Bilateral total extraperitoneal inguinal hernia repair (TEP) has outcomes similar to those for unilateral TEP: population-based analysis of prospective data of 6,505 patients

Background: Whether bilateral total extraperitoneal (TEP) inguinal hernia repair is associated with worse outcomes than unilateral TEP continues to be a matter of debate. This study aimed to compare different outcomes of large cohorts of patients undergoing bilateral versus unilateral TEP. Methods: Based on prospective data of the Swiss Association of Laparoscopic and Thoracoscopic Surgery (SALTS), all patients undergoing elective unilateral or bilateral TEP from 1995 to 2006 were included in the study. The outcomes compared included conversion rates; intraoperative, surgical, and general postoperative complications; duration of operation; and length of hospital stay (LOS). Unadjusted and risk-adjusted multivariable analyses were performed. Results: Data for 6,505 patients undergoing unilateral (n=3,457) and bilateral (n=3,048) TEP were prospectively collected. The average age and the American Society of Anesthesiologists (ASA) score were similar in the two groups. The patients undergoing bilateral TEP repair had a slightly increased rate of intraoperative complications (bilateral, 3.1% vs. unilateral, 1.9%) and surgical postoperative complications (bilateral, 3.2% vs. unilateral, 2.3%). The operation time was longer for bilateral TEP repair (86 vs. 67min). No significant differences in postoperative LOS, general postoperative complications, or conversion rates were found. Conclusions: This is the first population-based analysis in the literature to compare different outcomes in a prospective cohort of more than 6,500 patients undergoing bilateral versus unilateral TEP. Although the rates for intraoperative and surgical postoperative complications were slightly higher for the patients undergoing bilateral TEP repair, the absolute differences were small and of minor clinical relevance. Bilateral TEP repair is associated with a minimal increase in operating time and similar LOS, general postoperative complications, and conversion rates. Therefore, for patients with bilateral inguinal hernia, a simultaneous endoscopic approach represents an excellent therapeutic optio

Population-based SEER trend analysis of overall and cancer-specific survival in 5138 patients with gastrointestinal stromal tumor

Background: The objective of the present population-based analysis was to assess survival patterns in patients with resected and metastatic GIST. Methods: Patients with histologically proven GIST were extracted from the Surveillance, Epidemiology and End Results (SEER) database from 1998 through 2011. Survival was determined applying Kaplan-Meier-estimates and multivariable Cox-regression analyses. The impact of size and mitotic count on survival was assessed with a generalized receiver-operating characteristic-analysis. Results: Overall, 5138 patients were included. Median age was 62 years (range: 18–101 years), 47.3% were female, 68.8% Caucasians. GIST location was in the stomach in 58.7% and small bowel in 31.2%. Lymph node and distant metastases were found in 5.1 and 18.0%, respectively. For non-metastatic GIST, three-year overall survival increased from 68.5% (95% CI: 58.8–79.8%) in 1998 to 88.6% (95% CI: 85.3–92.0%) in 2008, cancer-specific survival from 75.3% (95% CI: 66.1–85.9%) in 1998 to 92.2% (95% CI: 89.4–95.1%) in 2008. For metastatic GIST, three-year overall survival increased from 15.0% (95% CI: 5.3–42.6%) in 1998 to 54.7% (95% CI: 44.4–67.3%) in 2008, cancer-specific survival from 15.0% (95% CI: 5.3–42.6%) in 1998 to 61.9% (95% CI: 51.4–74.5%) in 2008 (all PTrend < 0.05). Conclusions: This is the first SEER trend analysis assessing outcomes in a large cohort of GIST patients over a 11-year time period. The analysis provides compelling evidence of a statistically significant and clinically relevant increase in overall and cancer-specific survival from 1998 to 2008, both for resected as well as metastatic GIST

Critical appraisal of meta-analyses: an introductory guide for the practicing surgeon

Meta-analyses are an essential tool of clinical research. Meta-analyses of individual randomized controlled trials frequently constitute the highest possible level of scientific evidence for a given research question and allow surgeons to rapidly gain a comprehensive understanding of an important clinical issue. Moreover, meta-analyses often serve as cornerstones for evidence-based surgery, treatment guidelines, and knowledge transfer. Given the importance of meta-analyses to the medical (and surgical) knowledge base, it is of cardinal importance that surgeons have a basic grasp of the principles that guide a high-quality meta-analysis, and be able to weigh objectively the advantages and potential pitfalls of this clinical research tool. Unfortunately, surgeons are often ill-prepared to successfully conduct, critically appraise, and correctly interpret meta-analyses. The objective of this educational review is to provide surgeons with a brief introductory overview of the knowledge and skills required for understanding and critically appraising surgical meta-analyses as well as assessing their implications for their own surgical practice

