Anders Kald

Reoperation as surrogate endpoint in hernia surgery. A three year follow-up of 1565 herniorrhaphies.

OBJECTIVE Analysis of reoperation and recurrence rates three years after repair of groin hernias. DESIGN Prospective audit by questionnaire and selective follow-up. SETTING Eight Swedish hospitals. SUBJECTS All groin hernia operations done during 1992 on patients between the ages of 15 and 80 years. MAIN OUTCOME MEASURES Postoperative complications, reoperation for recurrence, and recurrence. RESULTS During 1992, 1565 hernia operations were done. The postoperative complication rate was 8% (125/1565). At 36 months postoperatively 108 recurrences had already been reoperated on, six patients with recurrences were on the waiting list for reoperation and a further 36 recurrences had been detected at follow-up. The interhospital variation in recurrence rate ranged from 3% to 20%. Postoperative complications, recurrent hernia, direct hernia and hospital catchment area over 100000 inhabitants were all factors associated with an increased relative risk of recurrence. CONCLUSIONS The recurrence rate exceeded the reoperation rate for recurrence by almost 40% which should be taken into account if the reoperation rate is used as the endpoint after repairs of groin hernia. An audit scheme, based on prospective recording, reoperation rate, and (periodic) calculation of the recurrence rate may be used to identify risk factors for recurrence and areas in need of improvement.

Cost-minimisation analysis of laparoscopic and open appendicectomy.

OBJECTIVE To compare the direct and indirect costs of laparoscopic and open appendicectomy. DESIGN Randomised study. SETTING University hospital, Sweden. MAIN OUTCOME MEASURES Total costs for a defined period of time for each option. RESULTS 102 patients were randomised and 99 were included in the final analysis. All patients had completely recovered within two months of operation. Disposable extra material used for the laparoscopic operation and longer operating time raised its median cost by SEK 912 and 1785, respectively. The mean duration of hospital stay, period off work (indirect costs), and time to complete recovery did not differ between the groups. CONCLUSION Laparoscopic appendicectomy has higher direct costs than open operation and is not as cost-effective when the longterm outcome is the same in both groups.

Outcome of repair of bilateral groin hernias: a prospective evaluation of 1487 patients

OBJECTIVE To find out whether simultaneous repair of bilateral hernias increases the risk of recurrence compared with unilateral repair. DESIGN Prospective study. SETTING Swedish hospitals participating in the Swedish Hernia Register (SHR). INTERVENTIONS Prospective collection of data from the SHR, 1992-1999 inclusive. The Cox proportional hazard test was used for calculating odds ratio (OR). MAIN OUTCOME MEASURES Hernia repairs were followed up in a life table fashion until re-operation for recurrence or death of the patient. RESULTS 33416 unilateral and 1487 bilateral operations on 2974 groin hernias were found. Direct hernias were more common in the bilateral than in the unilateral group, 1,825, 61% compared with 13,336, 40%, (p < 0.0001). A laparoscopic method was used for 1774 (60%) of bilateral and 3285 (10%) unilateral repairs, and 455 bilateral operations (31%) were done as day cases compared with 18376 (55%) unilateral ones (p < 0.0001 for both comparisons). The cumulative incidence of reoperation at three years for groin hernias after bilateral and unilateral repair was 4.1% (95% confidence interval 3.1% to 5.1%) and 3.4% (95% Cl 3.1% to 3.7%, respectively. After adjustment for other risk factors, the OR for reoperation for recurrence after bilateral repair was 1.2 (95% CI 0.9 to 1.5) with unilateral repair as reference. The OR for reoperation after laparoscopic bilateral repair compared with open bilateral repair was 0.9 (95% CI 0.6 to 1.4). CONCLUSIONS Simultaneous repair of bilateral hernias does not increase the risk of reoperation for recurrence and there is no significant difference in the risk of reoperation after bilateral repair using open or laparoscopic techniques.

Audit and Recurrence Rates after Hernia Surgery

OBJECTIVE To study the effect of quality assurance on the recurrence rate after hernia repair. DESIGN A prospective longitudinal cohort study. SETTING District hospital, Sweden. SUBJECTS All (n = 1232) patients aged 15-80 years operated upon for inguinal or femoral hernia in Motala 1984, 1986-1988, 1990, and 1992-1994. INTERVENTION A questionnaire enquiring about pain or a lump in the operated area was sent 3-6 years postoperatively to all patients, excluding those who had already been operated on for recurrence and those who had died. Selected cases were examined depending on the answers to the questionnaire. MAIN OUTCOME MEASURES Recurrence rate estimated by adding already confirmed recurrences to those found at the clinical examination; reoperation for recurrence; hospital stay; and number of day cases. Cumulative incidence of reoperation was analysed by actuarial analysis of all patients operated on from 1986-1997. RESULTS The recurrence rate decreased from 18% in 1984 and 1986 to 3% in 1993 and 1994. The reoperation rate for recurrence at three years was 10.8% (95% confidence interval, CI: 9.3 to 12.2%), 3.6% (2.6 to 4.4%) and 2.2% (1.7 to 2.7%) for patients operated on between 1986-1988, 1989-1991 and 1992-1997, respectively. Differences between the first and the second and between the first and the third period were both highly significant (p < 0.001) whereas the difference between the second and third period was not (p = 0.09). Mean hospital stay decreased from 3.5 days in 1984 to 0.9 days in 1994. CONCLUSION By recording recurrence rate or its surrogate endpoint, reoperation rate for recurrence, or both, hospital stay, and number of day cases, and presenting these results to participating surgeons, we provided incentives to improve outcome. This has resulted in a rapid decrease in recurrence rate and a shortened hospital stay, thereby improving cost-effectiveness.