After 12 years of simple watchful waiting for an inguinal hernia, 68% of men had eventually been operated on. That does not mean surgery is needed straight away, watchful waiting can be safe in some patients. But it has to come with clear criteria for reassessment, pain, growing discomfort, a complication or a change in quality of life.
If a hernia, gallstones or reflux leave you hesitating between watchful waiting and surgery, Noria Health Hub can arrange a full check-up or a second medical opinion in Brussels, with a report within 24 h, coordinate your care where needed across more than 40 medical pathways in 48 h, then, if your medical condition allows, arrange surgery within 7 days.
Inguinal hernia, watchful waiting can be safe, but many are operated on in the end
An American randomised trial compared watchful waiting with surgical repair in men with minimally symptomatic inguinal hernia. At 2 years, watchful waiting was safe. It was the long follow-up that changed the reading.
| What is measured | The result |
|---|---|
| Men randomised to watchful waiting who crossed over to surgery, at 12 years | 68% |
| Main reason for crossing over | Pain appearing or worsening, not a complication |
| Hernia strangulation over the whole follow-up period | 3.9%, about 1 case in 25 |
| What this means | Watchful waiting is not a final decision, it is a deferral for about 2 men in 3 |
The result does not invalidate watchful waiting, which remains safe. It invalidates the way it is presented. Telling a patient he may never need surgery is accurate in about 1 case in 3.
Hernia, chronic postoperative pain has to be taken into account
It is the most frequent complication of hernia repair, and the least announced in consultation. It affects 17.0% of operated patients in the largest series.
A considerable geographical gap must be flagged. Reported frequency is 6.0% in North America against 18.7% in Europe. Such a gap is not explained by biology. It very probably stems from the definitions used, the length of follow-up and the collection method. We will therefore not quote a single figure, we will quote the range and the reason for it.
Gallstones without symptoms, progression is often slow
The rule is clear and it is long-standing. A gallstone found by chance, in a person who has never had pain, becomes symptomatic in about 2% of cases per year. The great majority of stone carriers will never develop anything.
This is why surgery is not indicated in the absence of symptoms, outside particular situations. And it is also why an abdominal ultrasound performed without a precise indication can open onto a surgical decision nobody would have contemplated without it.
Cholecystectomy, the measured risks and a received idea to correct
| What is measured | The result |
|---|---|
| Injury to the main bile duct, the most feared complication | 0.40%, about 1 operation in 250 |
| Effect of centre activity volume on that risk | No volume-outcome relationship demonstrated on that precise endpoint |
| What distinguishes this from colonoscopy | In colonoscopy the operator effect is large and demonstrated. Here it is not |
| What remains true | The consequence of a bile duct injury is serious and lasting when it occurs |
We flag this difference because we argue elsewhere for the importance of the operator. On this particular procedure, the literature does not support that argument, and it would be dishonest to use it anyway.
Reflux, surgery or long-term medical treatment?
A European randomised trial compared continuous medical treatment with a proton pump inhibitor and antireflux surgery, in patients whose reflux responded to treatment. At 5 years, remission was 92% on medical treatment and 85% after surgery.
In other words, surgery did not do better in that trial. It remains a relevant option for patients who do not want lifelong treatment, who respond poorly, or who have a particular form. But presenting it as the definitive superior solution does not match what the trial measured.
On Barrett’s oesophagus, the reference datum comes from a Danish national cohort. The annual risk of progression to adenocarcinoma is 0.12%, about 1 case per 800 patient-years. That figure is far lower than the one previously in circulation, and it has led to lengthening the intervals between surveillance endoscopies.
Upper digestive endoscopy, what it finds when there is no alarm feature
In a patient consulting for upper digestive symptoms with no alarm feature, that is, no weight loss, no anaemia, no swallowing difficulty and no bleeding, more than 85% of endoscopies are normal.
