The risk of bowel strangulation is estimated to be small--less than 1% per year (strength of recommendation [SOR]: B, based on small cohort studies with short follow-up). Experts recommend repair for patients with risk factors for poor outcomes after potential strangulation. These risk factors include advanced age, limited access to emergency care, significant concomitant illness, inability to recognize symptoms of bowel incarceration, and poor operative risk (American Society of Anesthesiologists class III and IV) (SOR: C, based on expert opinion and case series). It is reasonable to offer elective surgery or watchful waiting to low-risk patients who understand the risks of strangulation (SOR: C, based on expert opinion and case series)

Chop, William M.

Ewigman, Bernard

Leubner, Kristel D.

Loven, Bridget

University of Missouri: MOspace

	 vol	56,	No	12	/	December	2007	 1039www.jfponline.comCliniCal INquIrIes From the Family Physicians Inquiries NetworkWhat is the risk of bowel strangulation in an adult with an untreated inguinal hernia?z Evidence summaryIn 2 randomized controlled trials (RCTs) comparing elective repair of inguinal hernias with watchful waiting, the co-horts who made up the control groups experienced strangulation rates of 1.8 per thousand (0.18%) and 7.9 per thou-sand (0.79%) occurrences per patient-year.1,2 In the first of these 2 trials,1 with 364 control group patients, median fol-low-up was only 3.2 years (maximum 4.5 years), and by 4 years 31% of pa-tients had crossed over to the treatment group for elective repair. The mean fol-low-up time in the second trial,2 which had 80 control group participants, was Kristel D. leubner, DO, and William M. Chop, Jr, MDFamily Medicine Residency Program, Waco, Texas,  an Affiliate of The University  of Texas Southwestern  Medical CenterBernard Ewigman, MD, MSPHDepartment of Family Medicine, University of ChicagoBridget loven, MliSLibrary and Information  Resource Center, Charlotte Area Health Education Center, Charlotte, NC  The	risk	of	bowel	strangulation	is	estimated	to	be	small—less	than	1%	per	year	(strength	of	recommendation	[sor]:	B,	based	on	small	cohort	studies	with	short	follow-up).	experts	recommend	repair	for	patients	with	risk	factors	for	poor	outcomes	after	potential	strangulation.	These	risk	factors	include	advanced	age,	limited	access	to	emergency	care,	significant	concomitant	illness,	inability	to	recognize	symptoms	of	bowel	incarceration,	and	poor	operative	risk	(American	society	of	Anesthesiologists	class	III	and	Iv)	(sor:	C,	based	on	expert	opinion	and	case	series).	It	is	reasonable	to	offer	elective	surgery	or	watchful	waiting	to	low-risk	patients	who	understand	the	risks	of	strangulation	(sor:	C,	based	on	expert	opinion	and	case	series).Watchful waiting, yes,but not for high-risk seniors The	evidence	reinforces	“watchful	waiting”	as	a	reasonable	management	approach.	However,	certain	patients—say,	a	66-year-old	diabetic	farmer—should	probably	undergo	elective	herniorrhaphy	to	preempt	the	increased	risk	of	complications	with	emergent	repair.	 shared	decision-making	is	an	essential	process	in	accounting	for	individual	preferences.	In	addition	to	knowing	the	risks	of	strangulation,	patients	opting	for	surgery	also	need	to	be	aware	of	the	differences	between	open	and	laparoscopic	techniques.	