ObjectiveInternational health systems had the opportunity to assess the resilience of core health services to severe disruption following the onset of the COVID-19 pandemic. This paper examines the resilience of a core health service to shocks from COVID-19. We compare outcomes following emergency admissions in England during the second (Winter 2020/21) and third (Winter 2021/22) major waves of COVID-19 with the first wave and historic admissions from 2016 to 2019.MethodsThis cohort study included adult emergency admissions for five common acute surgical conditions: appendicitis, symptomatic gallstone disease, intestinal obstruction, symptomatic diverticular disease, and abdominal wall hernia in 122 acute hospital Trusts in England. Participants were 647,367 admissions in the hospital episode statistics (HES) inpatient database including 34,560 in the second wave and 36,628 in the third wave. Outcome was all-cause mortality at 90 days.ResultsThere were 1308 deaths in wave two (3.8% of admissions) and 1235 (3.4%) in wave three compared with 3431 (3.4%) in the historic cohort and 577 (4.7%) in wave one. Compared with pre-COVID admissions, we found weak evidence of increased mortality in the second wave. There was no evidence of increased mortality in the third wave, compared to historic cohorts the case-mix adjusted odds ratios were: appendicitis 0.96 (95% CI 0.49-1.87); gallstone disease 1.27 (95% CI 0.94-1.72); diverticular disease 1.04 (95% CI 0.79-1.36); hernia 1.06 (95% CI 0.76-1.47); and intestinal obstruction 1.02 (95% CI 0.87-1.19).ConclusionsBy the end of wave three, outcomes for emergency admissions with five common acute conditions had returned to pre-pandemic levels. Lessons learnt during the disruption of the first wave of COVID-19 helped the NHS in England adapt emergency surgical services during subsequent waves. These findings emphasise the importance of maintaining, or quickly restoring core service capacity to help patient outcomes return to pre-pandemic levels.

Background The purpose of this scoping review was to systematically review the published literature of randomized controlled trials (RCT) in rectal cancer to generate a comprehensive list of study outcomes. The secondary objectives of this study were to describe trends in outcome reporting in rectal cancer RCTs with a particular focus on patient-reported outcome measures (PROM). Methods We systematically searched for rectal cancer RCTs suing several electronic databases. Eligible studies needed to be published after the year 2000 and had to evaluate a locoregional or systemic therapy for non-metastatic rectal cancer as its primary exposure. All reported outcomes were extracted verbatim from the article and subsequently re-categorized into “standardized outcome terms” and within OMERACT Core Areas of health. Data regarding the use of patient-reported outcome measures and the choice of primary outcome were also extracted. Results In total, 89 RCT’s were included: 56 (62.9%) were considered neoadjuvant trials, 24 (27.0) surgical trials, and 9 (10.1%) adjuvant trials. Fifty-three standardized outcome terms were identified and grouped into various domains and Core Areas. The primary outcomes utilized in each RCT were highly variable and differed by study type. In total, 37 (41.6%) trials used one or more patient-reported outcome measure as an outcome, mainly consisting of health-related quality of life. There were no significant trends in outcome reporting by year or author specialty. Conclusions A comprehensive list of study outcomes categorized into several domains and Core Areas was generated.

Introduction With the rapidly changing landscape of rectal cancer treatment, it is becoming increasingly challenging for clinicians to interpret and synthesise the vast amount of high-quality evidence being generated. A core outcome set (COS) for clinical trials in rectal cancer would help address issues surrounding outcome selection and reporting. The purpose of this research project is to develop a COS to be used in research comparing different treatment paradigms in the management of rectal cancer.Methods and analysis This will be a mixed-methods project, including a systematic review, semi-structured interviews and a Delphi consensus process. The project was designed in accordance with the COMET (Core Outcome Measures in Effectiveness Trials) Handbook, which provides a framework for COS development based on existing evidence. A multidisciplinary Study Advisory Group, composed of rectal cancer providers, methodologists and patients, will oversee the project. A systematic review will be performed to identify an inclusive list of outcomes reported by researchers in previous rectal cancer trials. Outcomes will be collapsed into various core areas and domains according to the OMERACT Filter V.2.0. Semi-structured interviews with rectal cancer survivors and their partners/caregivers will help identify additional patient-centric outcomes not captured in the systematic review. Finally, after a final list of outcomes is generated, patients and healthcare professionals will be invited to participate in a Delphi process to develop the final COS.Ethics and dissemination The study has received full approval with the Research Ethics Committee at the Integrated Health and Social Services Network for West-Central Montreal (health network responsible for the Jewish General Hospital) (REC: 2025-4377) and the Institutional Review Board of the Mount Sinai School of Medicine (IRB: STUDY-25-00515). The results of this study will be presented at national and international meetings and a manuscript will be submitted for publication in a high-impact surgery and/or oncology peer-reviewed journal.Trial registration number The study was registered in the COMET database in December 2023 (https://www.comet-initiative.org/Studies/Details/2941). The full systematic review protocol, along with the search strategy and inclusion/exclusion criteria, was registered online in September 2023 (researchregistry.com; reviewregistry1705).

