Laparoscopy for every acute appendicitis? The authors reply.
Explore the source record for details and available documents.
Acute Disease↗
Biomedical subjects
S Sauerland
Publications and source records attributed to S Sauerland.
Early versus delayed-interval laparoscopic cholecystectomy for acute cholecystitis: a metaanalysis.
Explore the source record for details and available documents.
Cholecystectomy, Laparoscopic↗
Securing the appendiceal stump in laparoscopic appendectomy: evidence for routine stapling?
BACKGROUND: This metaanalysis aimed to compare endoscopic linear stapling and loop ligatures used to secure the base of the appendix. METHODS: Randomized controlled trials on appendix stump closure during laparoscopic appendectomy were systematically searched and critically appraised. The results in terms of complication rates, operating time, and hospital stay were pooled by standard metaanalytic techniques. RESULTS: Data on 427 patients from four studies were included. The operative time was 9 min longer when loops were used (p = 0.04). Superficial wound infections (odds ratio [OR], 0.21; 95% confidence interval (CI), 0.06-0.71; p = 0.01) and postoperative ileus (OR, 0.36; 95% CI, 0.14-0.89; p = 0.03) were significantly less frequent when the appendix stump was secured with staples instead of loops. Of 10 intraoperative ruptures of the appendix, 7 occurred in loop-treated patients (p = 0.46). Hospital stay and frequency of postoperative intraabdominal abscess also were comparable in loop-treated and staple-treated patients. CONCLUSIONS: The clinical evidence on stump closure methods in laparoscopic appendectomy favors the routine use of endoscopic staplers.
Appendectomy↗
[The critical role of research evidence in the framework of health technology assessment].
In spite of their different aims, evidence-based medicine (EBM) and health technology assessment (HTA) to some extent use similar methodologies for the assessment of a technology's efficacy. The decision to include only a certain quality of studies in a HTA report usually follows the hierarchy of evidence with different levels of evidence. Problems arise if study evidence is completely lacking or if it is extrapolated or transferred to other healthcare settings. As subjectivity is inevitable when critically appraising the evidence or combining it with other sources of information, HTA decisions should be presented with maximum transparency. Since physicians usually have only limited knowledge of research methodology and read only an average of 20 articles per year, a cooperative approach is required when appraising the evidence for HTA.
Biomedical Technology↗
[Emergency surgery for chest injuries in the multiply injured: a systematic review].
OBJECTIVE: Severe chest injuries are still associated with significant morbidity and mortality. This systematic review assesses the early operative management of severe chest trauma in multi injured patients with special regard to the priority of the operative therapy. METHODS: Clinical trials were systematically sought and collected (MEDLINE, Cochrane and hand searches). Of 618 abstracts, 46 articles were selected for detailed appraisal and were classified into evidence levels (1 to 5 according to the Oxford system). RESULTS: Penetrating chest injuries in haemodynamically instable patients require emergency operative therapy. A thoracotomy is also indicated in excessive chest tube output (>1500 ml). An aortic rupture can be treated either by open suture or-in borderline patients-by endovascular stenting. In selected haemodynamically stable patients delayed treatment is also possible. Lesions of the tracheobronchial system should be treated urgently with primary surgical repair. Diaphragmatic ruptures should be closed urgently. Surgical stabilisation of rib fractures with an associated flail chest reduces the ventilator days and the length of intensive care unit stay. CONCLUSION: A large part of early surgery for chest injuries is justified because it averts immediate threats to life (level 1c evidence). No randomised and only a few controlled trials have examined the relative value of the different surgical options so far. Long-term data are lacking especially on the safety of endovascular stenting.
Aortic Rupture↗
Is routine preoperative upper endoscopy in gastric banding patients really necessary?
