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Jewish World Review May 4, 2004 / 13 Iyar, 5764
By Robert A. Wascher, M.D., F.A.C.S.
http://www.NewsAndOpinion.com |
Regular readers of this column are well aware that an elevated blood level
of C-reactive protein (CRP), an early player in the body's inflammatory
response to injury and stress, is associated with a high risk of heart
disease and stroke. Indeed, recent research indicates that CRP is actually
a more accurate marker of heart attack risk than the traditional blood
cholesterol tests that physicians have been ordering for years. Presently,
most authorities consider a high-sensitivity CRP (hsCRP) blood level less
than 1 mg/L to be associated with a very low risk of cardiovascular events
such as heart attack and stroke. HsCRP levels between 1 and 3 mg/L appear
to be correlated with a moderate risk of cardiovascular events, while hsCRP
blood levels at or greater than 3 mg/L are associated with a high risk of
such events. A new study out of Harvard University, just published in the
journal Circulation, has now extended our understanding of the
cardiovascular event risk associated with hsCRP levels below 1 mg/L and
above 3 mg/L.
In this very important study, 27,939 clinically healthy women were followed
within a large long-term cardiac health study. The incidences of heart
attack, stroke, coronary artery stent placement or bypass, and death due to
cardiovascular causes were monitored over the duration of this still ongoing
study. After statistically adjusting results to account for individual
cardiovascular risk factor differences in this large patient group, the
investigators found a significant and linear correlation between hsCRP
levels and the incidence of cardiovascular events, even at hsCRP levels as
low as 0.5 mg/L. A blood hsCRP level of 0.5 mg/L was associated with a 60%
increase in the relative risk of cardiovascular events when compared to
patients with hsCRP levels less than 0.5 mg/L. Among patients with hsCRP
levels of 4.0 to 5.0 mg/L, the increase in relative risk was 90% higher than
for hsCRP levels less than 0.5 mg/L. Patients with hsCRP levels at or above
20 mg/L had the highest risk of experiencing adverse cardiovascular events:
a more than 300% increase in relative risk when compared to patients with
hsCRP levels less than 0.5 mg/L. Among this group of nearly 28,000
apparently healthy adult women, 15% had hsCRP blood levels less than 0.5
mg/L, while 5% had levels higher than 10 mg/L.
Interestingly, the statin drugs not only reduce the
"bad cholesterol" (LDL) levels in the blood, but also appear to have an
anti-inflammatory effect too, resulting in a reduction of CRP levels.
Anti-inflammatory drugs such as aspirin and Celebrex may also exert as least
some of their heart-protective effects by reducing blood levels of
pro-inflammatory C-reactive protein. I predict that, within a few years,
the American Heart Association will revise, downward, the current
recommended target levels for LDL and CRP, based upon growing evidence that
driving the these substances in the blood down to the lowest achievable
levels is associated with significant reductions in cardiovascular disease
events.
LAPAROSCOPIC VS. OPEN HERNIA REPAIR
Basically, there are three options for the
repair of these weakened areas in the groin: repair with sutures alone,
repair with a panel of mesh sewn over the weakened site, and laparoscopic
mesh hernia repair. In the first two cases, a 3 to 4 inch incision is made
in the groin area, and the hernia is directly repaired through this
incision. When a laparoscopic hernia repair is performed, 3 or 4 small
puncture-like incisions are made on the lower abdomen, and highly
specialized laparoscopic instruments are used to internally open up the
hernia site, followed by repair of this weakened area of the abdominal wall
with mesh. All portions of the laparoscopic repair are performed through
the 3 or 4 small incision. (Suture-only open groin hernia repairs have been
abandoned by most surgeons due to the high recurrence rate and moderate
postoperative discomfort associated with this approach). Proponents of the
laparoscopic approach cite a modest but significant decrease in discomfort
during the early postoperative period, and a 1 or 2 day decrease in the
delay before resumption of normal daily activities. Critics of the
laparoscopic approach cite the increased expense of the equipment and
disposable supplies necessary to perform a laparoscopic hernia repair, the
extra time needed to do a laparoscopic repair in the OR when compared to
"open" repairs, and they cite several studies comparing open mesh repairs
with laparoscopic mesh repairs that have shown essentially no significant
differences in postoperative discomfort or recovery times between the two
procedures.
A new study in the New England Journal of Medicine randomly assigned healthy
adult males to either open mesh or laparoscopic mesh hernia repairs at 14
different VA medical centers. All patients were then followed for 2 years
to identify the incidence of postoperative complications and recurrent
hernias in each group of patients. A total of 1,983 patients participated
in this study, and complete 2-year follow-up was available for 1,696 (86%)
of participating patients. Recurrent hernias were twice as common in the
laparoscopic group (10.1%) when compared to the open surgery group (5%).
Postoperative complications were also slightly higher in the laparoscopic
group (39%) when compared to the open surgery group (33%), including
infection, numbness and chronic pain. However, as has been suggested by
previous studies, the laparoscopic surgery group had less incisional pain
immediately after their hernias were repaired, as well as 2 weeks later.
When compared to the open surgery group, the laparoscopic surgery group
returned to normal activities an average of only 1 day earlier, however.
When the investigators further analyzed their results, they also found that
hernias were more likely to recur following laparoscopic surgery if the
patient had undergone surgery to repair a hernia for the first time (10% for
laparoscopic repairs vs. 4% for open repairs). However, patients undergoing
repair of a recurrent groin hernia had essentially the same incidence of
subsequent hernia recurrence irrespective of the type of surgical repair
(10% to 14%, which was not statistically significant). Overall, the
investigators concluded that open mesh repair of inguinal hernias is
associated with fewer postoperative complications and a lower incidence of
hernia recurrence when compared to laparoscopic mesh surgical repairs.
