality, discharge to assisted care, 30-day readmissions, postoperative complications, and length of hospital stay. Effect sizes were calculated as Odds Ratio (OR) and Mean Difference (MD) based on random effect model analysis. The quality of included studies was assessed using the Cochrane Risk Bias Tool for RCTs and Newcastle-Ottawa Scale for observational cohort studies.ResultsFifty-three studies (196,491 patients) were included. Preoperative CI was associated with a significant risk of delirium in older patients after non-cardiac surgery (25.1% vs. 10.3%; OR: 3.84; 95%CI: 2.35, 6.26; I²: 76%; p < 0.00001). Cognitive impairment (26.2% vs. 13.2%; OR: 2.28; 95%CI: 1.39, 3.74; I²: 73%; p = 0.001) and dementia (41.6% vs. 25.5%; OR: 1.96; 95%CI: 1.34, 2.88; I²: 99%; p = 0.0006) significantly increased risk for 1-year mortality. In patients with CI, there was an increased risk of discharge to assisted care (44.7% vs. 38.3%; OR 1.74; 95%CI: 1.05, 2.89, p = 0.03), 30-day readmissions (14.3% vs. 10.8%; OR: 1.36; 95%CI: 1.00, 1.84, p = 0.05), and postoperative complications (40.7% vs. 18.8%; OR: 1.85; 95%CI: 1.37, 2.49; p < 0.0001).ConclusionsPreoperative CI in older surgical patients significantly increases risk of delirium, 1-year mortality, discharge to assisted care, 30-day readmission, and postoperative complications. Dementia increases the risk of 1-year mortality. Cognitive screening in the preoperative assessment for older surgical patients may be helpful for risk stratification so that appropriate management can be implemented to mitigate adverse postoperative outcomes.     

Laparoscopic Extraperitoneal Hernia Repair Versus Open Repair in Boys with Inguinal Hernia: A Meta-Analysis

ObjectivePediatric inguinal hernia is a common surgical problem in boys. Open hernia repair surgery (OH) has been traditionally used to treat this condition, but it leads to complications, such as testicular complications. Laparoscopic hernia repair by using the extraperitoneal method (LHE) is performed through the percutaneous insertion of sutures and extracorporeal closure of patent vaginalis processus; thus, injury to spermatic cord structures is avoided. However, a meta-analysis comparing LHE and OH is lacking.MethodsPubMed, EMBASE, and Cochrane Library databases were searched for relevant studies. A meta-analysis of the retrieved studies was performed, and a random-effects model was used to calculate the pooled effect size. The primary outcome was testicular complications, including ascending testis, hydrocele, and testicular atrophy. The secondary outcomes were surgical metachronous contralateral inguinal hernia (MCIH), ipsilateral hernia recurrence, and operation time.ResultsIn total, 6 randomized controlled trials (RCTs) and 20 non-RCTs involving 17,555 boys were included. The incidence of ascending testis (risk ratio [RR]: 0.38, 95% confidence interval [CI]: 0.18–0.78; p = 0.008) and MCIH (RR: 0.17, 95% CI: 0.07–0.43; p = 0.0002) was significantly lower in LHE than in OH. The incidence of hydrocele, testicular atrophy, and ipsilateral hernia recurrence did not differ between LHE and OH.ConclusionCompared with OH, LHE led to fewer or equivalent testicular complications without increasing ipsilateral hernia recurrence. Moreover, MCIH incidence was lower in LHE than in OH. Hence, LHE could be a feasible choice with less invasiveness for inguinal hernia repair in boys.Level of EvidenceTreatment study, LEVEL III.     

Risk Factors for Incarceration in Patients with Primary Abdominal Wall and Incisional Hernias: A Prospective Study in 4472 Patients

Background

Incarceration of primary and incisional hernias often results in emergency surgery. The objective of this study was to evaluate the relation of defect size and location with incarceration. Secondary objectives comprised identification of additional patient factors associated with an incarcerated hernia.

Methods

A registry-based prospective study was performed of all consecutive patients undergoing hernia surgery between September 2011 and February 2016. Multivariate logistic regression was performed to identify risk factors for incarceration.