BACKGROUND: Preoperative evaluation for bariatric surgery is complex. Our investigation focused on the necessity for upper gastrointestinal (GI) endoscopy as a routine procedure before performing gastric banding. METHODS: A consecutive series of 145 patients underwent laparoscopic adjustable gastric banding (LAGB). Gastroscopy was performed routinely before LAGB. All patients were interviewed before gastroscopy regarding gastroesophageal symptoms. Gastroscopic findings and the results of the interview were blinded and set in comparison. Furthermore, we analyzed whether upper GI symptoms, BMI, age or gender were predictive parameters for pathological findings on gastroscopy. Small hiatal hernia was not considered a clinically relevant finding. RESULTS: Gastroscopy yielded abnormal findings in only 15 patients (10%). There were 8 patients with hiatal hernia, 4 patients with esophagitis, 1 gastric ulcer, 1 erosive gastritis, and 1 gastric polyp. Abnormal findings on gastroscopy did not correlate with age, BMI, or gender. The 18 patients who reported gastroesophageal symptoms were more likely to have abnormal gastroscopic findings (P<0.001). Gastroesophageal symptoms had a sensitivity of 80% and a specificity of 98% in the prediction of a GI abnormality. CONCLUSIONS: The data suggest that it may not be necessary to continue performing gastroscopy in all patients preparing for gastric banding. The data collected support the policy of a selective use of gastroscopy, only focusing on patients suffering from gastroesophageal symptoms. By following this strategy, the rate of preoperative gastroscopies can be reduced safely by 80%.
Adult↗
Evidence-based medicine--from best research evidence to a better surgical practice and health care.
BACKGROUND: The use of the terms evidence-based medicine (EBM) and healthcare (EBHC) has become commonplace in the medical as well as in the surgical literature. Using the best available evidence, however, is not yet a working routine among surgeons because of the large amount and complexity of published research and the lack of user-friendly tools and necessary skills for the use of research results. DISCUSSION: This article encourages to formulate surgically relevant questions and to answer them on the basis of high-quality research, preferably by using systematic reviews which are based on the quality criteria of the Cochrane Collaboration. CONCLUSIONS: As currently only 77 Cochrane reviews address surgical procedures; much work remains to be done to enlarge the number of high-quality and relevant reviews. Similarly, the number and quality of randomized controlled trials need to be increased in all surgical specialties.
Clinical Trials as Topic↗
Laparoscopy for abdominal emergencies: evidence-based guidelines of the European Association for Endoscopic Surgery.
BACKGROUND: Emergency laparoscopic exploration can be used to identify the causative pathology of acute abdominal pain. Laparoscopic surgery also allows treatment of many intraabdominal disorders. This report was prepared to describe the effectiveness of laparoscopic surgery compared to laparotomy or nonoperative treatment. METHODS: A panel of European experts in abdominal and gynecological surgery was assembled and participated in a consensus conference using Delphi methods. The aim was to develop evidence-based recommendations for the most common diseases that may cause acute abdominal pain. RECOMMENDATIONS: Laparoscopic surgery was found to be clearly superior for patients with a presumable diagnosis of perforated peptic ulcer, acute cholecystitis, appendicitis, or pelvic inflammatory disease. In the emergency setting, laparoscopy is of unclear or limited value if adhesive bowel obstruction, acute diverticulitis, nonbiliary pancreatitis, hernia incarceration, or mesenteric ischemia are suspected. In stable patients with acute abdominal pain, noninvasive diagnostics should be fully exhausted before considering explorative surgery. However, diagnostic laparoscopy may be useful if no diagnosis can be found by conventional diagnostics. More clinical data are needed on the use of laparoscopy after blunt or penetrating trauma of the abdomen. CONCLUSIONS: Due to diagnostic and therapeutic advantages, laparoscopic surgery is useful for the majority of conditions underlying acute abdominal pain, but noninvasive diagnostic aids should be exhausted first. Depending on symptom severity, laparoscopy should be advocated if routine diagnostic procedures have failed to yield results.
Abdomen↗
Fewer adhesions after laparoscopic surgery?
Explore the source record for details and available documents.
Humans↗
Comparison of endoscopic techniques vs Shouldice and other open nonmesh techniques for inguinal hernia repair: a meta-analysis of randomized controlled trials.