The most common long-term stoma-related morbidity following colorectal surgery is parastomal hernia formation. Given the risk of developing parastomal hernias and the risk of postoperative complications following their repair, practices have evolved to incorporate prophylactic strategies to reduce the risk of parastomal hernia formation after colorectal surgery. The majority of the data forming the evidence base for parastomal hernia prophylaxis pertains to patients undergoing end colostomy formation in the setting of colorectal cancer. The only prophylactic intervention for prevention of parastomal hernia formation with substantial amounts of high-quality data is the insertion of prophylactic mesh at the index operation for patients undergoing formation of a permanent end colostomy. Other interventions that have been proposed but have less published data substantiating their use include lateral pararectus stoma placement, extraperitoneal stoma creation, circular stoma trephine, and small fascial defects. This chapter will review each of these interventions in detail, along with the associated literature supporting or refuting their use. Additionally, we will discuss other important issues regarding the evidence base for parastomal hernia prophylaxis, parastomal hernia classifications, and risk factors for developing parastomal hernias.

BACKGROUND:The role of water-soluble contrast agent (WSCA) as a therapeutic tool in the nonoperative management of adhesional small bowel obstruction (ASBO) remains indeterminate. This survey aimed to understand current surgical practices in WSCA use in the conservative approach to ASBO, and to evaluate key design and feasibility factors to inform a future controlled trial of WSCA in ASBO. METHODS:This study is reported in line with CROSS guidance. The survey consisted of 16 questions organised into three sections: respondent characteristics, current decision-making and WSCA use, and opinions on future trial. Pilot testing was conducted before online distribution to surgeons in the UK delivering Emergency General Surgery. Descriptive analysis was performed. RESULTS:Of 73 total respondents, 52 (71.2%) were consultants. When treating ASBO conservatively, 80.8% (59/73) reported using WSCA in more than half of cases, but there was wide variation in timings, use and repeat challenges. Between 71.2% and 89.0% of respondents affirmed their willingness to adhere to specific trial protocols. Regarding feasibility, 76.7% (56/73) of respondents agreed or strongly agreed that they would be willing to recruit to a trial and 75.3% (55/73) agreed or strongly agreed that their unit would be able to deliver a trial. CONCLUSIONS:The survey revealed widespread acceptance of WSCA as a therapeutic tool in ASBO among emergency general surgeons. Although practices around its administration varied, there was a clear readiness to adopt standardised protocols. The majority of respondents expressed support for a controlled trial comparing WSCA against a placebo.

Current trials assessing water soluble contrast agents (WSCAs) demonstrate contrasting results. The aim of this review was to systematically appraise the use of WSCAs in adhesional small bowel obstruction (aSBO). This systematic review and meta-analysis was registered on PROSPERO (CRD42024573136) and conducted in line with PRISMA guidelines. Searches of Medline, Embase and Central databases were undertaken to include randomised controlled trials (RCTs) reporting use of WSCA in aSBO. Primary outcome was need for operative intervention. Secondary outcomes include rate of intestinal ischaemia, need for bowel resection and mortality. Random effects meta-analysis was conducted for outcomes reported in three or more studies. Risk of bias was assessed using Cochrane Risk of Bias Tool, and trial methods were appraised using PRECIS-2. A total of 11 RCTs were included with a median sample size of 88 (range 27-242), nine of which were single-centre, and only one study used CT imaging to diagnoses aSBO. Meta-analysis revealed no significant difference in operative intervention (OR 0.63 (95% CI 0.39-1.01) p = 0.053), or small bowel ischaemia (OR 0.41 (95% CI 0.11-1.51), p=0.18), small bowel resection (OR 1.24 (95% CI 0.68-2.27), p = 0.48)), or mortality (OR 1.27 (95% CI 0.47-3.23), p=0.67). Risk of bias raised concerns in several domains. PRECIS-2 assessment showed trials were pragmatic rather than explanatory designs. Available evidence in the literature does not support use of WSCA in aSBO. Further adequately-powered trials are needed. Standardisation of diagnostic modality, and consideration of explanatory designs should be considered