Results

In total, 83 (3.5%) of 2352 primary hernias and 79 (3.7%) of 2120 incisional hernias had a non-reducible incarceration. For primary hernias, a defect width of 3–4 cm compared to defects of 0–1 cm was significantly associated with an incarcerated hernia (OR 2.85, 95% CI 1.57–5.18, p = 0.0006). For incisional hernias, a defect width of 3–4 cm compared to defects of 0–2 cm was significantly associated with an incarceration (OR 2.14, 95% CI 1.07–4.31, p = 0.0324). For primary hernias, defects in the peri- and infra-umbilical region portrayed a significantly increased odds for incarceration as compared to supra-umbilical defects (OR 1.98, 95% CI 1.02–3.85, p = 0.043). Additionally, in primary hernias age, BMI, and constipation were associated with incarceration. In incisional hernias age, BMI, female sex, diabetes mellitus and ASA classification were associated with incarceration.

Conclusion

For primary and incisional hernias, mainly defects of 3–4 cm were associated with incarceration. For primary hernias, mainly defects located in the peri- and infra-umbilical region were associated with incarceration. Based on patient and hernia characteristics, patients with increased odds for incarceration may be selected and these patients may benefit from elective surgical treatment.

     

Risk factors for acute kidney injury after Stanford type A aortic dissection repair surgery: a systematic review and meta-analysis

Background: Risk factors for acute kidney injury (AKI) after Stanford type A aortic dissection (TAAD) repair are inconsistent in different studies. This meta-analysis systematically analyzed the risk factors so as to early identify the therapeutic targets for preventing AKI.Methods: Studies exploring risk factors for AKI after TAAD repair were searched from four databases from inception to June 2022. The synthesized incidence and risk factors of AKI and its impact on mortality were calculated.Results: Twenty studies comprising 8223 patients were included. The synthesized incidence of postoperative AKI was 50.7%. Risk factors for AKI included cardiopulmonary bypass (CPB) time >180 min [odds ratio (OR), 4.89, 95% confidence interval (CI), 2.06–11.61, I² = 0%], prolonged operative time (>7 h) (OR, 2.73, 95% CI, 1.95–3.82, I² = 0), advanced age (per 10 years) (OR, 1.34, 95% CI, 1.21–1.49, I² = 0], increased packed red blood cells (pRBCs) transfusion perioperatively (OR, 1.09, 95% CI, 1.07–1.11, I² = 42%), elevated body mass index (per 5 kg/m²) (OR, 1.23, 95% CI, 1.18–1.28, I² = 42%) and preoperative kidney injury (OR, 3.61, 95% CI, 2.48–5.28, I² = 45%). All results were meta-analyzed using fixed-effects model finally (p < 0.01). The in-hospital or 30-day mortality was higher in patients with postoperative AKI than in that without AKI [risk ratio (RR), 3.12, 95% CI, 2.54–3.85, p < 0.01].Conclusions: AKI after TAAD repair increased the in-hospital or 30-day mortality. Reducing CPB time and pRBCs transfusion, especially in elderly or heavier weight patients, or patients with preoperative kidney injury were important to prevent AKI after TAAD repair surgery.     

A meta-analysis of translumbar embolization versus transarterial embolization for type II endoleak after endovascular repair of abdominal aortic aneurysm

