Gabriel Sandblom

Risk factors for long-term pain after hernia surgery.

Objective:To estimate the prevalence of residual pain 2 to 3 years after hernia surgery, to identify factors associated with its occurrence, and to assess the consequences for the patient. Summary Background Data:Iatrogenic chronic pain is a neglected problem that may totally annul the benefits from hernia repair. Methods:From the population-based Swedish Hernia Register 3000 patients aged 15 to 85 years were sampled from the 9280 patients registered as having undergone a primary groin hernia operation in the year 2000. Of these, the 2853 patients still alive in 2003 were requested to fill in a postal questionnaire. Results:After 2 reminders, 2456 patients (86%), 2299 men and 157 women responded. In response to a question about “worst perceived pain last week,” 758 patients (31%) reported pain to some extent. In 144 cases (6%), the pain interfered with daily activities. Age below median, a high level of pain before the operation, and occurrence of any postoperative complication were found to significantly and independently predict long-term pain in multivariate logistic analysis when “worst pain last week” was used as outcome variable. The same variables, along with a repair technique using anterior approach, were found to predict long-term pain with “pain right now” as outcome variable. Conclusion:Pain that is at least partly disabling appears to occur more often than recurrences. The prevalence of long-term pain can be reduced by preventing postoperative complications. The impact of repair technique on the risk of long-term pain shown in our study should be further assessed in randomized controlled trials.

Randomised prostate cancer screening trial: 20 year follow-up

Objective To assess whether screening for prostate cancer reduces prostate cancer specific mortality. Design Population based randomised controlled trial. Setting Department of Urology, Norrköping, and the South-East Region Prostate Cancer Register. Participants All men aged 50-69 in the city of Norrköping, Sweden, identified in 1987 in the National Population Register (n=9026). Intervention From the study population, 1494 men were randomly allocated to be screened by including every sixth man from a list of dates of birth. These men were invited to be screened every third year from 1987 to 1996. On the first two occasions screening was done by digital rectal examination only. From 1993, this was combined with prostate specific antigen testing, with 4 µg/L as cut off. On the fourth occasion (1996), only men aged 69 or under at the time of the investigation were invited. Main outcome measures Data on tumour stage, grade, and treatment from the South East Region Prostate Cancer Register. Prostate cancer specific mortality up to 31 December 2008. Results In the four screenings from 1987 to 1996 attendance was 1161/1492 (78%), 957/1363 (70%), 895/1210 (74%), and 446/606 (74%), respectively. There were 85 cases (5.7%) of prostate cancer diagnosed in the screened group and 292 (3.9%) in the control group. The risk ratio for death from prostate cancer in the screening group was 1.16 (95% confidence interval 0.78 to 1.73). In a Cox proportional hazard analysis comparing prostate cancer specific survival in the control group with that in the screened group, the hazard ratio for death from prostate cancer was 1.23 (0.94 to 1.62; P=0.13). After adjustment for age at start of the study, the hazard ratio was 1.58 (1.06 to 2.36; P=0.024). Conclusions After 20 years of follow-up the rate of death from prostate cancer did not differ significantly between men in the screening group and those in the control group. Trial registration Current Controlled Trials, ISRCTN06342431.

Emergency Femoral Hernia Repair : A Study Based on a National Register

Objective:To describe the characteristics of femoral hernias and outcome of femoral repairs, with special emphasis on emergency operations. Background:Femoral hernias account for 2% to 4% of all groin hernias. However, the lack of large-scale studies has made it impossible to draw conclusions regarding the best management of these hernias. Methods:The study is based on patients 15 years or older who underwent groin hernia repair 1992 to 2006 at units participating in the Swedish Hernia Register. Results:Three thousand nine hundred eighty femoral hernia repairs were registered, 1490 on men and 2490 on women: 1430 (35.9%) patients underwent emergency surgery compared with 4.9% of the 138,309 patients with inguinal hernias. Bowel resection was performed in 22.7% (325) of emergent femoral repairs and 5.4% (363) of emergent inguinal repairs. Women had a substantial over risk for undergoing emergency femoral surgery compared with men (40.6% vs. 28.1%). An emergency femoral hernia operation was associated with a 10-fold increased mortality risk, whereas the risk for an elective repair did not exceed that of the general population. In elective femoral hernias, laparoscopic (hazard ratio, 0.31; 95% confidence interval, 0.15–0.67) and open preperitoneal mesh (hazard ratio, 0.28; confidence interval, 0.12–0.65) techniques resulted in fewer re-operations than suture repairs. Conclusions:Femoral hernias are more common in women and lead to a substantial over risk for an emergency operation, and consequently, a higher rate of bowel resection and mortality. Femoral hernias should be operated with high priority to avoid incarceration and be repaired with a mesh.

