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Mortality and morbidity after groin hernia surgery: the role of nationwide registers in finding and analysing rare outcomes
Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
2013 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Introduction: Groin hernia surgery is one of the most common surgical procedures world-wide. Although mainly uncomplicated, the large volume of these operations makes it important to consider severe postoperative complications. The Swedish Hernia Register (SHR) started in 1992 and has grown to include more than 95% of all groin hernia operations performed in Sweden empowering it to be merged with other registers in population-based studies. The aim of this thesis is to merge SHR with other nation-wide registers to analyse postoperative mortality, cardiovascular morbidity, surgical hazards, as well as to study the influence of prostatectomy upon the risk for subsequent groin hernia surgery.

Methods: SHR was interlinked with the Cause of Death Register to find standardised mortality ratio, the National Prostate Cancer Register to find incidence of groin hernia surgery after prostatectomy compared to a control group and with the National Patient Register to find morbidity within 30 days of groin hernia surgery. In paper II, medical records of deceased patients were retrieved and scrutinised.

Results: Elective groin hernia surgery was found to be a low risk procedure even for elderly patients. The mortality risk within 30 days of emergency surgery was raised sevenfold compared to that of the background population. Women had a threefold increased risk of postoperative mortality compared to men. Patients with bowel obstruction, not examined for groin hernia in the emergency room, were subject to more radiological examinations and were operated significantly later than patents with a clinical diagnosis of groin hernia. Compared to men, significantly fewer women were examined for groin hernia in the emergency ward, 61% vs. 78%, (P=0.04). High age, co-morbidity, emergency operation, and regional anaesthesia were risk factors for cardiovascular events. Compared to open anterior mesh repair, all other methods were associated with increased risk of surgical complication, intra-operatively or postoperatively. A threefold increase in groin hernia surgery was seen after radical prostatectomy, conventional as well as minimally invasive.

Discussion: Women are significantly overrepresented concerning mortality after groin hernia surgery. This thesis shows the importance of nation-based registers in the analysis of infrequent phenomena in surgical care.

Place, publisher, year, edition, pages
Umeå: Umeå universitet , 2013. , 54 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1614
National Category
Surgery
Research subject
Surgery
Identifiers
URN: urn:nbn:se:umu:diva-82975ISBN: 978-91-7459-755-4 (print)OAI: oai:DiVA.org:umu-82975DiVA: diva2:664389
Public defence
2013-12-13, Tandläkarhögskolan, sal B, 9 tr, Norrlands universitetssjukhus, Umeå, 13:00 (English)
Opponent
Supervisors
Available from: 2013-11-19 Created: 2013-11-14 Last updated: 2013-11-19Bibliographically approved
List of papers
1. Mortality after groin hernia surgery
Open this publication in new window or tab >>Mortality after groin hernia surgery
Show others...
2007 (English)In: Annals of Surgery, ISSN 0003-4932, E-ISSN 1528-1140, Vol. 245, no 4, 656-660 p.Article in journal (Refereed) Published
Abstract [en]

Objective: To analyze mortality following groin hernia operations.

Summary Background Data: It is well known that the incidence of groin hernia in men exceeds the incidence in women by a factor of 10. However, gender differences in mortality following groin hernia surgery have not been explored in detail.

Methods: The study comprises all patients 15 years or older who underwent groin hernia repair between January 1, 1992 and December 31, 2005 at units participating in the Swedish Hernia Register (SHR). Postoperative mortality was defined as standardized mortality ratio (SMR) within 30 days, ie, observed deaths of operated patients over expected deaths considering age and gender of the population in Sweden.

Results: A total of 107,838 groin hernia repairs (103,710 operations), were recorded prospectively. Of 104,911 inguinal hernias, 5280 (5.1%) were treated emergently, as compared with 1068 (36.5%) of 2927 femoral hernias. Femoral hernia operations comprised 1.1% of groin hernia operations on men and 22.4% of operations on women. After femoral hernia operation, the mortality risk was increased 7-fold for both men and women. Mortality risk was not raised above that of the background population for elective groin hernia repair, but it was increased 7-fold after emergency operations and 20-fold if bowel resection was undertaken. Overall SMR was 1.4 (95% confidence interval, 1.2-1.6) for men and 4.2 (95% confidence interval, 3.2-5.4) for women, in accordance with a greater proportion of emergency operations among women compared with men, 17.0%, versus 5.1%.

Conclusions: Mortality risk following elective hernia repair is low, even at high age. An emergency operation for groin hernia carries a substantial mortality risk. After groin hernia repair, women have a higher mortality risk than men due to a greater risk for emergency procedure irrespective of hernia anatomy and a greater proportion of femoral hernia.

National Category
Surgery
Identifiers
urn:nbn:se:umu:diva-5976 (URN)10.1097/01.sla.0000251364.32698.4b (DOI)17414617 (PubMedID)
Available from: 2007-12-04 Created: 2007-12-04 Last updated: 2017-05-29Bibliographically approved
2. Mortality after groin hernia surgery: delay of treatment and cause of death
Open this publication in new window or tab >>Mortality after groin hernia surgery: delay of treatment and cause of death
2011 (English)In: Hernia, ISSN 1265-4906, E-ISSN 1248-9204, Vol. 15, no 3, 301-307 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Emergency hernia surgery, in contrast to elective hernia surgery, is associated with appreciable mortality. Incarcerated hernia is the second most common cause of small bowel obstruction after adhesions, and the leading cause of bowel strangulation.