BACKGROUND: We performed a scientific evaluation of the efficacy of different surgical techniques for inginual hernia repair and supported our findings by conducting a systematic review of randomized studies comparing endoscopic with open nonmesh suture techniques. METHODS: After an extensive search of the literature, a total of 27 studies (41 publications) with evidence level lb were identified. These studies randomly compared endoscopic with open nonmesh suturing techniques. The quality of data sufficed to enable a quantitative meta-analysis of various parameters using the original software of the Cochrane Collaboration. Due to its superiority in comparison to other open nonmesh suturing techniques, the Shouldice repair technique was analyzed separately. RESULTS: The systematic comparison of endoscopic techniques with the Shouldice repair showed that these techniques had significant advantages in terms of the following parameters: total morbidity, hematoma, nerve injury, and pain-associated parameters such as time to return to work, and chronic groin pain. The Shouldice operation has the advantages of a shorter operating time and a lower incidence of wound seroma. There was no difference regarding the incidence of major complications, wound infection, testicular atrophy, or hernia recurrence. Open non-Shouldice suturing techniques are associated with higher recurrence rates and more wound infections than endoscopic operations. CONCLUSION: In comparison to open nonmesh suture repair techniques, endoscopic repair techniques have significant advantages in terms of pain-associated parameters. For the revaluation of long-term complications such as hernia recurrence and chronic groin pain, further clinical examination of the existing study collectives is needed.
Atrophy↗
[Impact of rescue method and the destination clinic on mortality in polytrauma. A status report].
BACKGROUND: The aim of this study was to document the present knowledge from the medical literature on (1) efficacy of aeromedical evacuation (helicopter emergency medical service, HEMS) and (2) influence of the level of the first receiving hospital on mortality of patients. METHODS: Systematic review of the literature between 1970 and 2003; identification of studies with an evidence level of at least III and included control group; own results. RESULTS: (1) 17 studies concerning the efficacy of HEMS were included into the review. No single study yielded shorter rescue times with the use of HEMS. 11 of 17 studies showed a significantly higher survival rate (8.2 to 52%) with the employment of HEMS especially with mid-degree polytrauma. (2) All 6 relevant studies dealing with hospital level found a considerable lower mortality rate (19 to 42%) for patients treated primarily at a level 1 trauma center or comparable institution. CONCLUSIONS: The analyzed studies showed a trend toward decreased mortality rates with the employment of HEMS. Considering the comparable hospital level and even longer rescue times with HEMS, these differences can be explained with higher quality of initial diagnosis and treatment of the HEMS rescue team. Furthermore, mortality rates can be lowered significantly through primary treatment at a level 1 trauma center. Thus, the more flexible choice of the first receiving hospital represents a specific, clinically relevant advantage of HEMS in emergency medicine.
Air Ambulances↗
[Urinary tract injuries in polytraumatized patients].
BACKGROUND: Within the S3 Guideline Project of the European Association of Urology (EAU) an expert committee was set up to develop guidelines for the appropriate management of genitourinary trauma. These European guidelines were accepted in principle as national guidelines by the German Urological Society. Therefore, they also became the basis of the contribution of the German Urological Society to the S3 Guideline Project "Polytrauma" of the German Society for Trauma Surgery. METHOD: For the guideline "management of genitourinary trauma" all the requirements for classification as S3 guidelines were full-filled. The guideline itself was developed in accordance with the principles of "evidence-based medicine". A systematic analysis of literature published between 1966 and 2004 was carried out. The articles retrieved were assessed in respect of study design and clinical relevance and classified following the scheme of the Centre for Evidence-Based Medicine in Oxford. CONCLUSION: In suspected renal injuries the hemodynamic situation of the patient is the benchmark for the diagnostic and therapeutic algorithm. The diagnostic gold standard for the assessment of haemodynamically stable patients is CT scanning. Uncontrolled haemodynamic instability is an indication for immediate explorative laparotomy. Partial ureteral tears are managed by stenting; complete tears by immediate surgical repair. Pelvic fractures are often associated with bladder ruptures. Extraperitoneal bladder ruptures, identified by retrograde cystography, are in most cases safely managed by simple catheter drainage. Intraperitoneal ruptures require surgical intervention. Blood at the meatus may suggest a urethral lesion-blind urethral catheterization should not be attempted. Suprapubic cystostomy and delayed urethroplasty are recommended.
