Good intentions
Forum Replies Created
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Tightness and loss of flexibility is common around mesh implantations. And, apparently, incisional hernias are difficult to repair. The recurrence rate is higher than for inguinal hernias.
If you can get your medical records, and if necessary, translate them to English, it migth be worthwhile to contact Dr. Meyers at the Vincera Institute. He is well-known for working on runners, among other athletes. He offers a free consultation, but is expensive, as I understand things. But he might have some ideas.
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Dr. van Veenendaal presented at the EHS Manchester meeting on “Recommendations of hernia surge update on CPIP”. The publication in Hernia looks like the official document. “Herniasurge” seems to be some sort of phantom organization now. Professionals are referring to “Herniasurge” but there is no way to find out who or what, exactly, the thing is today. It seems to exist only as a memory of the group that created the “Guidelines”.
The only mention of “Herniasurge” in the paper referred to in the first post is a single reference back to the 2018 Guidelines publication. Edit – actually I see that Dr. Veenendaal split the word in to two in the paper. Even the author does not know what it is.
https://herniatalk.com/forums/topic/european-hernia-society-manchester-2022/
Even the use of “hernia surge” as two separate words is odd. Where is it? What is it? How does a person contact them? Who is leading them?
“CHRONIC PAIN IN INGUINAL HERNIA SURGERY: MDT Main Auditorium
Moderator: Maciej Pawlak, UK, Diego Cuccurollo, Italy
MDT approach to diagnosing and treatment CPIP
Maciej Pawlak, UK
MDT treatment of CPIP in the US
David Chen, USA
Persistent Pain cycle; why we need to focus on patient’s ideas and concerns
Matthew Lund, UK
Non-surgical treatment of CPIP
Eske Kvanner Aasvang, Denmark
Recommendations of hernia surge update on CPIP
Nadine Van Veenendaal, Netherlands
When all else fails is it ACNES?
Rudi Roumen, Netherlands” -
Here is some of Dr. van Veenendaal’s previous work. He did not report a conflict in the latest paper above, even though he is still referring to and supporting the Guidelines that he reported a conflict for below. Ethically, they still seem very well tied together.
https://link.springer.com/article/10.1007/s10029-018-1729-9
“Summary for patients: International guidelines for groin hernia management
N. van Veenendaal, M. P. Simons & H. J. Bonjer
Hernia volume 22, pages167–168 (2018)”“Ethics declarations
Conflict of interest
N van Veenendaal and M.P. Simons report grants for meeting expenses related to the submitted work from Johnson & Johnson and Bard, during the conduct of the study. H.J. Bonjer declares conflict of interest not directly related to the submitted work by receiving grants from Johnson & Johnson, Medtronic, Olympus, Applied Medical and Stryker; and by receiving personal fees from Medtronic, Olympus and Cook and reports grants for meeting expenses related to the submitted work from Johnson & Johnson and Bard, during the conduct of the study.” -
Chuck had a bilateral repair. I had a bilateral repair. The trend today is for all laparoscopic repairs to be bilateral.
But unilateral versus bilateral is a minor issue. You’ve been on the forum for quite a while. You must be reading the posts.
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It would have been interesting to see how Dr. Pawlak’s views were received at the conference. Herniasurge on one side, promoting mesh, others expressing solid counterpoints.
Here is their final paragraph –
“Guidelines – friend or foe? Guidelines that conform to current development standards should be our friend. There seems to be a fear among many herniologists that guidelines set a standard of care. And deviation from them will thus become ammunition for patients and their lawyers to trip us up. This is a view that is very wrong, both for what guidelines are for and what they mean. We end this editorial with the words of John Kinsella, recently retired Chair of the Scottish Intercollegiate Guidelines Network (SIGN). “In the era of realistic medicine, SIGN guidelines should be the starting point for decision-making at the clinician-patient interface, and should inform the joint decision, not dictate a particular course of action.”[21]”
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I don’t remember anything specific to Mark T’s comment but I did post something in the past about Dr. Pawlak and his views on Guidelines. He was on the presentation list at the Manchester conference.
The Manchester conference seems primed to drive change but Dr. Pawlak’s editorial shows why what the Herniasurge group manufactured is so powerful. They have defined an artificial “standard of care” that perpetuates the use of mesh for hernia repair. I think that that is why they get so much support from companies like Medtronic. If I was an executive at Medtronic I would be all-in on helping the Herniasurge group get heir message out. Full funding, whatever they need.