That does not mean none should ever be done. It means the value of the test depends entirely on who is taking it, and that a test ordered by reflex exposes the patient to sedation, cost and incidental findings with no diagnostic return in the great majority of cases.
How long people wait
In England, 62.7% of patients referred to general surgery start treatment within 18 weeks. About 1 patient in 3 therefore exceeds that period, for conditions most of which are not emergencies but many of which limit daily activity.
What the studies do not allow us to state
We will not claim that a minimally symptomatic hernia should be operated on, because watchful waiting is safe. Nothing entitles us to write that it should never be operated on either, because 2 men in 3 end up operated by 12 years. You will not read here that reflux surgery is superior to medical treatment, because the available randomised trial says the opposite at 5 years.
What we will say is that these 3 decisions depend more on your tolerance of the symptom and on your plans for your life than on an objective medical threshold. They are decisions to be taken with complete information, and complete information includes the figures that do not favour intervention.
In practice, if this concerns you
You set out your problem, your symptoms or your question. Reports, test results and images already available can be studied before you arrive, so that the pathway can be prepared. The aim is not to run every test as a matter of course, but to select those that can genuinely help confirm a hypothesis, rule out a risk or guide the decision. The results are brought together and the next steps are organised. Follow-up is then coordinated.
Need medical advice quickly? For a concern that does not call for emergency services, you can ask to speak to a doctor at any time through Noria Health Hub. This on-demand medical consultation is billed separately from the check-up pathway.
Further reading
The companion articles.
Who” rel=”noopener” target=”_blank”>https://noriahealth.com/blog/who-performs-your-examination-changes-what-it-finds/”>Who performs your examination changes what it finds
Pain” rel=”noopener” target=”_blank”>https://noriahealth.com/blog/pain-that-waits-what-the-literature-measures/”>Pain that waits, what the literature measures
Sources
Fitzgibbons RJ et al., Watchful waiting versus repair of inguinal hernia in minimally symptomatic men, a randomized clinical trial, JAMA, 2006. https://doi.org/10.1001/jama.295.3.285
Fitzgibbons RJ et al., Long-term results of a randomized controlled trial of a nonoperative strategy for inguinal hernia, Annals of Surgery, 2013. https://doi.org/10.1097/SLA.0b013e318288a25e
HerniaSurge Group, International guidelines for groin hernia management, Hernia, 2018. https://doi.org/10.1007/s10029-017-1668-x
Chronic postoperative inguinal pain after hernia repair, systematic review and meta-analysis, British Journal of Surgery.
Gracie WA, Ransohoff DF, The natural history of silent gallstones, the innocent gallstone is not a myth, New England Journal of Medicine, 1982. https://doi.org/10.1056/NEJM198203253061203
Halldestam I et al., Development of symptoms and complications in individuals with asymptomatic gallstones, British Journal of Surgery, 2004. https://doi.org/10.1002/bjs.4547
Bile duct injury after laparoscopic cholecystectomy, national population-based analysis of incidence and volume-outcome relationship, Surgical Endoscopy.
Galmiche JP et al., LOTUS, Laparoscopic antireflux surgery versus esomeprazole treatment for chronic gastro-oesophageal reflux disease, a randomized clinical trial, JAMA, 2011. https://doi.org/10.1001/jama.2011.626
Hvid-Jensen F et al., Incidence of adenocarcinoma among patients with Barrett’s esophagus, New England Journal of Medicine, 2011. https://doi.org/10.1056/NEJMoa1103042
American Society for Gastrointestinal Endoscopy, The role of endoscopy in dyspepsia, Gastrointestinal Endoscopy.
Moayyedi P et al., ACG and CAG clinical guideline, management of dyspepsia, American Journal of Gastroenterology, 2017. https://doi.org/10.1038/ajg.2017.154
NHS England, Referral to Treatment Waiting Times, general surgery. https://www.england.nhs.uk/statistics/statistical-work-areas/rtt-waiting-times/