ObjectiveThis systematic review and meta-analysis aimed to compare the clinical outcomes between transarterial and translumbar (direct aneurysm sac puncture) approaches for persistent type II endoleak after endovascular repair of abdominal aortic aneurysm.MethodsWe searched multiple electronic databases (up to October 31, 2018) for eligible trials in patients with type II endoleaks after endovascular abdominal aortic aneurysm repairs that evaluated the outcomes of translumbar embolization vs transarterial embolization. The primary outcome was clinical success (absence of the endoleak on the last examination); the secondary outcomes were technical success and complication rate. Odds ratios (ORs) with 95% confidence intervals (CIs) were estimated.ResultsAmong the 904 studies screened, 9 studies with 354 participants were included in this review. None of the studies reported rupture or mortality. The translumbar group had a relatively higher clinical success rate than the transarterial group, but this difference was not statistically significant (OR, 2.29; 95% CI, 1.00-5.25; P = .05; I² = 52%). The technical success rate was significantly higher in the translumbar group than in the transarterial group (OR, 13.32; 95% CI, 3.41-52.07; P = .0002; I² = 0%). No significant difference was found in the complication rate of the two groups (OR, 1.15; 95% CI, 0.26-4.96; P = .85; I² = 0%). We also included five studies that reported the clinical outcomes of open repair. All patients were technically treated by open repair, and 58 of 60 patients owned clinical success during the follow-up period.ConclusionsThe translumbar route was more successful in obliterating the endoleak on follow-up imaging. When repeated endovascular embolizations fail, a laparotomy should follow.     

Transabdominal preperitoneal versus totally extraperitoneal repair of inguinal hernia: a meta-analysis of randomized studies

Background

The aim of the present study was to comparatively evaluate the outcomes of laparoscopic transabdominal preperitoneal inguinal hernia repair and totally extraperitoneal repair.

Methods

The electronic databases of Medline, EMBASE, and the Cochrane Central Register of Controlled Trials were searched, and a meta-analysis of randomized clinical trials was undertaken.

Results

Seven studies comprising 516 patients with 538 inguinal hernia defects were identified. A shorter recovery time (P = .02) was found for totally extraperitoneal repair in comparison with transabdominal preperitoneal inguinal hernia repair (weighted mean difference = −.29; 95% confidence interval [CI], −.71 to .07) although the length of hospitalization (P = .89) was similar in the 2 treatment arms (weighted mean difference = .01; 95% CI, −.13 to .15). Operative morbidity (P = .004) was higher for the preperitoneal approach (odds ratio = 2.15; 95% CI, 1.29 to 3.61). No differences were found with regard to the incidence of recurrence, long-term neuralgia, and operative time.

Conclusions

Current evidence suggests similar operative results for endoscopic and laparoscopic inguinal hernia repair, with a trend toward higher morbidity for the preperitoneal approach. Randomized trials with a longer-term follow-up are needed in order to assess the effect of each approach on the prevention of recurrence.     

Association of postoperative delirium with cognitive outcomes: A meta-analysis

Study objectiveTo determine the association between postoperative delirium (POD) and cognitive outcomes at least 1 month after surgery in elderly patients, and synthesize the dynamic risk trajectory of cognition impairment after POD.DesignMeta-analysis searching PubMed, Cochrane and EMBASE from inception to November 1, 2020. The terms postoperative delirium, delirium after surgery, postsurgical delirium, postoperative cogniti*, postoperative cognitive dysfunction, postoperative cognition decline, cognitive decline, cognitive impair* and dement* were searched alone or in combination.MeasurementsInclusion criteria were prospective cohort studies investigating the association between POD and cognitive outcomes in patients aged ≥60 years underwent surgery. The primary outcome was the association between POD and cognitive outcomes at 1 or more months after surgery. We considered cognitive outcomes measured up to 12 months after surgery as short-term and beyond 12 months as long-term. Two authors performed the study screening, data extraction and quality assessments. Effect sizes were calculated as Hedges g or Odds ratio (OR) based on random- and fixed-effects models. Meta-regression was conducted to analyze the role of potential contributors to heterogeneity.Main resultsEighteen studies were included. Our result showed a significant and medium association between POD and cognitive outcomes after at least 1 month postoperatively (g = 0.61 95% CI 0.43–0.79; I² = 65.1%), indicating that patients with POD were associated with worse cognitive outcomes. The association of POD with short- and long-term cognitive impairment were also both significant (short-term: g = 0.46 95% CI 0.24–0.68; I² = 53.1%; and long-term: g = 0.82 95% CI 0.57–1.06; I² = 57.1%). A multivariate meta-regression suggested that age and measure of delirium were significant sources of heterogeneity. POD was also associated with the significant risk for dementia (OR = 6.08 95% CI 3.80–9.72; I² = 0) as well as attention (OR = 1.74 95% CI 1.13–2.68; I² = 0), executive (OR = 1.33 95% CI 1.00–1.80; I² = 0) and memory impairment (OR = 1.59 95% CI 1.20–2.10; I² = 43.0%). Additionally, our results showed that the risk trajectory for cognitive decline associated with POD within five years after surgery revealed exponential growth.ConclusionsThis is the first meta-analysis quantifying the association between POD and cognitive outcomes. Our results showed that POD was significantly associated with worse cognitive outcomes, including short- and long-term cognitive outcomes following surgery.     