Here is my old Topic. I will pull out the Editorial in the post after this.
https://herniatalk.com/forums/topic/dr-m-pawlak-a-new-surgeon-worth-following-and-hoping-for/
And the Topic about the Manchester conference.
https://herniatalk.com/forums/topic/european-hernia-society-manchester-2022/
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The study is incomplete but Ethicon has no problem pulling out anything that helps sell the product. The study started in 2007, it’s 2022, and they use one year as the evidence for their statements. The statement itself is vague, what is “baseline”? Just marketing stuff.
https://www.jnjmedtech.com/en-US/product/ultrapro-mesh-ethicon
“ULTRAPRO® Macroporous Partially Absorbable Mesh offers strength with reduced foreign body mass1,5 and may reduce the risk of patient complications compared with mircroporous mesh.2,6 In a study of patients from the International Mesh Hernia Registry (IHMR), patients demonstrated low rates of intra- and postoperative complications, such as seromas, and recurrence (<1%) after 1 year.2-4,7-12 In the same study, patients reported improvement in pain and movement limitations from baseline at 1 year postsurgery.2,3,7,8 ULTRAPRO Mesh withstands more than 2x the maximum abdominal pressure in healthy adults.13,14”
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I just stumbled across the Ethicon IHMR site again. The study completion date has been pushed out again, to March 2024. And they are still using data from the study in their marketing literature to promote the mesh as “pain-free”. The people that sell mesh have no connection to healthcare. They are just selling a product.
https://www.clinicaltrials.gov/ct2/show/NCT00622583
Official Title: A Two-Year Follow-up, Post-Implantation, Multi-center, International Hernia Mesh Registry
Actual Study Start Date : September 1, 2007
Actual Primary Completion Date : April 24, 2019
Estimated Study Completion Date : March 31, 2024 -
The Herniasurge web page is still inactive, and their Facebook page has no activity either.
I hope that something good happens but history suggests that the effort will be mainly to reaffirm what has already been created, as shown by their very recent survey of surgeons to reaffirm (or really, just to affirm) support of the Guidelines. Why would they do that if significant changes were in progress? Any changes would be used by the lawyers for current lawsuits. I will be surprised if there is any suggestion to reduce the use of mesh. It’s just how corporations work.
Good luck with your efforts to drive change for hernia repair for women. I think that there is real possibility there since the volume is so small compared to male hernias.
https://twitter.com/Herniadoc?ref_src=twsrc%5Egoogle%7Ctwcamp%5Eserp%7Ctwgr%5Eauthor
https://twitter.com/eurohernias?ref_src=twsrc%5Egoogle%7Ctwcamp%5Eserp%7Ctwgr%5Eauthor
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Thanks Dr. Towfigh. You might not be aware that people without Twitter accounts can only see a few Tweets before Twitter blocks access to the site, until the person signs in or signs up. So your EHS live tweets will soon be unviewable to people without accounts, as you add other tweets behind them.
The Guidelines on the EHS web site have not changed (https://www.europeanherniasociety.eu/ ). The 2018 version is still up. I assume that EHS will update them, and their summary of them, as soon as possible. (I just noticed that Medtronic managed to get their name on to the Guidelines summary page, at the end. The Guidelines should really be called “Guidelines for Mesh Repair of Hernias”. https://www.europeanherniasociety.eu/sites/www.europeanherniasociety.eu/files/medias/cov13178_ehs_groin_hernia_management_a5_en_10_lr_1.pdf)
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Did you try centers in Europe? Countries with more “socialized” medicine. The United States is very money-first oriented, they need to be sure that there is a way for them to get paid. Since you are from out of country you could easily skip town and they would never get paid. I’m not defending the way things are done here, just describing what is.
Post a copy of your letter. There might be a clue there. The tone of the communication is important. If your letter is like your commentary on the forum that migth be part of your problem. Nobody wants to get involved with what looks like a difficult person. Good luck.
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Here is a link to the fourth paper.
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I think that you need more information than “tiny direct hernia”. He might mean that he sees a bulge, and that the bulge will probably not get bigger. Surgery has its own risks. The risk/reward ratio is what’s important. If he is well known and has done many lap mesh repairs then he probably thinks, or knows, that implanting more mesh for a tiny hernia might cause more problems than the small one that it fixes. He knows that you probably have a sensitivity to mesh, because you have discomfort around a mesh repair.
What’s interesting, but common, is that nothing was seen on the mesh repair side to explain the discomfort. “Nothing wrong”. Yet there is constant discomfort. Does that make sense? What did he recommend to deal with the discomfort?
If he offered to do the same surgery for the tiny hernia as what he did for the uncomfortable repair would you take it? Would you be okay with the same consistent discomfort on both sides? He’s probably making the decision for you, and himself.
There is nothing wrong with getting a second opinion. But if you go to another lap mesh surgeon they will probably assume that they can do a better job than the other guy. That’s what I found when I talked to surgeons about mesh problems. So choose your second opinion expert carefully.
