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A Clinician's Guide to Patient Selection for Watchful Waiting Management of Inguinal Hernia

Sarosi, George A. Jr, MD*; Wei, Yongliang MS; Gibbs, James O. PhD; Reda, Domenic J. PhD; McCarthy, Martin Jr, PhD§; Fitzgibbons, Robert J. Jr, MD; Barkun, Jeffrey S. T. MD**

doi: 10.1097/SLA.0b013e31820b04e9
Original Article

Objective: The goal of this study was to assist surgeons in managing patients with minimally symptomatic inguinal hernia by identifying characteristics that predict crossover to surgery or worsening of hernia symptoms.

Background: Randomized trials have suggested that watchful waiting mana-gement of minimally symptomatic inguinal hernia is an acceptable alternative to surgical repair. However, these trials found that roughly a quarter of patients would elect for repair in the first 2 years, suggesting that not all patients are good candidates for watchful waiting.

Methods: The 336 patients randomized to watchful waiting in the American College of Surgeons Watchful Waiting Hernia Trial constituted the study popu-lation. Preoperative patient characteristics were used to predict 2 outcomes, either crossover to surgery or the development of hernia pain limiting activities and/or crossover to surgery. Patients in our study were part of a previously registered randomized trial: NCT00263250.

Results: At 2 years, 72 patients crossed over to surgery, with pain with strenuous activities [odds ratio (OR), 1.3 per 10-mm visual analog scale pain scale], chronic constipation (OR, 4.9), prostatism (OR, 2.9), being married (OR, 2.3), and good health [OR, 3.0 American Society of Anesthesiologists Class (ASA) 1 vs 2], predicting crossover. An additional 28 patients developed pain, limiting their activities, with pain during strenuous activities (OR, 1.3 per 10-mm visual analog scale) and chronic constipation (OR, 4.5), predicting the combined outcome of pain limiting activities and/or crossover to surgery. Higher levels of activity reduced the risk (OR, 0.95) of this combined outcome.

Conclusions: Readily identifiable patient characteristics can predict those patients with minimally symptomatic inguinal hernia who are likely to “fail” watchful waiting hernia management. Consideration of these factors will allow surgeons to optimally tailor hernia management.

Watchful waiting management of minimally symptomatic inguinal hernia is safe and results in similar patient outcomes to surgical repair. However, up to a quarter of watchful waiting patients convert to surgery at 2 years. This study identifies patient characteristics that predict conversion to surgery in watchful waiting patients.

From the *Department of Surgery, University of Florida College of Medicine, Gainesville; †Hines VA Hospital, Cooperative Study Program Coordinator Center, Hines, IL; ‡Institute for Healthcare Studies and §Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University; Chicago, IL; ¶Department of Surgery, Creighton University School of Medicine, Omaha, NE; and **Department of Surgery, McGill University School of Medicine, Montreal, Quebec, Canada.

Reprints: George A. Sarosi, Jr, MD, Department of Surgery, University of Florida College of Medicine, 1600 SW Archer Rd, Box 100286, Gainesville, FL 32610.

Copyright © 2011 Wolters Kluwer Health, Inc. All rights reserved.