Postoperative delirium: An independent risk factor for poorer quality of life with long-term cognitive and functional decline after cardiac surgery

Study objectiveTo evaluate the influence of delirium on the functional and cognitive capacity of patients included in the DELIPRECAS study, as well as on their quality of life, in the 3–4 years after cardiac surgery.DesignProspective observational study.SettingAssessment of cognitive and functional status from hospital discharge to the present, 3 years after cardiac surgery.Patients313 patients undergoing cardiac surgery consecutively, aged 18 years or over.MeasurementsThe primary outcome measure was the cognitive and functional status of the patients 3 years after cardiac surgery, evaluated by telephone interview, and the possible influence on them of delirium diagnosed by the Confusion Assessment Method in Intensive Care Units (CAM-ICU) during their stay in the intensive care unit after cardiac surgery.Main resultsPostoperative delirium acts as an independent risk factor for the long-term development of memory problems (OR 6.11, 95% CI 2.54 to 14.68, p < 0.001), concentration (OR 11.20, 95% CI 3.58 to 35.09, p > 0.001), confusion/disorientation (OR 10.93, 95% CI 3.61 to 33.12, p > 0.001), sleep problems (OR 5.21, 95% CI 2 0.29 to 11.84, p < 0.001), nightmares (OR 8.99, 95% CI 1.98 to 40.90, p = 0.004), emotional problems (OR 4.30, 95% CI 1.87 to 9.91, p = 0.001) and poorer mobility after hospital discharge (OR 2.436, 95% CI 1.06 to 5.61, p = 0.037). The number of hospital readmissions was also significantly higher in those patients who developed delirium after cardiac surgery (27% vs 13.8%, p = 0.022).ConclusionPostoperative delirium is a risk factor for decreased quality of life in patients 3 years after heart surgery, being associated with greater cognitive and functional deterioration, as well as greater risk of hospital readmission. Therefore, emphasis should be placed on both prevention and early recognition and treatment of delirium to improve long-term outcomes for patients after cardiac surgery.     

Surgical factors associated with symptomatic implant removal after patella fracture

ObjectivesTo determine whether certain types of fixation and other factors associated with the fixation could be identified that predict an increased risk of symptomatic implant removal.MethodsWe conducted a retrospective cohort study at our urban academic level 1 trauma center. Patients aged ≥18 years who underwent operative fixation for patella fracture were included. The primary outcome was symptomatic implant removal after operative fixation.ResultsOf the 186 study patients (mean age, 44 [SD 17] years, 65% male), 53 patients (28.5%) underwent symptomatic implant removal. Modifiable risk factors for symptomatic implant removal included the use of Kirschner (k)-wires (OR: 4.93; 95% CI, 1.89–14.10; p < 0.001), and a trend towards significance for implant prominence >5 mm (OR: 2.57; 95% CI, 0.93–7.93; p = 0.07). Symptomatic implant removal was also less likely in patients >45 years of age (OR: 0.14; 95% CI, 0.06–0.34; p < 0.01), of a racial minority (OR: 0.40; 95% CI, 0.17–0.88; p = 0.03), and a body mass index >25 kg/m² (OR: 0.39; 95% CI, 0.18–0.84; p = 0.02). The final model demonstrated excellent prognostic performance, with an AUC of 0.83 (0.76–0.90).ConclusionWe identified both modifiable and non-modifiable factors associated with symptomatic implant removal in patients with patella fractures. Surgeons should be aware that the use of k-wires and any implant prominence exceeding 5 mm might be associated with increased odds of symptomatic implant removal in patients with patella fractures.     