METHODS: Information on patients who died within 30 days of groin hernia surgery was retrieved from the Swedish Hernia Register, from the Cause-of-Death Register, and from hospital notes.

RESULTS: Of 103,710 groin hernia operations between 1992 and 2004, 292 patients died within 30 days of surgery. Hospital notes and cause of death were retrieved for 242 cases (82%). In 5 of these patients, the hernia operation was done in addition to more urgent surgery and therefore excluded from further analyses; 152 patients were admitted as emergency cases and 55 of these patients underwent bowel resection. A total of 107 patients had signs of bowel obstruction when admitted. For 37% of these patients, physical examination of the groin was not documented. Patients with bowel obstruction without a note on a palpable groin lump were more likely to undergo imaging investigation preoperatively (P < 0.001) and they had an increased time to surgery compared to patients with a palpable lump. Women and patients with femoral hernia were significantly less likely to undergo a groin examination compared to other patients. Local anaesthesia was used in 7% of all patients who died postoperatively, and in 3% of emergency cases. Pulmonary disease, sepsis and malignant disease were more common as causes of death after emergency surgery than after elective surgery.

CONCLUSIONS: Groin examination of patients presenting with bowel obstruction is of utmost importance in order to minimise delay to hernia surgery.

Place, publisher, year, edition, pages
Paris: Springer, 2011
Keyword
Groin hernia, Inguinal hernia, Femoral hernia, Mortality, Bowel obstruction
National Category
Surgery
Identifiers
urn:nbn:se:umu:diva-57293 (URN)10.1007/s10029-011-0782-4 (DOI)21267615 (PubMedID)
Available from: 2012-07-11 Created: 2012-07-11 Last updated: 2017-05-29Bibliographically approved
3. Incidence of groin hernia repair after radical prostatectomy: a population-based nationwide study
Open this publication in new window or tab >>Incidence of groin hernia repair after radical prostatectomy: a population-based nationwide study
2014 (English)In: Annals of Surgery, ISSN 0003-4932, E-ISSN 1528-1140, Vol. 259, no 6, 1223-1227 p.Article in journal (Refereed) Published
Abstract [en]

Objective: To assess the incidence of groin hernia repair after radical prostatectomy for prostate cancer compared with the incidence in a control population without prostate cancer in a nationwide, population-based study.

Background: Recent reports indicate an increase in the incidence of groin hernia repair after radical prostatectomy. Inadequate knowledge of the incidence of groin hernia in the general population makes this information hard to interpret.

Methods: Information was retrieved from the Prostate Cancer Database (PCBaSe) and Swedish Hernia Register for events between 1998 and 2010. The incidence of groin hernia surgery was calculated for a group of men treated with radical prostatectomy (open and minimally invasive) and for a group treated with radiation therapy, and these were compared with the incidence in a control cohort of men matched for age and county of residence. Multivariate analysis was used to assess the hazard ratio (HR) of groin hernia repair according to age, tumor risk category, and Charlson Comorbidity Index.

Results: A total of 28,608 cases and 105,422 controls were included in the study. Men treated with radical prostatectomy and radiation therapy had a significantly higher incidence of groin hernia repair than the control cohort: HR: 3.95 (95% confidence interval: 3.70-4.21) for retropubic prostatectomy, HR: 3.37 (95% confidence interval: 2.95-3.87) for minimally invasive prostatectomy, and HR: 1.84 (95% confidence interval: 1.66-2.04) for radiation therapy.

Conclusions: An almost 4-fold increase in groin hernia repair was observed after radical prostatectomy compared with controls, and men who received radiation therapy had an almost 2-fold increase in incidence. As well as postoperative changes in the abdominal wall, increased vigilance for groin hernia seems to be important for the increased incidence of groin hernia repair seen after radical prostatectomy or radiation therapy for prostate cancer.

Keyword
groin hernia, nationwide register, population-based, radiation therapy, radical prostatectomy
National Category
Surgery
Identifiers
urn:nbn:se:umu:diva-82944 (URN)10.1097/SLA.0b013e3182975c88 (DOI)000337296700037 ()
Available from: 2013-11-13 Created: 2013-11-13 Last updated: 2017-12-06Bibliographically approved
4. Serious adverse events within 30 days of groin hernia surgery
Open this publication in new window or tab >>Serious adverse events within 30 days of groin hernia surgery
(English)Manuscript (preprint) (Other academic)
Keyword
Groin Hernia, Inguinal Hernia, Femoral Hernia, Morbidity
National Category
Surgery
Research subject
Surgery
Identifiers
urn:nbn:se:umu:diva-82992 (URN)
Available from: 2013-11-14 Created: 2013-11-14 Last updated: 2013-11-19Bibliographically approved

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