AimThe aim was to develop and pilot a patient-reported outcome measure (PROM) to assess symptoms of parastomal hernia (PSH).MethodsStandard questionnaire development was undertaken (phases 1-3). An initial list of questionnaire domains was identified from validated colorectal cancer PROMs and from semi-structured interviews with patients with a PSH and health professionals (phase 1). Domains were operationalized into items in a provisional questionnaire, and 'think-aloud' patient interviews explored face validity and acceptability (phase 2). The updated questionnaire was piloted in patients with a stoma who had undergone colorectal surgery and had a computed tomography scan available for review. Patient-reported symptoms were examined in relation to PSH (phase 3). Three sources determined PSH presence: (i) data about PSH presence recorded in hospital notes, (ii) independent expert review of the computed tomography scan and (iii) patient report of being informed of a PSH by a health professional.ResultsFor phase 1, 169 and 127 domains were identified from 70 PROMs and 29 interviews respectively. In phase 2, 14 domains specific to PSH were identified and operationalized into questionnaire items. Think-aloud interviews led to three minor modifications. In phase 3, 44 completed questionnaires were obtained. Missing data were few: 5/660 items. PSH symptom scores associated with PSH presence varied between different data sources. The scale with the most consistent differences between PSH presence and absence and all data sources was the stoma appearance scale.ConclusionA PROM to examine the symptoms of PSH has been developed from the literature and views of key informants. Although preliminary testing shows it to be understandable and acceptable it is uncertain if it is sensitive to PSH-specific symptoms and further psychometric testing is needed.

Abstract Background Umbilical hernias, while frequently asymptomatic, may become acutely symptomatic, strangulated, or obstructed, and require emergency treatment. Robust evidence is required for high-quality care in this field. This scoping review aims to elucidate evidence gaps regarding emergency care of umbilical hernias. Methods Systematic searches were used to identify primary research studies reporting on any aspect of emergency umbilical hernia care. Studies were excluded where emergency umbilical hernia care was not the primary focus and subsets of relevant data were unable to be extracted. Two independent reviewers screened abstracts and full texts, resolving disagreements by consensus or a third reviewer. Data was charted according to core concepts addressed by each study and a narrative synthesis was performed. Results Searches generated 299 abstracts, from which 32 full texts were assessed and 14 included in the final review. This encompassed 52,042 patients undergoing emergency umbilical hernia care. Most were retrospective cohort designs (11/14), split between single (6/14) and multi-centre (8/14) with only one randomised trial. Most multi-centre studies were from national databases (7/8). Themes arising included risk assessment (n = 4), timing of surgery (n = 4), investigations (n = 1), repair method (n = 8, 4 mesh vs. suture; 4 laparoscopic vs. open), and operative outcomes (n = 11). No studies included patient-reported outcomes specific to emergency umbilical hernia repair. Conclusion This scoping review demonstrates the paucity of high-quality data for this condition. There is a need for randomised trials addressing all aspects of emergency umbilical hernia repair, with patient-reported outcomes.

BACKGROUND:Umbilical hernias, while frequently asymptomatic, may become acutely symptomatic, strangulated or obstructed, and require emergency treatment. Robust evidence is required for high-quality care in this field. This scoping review aims to elucidate evidence gaps regarding emergency care of umbilical hernias. METHODS:EMBASE, MEDLINE and CENTRAL databases were searched using a predefined strategy until November 2023. Primary research studies reporting on any aspect of emergency umbilical hernia care and published in the English language were eligible for inclusion. Studies were excluded where emergency umbilical hernia care was not the primary focus and subsets of relevant data were unable to be extracted. Two independent reviewers screened abstracts and full texts, resolving disagreements by consensus or a third reviewer. Data were charted according to core concepts addressed by each study and a narrative synthesis was performed. RESULTS:Searches generated 534 abstracts, from which 32 full texts were assessed and 14 included in the final review. This encompassed 52 042 patients undergoing emergency umbilical hernia care. Most were retrospective cohort designs (11/14), split between single (6/14) and multicentre (8/14) with only one randomized trial. Most multicentre studies were from national databases (7/8). Themes arising included risk assessment (n = 4), timing of surgery (n = 4), investigations (n = 1), repair method (n = 8, four mesh versus suture; four laparoscopic versus open) and operative outcomes (n = 11). The most commonly reported outcomes were mortality (n = 9) and morbidity (n = 7) rates and length of hospital stay (n = 5). No studies included patient-reported outcomes specific to emergency umbilical hernia repair. CONCLUSION:This scoping review demonstrates the paucity of high-quality data for this condition. There is a need for randomized trials addressing all aspects of emergency umbilical hernia repair, with patient-reported outcomes.

