Liberiamoci dalla Rete. Oltre l Evidenza

Transcription

1 Presid Liberiamoci dalla Rete. Oltre l Evidenza Umberto Bracale MD PhD Università degli Studi di Napoli Federico II AUOP II Policlinico di Napoli Dipartimento di Gastroenterologia, Endocrinologia e Chirurgia Endoscopica

2 Presid The 2009 European Guidelines concluded that the Shouldice hernia repair technique is the best non-mesh repair method with a 1A level of evidence 3.

3 Presid

4 Presid

5 The traditional inguinal herniorrhaphy proposed by Bassini has represented the mainstay of cure for decades. None of the tissue repairs proposed after Bassini received attention and Presid obtained good results out of the centers where they were initially adopted (recurrence rate was greater than 25%). The work of Shouldice resisted several years as the gold standard for groin hernias. Nevertheless, in the recent past, a significant concern among patients and patients associations has been raised on the safety profile of synthetic implants. Robert Bendavid has raised a similar debate among hernia specialists, raised on the long-term effects of meshes, their chemical stability, and their effect on male fertility because of possible erosion in vas deferens.

6 Presid Possible indications to a tissue-based hernia repair: - Lower cost or non-availability of meshes in low-resource settings - Contaminated cases - Patient refusal of a mesh repair. There is lower level evidence that the Shouldice technique has a recurrence rate of less than 2% especially when performed in high-volume expert settings like the Shoul- dice Hospital.153 These data come primarily from expert centers. Often the studies suffer from inadequate follow-up and there is patient selection bias in some. This gives rise to a dispute between open non-mesh surgeons and surgeons advocating mesh repair on the true value of the Shouldice repair.

7 Desarda technique, was introduced in the daily clinical practice of some centers in 2001, especially in eastern countries and low resource settings. Presid A recent study would suggest that Desarda Technique seems to satisfy, more than Shouldice, recurrence rate, rate of complications and reproducibility. In light of this, our study aims to compare the efficacy of Shouldice and Desarda for primary inguinal hernia repair based on data reported by randomized controlled trials (RCTs). Because of the lack of RCTs directly comparing Shouldice and Desarda, we performed an indirect comparison through a network meta-analysis

8 PubMed, Ovid and Web of Science databases were used to identify previous meta-analyses and Presid RCTs comparing Shouldice or Desarda versus Lichtenstein for groin hernia repair starting from 01/01/2008 up to 01/09/2018.

9 Presid

10 Presid The present network metanalysis of trials comparing Shouldice and Desarda techniques shows that Desarda takes approximatively 13 minutes less than Shouldice to be performed and offers the patients an earlier return to normal activities, on average 6.6 days less than Shouldice technique. No other statistically significant differences could be detected in terms of intraoperative and postoperative complications, recurrence, postoperative pain and discomfort among the two non- mesh techniques.

11 Presid Conclusion The present network meta-analysis shows that Desarda technique can be considered at least as a safe and effective alternative to Shouldice technique, that is still considered the gold standard in non-mesh approaches to groin hernia repair. However, Desarda has showed potential advantages such as reduced operative time and quicker return to life activities. Further studies are needed in the future focusing on the short and long-term results specifically in the group of currently accepted indications for tissue repair (i.e., contaminated cases, young adults and in cases of patient refusal to mesh implants).

12 Presid It is unclear whether it is appropriate to compare the results of the Shouldice technique, usually performed by highly trained surgeons and/or in specialized centers, to the open mesh repair techniques which tend to be performed by generalists. Specialized centers have not published their results in a reliable manner. Many cohort studies contain bias and thus lack external validity. It is necessary to improve knowledge concerning this question concerning the value of nonmesh techniques especially for long-term recurrence rate and chronic pain. Although the level of evidence seems only moderate, by consensus in Hernia Surge the recommendation to use a mesh-based technique in inguinal hernia repair is upgraded to strong.