Recurrance rates….is there any clarity?

[Herniated]

Two thoughts for Chuck.
1. You might enjoy the following brief introduction to indecision: https://www.psychologytoday.com/us/blog/still-procrastinating/202103/what-makes-people-indecisive

2. If I recall correctly you are located in the DC/Baltimore region. If so, Johns Hopkins University Hernia Center is in the neighborhood, and offers a large number of expert surgeons. IF you haven’t already ruled them out, it would be worth some time exploring their surgeons: https://www.hopkinsmedicine.org/surgery/specialty-areas/hernia-center/index.html#:~:text=The%20Johns%20Hopkins%20Comprehensive%20Hernia%20Center%20offers%20world-class,patients%20whose%20complicated%20conditions%20cannot%20be%20treated%20elsewhere.

[Unknown Member]

I really feel stupid about selecting a lap repair…i cant believe i feel for it…the minimally invasive BS. All the stuff on mesh studies implied tissue repairs would be chronically painful and wouldnt last. Lap seemed so seemless..and then i bought the recurrance nonsense, Like any of these doctors would spend 5 minutes of their time following up with ex patients to see how they were doing….its just on to the next sucker for these snakes. Dr, Kang seems different because he is in a good position to see his recurrances…given that he offers a free fix in a small country…but then he has only been at this 10 years….of course he could be lying like all the rest…but kang seems different….he seems determined to develop the best possible repair….

[Watchful]

This study (among others) is one of the things that convinced me to go there.

One thing that bothered me with this study is that it didn’t look like they compensated for BMI (weight) in any way. The Shouldice Hospital treats only people of normal weight, and rejects those who are overweight or obese, while other providers treat them all. It is known that weight contributes to recurrence.

Regardless, these recurrence results for the Shouldice Hospital as shown in this study were definitely very impressive. As you mentioned, things have changed since then, so it’s possible that the results would be different now. The surgeons are mostly different. Also, they’ve been tweaking the original procedure, and stopped adhering religiously to some of the original details, which is something that surprised me when I was there. It’s not clear what the effects might be. Things have probably changed with other providers, possibly leading to better results than what they had back then.

The weakness in the studies of the Shouldice Hospital has always been the lack of the study of chronic pain. Their record on recurrence was really good, but what about chronic pain? Based on reviews, that seems more problematic. Virtually no one complains about recurrence, but quite a few complain about chronic pain. Like I mentioned before, they are currently studying it, but they’re doing it wrong from a logistical perspective in my opinion.

[Herniated]

There was a recurrence rate study that compared the recurrence rate of patients whose primary repair occurred at the Shouldice Hospital with those of patients whose primary repair occurred at various other Ontario hospitals. They did this by scanning the Ontario Hospital Insurance Program (OHIP) records, which captures recurrence codes in hospital billing requests (which captures Ontario recurrences regardless of whether the recurrence is repaired at the site of the primary repair. They found that the recurrence rate for patients receiving their primary repair at the Shouldice was dramatically less than that of patients served at other Ontario hospitals.

Not perfect because it missed the subset of patients who had their primary repair in Ontario but then had a recurrence repaired outside of Ontario. Nor would it capture patients not covered by OHIP (e.g. foreign patients). Also it only studied patients whose primary surgery occurred prior to 2008, and things have changed since then…

Malik et al., 2016, Recurrence of inguinal hernias repaired in a large hernia surgical specialty hospital and general hospitals in Ontario, Canada. Can J Surg, 59, 19. DOI: https://doi.org/10.1503/cjs.003915

[Unknown Member]

Thanks for your usual excellent analysis…I really wish you would join my FB natural health all stars page….this nonsense we run into in the hernia area pervades all of health care….its one big minefield and the only way to avoid it is to rely on super smart folks like yourself without an agenda. I have a bunch of folks like you on my forum…and I have learned a ton in only a few months…useless and dangerous medical procedures…dieatary and supplement advice….exercise….light exposure…approaches to deal with nearly every kind of condition, Regarding your comment on open mesh —that has not been my experience….and i have probed hard.. the only comment I hear back is usually it hurt me for about a week…but not even that badly…and afterward…NOTHING!! It seems inconcievable given what i know about the plastic garbage but that has been my result.

[Watchful]

Apropos your comment about open mesh on another thread (27 good cases you know, etc.) I happened to have coffee with an old colleague and friend of mine yesterday, and I mentioned my hernia surgery. He then told me that he had an open mesh surgery 20 years ago for an inguinal hernia, and he still gets occasional pain. He said it’s rare, but he still gets it from time to time.

He never told me about this pain before, even though I’ve known him for almost 20 years now. He did tell me about the surgery at some point, but not the pain. People really don’t like talking about these issues, and it may only come out in a conversation where you share your own experience, or probe a bit more.

[Watchful]

Chuck,

Studies of Shouldice surgeries performed outside the Shouldice Hospital in the old days showed significantly higher recurrence rates than at the Shouldice Hospital, and this includes German studies. However, those studies didn’t focus necessarily on the top surgeons.

I don’t know of any current data on recurrence rates at the Shouldice Hospital, and I don’t think you are correct in stating that they follow up. If you go there with a recurrence, they will know about it, but I don’t believe they actively follow up, and no one followed up with me so far. If I had a recurrence, they wouldn’t know about it unless I went back to their clinic complaining about it.

The situation with the Germans is similar. They don’t chase former patients and ask them about recurrence, chronic pain, etc. If a patient comes back with a complaint, they will register it in their database, but otherwise they wouldn’t know, and it wouldn’t be registered or counted in their statistics.

I did ask Conze this question about the validity of the statistics. He said that patients typically lose trust in the surgeon if they get a bad result (recurrence, chronic pain), and at that point they often don’t bother going back to the original surgeon. He was talking about the situation in Germany specifically. He said this means that he doesn’t really have the most accurate picture of his results. His results are very good based on the data he has, but that may be an incomplete picture.

Having said all that, I can tell you my subjective assessment which may be wrong or delusional, and it’s not something I can substantiate. I don’t think recurrence is a big concern even these days if you go to one of the highly experienced surgeons at the Shouldice Hospital. I don’t think it’s a big concern with the top German surgeons that we’re talking about either, but I’m a bit less confident about that. With chronic pain, my impression is flipped. A bit more likely at the Shouldice Hospital than with the German surgeons. Again, all this is just my hunch after all my research, discussions with surgeons and patients, and reading reviews, nothing very solid.

Something to bear in mind in this context, is that the Germans are a lot more selective in the cases where they perform tissue repair. Not as picky as the Shouldice Hospital on the weight front, but more selective in other areas such as hernia size, anatomy, and tissue quality. This means that the statistics on the results would be hard to compare even if we had them.