{"doi":"10.1111/apa.17361","title":"<scp>EBNEO</scp> Commentary: The impact of timing of inguinal hernia repair on outcomes in preterm infants","abstract":null,"journal":"Acta Paediatrica","year":2024,"id":625127,"datarank":0.0,"base_score":0.0,"endowment":0.0,"self_citation_contribution":0.0,"citation_network_contribution":0.0,"self_endowment_contribution":0.0,"citer_contribution":0.0,"corpus_percentile":null,"corpus_rank":null,"citation_count":0,"citer_count":0,"citers_with_citation_signal":0,"citers_with_endowment":0,"datacite_reuse_total":0,"is_dataset":false,"is_dataset_confidence":null,"is_data_producer":false,"deposit_databanks":null,"is_oa":false,"file_count":0,"downloads":0,"has_version_chain":false,"published_date":null,"fair_score":null,"fair_percentile":null,"algorithm_id":"datarank_citation_only_1hop_v6","ranking_scope":"data_only","authors":[{"id":1616354,"name":"Brian King","orcid":null,"position":1,"is_corresponding":false},{"id":328243,"name":"Puneet Sharma","orcid":"0000-0003-3346-3928","position":0,"is_corresponding":false}],"reference_count":0,"raw_metadata":{"has_enrichment":true,"resolved":true,"title":"<scp>EBNEO</scp> Commentary: The impact of timing of inguinal hernia repair on outcomes in preterm infants","abstract":"Optimal timing of inguinal hernia repair is uncertain due to the competing concerns around risk of anaesthesia in neonates and risk of hernia-related complications such as incarceration.1 This study is a well-designed, multicentre trial that demonstrates short-term benefits to performing inguinal hernia repair after NICU discharge. Furthermore, the use of Bayesian analyses allows for more pragmatic and clinically oriented interpretation of the outcomes. Late repair led to fewer serious adverse events and fewer days in the hospital, with a greater effect on vulnerable populations like extremely preterm infants and those with BPD. Of note, there were more laparoscopic procedures in the early repair group, which are associated with shorter operation time and less complications than laparotomy.2 However, the combination of better outcomes for patients and potentially less healthcare utilisation (and costs), makes late repair an appealing choice. Furthermore, this intervention is very straightforward to implement. However, the broad definition of serious adverse event that is used in the composite primary outcome highlights important limitations when interpreting the results. For example, the most common adverse event in both groups was apnoea requiring intervention, which could have a very broad range of clinical significance. Furthermore, cardiac arrest, of which there were three in the late repair group compared with zero in the early, is weighted equally to apnoea. Similarly, more infants in the late repair group had incarcerated hernia, but this was broadly classified and included both surgical repairs and bedside reductions. A major limitation with composite outcomes is that they can provide a false equivalency between included outcomes, making it difficult to assess an intervention's effect on individual outcomes. This limitation is well documented, and yet many trials in neonatology continue to use them due to their benefits when powering trials.3 Alternate statistical approaches exist to address some of these limitations, one of which is the desirability of outcome ranking (DOOR). DOOR uses a patient-centric approach to rank outcomes from most to least desirable and was recently used in a post hoc analysis of a neonatal trial.4 Interpretation of this study's findings might change using the DOOR approach. For example, more patients in the late repair group did not undergo surgery, often due to spontaneous closure. This outcome was not emphasised by the authors but may be a desirable outcome ranked highly by families. Similarly, the outcomes of apnoea and incarceration would likely not be ranked equivalently using the DOOR approach. Another important factor to consider with late repair is the additional burden it can place on families. Families that were deemed unable to follow-up were excluded, but this is an important cohort. Families may prefer repair during admission as both a financial decision and convenience. While the late repair group had fewer hospital days, a readmission was required. Greater financial burden may be placed on families with readmission, both due to increased cost-sharing and out-of-pocket costs.5 If many of the adverse events in the early repair group are short term and mild, some families may still elect for early repair depending on their values and preferences. Differences in long-term outcomes, which are being studied, may also alter the potential trade-offs. Studies have been conducted to clarify what outcomes are most important to parents of children with bronchopulmonary dysplasia.6 A similar study in this patient population would undoubtedly provide important context on the timing of repair. URL link: https://ebneo.org/ebneo-commentary-the-impact-of-timing-of-inguinal-hernia-repair-on-outcomes-in-preterm-infants/. Puneet Sharma: Funding acquisition; writing – original draft; writing – review and editing; formal analysis. Brian King: Conceptualization; writing – review and editing; supervision. This work was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (5T32HD098061). 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