Abstract Background Reviewing abstracts for inclusion in scientific conferences involves substantial time and effort. Recent innovations in Large Language Model (LLM)s, such as OpenAI’s ChatGPT, have the potential to reduce the burden on reviewers. This study aimed to test that potential by programmatically grading abstracts using custom-trained LLMs. Methods Abstracts and reviewer grades of American Hernia Society (AHS – 2021) and American Plastic Surgery Association (ASPS 2021–2022) abstracts were obtained. Two new models of the state-of-the-art ChatGPT-3.5-turbo-1106 were fine-tuned on corpuses of these abstracts and grades. We trained for three epochs with a standard loss function and four inputs: a “system” directive, the grading rubric, the abstract, and the average reviewer grade on a five-point scale. The models were evaluated with the 2023 abstracts and grades from both societies. The trained models graded the abstracts and ranked them using three custom algorithms: QuickSort, which iteratively compared two abstracts at a time; Quartile, which ranked four; and Bridging, which combined batches of fifteen. Mean differences and Spearman correlation coefficients were calculated between actual and predicted grades/rankings. Results The trained models successfully followed the 2023 rubrics and produced in less than 20 minutes predicted grades centered near the actual: the mean difference in groups was 0.0719 ± 0.881 for AHS and 0.104 ± 0.944 for ASPS. However, variance was high and the predicted rankings had at best weak rank correlations with the actual rankings. Conclusion Custom-trained LLMs present a novel method for evaluating abstracts efficiently, but further research is needed to fine-tune the models for more precise results.

Colorectal DiseaseVolume 26, Issue 2 p. 225-226 EDITORIAL Are pulses racing fast enough? Neil Smart, Corresponding Author Neil Smart [email protected] Exeter, UKSearch for more papers by this author Neil Smart, Corresponding Author Neil Smart [email protected] Exeter, UKSearch for more papers by this author First published: 28 February 2024 https://doi.org/10.1111/codi.16923Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat No abstract is available for this article. REFERENCES 1Levett DZH, Jack S, Swart M, Carlisle J, Wilson J, Snowden C, et al. Perioperative exercise testing and training society (POETTS). Perioperative cardiopulmonary exercise testing (CPET): consensus clinical guidelines on indications, organization, conduct, and physiological interpretation. Br J Anaesth. 2018; 120(3): 484–500. https://doi.org/10.1016/j.bja.2017.10.020 10.1016/j.bja.2017.10.020 CASPubMedWeb of Science®Google Scholar 2Jiang W, Brown KGM, Koh C, Karunaratne S, Solomon M, Beckenkamp PR, et al. Outcome heterogeneity in prehabilitation trials-are we comparing apples and oranges? J Surg Res. 2024; 296: 366–375. https://doi.org/10.1016/j.jss.2023.12.042 10.1016/j.jss.2023.12.042 PubMedGoogle Scholar 3Pearson I, Blackwell S, Fish R, Daniels S, West M, Mutrie N, et al. Defining standards in colorectal optimisation: a Delphi study protocol to achieve international consensus on key standards for colorectal surgery prehabilitation. BMJ Open. 2021; 11(3):e047235. https://doi.org/10.1136/bmjopen-2020-047235 10.1136/bmjopen-2020-047235 PubMedWeb of Science®Google Scholar 4Steffens D, Solomon M, Young J, Beckenkamp PR, Bartyn J, Koh C, et al. A review of patient recruitment in randomised controlled trials of preoperative exercise. Clin Trials. 2023;17407745231219270. Epub ahead of print. https://doi.org/10.1177/17407745231219270 10.1177/17407745231219270 Google Scholar 5Zhang X, Wang S, Ji W, Wang H, Zhou K, Jin Z, et al. The effect of prehabilitation on the postoperative outcomes of patients undergoing colorectal surgery: a systematic review and meta-analysis. Front Oncol. 2022; 12:958261. https://doi.org/10.3389/fonc.2022.958261 10.3389/fonc.2022.958261 PubMedWeb of Science®Google Scholar 6Molenaar CJ, van Rooijen SJ, Fokkenrood HJ, Roumen RM, Janssen L, Slooter GD. Prehabilitation versus no prehabilitation to improve functional capacity, reduce postoperative complications and improve quality of life in colorectal cancer surgery. Cochrane Database Syst Rev. 2023; 5(5):CD013259. https://doi.org/10.1002/14651858.CD013259.pub3 10.1002/14651858.CD013259.pub3 PubMedGoogle Scholar 7Meneses-Echavez JF, Loaiza-Betancur AF, Díaz-López V, Echavarría-Rodríguez AM, Triana-Reina HR. Prehabilitation programs for individuals with cancer: a systematic review of randomized-controlled trials. Syst Rev. 2023; 12(1): 219. https://doi.org/10.1186/s13643-023-02373-4 