The	former	may	be	done	under	local	anesthesia;	the	latter	decreases	postoperative	pain	and	recovery	time,	but	requires	general	anesthesia	and	increases	the	rates	of	serious	complications.Michael K. Park, MDuniversity	of	colorado	Health	sciences	center,	rose	Family	medicine	residency,	DenverEvidence-based answerClinical commentary fast trackElective surgery and watchful  waiting are both reasonable  choices for  low-risk patientsfast track1040 vol	56,	No	12	/	December	2007		ThE Journal of family PraCTiCECliniCal INquIrIes1.6 years; 29% of patients eventually crossed over for repair. Spanish study may have overestimat-ed the risk. A retrospective study3 of 70 patients with incarcerated inguinal her-nias presenting for emergency surgery in Northern Spain reported a cumulative 2.8% probability of strangulation at 3 months, rising to 4.5% after 2 years. This study did not include patients presenting for elective repair of hernias, and therefore it likely overestimated the rate of strangu-lation among patients in a primary care setting. In 2001, a prospective study4 of 669 patients presenting for elective hernia repair in London found that only 0.3% of patients required resection of bowel or omentum. risk appears to be <1% a year. Collec-tively, these studies suggest that the risk of strangulation is less than 1% per year (0.18% to 0.79%) among all patients with inguinal hernias, at least in the first few years of the onset of the hernia. As you’d expect, the risk of strangulation is higher (2.8% to 4.5%) among patients presenting for emergency repair of incar-cerated hernias. We found no prospective studies that followed patients for more than 4.5 years. Age factors into poor outcomesA number of studies5,6 have examined risk factors for increased rates of stran-gulation and poor outcomes. Older age increases the risk of a poor outcome, peaking in the seventh decade. Patient comorbidity and late hospitalization also make emergent repair more risky.3,5 Retrospective studies3,5,7 of the tem-poral duration and the natural history of inguinal hernias, as well as operative complication rates, have shown conflict-ing results.70- and 80-year olds have greater risk. A Turkish study5 of patients needing emer-gent surgical repair found morbidity to be significantly related to American Society of Anesthesiologists (ASA) class, with mor-tality rates of 3% and 14% for ASA class III and IV patients, respectively. This was a retrospective chart review that analyzed factors responsible for unfavorable out-comes; it found increased complications in hernia patients who had coexisting dis-ease, hernias of longer duration, as well as higher ASA class. This study5 and another retrospective study6 found the need for emergent repair peaked for patients 70 to 80 years of age.longer history of herniation may = more postop complications. The Spanish Consider surgical repair for patients of advanced age and those  with significant comorbiditiesIllusTrATIoN	by	rob	Flewell	©	2007When to repair inguinal herniaExperts recommend repair of  an inguinal hernia	in	patients	with	risk	factors	for	poor	outcomes	after	potential	strangulation.	risk	factors	include	advanced	age	and	significant	concomitant	illness.fast trackwww.jfponline.com 	 vol	56,	No	12	/	December	2007	 1041retrospective review3 of emergent surgi-cal repair of incarcerated hernias (noted earlier) reported a 3.4% postoperative mortality rate. All deaths were among patients over 65 years of age and ASA class III or IV. This review also found more postoperative complications and a higher mortality for hernias present for more than 10 years. another study raises questions. A ret-rospective study from Israel8 also showed that patients who underwent emergency repair were older, had a longer history of herniation than those undergoing elec-tive repair, and had higher ASA scores. However, a case-control study7 and a chart review9 found that the risk of strangulation was higher for hernias of shorter duration. We found no studies addressing potential exacerbating conditions of in-guinal hernia, such as chronic cough, bladder outlet obstruction with strain-ing, constipation, obesity, or bilateral hernias. Recommendations from othersAll the textbooks and guidelines we iden-tified