Although I am primarily a cancer surgeon, I still perform a considerable
number of hernia repairs. While I do not perform as many laparoscopic
repairs as I did when this technique was first developed, and surgeons were
eager to apply this new approach in their practices, I still occasionally
use the laparoscopic approach. My own indications for a laparoscopic repair
include patients with recurrent groin hernias following a previous open mesh
repair (it is a very destructive and morbid process to try and remove an old
mesh implant that has scarred into surrounding structures), and patients
with bilateral ("double") hernias (one can repair both sides simultaneously
through the same 3 to 4 small incisions using the laparoscopic technique).
Occasionally, I will also primarily repair the groin hernias of patients who
have a compelling need to immediately resume work, and those who have
physically demanding jobs in particular. In my own experience of performing
laparoscopic internal hernia repairs for more than a decade, most patients
experience very mild discomfort, and return to full activity within 24 to 48
hours following laparoscopic surgery. Patients undergoing open mesh hernia
repair tend to have a bit more discomfort during the first week or two after
surgery, and tend to return to work several days later than my patients who
have undergone laparoscopic hernia repair. However, overall, my
observations in my own practice over the years, and in the practices of my
colleagues, are generally consistent with the findings of this study. As I
have already long ago altered my own practice to more selectively recommend
laparoscopic hernia repair, this study will not change my own approach to
inguinal hernia repairs. However, I do believe that surgeons who emphasize
laparoscopic hernia repair in their practices should compare their own
patient outcomes with those in this study. If an individual surgeon's
results are essentially equivalent irrespective of the technique used, then
there should be no problem with emphasizing laparoscopic hernia repair.
However, the findings of this study, and of previous similar studies,
suggest that most surgeons who perform hernia repairs should consider being
very selective regarding the indications for performing a laparoscopic groin
hernia repair.
BRIEFLY...
JAMA: In the first formal report on the "estrogen-only" arm of the Women's
Health Initiative (WHI) study, the study's directors explain why they
prematurely terminated their research project in February 2004. All 10,739
participants in this part of the WHI study were notified of the study's
interim findings, and advised to discontinue their estrogen hormone
replacement therapy (HRT). This large scale prospective, randomized,
double-blinded, placebo-controlled study, started in 1993, was prematurely
stopped because the women who were randomized to receive estrogen pills
experienced a 40% increase in the relative risk of stroke when compared to
the women who received the placebo pills. Over an average follow-up period
of just under 7 years, 12 additional strokes per 10,000 person-years
resulted from the use of estrogen-only HRT. At the same, there was no
improvement in the incidence of coronary heart disease or heart attacks
among the women taking the estrogen pills. Interestingly, there appeared to
be a 30% reduction in the relative risk of breast cancer among the study
volunteers who received the estrogen pills (remember that the combination
estrogen/progesterone HRT arm of the WHI was prematurely shut down in the
spring of 2002 after it was discovered that combination HRT significantly
increased the risk of breast cancer, as well as stroke and heart disease).
While the adverse effects of HRT appear to be less egregious with the
estrogen-only regimen when compared to the estrogen/progesterone regimen,
the two arms of the WHI clearly show that, at a minimum, HRT does not reduce
coronary heart disease (indeed, combination HRT appears to significantly
increase the risk of heart disease), and that both regimens significantly
increase the risk of stroke as well. The discordant effects of each regimen
on the incidence of breast cancer will certainly be the focus of intense
future study.
British Medical Journal: Here's a study that one might file under the
category of "research that confirms what everyone already knows:" A targeted
school-based education program to reduce the consumption of carbonated soft
drinks on campus resulted in a significant reduction in obesity among those
children who reduced their intake of these sugary drinks....
JWR contributor Dr. Robert Wascher is an oncologic surgeon, professor of surgery, oncology research scientist, and author. He lives in Honolulu with his wife and two daughters.
Comment by clicking here.
The highs & lows of C-reactive protein; Laparoscopic vs. open hernia repair; more
This study is important because it demonstrates a linear correlation between
CRP blood levels and the risk of adverse cardiovascular events at virtually
all measurable levels of this pro-inflammatory protein. This study also
confirms that, essentially, there is no "minimum" target for CRP reduction
that is completely protective against cardiovascular events. This is
analogous to recent research showing that reduction of even normal blood
cholesterol levels in otherwise high-risk patients, using statin drugs, is
associated with a significant decrease in the incidence of adverse
cardiovascular events.
Over the past decade, patients with groin hernias have had several choices
available to them in deciding how to have their hernias surgically repaired.
Approximately 500,000 inguinal hernia repairs are performed every year in
the US, making it the most common operation done outside of the abdominal
cavity by general surgeons.
Journal of the American Medical Association (JAMA): 185 patients were
randomized to coronary artery bypass surgery (CABS) with the cardiopulmonary
bypass machine ("on pump") or without the bypass machine ("off pump").
Previous evaluations of "off pump" CABS have shown fewer complications and
shorter hospital stays when compared to the traditional "on pump" method of
CABS. However, the long-term results of this newer approach to coronary
artery revascularization have been unclear. In this study, there was no
significant difference in coronary artery graft patency or heart function
between the "off pump" and "on pump" patients 1 year after CABS. At the
same time, the hospital costs associated with "off pump" CABS were, on the
average, more than $2000 lower than for the "on pump" group.