10.1186/s13643-023-02373-4 PubMedWeb of Science®Google Scholar 8Molenaar CJL, Minnella EM, Coca-Martinez M, Ten Cate DWG, Regis M, Awasthi R, et al. Effect of multimodal prehabilitation on reducing postoperative complications and enhancing functional capacity following colorectal cancer surgery: the PREHAB randomized clinical trial. JAMA Surg. 2023; 158(6): 572–581. https://doi.org/10.1001/jamasurg.2023.0198 10.1001/jamasurg.2023.0198 PubMedWeb of Science®Google Scholar 9Onerup A, Li Y, Afshari K, Angenete E, de la Croix H, Ehrencrona C, et al. Long-term results of a short-term home-based pre- and postoperative exercise intervention on physical recovery after colorectal cancer surgery (PHYSSURG-C): a randomized clinical trial. Color Dis. 2024. Epub ahead of print. https://doi.org/10.1111/codi.16860 10.1111/codi.16860 PubMedWeb of Science®Google Scholar 10 PREPARE-ABC Trial Collaborative. SupPoRtive exercise Programmes for accelerating REcovery after major ABdominal cancer surgery trial (PREPARE-ABC): study protocol for a multicentre randomized controlled trial. Color Dis. 2021; 23(10): 2750–2760. https://doi.org/10.1111/codi.15805 10.1111/codi.15805 PubMedWeb of Science®Google Scholar Volume26, Issue2February 2024Pages 225-226 ReferencesRelatedInformation

Opioid-sparing pain management is an integral component of enhanced recovery after colonic and rectal surgery. In our hospital, rectus sheath catheters (RSCs) are routinely placed during emergency laparotomy for colorectal procedures to allow a postoperative compartmental block of the surgical site with repeated doses of bupivacaine. However, RSCs require a significant amount of clinical nursing time to maintain and ‘top-up’. We present a quality improvement project in which we administered single-shot liposomal bupivacaine (LB) intraoperatively as an alternative to bolus doses of conventional bupivacaine delivered through RSCs. Having thereby reduced the demands placed on nursing time through a reduction in the use of RSCs, we sought to establish whether there was any associated change in analgesic efficacy. Patient pain scores, use of patient-controlled analgesia (PCA) and length of stay following surgery were analysed before and after the introduction of LB. No disruption in these outcomes was identified using statistical process control analysis. A direct comparison of results for patients who received LB versus those who received bolus dosing of bupivacaine via RSCs found no significant differences, with a median total PCA dose of 270 mg oral morphine equivalents (OME) for patients who received LB versus 396 mg OME for patients who had RSCs (p=0.54). The median length of stay for patients who received LB was 15.5 days versus 16 days for those who had RSCs (p=0.87). We conclude that LB represents a viable alternative to boluses of conventional bupivacaine via RSCs in promoting enhanced recovery after emergency laparotomy and look to extend its use locally.

Journal Article What defines an incisional hernia as 'complex': results from a Delphi consensus endorsed by the European Hernia Society (EHS) Get access Sara Capoccia Giovannini, Sara Capoccia Giovannini Department of Integrated Surgical and Diagnostic Sciences, University of Genoa, IRCCS Ospedale Policlinico San Martino, Genoa, Italy Correspondence to: Sara Capoccia Giovannini, Department of Integrated Surgical and Diagnostic Sciences, Viale Benedetto XV, 6, 16139 Genova, Italy (e-mail: scapocciagiovannini@gmail.com) https://orcid.org/0000-0002-3959-0349 Search for other works by this author on: Oxford Academic Google Scholar Mauro Podda, Mauro Podda Department of Surgical Science, University of Cagliari, Cagliari, Italy https://orcid.org/0000-0001-9941-0883 Search for other works by this author on: Oxford Academic Google Scholar Sonia Ribas, Sonia Ribas Department of General Surgery, Centro Hospitalar Póvoa de Varzim-Vila do Conde, Póvoa de Varzim, Portugal Search for other works by this author on: Oxford Academic Google Scholar Giulia Montori, Giulia Montori General Surgery Department, Azienda ULSS2 'Trevigiana', Hospital Vittorio Veneto, Treviso, Italy Search for other works by this author on: Oxford Academic Google Scholar Emanuele Botteri, Emanuele Botteri Department of General Surgery, ASST Spedali Civili Brescia PO, Montichiari, Brescia, Italy Search for other works by this author on: Oxford Academic Google Scholar Ferdinando Agresta, Ferdinando Agresta General Surgery Department, Azienda ULSS2 'Trevigiana', Hospital Vittorio Veneto, Treviso, Italy Search for other works by this author on: Oxford Academic Google