Validation of an Inguinal Pain Questionnaire for assessment of chronic pain after groin hernia repair

Long‐term pain is an important outcome after inguinal hernia repair. The aim of this study was to test the validity and reliability of a specific Inguinal Pain Questionnaire (IPQ).

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.

Long‐term pain after inguinal hernia repair in a population‐based cohort; risk factors and interference with daily activities

In the Swedish Hernia Register 2834 inguinal hernia repairs in 2583 patients were registered in the county of Uppsala 1998–2004. In May 2005 the 2421 patients still alive were requested by mail to fill in a validated questionnaire concerning postherniorrhaphy pain. The final response rate became 72%. Altogether 519 patients (29%) stated that they had pain in the operated groin to some extent during past week. In 98 patients (6%) the pain interfered with daily activities. Factors associated with an increased risk of residual pain in a multivariate logistic regression analysis were age below median, operation for recurrence, open repair technique, history of preoperative pain, and less than three years from surgery. Factors not associated with occurrence of residual pain were gender, method of anaesthesia during surgery, hernia sac diameter, postoperative complications, hernia type, need for emergency operation, reducibility of the hernia sac and complete dissection of the hernia sac. Factors found to be associated with impairment of function due to pain in a multivariate logistic regression analysis were: age below median, female gender, medial hernia, open repair technique, postoperative complications, need for operation for recurrence, presence of preoperative pain and less than three years from surgery. The possibility of long‐term pain as an outcome after hernia operations should be taken into consideration in the decision making prior to operation.

Survival in prostate carcinoma - Outcomes from a prospective, population-based cohort of 8887 men with up to 15 years of follow-up: Results from three counties in the population-based National Prostate Cancer Registry of Sweden

To decide on screening strategies and curative treatments for prostate carcinoma, it is necessary to determine the incidence and survival in a population that is not screened.

A population-based study of pain and quality of life during the year before death in men with prostate cancer

In order to explore how health-related quality of life changes towards the end of life, a questionnaire including the EuroQOl form and the Brief Pain Inventory form was sent to all men with prostate cancer in the county of Östergötland, Sweden, in September 1999. Responders who had died prior to 1 January 2001 were later identified retrospectively. Of the 1442 men who received the questionnaire, 1243 responded (86.2%). In the group of responders, 167 had died within the study period, 66 of prostate cancer. In multivariate analysis, pain as well as death within the period of study were found to predict decreased quality of life significantly. Of those who died of prostate cancer, 29.0% had rated their worst pain the previous week as severe. The same figure for those still alive was 10.5%. On a visual analogue scale (range 0–100), the mean rating of quality of life for those who subsequently died of prostate cancer was 54.0 (95% confidence interval ±5.2) and those still alive was 70.0 (±1.2). In conclusion, health-related quality of life gradually declines during the last year of life in men with prostate cancer. This decline may partly be avoided by an optimised pain management.

How reliable is intraoperative cholangiography as a method for detecting common bile duct stones? : A prospective population-based study on 1171 patients.

BackgroundAlthough intraoperative cholangiography (IOC) is a widely used method for detecting common bile duct stones (CBDS), its accuracy has not been fully evaluated in large nonselected patient samples. The purpose of this study was to assess the sensitivity, specificity and predictive value of dynamic IOC regarding its ability to diagnose CBDS in a population-based setting, and to assess the morbidity associated with the investigation.MethodsAll patients operated on for gallstone disease between 2003 and 2005 in the county of Uppsala in Sweden, a county with a population of 302,000 in December 2004, were registered prospectively. The outcome of cholangiography was validated against the postoperative clinical course.Results1171 patients were registered, and among these IOC was performed in 1117 patients (95%). Common bile duct stones were found in 134 patients (11%). One perforation of the common bile duct caused by the IOC catheter was recorded. Sensitivity was 97%, specificity 99%, negative predictive value 99%, positive predictive value 95%, and overall accuracy 99%. In 7 of the 134 cases where IOC indicated CBDS, no stones could be verified on exploration. In 4 of the 979 cases where IOC was normal, the clinical course indicated overlooked CBDS.ConclusionIntraoperative cholangiography is a safe and accurate method for detecting common bile duct stones.

Persistent pain after groin hernia surgery: a qualitative analysis of pain and its consequences for quality of life

Background: Despite a high prevalence of persistent groin pain after hernia repair, the specific nature of the pain and its clinical manifestation are poorly known. The aim of this study was to determine the type of post‐herniorrhaphy pain and its influence on daily life.