TAPP or TEP? Population-Based Analysis of Prospective Data on 4,552 Patients Undergoing Endoscopic Inguinal Hernia Repair

Background: Whether total extraperitoneal inguinal hernia repair (TEP) is associated with worse outcomes than transabdominal preperitoneal inguinal hernia repair (TAPP) continues to be a matter of debate. The objective of this large cohort study is to compare outcomes between patients undergoing TEP or TAPP. Methods: Based on prospective data of the Swiss association of laparoscopic and thoracoscopic surgery, all patients undergoing unilateral TEP or TAPP between 1995 and 2006 were included. The following outcomes were compared: conversion rates, intraoperative and postoperative complications, duration of operation. Results: Data on 4,552 patients undergoing TEP (n=3,457) and TAPP (n=1,095) were collected prospectively. Average age and American Society of Anesthesiologists score were similar in the two groups. Patients undergoing TEP had a significantly higher rate of intraoperative complications (TEP 1.9% vs. TAPP 0.9%, p=0.029) and surgical postoperative complications (TEP: 2.3% vs. TAPP: 0.8%, p=0.003). The postoperative length of stay was longer for patients undergoing TAPP (2.9 vs. 2.3days, p=0.002), whereas the duration of the operation was longer for TEP (66.6 vs. 59.0min, p<0.001) and the conversion rate was higher (TEP 1.0% vs. TAPP 0.2%, p=0.011). Conclusions: This study is one of the first population-based analyses comparing TEP and TAPP in a prospective cohort of more than 4,500 patients. Intraoperative and surgical postoperative complications were significantly higher in patients undergoing TEP. TEP is also associated with longer operating times and higher conversion rates. Therefore, on a population-based level, the TAPP technique appears to be superior to the TEP repair in patients undergoing unilateral inguinal hernia repai

Relative survival is an adequate estimate of cancer-specific survival: baseline mortality-adjusted 10-year survival of 771 rectal cancer patients.

BACKGROUND The objective of the present investigation is to assess the baseline mortality-adjusted 10-year survival of rectal cancer patients. METHODS Ten-year survival was analyzed in 771 consecutive American Joint Committee on Cancer (AJCC) stage I-IV rectal cancer patients undergoing open resection between 1991 and 2008 using risk-adjusted Cox proportional hazard regression models adjusting for population-based baseline mortality. RESULTS The median follow-up of patients alive was 8.8 years. The 10-year relative, overall, and cancer-specific survival were 66.5% [95% confidence interval (CI) 61.3-72.1], 48.7% (95% CI 44.9-52.8), and 66.4% (95% CI 62.5-70.5), respectively. In the entire patient sample (stage I-IV) 47.3% and in patients with stage I-III 33.6 % of all deaths were related to rectal cancer during the 10-year period. For patients with AJCC stage I rectal cancer, the 10-year overall survival was 96% and did not significantly differ from an average population after matching for gender, age, and calendar year (p = 0.151). For the more advanced tumor stages, however, survival was significantly impaired (p < 0.001). CONCLUSIONS Retrospective investigations of survival after rectal cancer resection should adjust for baseline mortality because a large fraction of deaths is not cancer related. Stage I rectal cancer patients, compared to patients with more advanced disease stages, have a relative survival close to 100% and can thus be considered cured. Using this relative-survival approach, the real public health burden caused by rectal cancer can reliably be analyzed and reported

Tissue Banking in a Regional Hospital: A Promising Future Concept? First Report on Fresh Frozen Tissue Banking in a Hospital Without an Integrated Institute of Pathology

