By Anthony J. Brown, MD
NEW YORK (Reuters Health) – Men who experience few or no
symptoms from an inguinal hernia do not require immediate
surgery; instead, they can be safely followed and treated if
symptoms worsen, new research shows.
If this approach catches on with surgeons throughout the
US, it could markedly reduce the number of hernia repairs
performed.
Inguinal hernias, the most common type, occur in the groin
when tissue that normally resides in the abdomen pushes through
a weak area in the abdominal wall. This bulging mass of tissue,
which may contain intestine, can cause pain, but usually can be
pushed back into the abdomen without difficulty. In some cases,
however, it may become stuck, a potentially life-threatening
complication called incarceration.
Out of fear that incarceration and other problems may
occur, “surgeons are generally taught that all hernias should
be repaired at diagnosis,” lead author Dr. Robert J.
Fitzgibbons, from Creighton University in Omaha, Nebraska told
Reuters Health.
“Our study questioned this conventional wisdom, he
explained, “and found that a ‘watchful waiting’ approach can be
safely applied to men with minimal symptoms. I suspect that 50
percent of patients with hernias could keep them for the rest
of their lives and never have a problem.”
One of the key findings “was that there didn’t appear to be
any penalty for waiting to perform surgery,” Fitzgibbons said.
“The concern had been that waiting could lead to worse hernias
that are more difficult to repair and associated with greater
complications. But in our study, the complication rate for
patients having initial surgery and those having delayed
surgery was exactly the same.”
The study, which is reported in this week’s Journal of the
American Medical Association, involved 720 men with inguinal
hernias that caused minimal symptoms who were randomly assigned
to receive immediate surgery or watchful waiting. With the
latter approach, subjects were seen after 6 months and then
annually to determine if hernia symptoms worsened, an
indication for surgery.
At 2-year follow-up, the rate of pain limiting activities
in each group was comparable, hovering around 3.5 percent.
Likewise, both groups showed a similar improvement in the
physical component of a standard health survey.
Twenty-three percent of patients assigned to watchful
waiting ultimately moved to the surgery group, typically due to
an increase in hernia-related pain. As noted, these patients
were not at heightened risk for surgical complications compared
with men who had their hernias repaired immediately.
One patient in the watchful waiting group developed
incarceration within 2 years. In addition, another patient in
the group had incarceration with intestinal blockage at 4
years.
Fitzgibbons believes the new findings will lead many
surgeons to “discuss nonoperative options with their hernia
patients.” He said that for legal reasons, surgeons may have
been reluctant to adopt a watchful waiting approach in the
past. “But now there is good scientific evidence that it’s a
reasonable strategy and that takes the medicolegal burden
away.”
“If the results of this study are reproduced in other
populations and for other types of hernia, then the era of
preventive hernia repair should go the way of prophylactic
tonsillectomy, (gallbladder removal), and appendectomy,” Dr.
David R. Flum, from the University of Washington in Seattle,
comments in a related editorial.
SOURCE: Journal of the American Medical Association,
January 18, 2006.
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