Scholar Alberto Sartori, Alberto Sartori Department of General Surgery, San Valentino Hospital, Montebelluna, Treviso, Italy Search for other works by this author on: Oxford Academic Google Scholar Hana Chàrvàtova, Hana Chàrvàtova Faculty of Applied Informatics, Tomas Bata University in Zlín, Zlín, Czech Republic Search for other works by this author on: Oxford Academic Google Scholar Alberto Aiolfi, Alberto Aiolfi Department of General Surgery, RCCS Ospedale Galeazzi-Sant'Ambrogio, University of Milan, Milan, Italy https://orcid.org/0000-0002-7764-6075 Search for other works by this author on: Oxford Academic Google Scholar Stavros A Antoniou, Stavros A Antoniou Department of Surgery, Papageorgiou General Hospital, Thessaloniki, Greece https://orcid.org/0000-0002-4630-6748 Search for other works by this author on: Oxford Academic Google Scholar ... Show more Catherine Arvieux, Catherine Arvieux Department of Surgery, University Hospital Grenoble-Alpes, France https://orcid.org/0000-0001-6674-799X Search for other works by this author on: Oxford Academic Google Scholar Frederik Berrevoet, Frederik Berrevoet Department of General and Hepatobiliary Surgery and Liver Transplantation Service, University Hospital Medical School, Ghent, Belgium https://orcid.org/0000-0002-3575-5345 Search for other works by this author on: Oxford Academic Google Scholar Marja A Boermeester, Marja A Boermeester Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands Search for other works by this author on: Oxford Academic Google Scholar Giampiero Campanelli, Giampiero Campanelli Department of Abdominal Wall Surgery, University of Insubria, Ospedale Galeazzi Sant' Ambrogio, Milan, Italy Search for other works by this author on: Oxford Academic Google Scholar Srinivas Chintapatla, Srinivas Chintapatla Department of Surgery, York and Scarborough Teaching Hospitals NHS Foundation Trust, York, UK Search for other works by this author on: Oxford Academic Google Scholar Mette Willaume Christoffersen, Mette Willaume Christoffersen Digestive Disease Centre, Bispebjerg University Hospital, Copenhagen, Denmark https://orcid.org/0000-0003-2239-1615 Search for other works by this author on: Oxford Academic Google Scholar Ursula Dahlstrand, Ursula Dahlstrand Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, SwedenDepartment of Surgery, Enköping Hospital, Enköping, Sweden https://orcid.org/0000-0003-3281-0959 Search for other works by this author on: Oxford Academic Google Scholar Hanna De la Croix, Hanna De la Croix Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden https://orcid.org/0000-0003-3745-7162 Search for other works by this author on: Oxford Academic Google Scholar Ulrich A Dietz, Ulrich A Dietz Department of Visceral, Vascular and Thoracic Surgery, Cantonal Hospital Olten, Olten, Switzerland Search for other works by this author on: Oxford Academic Google Scholar Antonio Ferreira, Antonio Ferreira General Surgery Unit, Centro Hospitalar Vila Nova de Gaia/Espinho, Porto, Portugal Search for other works by this author on: Oxford Academic Google Scholar Renè H Fortenly, Renè H Fortenly General Surgery Unit, Medical Faculty Sigmund Freud Private University, Vienna, Austria https://orcid.org/0000-0002-0066-7716 Search for other works by this author on: Oxford Academic Google Scholar Christine Gaarder, Christine Gaarder Department of Traumatology, University Hospital, Oslo University Hospital Ullevål, Oslo, Norway Search for other works by this author on: Oxford Academic Google Scholar Miguel Angel Garcia Urena, Miguel Angel Garcia Urena Grupo de Investigación de Pared Abdominal Compleja, Universidad Francisco de Vitoria Hospital Universitario del Henares Carretera Pozuelo-Majadahonda, Madrid, Spain https://orcid.org/0000-0002-7356-6211 Search for other works by this author on: Oxford Academic Google Scholar Hakan Gok, Hakan Gok Hernia Istanbul®, Comprehensive Hernia Centre, Istanbul, Turkey https://orcid.org/0000-0002-2925-8326 Search for other works by this author on: Oxford Academic Google Scholar Pilar Hernández-Granados, Pilar Hernández-Granados General Surgery Unit, Hospital Universitario Fundación Alcorcón, Rey Juan Carlos University, Alcorcón, Spain https://orcid.org/0000-0001-8998-5165 Search for other works by this author on: Oxford Academic Google Scholar Barbora Jisova, Barbora Jisova Third Department of Surgery, First Medical Faculty of Charles University, Motol University Hospital, Prague, Czech Republic https://orcid.org/0000-0002-1169-2765 Search for other works by this author on: Oxford Academic Google Scholar Orest Laver, Orest Laver General