Background: Vital tissue provided by fresh frozen tissue banking is often required for genetic tumor profiling and tailored therapies. However, the potential patient benefits of fresh frozen tissue banking are currently limited to university hospitals. The objective of the present pilot study—the first one in the literature—was to evaluate whether fresh frozen tissue banking is feasible in a regional hospital without an integrated institute of pathology. Methods: Patients with resectable breast and colon cancer were included in this prospective study. Both malignant and healthy tissue were sampled using isopentan-based snap-freezing 1h after tumor resection and stored at −80°C before transfer to the main tissue bank of a University institute of pathology. Results: The initial costs to set up tissue banking were 35,662 US$. Furthermore, the running costs are 1,250 US$ yearly. During the first 13months, 43 samples (nine samples of breast cancer and 34 samples of colon cancer) were collected from 41 patients. Based on the pathology reports, there was no interference with standard histopathologic analyses due to the sample collection. Conclusions: This is the first report in the literature providing evidence that tissue banking in a regional hospital without an integrated institute of pathology is feasible. The interesting findings of the present pilot study must be confirmed by larger investigation

Discrete Improvement in Racial Disparity in Survival among Patients with Stage IV Colorectal Cancer: a 21-Year Population-Based Analysis

Purpose Recently, multiple clinical trials have demonstrated improved outcomes in patients with metastatic colorectal cancer. This study investigated if the improved survival is race dependent. Patients and Methods Overall and cancer-specific survival of 77,490 White and Black patients with metastatic colorectal cancer from the 1988–2008 Surveillance Epidemiology and End Results registry were compared using unadjusted and multivariable adjusted Cox proportional hazard regression as well as competing risk analyses. Results Median age was 69 years, 47.4 % were female and 86.0 % White. Median survival was 11 months overall, with an overall increase from 8 to 14 months between 1988 and 2008. Overall survival increased from 8 to 14 months for White, and from 6 to 13 months for Black patients. After multivariable adjustment, the following parameters were associated with better survival: White, female, younger, better educated and married patients, patients with higher income and living in urban areas, patients with rectosigmoid junction and rectal cancer, undergoing cancer-directed surgery, having well/moderately differentiated, and N0 tumors (p<0.05 for all covariates). Discrepancies in overall survival based on race did not change significantly over time; however, there was a significant decrease of cancer-specific survival discrepancies over time between White and Black patients with a hazard ratio of 0.995 (95 % confidence interval 0.991–1.000) per year (p=0.03). Conclusion A clinically relevant overall survival increase was found from 1988 to 2008 in this population-based analysis for both White and Black patients with metastatic colorectal cancer. Although both White and Black patients benefitted from this improvement, a slight discrepancy between the two groups remained

Better survival in right-sided versus left-sided stage I - III colon cancer patients

Background: The distinction between right-sided and left-sided colon cancer has recently received considerable attention due to differences regarding underlying genetic mutations. There is an ongoing debate if right- versus left-sided tumor location itself represents an independent prognostic factor. We aimed to investigate this question by using propensity score matching. Methods: Patients with resected, stage I - III colon cancer were identified from the Surveillance, Epidemiology, and End Results (SEER) database (2004–2012). Both univariable and multivariable Cox regression as well as propensity score matching were used. Results: Overall, 91,416 patients (51,937 [56.8%] with right-sided, 39,479 [43.2%] with left-sided colon cancer; median follow-up 38 months) were eligible. In univariable analysis, patients with right-sided cancer had worse overall (hazard ratio [HR] = 1.32, 95% CI:1.29–1.36, P < 0.001) and cancer-specific survival (HR = 1.26, 95% CI:1.21–1.30, P < 0.001) compared to patients with left-sided cancer. After propensity score matching, the prognosis of right-sided carcinomas was better regarding overall (HR = 0.92, 95% CI: 0.89 − 0.94, P < 0.001) and cancer-specific survival (HR = 0.90, 95% CI:0.87 − 0.93, P < 0.001). In stage I and II, the prognosis of right-sided cancer was better for overall (HR = 0.89, 95% CI:0.84–0.94 and HR = 0.85, 95% CI:0.81–0.89) and cancer-specific survival (HR = 0.71, 95% CI:0.64 − 0.79 and HR = 0.75, 95% CI:0.70–0.80). Right- and left-sided colon cancer had a similar prognosis for stage III (overall: HR = 0.99, 95% CI:0.95–1.03 and cancer-specific: HR = 1.04, 95% CI:0.99–1.09). Conclusions: This population-based analysis on stage I - III colon cancer provides evidence that the prognosis of localized right-sided colon cancer is better compared to left-sided colon cancer. This questions the paradigm from previous research claiming a worse survival in right-sided colon cancer patients