acknowledge that many patients forego operation and remain minimally symptomatic for long periods of time, and that operations themselves have risks and complications.10–12 The avoid-able risks of strangulation and emergent operation lead most experts to favor op-erative treatment. In ACS Surgery: Principles & Prac-tice 2007,10 the authors lament the dif-ficulty of obtaining accurate studies of the natural history of inguinal hernia because surgeons have been taught that it is best to operate at diagnosis, mak-ing it hard to find an adequate popula-tion to study. The authors acknowledge that while many primary care physicians advise their patients to delay operations if the hernia is minimally asymptomatic, they do not share this belief. The American College of Physicians’ PIER: The Physicians’ Information and Education Resource11 recommends as-sessing the hernia and the patient on a case-by-case basis. They recommend deferring an operation for poor-risk pa-tients with minimal symptoms if the her-nia is easily reducible and is unquestion-ably an inguinal hernia, if there are no past episodes of obstruction, and if the risks of untreated hernia are fully under-stood by the patient. Sabiston Textbook of Surgery makes virtually the same points and recommendations.12   nreferences	 1.	 	Fitzgibbons	rJ,	Giobbie-Hurder	A,	Gibbs	Jo,	et	al.	watchful	waiting	vs	repair	of	inguinal	hernia	in	mini-mally	symptomatic	men:	a	randomized	clinical	trial.	JAMA 2006;	295:285–292.	 2.	 	o’Dwyer	PJ,	Norrie	J,	Alani	A,	walker	A,	Duffy	F,	Horgan	P.	observation	or	operation	for	patients	with	an	 asymptomatic	 inguinal	 hernia:	 A	 randomised	clinical	trial.	Ann Surg	2006;	244:167–173.		 3.	 	Alvarez	 JA,	 baldonedo	 rF,	 bear	 IG,	 solis	 JAs,	Alvarez	A,	 Jorge	 JI.	 Incarcerated	 groin	 hernias	 in	adults:	 Presentation	 and	 outcome.	 Hernia 2004;	8:121–126.	 4.	 	Hair	A,	Paterson	c,	wright	D,	baxter	JN,	o’Dwyer	PJ.	what	 effect	 does	 the	 duration	 of	 an	 inguinal	hernia	have	on	patient	symptoms?	J Am Coll Surg	2001;	193:125–129.		 5.	 	Kulah	b,	Duzgun	AP,	moran	m,	Kulacoglu	IH,	oz-men	mm,	coskun	F.	emergency	hernia	 repairs	 in	elderly	patients.	Am J Surg	2001;	182:455–459.		 6.	 	mcentee	G,	o’carroll	A,	mooney	b,	egan	TJ,	Del-aney	Pv.	Timing	of	strangulation	in	adult	hernias.	Br J Surg	1989;	76:725–726.		 7.	 	rai	s,	chandra	ss,	smile	sr.	A	study	of	the	risk	of	strangulation	and	obstruction	in	groin	hernias. Aust N Z J Surg	1998;	68:650–654.	 8.	 	ohana,	manevwitch	I,	weil	r,	et	al.	Inguinal	hernia:	challenging	the	traditional	indication	for	surgery	in	asymptomatic	patients.	Hernia	2004;	8:117–120.		 9.	 	Gallegos	Nc,	Dawson	J,	Jarvis	m,	Hobsley	m.	risk	of	strangulation	 in	groin	hernias.	Br J Surg 1991;	78:1171–1173.	10.	 	Fitzgibbons	rJ,	richards	AT,	quinn,	TH.	open	her-nia	 repair.	 In:	 souba	ww,	wilmore	Dw,	 Fink	mP,	et	 al,	 eds.	ACS Surgery: Principles and Practice 2007. New	york,	Ny:	webmD	Professional	Publish-ing;	2007.	Available	at:	www.acssurgery.com.	Ac-cessed	on	June	22,	2007.	11.	 	Kingsnorth,	 AN,	 Khan	 JA.	 Hernia.	 In:	 PIer—The	Physicians’	 Information	 and	 education	 resource	[database	online].	Philadelphia,	Pa:	American	col-lege	of	Physicians;	2007.	12.	 	malangoni	mA,	Gagliardi	rJ.	Hernias.	In:	Townsend	cm,	beauchamp	rD,	evers	bm,	mattox	Kl,	eds.	Sabiston Textbook of Surgery.	 17th	 ed.	 Philadel-phia,	Pa:	saunders;	2004:1199–1217.	Available	at:	www.mdconsult.com/das/book/0/view/1235/394.html.	Accessed	on	November	8,	2007.	inguinal herniaLong history  of herniation  (>10 years) may lead to higher rates of mortality and postoperative complications

What is the risk of bowel strangulation in an adult with an untreated inguinal hernia?

Abstract

Similar works

Full text

Available Versions

University of Missouri: MOspace