Surgery Department, Uzhhorod City Central Clinical Hospital, Uzhhorod, National University Uzhhorod, Ukraine Search for other works by this author on: Oxford Academic Google Scholar Orest Lerchuk, Orest Lerchuk Department of General and Endocrine Surgery, Lviv Regional Clinical Hospital, Lviv Danylo Halytsky National Medical University, Lviv, Ukraine Search for other works by this author on: Oxford Academic Google Scholar Manuel Lopez-Cano, Manuel Lopez-Cano Abdominal Wall Surgery Unit, University Hospital Vall d´Hebrón, Barcelona, SpainUniversidad Autónoma de Barcelona (UAB), Barcelona, Spain https://orcid.org/0000-0003-3337-0756 Search for other works by this author on: Oxford Academic Google Scholar Manuel Mega, Manuel Mega Abdominal Wall Unit, Department of General Surgery, Local Health Unit of Castel Branco, Castel Branco, Portugal Search for other works by this author on: Oxford Academic Google Scholar Kryspin Mitura, Kryspin Mitura University of Natural Sciences and Humanities in Siedlce, Siedlce, Masovian Voivodeship, Poland Search for other works by this author on: Oxford Academic Google Scholar Filip Muysoms, Filip Muysoms Department of Abdominal Wall Surgery, AZ Maria Middelares, Ghent, Belgium https://orcid.org/0000-0002-2413-1692 Search for other works by this author on: Oxford Academic Google Scholar Andrè Oliva, Andrè Oliva Department of General Surgery, Coimbra University Hospital, Coimbra, Portugal Search for other works by this author on: Oxford Academic Google Scholar Monica Ortenzi, Monica Ortenzi Department of General and Emergency Surgery, Università Politecnica delle Marche, Ancona, Italy https://orcid.org/0000-0002-6508-6488 Search for other works by this author on: Oxford Academic Google Scholar Ulf Petersson, Ulf Petersson Department of Surgery, Skane University Hospital, Malmö, SwedenDepartment for Clinical Sciences Malmö, Lund University, Malmö, Sweden Search for other works by this author on: Oxford Academic Google Scholar Micaela Piccoli, Micaela Piccoli General Surgery Unit, Civil Hospital of Baggiovara Azienda Ospedaliero–Universitaria di Modena, Modena, Italy Search for other works by this author on: Oxford Academic Google Scholar Victor G Radu, Victor G Radu Department of General Surgery, Life Memorial Hospital—Medlife Bucharest, Romania Search for other works by this author on: Oxford Academic Google Scholar Yohann Renard, Yohann Renard University of Reims Champagne Ardenne, France, Unit of Visceral Surgery, Robert Debre University Hospital, Reims, France https://orcid.org/0000-0001-6036-0006 Search for other works by this author on: Oxford Academic Google Scholar Peder Rogmark, Peder Rogmark Department of Clinical Sciences, Lund University, Malmö, Sweden Search for other works by this author on: Oxford Academic Google Scholar Danny Rosin, Danny Rosin Sheba Medical Centre, University of Tel Aviv, Tel Aviv, Israel Search for other works by this author on: Oxford Academic Google Scholar Ana Senent-Boza, Ana Senent-Boza Department of General and Digestive Surgery, Virgen del Rocío University Hospital, Seville, Spain https://orcid.org/0000-0002-0033-5850 Search for other works by this author on: Oxford Academic Google Scholar Maarten Simons, Maarten Simons Department of Surgery, OLVG Hospital Amsterdam, Amsterdam, the Netherlands Search for other works by this author on: Oxford Academic Google Scholar Dominic Slade, Dominic Slade Department of General Surgery, Salford Royal Hospital, Salford, UK https://orcid.org/0000-0002-6032-8580 Search for other works by this author on: Oxford Academic Google Scholar Neil Smart, Neil Smart Department of Gastrointestinal Surgery, Royal Devon and Exeter Hospital, Exeter, UK Search for other works by this author on: Oxford Academic Google Scholar Stella R Smith, Stella R Smith General and Colorectal Surgery, Manchester Royal Infirmary, Manchester Foundation Trust, Manchester, UK Search for other works by this author on: Oxford Academic Google Scholar Cesare Stabilini, Cesare Stabilini Department of Integrated Surgical and Diagnostic Sciences, University of Genoa, IRCCS Ospedale Policlinico San Martino, Genoa, Italy https://orcid.org/0000-0002-5410-0352 Search for other works by this author on: Oxford Academic Google Scholar Alexis Theodorou, Alexis Theodorou First Surgical Unit, Hygeia Hospital, Athens, GreeceDepartment of Surgery, Aretaieio University Hospital, Athens, Greece Search for other works by this author on: Oxford Academic Google Scholar Jared Torkington, Jared Torkington Department of General Surgery, University Hospital of Wales, Cardiff, UK Search for other works by