The Timing of Congenital Diaphragmatic Hernia Repair on Extracorporeal Membrane Oxygenation Impacts Surgical Bleeding Risk

BackgroundThe optimal timing of surgical repair for infants with congenital diaphragmatic hernia (CDH) treated with extracorporeal membrane oxygenation (ECMO) support remains controversial. The risk of surgical bleeding is considered by many centers as a primary factor in determining the preferred timing of CDH repair for infants requiring ECMO support. This study compares surgical bleeding following CDH repair on ECMO in early versus delayed fashion.MethodsA retrospective review of 146 infants who underwent CDH repair while on ECMO support from 1995 to 2021. Early repair occurred during the first 48 h after ECMO cannulation (ER) and delayed repair after 48 h (DR). Surgical bleeding was defined by the requirement of reoperative intervention for hemostasis or decompression.Results102 infants had ER and 44 infants DR. Surgical bleeding was more frequent in the DR group (36% vs 5%, p < 0.001) with an odds ratio of 11.7 (95% CI: 3.48–39.3, p < 0.001). Blood urea nitrogen level on the day of repair was significantly elevated among those who bled (median 63 mg/dL, IQR 20–85) vs. those who did not (median 9 mg/dL, IQR 7–13) (p < 0.0001). Duration of ECMO support was shorter in the ER group (median 13 vs 18 days, p = 0.005). Survival was not statistically different between the two groups (ER 60% vs. DR 57%, p = 0.737).ConclusionWe demonstrate a significantly lower incidence of bleeding and shorter duration of ECMO with early CDH repair. Azotemia was a strong risk factor for surgical bleeding associated with delayed CDH repair on ECMO.Level of evidenceLevel III cohort study.     

Erector spinae plane block for postoperative analgesia in breast and thoracic surgery: A systematic review and meta-analysis

Study objectiveThe erector spinae plane block (ESPB) is a newly defined regional anesthesia technique first introduced in 2016. The aim of this study is to determine its analgesic efficacy compared with non-block care and thoracic paravertebral block (TPVB).DesignWe systematically searched PubMed, Web of Science citation index, Embase, the Cochrane Library, Google Scholar, and ClinicalTrials.gov register searched up to March 2020. We conducted a meta-analysis of randomized controlled trials (RCTs) that compared an ESPB to non-block care or TPVB for postoperative analgesia in breast and thoracic surgery patients. Primary outcome was 24-hour postoperative opioid consumption. Risk of bias was assessed using Cochrane methodology.Results14 RCTs that comprised 1018 patients were included. Seven trials involved thoracic surgery patients and seven included breast surgery patients. Meta-analysis revealed that ESPB significantly reduced 24-hour opioid consumption compared with the non-block groups (−10.5 mg; 95% CI: −16.49 to −3.81; p = 0.002; I² = 99%). Similarly, the finding was consistent in subgroup analysis between the breast surgery (−7.75 mg; 95%CI −13.98 to −1.51; p = 0.01; I² = 97%) and thoracic surgery (−14.81 mg; 95%CI −21.18 to −8.44; p < 0.001; I² = 96%) subgroups. The ESPB significantly reduced pain scores at rest or movement at various time points postoperatively compared with non-block group, and reduced the rate of postoperative nausea and vomiting (OR 0.48; 95%CI 0.27 to 0.86; p = 0.01; I² = 0%). In contrast, there were no significative differences reported in any of the outcomes for ESPB versus TPVB strata.ConclusionsESPB improved analgesic efficacy in breast and thoracic surgery patients compared with non-block care. Furthermore, current literature supported the ESPB offered comparable analgesic efficacy to a TPVB.     

