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January 27, 2006

BehindTheMedspeak: 'Hernias may not require surgery'

3of4doctors_1_1

Above, the headline (no, not the "three out of four doctors...", silly — above that) of a story in the January 23 Wall Street Journal about a study just published in the Journal of The American Medical Association (JAMA).

The question was, is it safe to simply keep an eye on symptomless hernias instead of operating?

Here at bookofjoe our philosophy is to avoid any and all interaction with doctors if at all possible.

That's the dirty little secret of a long and happy life.

I guess it's not so secret anymore, what?

No matter.

Here's the abstract of the JAMA article.

    Watchful Waiting vs Repair of Inguinal Hernia in Minimally Symptomatic Men: A Randomized Clinical Trial

    Context: Many men with inguinal hernia have minimal symptoms. Whether deferring surgical repair is a safe and acceptable option has not been assessed.

    Objective: To compare pain and the physical component score (PCS) of the Short Form-36 Version 2 survey at 2 years in men with minimally symptomatic inguinal hernias treated with watchful waiting or surgical repair.

    Design, Setting and Participants: Randomized trial conducted January 1, 1999, through December 31, 2004, at 5 North American centers and enrolling 720 men (364 watchful waiting, 356 surgical repair) followed up for 2 to 4.5 years.

    Interventions: Watchful-waiting patients were followed up at 6 months and annually and watched for hernia symptoms; repair patients received standard open tension-free repair and were followed up at 3 and 6 months and annually.

    Main Outcome Measures: Pain and discomfort interfering with usual activities at 2 years and change in PCS from baseline to 2 years. Secondary outcomes were complications, patient-reported pain, functional status, activity levels, and satisfaction with care.

    Results: Primary intention-to-treat outcomes were similar at 2 years for watchful waiting vs surgical repair: pain limiting activities (5.1% vs 2.2%, respectively; P = .52); PCS (improvement over baseline, 0.29 points vs 0.13 points; P = .79). Twenty-three percent of patients assigned to watchful waiting crossed over to receive surgical repair (increase in hernia-related pain was the most common reason offered); 17% assigned to receive repair crossed over to watchful waiting. Self-reported pain in watchful-waiting patients crossing over improved after repair. Occurrence of postoperative hernia-related complications was similar in patients who received repair as assigned and in watchful-waiting patients who crossed over. One watchful-waiting patient (0.3%) experienced acute hernia incarceration without strangulation within 2 years; a second had acute incarceration with bowel obstruction at 4 years, with a frequency of 1.8/1000 patient-years inclusive of patients followed up for as long as 4.5 years.

    Conclusions: Watchful waiting is an acceptable option for men with minimally symptomatic inguinal hernias. Delaying surgical repair until symptoms increase is safe because acute hernia incarcerations occur rarely.

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In case you weren't up to reading the abstract, long story short: if your hernia doesn't hurt, leave it alone.

Dr. David Flum of the University of Washington, in an accompanying JAMA editorial, said hernia surgery for patients without pain may soon disappear, just as preventive tonsillectomies have done.

FunFacts:

• About 2% of all men in the U.S. have inguinal hernias

• Overall, about 5 million Americans of all ages have some type of abdominal hernia

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I've always been impressed by how involved seemingly "minor" inguinal hernia surgery can be.

I've watched hundreds of these procedures from the other side of the surgical drape.

It's a tricky thing, finding and repairing a hole in the abdominal wall.

Nowadays surgeons routinely insert a mesh screen over the hole to reinforce the closure: that takes some doing since they're working in a very small space.

Much better to avoid the whole thing.

January 27, 2006 at 10:01 AM | Permalink


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