this author on: Oxford Academic Google Scholar Jaanna Vironen, Jaanna Vironen Abdominal Centre, Helsinki University Hospital, Helsinki University, Helsinki, Finland Search for other works by this author on: Oxford Academic Google Scholar Guido Woeste, Guido Woeste Department of General and Visceral Surgery, Agaplesion Elisabethenstift, Darmstadt, Germany Search for other works by this author on: Oxford Academic Google Scholar Andrew De Beaux, Andrew De Beaux Department of General Surgery, Spire Murrayfield Hospital, Edinburgh, UK Search for other works by this author on: Oxford Academic Google Scholar Barbora East Barbora East Third Department of Surgery, First Medical Faculty of Charles University, Motol University Hospital, Prague, Czech Republic https://orcid.org/0000-0003-0112-1747 Search for other works by this author on: Oxford Academic Google Scholar British Journal of Surgery, Volume 111, Issue 1, January 2024, znad346, https://doi.org/10.1093/bjs/znad346 Published: 28 October 2023 Article history Received: 05 August 2023 Revision received: 12 September 2023 Accepted: 21 September 2023 Published: 28 October 2023

INTRODUCTION:There is a lack of consensus on the management of inguinal hernia with limited symptoms. To address this issue a systematic review of existing randomized clinical trials (RCTs) was performed to critically appraise all existing data on asymptomatic hernia management, focusing on generalizability. METHODS:A scoping review to identify all RCTs comparing surgical and conservative management of patients with inguinal hernias was undertaken. Medline, Embase, Cochrane and ClinicalTrials.gov databases were searched. Data collected included study characteristics and definitions of population, intervention/comparator, and outcomes; and limitations of each study were also extracted. The quality and generalizability of included RCTs were evaluated using Cochrane's ROB-2 and the PRECIS-2 tool, respectively. RESULTS:Searches returned 661 papers; 14 full-text papers were assessed and three RCTs were identified. All RCTs included only male patients with a mean age above 55 years. All RCTs included asymptomatic patients and two included those with minimal symptoms. Different definitions for 'minimally symptomatic' were used in RCTs and none provided details of what was meant by conservative treatment. Follow-up periods varied between studies (1, 2, 3 years). All RCTs had an overall high risk of bias. According to PRECIS-2, two RCTs were classified as pragmatic, and one was equally pragmatic and explanatory. DISCUSSION:This systematic review highlights a high risk of bias but a good generalizability of the findings from the RCTs conducted on minimally symptomatic inguinal hernia patients. To improve the guidelines for the management of this group of patients, more generalizable data are needed.

Abstract Aim Umbilical hernias may become acutely symptomatic, strangulated, or obstructed, necessitating emergency intervention. Robust evidence is required for high-quality care in this field. This scoping review aims to elucidate the existing evidence gaps in emergency care of umbilical hernias. Methods A systematic search of EMBASE, MEDLINE, and CENTRAL databases was conducted using a predefined strategy. Primary research reporting on any aspect of emergency umbilical hernia care and published in the English language were eligible for inclusion. Two independent authors screened abstracts and full texts, resolving disagreements through consensus or a third author. Data was charted according to core concepts addressed by each study and a narrative synthesis was performed. Results The search generated 299 abstracts, with 32 full texts assessed and 14 included in the final review. This encompassed 52,042 patients undergoing emergency umbilical hernia care. Studies were predominantly retrospective cohort designs (10/14), evenly distributed between single (6/14) and multi-centre (8/14), with only one randomised trial. Most multi-centre studies utilised national databases (7/8). Themes arising included risk profile (n=4), timing of surgery (n=4), investigations (n=1), repair method (n=8, 4 mesh vs suture; 4 laparoscopic vs open), and operative outcomes (n=11). Commonly reported outcomes were mortality (n=9), morbidity (n=7), and length of hospital stay (n=5). Conclusion This scoping review demonstrates the paucity of high-quality data concerning emergency umbilical hernia care. The significant evidence gaps highlight a pressing need for randomised trials addressing timing and technical aspects of repair, incorporating patient-reported outcomes.