Systematic review and meta-analysis of safety and efficacy of early enteral nutrition as an isolated component of Enhanced Recovery After Surgery [ERAS] in children after bowel anastomosis surgery

BackgroundPostoperative feeding practices are not uniform in children undergoing bowel anastomosis surgery. Primary aim of this review was to evaluate the safety and efficacy of early enteral nutrition (EEN) as an isolated component of enhanced recovery in children undergoing bowel anastomosis surgery.MethodsMedical search engines (PubMed, CENTRAL, Google scholar) were accessed from inception to January 2021. Randomized Controlled Trials (RCT)s, non-randomized controlled trials, observational studies and retrospective studies comparing EEN, initiated within 48 h vs late enteral nutrition (LEN), initiated after 48 h in children ≤ 18 years undergoing bowel anastomosis surgery were included. Primary outcome measure was the incidence of postoperative complications (anastomotic leak, abdominal distension, surgical site infection, wound dehiscence, vomiting and septic complications). Secondary outcome measures were the time to passage of first feces and the length of hospital stay.ResultsTwelve hundred and eighty-six children from 10 studies were included in this review. No difference was seen between the EEN and LEN groups in the incidence of anastomotic leak (1.69% vs 4.13%; p = 0.06), abdominal distention (13.87% vs 12.31%; p = 0.57), wound dehiscence (3.07% vs 2.69%; p = 0.69) or vomiting (8.11% vs 8.67%; p = 0.98). The incidence of surgical site infections (7.51% vs 11.72%; p = 0.04), septic complications (14.02% vs 26.22%; p = 0.02) as well as pooled overall complications (8.11% vs 11.27%; RR 0.71; 95% CI = 0.56 to 0.89; p = 0.003; I² = 33%) were significantly lower in the EEN group. The time to passage of first feces (MD – 17.23 h; 95% CI -23.13 to -11.34; p < 0.00001; I² = 49%) and the length of hospital stay (MD -2.95 days; 95% CI -3.73 to -2.17; p < 0.00001; I² = 93%) were significantly less in the EEN group.ConclusionEEN is safe and effective in children following bowel anastomosis surgery and is associated with a lower overall incidence of complications as compared to LEN. EEN also promotes early bowel recovery and hospital discharge. However, further well designed RCTs are required to validate these findings.Level of evidence: V     

Predictors of chronic pain after laparoscopic inguinal hernia repair

BackgroundMultiple studies have analyzed predictors for chronic pain after open hernia repair. The purpose of this study is to determine which factors predict the development of chronic pain after a laparoscopic inguinal hernia repair.MethodsWe identified patients who underwent laparoscopic inguinal hernia repair between 2008 and 2020 at a single institution. Quality of life was measured using the Surgical Outcomes Measurement System and Carolinas Comfort Scale. We categorized patients with chronic pain if their score on Carolinas Comfort Scale was greater than or equal to 3. Multivariable logistic regression analysis was used to identify predictors of chronic pain.ResultsA total of 960 patients met inclusion criteria. Mean age was 59 (± 14, standard deviation) years, 89 (9.3%) of whom were female. Six percent of patients met criteria for chronic pain (Carolinas Comfort Scale ≥3). On multivariable analysis, predictors for chronic pain were age 45 (P < .001), female sex (P = .006), preoperative pain visual analog scale ≥1 (P = .025), prior inguinal hernia repair (P = .045), higher American Society of Anesthesiologists class (P = .041), use of multifilament polyester mesh (P = .0448), and intraoperative placement of a urinary catheter (P = .009).ConclusionLaparoscopic inguinal hernia repair results in 6.0% of patients experiencing chronic pain. We identified multiple predictors for chronic pain.     

Bilateral congenital inguinal hernia with right-sided Amyand's hernia in a premature twin: Case report and a summary of clinical presentations,management and outcomes in neonates and infants with Amyand's hernia