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I think that Dr. Kang understands English and writes well in English, although he might not speak it fluently. I think that comments on the forum from Dr. Kang are written by Dr. Kang. If you go to see him you’re not going for the conversation anyway, so the need for fluency in English is pointless.
The comments about “poison” and insulting names for political figures indicate a not-so-rational approach to choosing a surgeon or a method. That type of thinking will probably lead to choosing a surgeon who agrees with personal and political views more than one with the best odds of a good long-term result. That’s just how decision-making works. The comments about “carving” and “sushi” are in the same vein. You’ll come across a surgeon who aligns their speech with their assessment of your opinions and the sale will be made. Like Chuck remembers (or his interpretation of what he thinks he heard) all of the negative comments that various surgeons made about other surgeons and that’s his end-point. The odds of success don’t matter, he’s looking for the perfect surgeon to perform the perfect surgery. The perfect surgeon will be one who has not performed any hernia repairs at all.
If you’re not careful you’ll end up like this guy.
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Here is a link to the paper. It’s been cited by 53 people according to Google Scholar. It was published in 2013.
https://www.sciencedirect.com/science/article/abs/pii/S0304395912006483
https://scholar.google.com/scholar?hl=en&as_sdt=0%2C48&q=DQB1+*03%3A02+HLA+haplotype+&btnG=
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Dr. Campanelli seems to be thinking deeply about what it means to be a physician in today’s world and expressing his thoughts in Editorials. It will be interesting to see what the corporations think of the issues he is raising.
Here is a search page and a couple of his most recent articles.
https://link.springer.com/search?dc.creator=G.%20Campanelli
“Quality of life is the most important outcome measure of hernia repair”
https://link.springer.com/article/10.1007/s10029-022-02634-6
“Super-technology, quality of life and ethics in surgery”
https://link.springer.com/article/10.1007/s10029-022-02655-1
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I think that Dr. Towfigh touched on some possibilities for the first question in her presentation.
Here is a recent commentary that I ran across today, also about hernias in female patients. Topics generally tend to become focused then fade away as the years go by. Maybe this is the time of the female hernia. Trans vaginal mesh brought a renewed focus on mesh problems. Maybe hernia repair mesh in females will do the same again.
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Dr. Lorenz was in the LinkedIn picture and he posted soon after the Guidelines were published about one of the deficiencies of the Guidelines. It will be interesting to see if they take the obvious step, as Dr. Towfigh noted in her recent presentation, of recommending more pure tissue repairs. It’s hard to see how they could avoid it.
Excerpt –
“For many years, the only quality criteria used after a hernia operation was the recurrence rate. Subsequently, the tension-free concept was developed and is now used throughout the world. In recent years, the focus has increasingly shifted to possible chronic pain after hernia surgery. Based on these two criteria, the currently applicable “International Guidelines for Groin Hernia Management” published by the HerniaSurge Group recommends the use of mesh as a rule, either endoscopically via transabdominal preperitoneal or total extraperitoneal or in open surgery using the Lichtenstein technique.[1]
However, newer studies have shown that use of the Lichtenstein technique is possibly linked to a higher rate of postoperative pain.[2] The guidelines currently do not include alternative open surgical techniques, particularly mesh-free techniques, due to the small amount of scientific evidence. However, in recent years, numerous reports on postoperative pain after mesh implantation[3] and mesh-related complications[4] have led to increasing uncertainty among patients. Moreover, there have recently been register studies that showed at least equally good results for the mesh-free procedures for selected patients.[5],[6] Thus, the mesh-free procedures are regaining importance.[7]”
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Thanks for the reply Dr. Towfigh. There is really nothing substantial to read in that single month old LinkedIn posting, but it is something, at least.
My understanding is that Herniasurge is just a formalization of a combined effort, based on past efforts by several organizations. The same group that put together the 2009 European Hernia Society guidelines was involved. The same names plus some new ones. So, not really “impromptu”. Looks like a pretty long-term plan.
It will be interesting to see what they come up with. Especially after Dr. Campanelli’s Editorial about how “chronic pain is real” and that there will be a focus on it this year. Strange though that the Herniasurge web site is dead, and the Facebook page inactive, but somebody found the time to post on EHS’s Linkedin page.
Here is a good summary of the efforts that resulted in the Herniasurge Guidelines. And a link to the EHS guidelines of 2009.
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It seems too early to consider more surgery. Is it possible that you’re trying to exercise your body back to its old self and overworking the surgery area? I have found that the occasional extended rest time helps when aches and pains in the surgery area start to build up. It’s getting close to five years since mesh removal for me and I can still feel adjustments down there as time and activities go on.