Introduction and importanceCongenital hernias occur 70% on the right side, 25% on the left side, and approximately 5% bilaterally. The finding of a congenital Amyand's hernia is of interest, especially in patients who do not present risk factors associated with connective tissue disorders, ascitic conditions, fetal developmental disorders or any condition that increases abdominal pressure.Case presentationMale patient, 6 months old, was brought to the pediatric surgery department due to a visible mass in the bilateral inguinal region, which protruded with crying. The parents report that he was a 36-week preterm, low birth weight, monochorionic monoamniotic twin with bilateral congenital inguinal hernia. An open herniorrhaphy was performed, showing a left communicating hydrocele with an indirect left inguinal hernia and right communicating hydrocele with indirect inguinal hernia containing cecal appendix with no signs of inflammation.Clinical discussionThe most common clinical presentation is the presence of a reducible or irreducible mass, erythema and/or inguino-scrotal edema, irritability manifested by crying and recurrent pain in older infants. This condition may be associated with cryptorchidism, intrauterine structural developmental disorder, and the presence of fistulas. Appendectomy and traditional hernia reduction are the most common surgical approach. The evolution of this condition is favorable with extremely low complication rates.ConclusionAmyand's hernia in the neonate is a rare presenting condition, which frequently involves nearby structures with risk of inflammation, incarceration and perforation, so repair should be performed early.     

Association between common risk factors and molecular subtypes in breast cancer patients

BackgroundBreast cancer is the most commonly diagnosed cancer in women worldwide and characterized its by molecular and clinical heterogeneity. Gene expression profiling studies have classified breast cancers into five subtypes: luminal A, luminal B, HER-2 overexpressing, basal-like, and normal breast-like. Although clinical differences between subtypes have been well described in the literature, etiologic heterogeneity have not been fully studied. The aim of this study was to assess the associations between several hormonal and nonhormonal risk factors and molecular subtypes of breast cancer.MethodsThis cross-sectional study consisted of 1884 invasive breast cancer cases. Variables studied included family history, age at first full-term pregnancy, number of children, duration of lactation, menstruation history, menopausal status, blood type, smoking, obesity, oral contraceptive use, hormone replacement therapy and in vitro fertilization. The odds ratios (OR) and 95% confidence intervals (CI) were estimated using multivariate logistic regression analysis.ResultsThousand two-hundred and forty nine patients had luminal A, 234 had luminal B, 169 had HER-2 overexpressing and 232 had triple negative breast cancer. The age of ≥40 years was found to be a risk factor for luminal A (OR 1.41 95% CI 1.15–1.74; p = 0.001) and HER-2 overexpressing subtype (OR: 1.51, 95% CI: 1.01–2.25; p = 0.04). Women who were nulliparous (OR 1.48, 95% CI 1.03–2.13; p = 0.03) or who had their first full-term pregnancy at age 30 years or older (OR 1.25 95% CI 0.83–1.88; p = 0.04) were at increased risk of luminal breast cancer, whereas women with more than two children had a decreased risk (OR 0.68, 95% CI 0.47–0.97; p = 0.03). Breast-feeding was also a protective factor for luminal subtype (OR 0.74, 95% CI 0.53–1.04; p = 0.04) when compared to non-luminal breast cancer. We found increased risks for postmenopausal women with HER-2 overexpressing (OR 2.20, 95% CI 0.93–5.17; p = 0.04) and luminal A (OR 1.87, 95% CI 0.93–3.90, p = 0.02) breast cancers, who used hormone replacement therapy for 5 years or more. Overweight and obesity significantly increased the risk of triple negative subtype (OR 1.89 95% CI 1.06–3.37; p = 0.04 and OR 1.90 95% CI 1.00–3.61; p = 0.03), on the contrary, decreased the risk of luminal breast cancer (OR 0.63 95% CI 0.43–0.95; p = 0.02 and OR 0.50 95% CI 0.32–0.76; p = 0.002, respectively) in premenopausal women. There were no significant differences between risk of breast cancer subtypes and early menarche, late menopause, family history, postmenopausal obesity, oral contraseptive use, smoking, in vitro fertilization, blood groups and use of hands.ConclusionsReproductive and hormonal characteristics (breastfeeding, parity, age at first full-term birth, hormone replacement therapy) were associated with luminal subtype, compared to non-luminal breast cancer, as consistent with previous studies. Obesity and overweight increased the risk of triple negative subtype, particularly in premenopausal women. Older age and use of hormone replacement therapy were related to the risk of HER-2 overexpressing breast cancer. Our data suggest a significant heterogeneity in association of traditional breast cancer risk factors and tumor subtypes.