Germany↗
[Management strategies in the first operative phase after long-bone injury of the lower extremity in multiple-injured patients. A systematic literature review].
OBJECTIVE: Lower extremity injuries make up a substantial proportion of the injuries in multiply injured patients. The aim of this systematic literature analysis was to give an overview of the levels of evidence for different management strategies in the first operative phase after long-bone injuries of the lower extremity in multiply injured patients to enable, in the presence of adequate evidence, the development of clinical management corridors or, if the evidence was found to be inadequate, to document the necessity for scientific proof. METHODS: Clinical trials were systematically collected (Medline, Cochrane and hand searches) and classified into evidence levels (EL 1 to 5 according to the Oxford system). RESULTS: The necessity for primary or secondary definitive osteosynthesis of femur/tibia shaft fractures is still a matter of discussion. Intramedullary nailing is the preferred operative procedure for definitive treatment of femur shaft fractures. Stabilization of proximal and distal femur and tibia fractures is predominantly based on expert opinion. According to the literature, perioperative antibiotic prophylaxis is essential in fracture treatment. CONCLUSION: Numerous comparative studies (EL 2) dealing with management strategies in the first operative phase after long-bone injuries of the lower extremity in multiply injured patients are available, but there are only a few randomized studies. Based on the available data, it is possible to develop a rational therapy for this patient population.
Clinical Trials as Topic↗
In vivo contact areas of the knee in patients with patellar subluxation.
OBJECTIVE: Ex vivo studies have suggested that cartilage contact areas and pressure are of high clinical relevance in the etiology of osteoarthritis in patients with patellar subluxation. The aims of this study were therefore to validate in vivo measurements of contact areas with 3D open magnetic resonance imaging (MRI), and to study knee joint contact areas in patients with patellar subluxation at different angles of knee flexion in comparison with healthy subjects. METHODS: 3D-MRI data sets of 12 healthy volunteers and eight patients with patellar subluxation were acquired using a standard clinical (1.5 T) and an open (0.2 T) MRI scanner. We compared femoro-patellar and femoro-tibial contact areas obtained with two different sequences from open MRI [dual-echo-steady-state (DESS) and fast-low-angle-shot (FLASH) sequences] with those derived from standard clinical 1.5 T MRI. We then analyzed differences in joint contact areas between healthy subjects and patients with patellar subluxation at 0 degree, 30 degrees, and 90 degrees of knee flexion using open MRI. RESULTS: The correlation of the size of contact areas from open MRI with standard clinical MRI data ranged from r = 0.52 to 0.92. Open-MRI DESS displayed a smaller overestimation of joint contact areas (+21% in the femoro-patellar, +12% in the medial femoro-tibial, and +19% in the lateral femoro-tibial compartment) than FLASH (+40%, +37%, +30%, respectively). The femoro-patellar contact areas in patients were significantly reduced in comparison with healthy subjects (-47% at 0 degree, -56% at 30 degrees, and -42% at 90 degrees of flexion; all p < 0.01), whereas no significant difference was observed in femoro-tibial contact areas. CONCLUSIONS: Open MRI allows one to quantify joint contact areas of the knee with reasonable accuracy, if an adequate pulse sequence is applied. The technique permits one to clearly identify differences between patients with patellar subluxation and healthy subjects at different flexion angles, demonstrating a significant reduction and lateralization of contact areas in patients. In the future, application of this in vivo technique is of particular interest for monitoring the efficacy of different types of surgical and conservative treatment options for patellar subluxation.
Adult↗
Comparison of endoscopic procedures vs Lichtenstein and other open mesh techniques for inguinal hernia repair: a meta-analysis of randomized controlled trials.
BACKGROUND: For the scientific evaluation of the endoscopic and open mesh techniques for the repair of inguinal hernia, meta-analyses of randomized controlled trials (RCT) are necessary. The Lichtenstein repair is one of the most common open mesh techniques and therefore of special interest. METHODS: After an extensive search of the literature and a quality assessment, a total of 34 RCT comparing endoscopic procedures both transabdominal preperitoneal (TAPP) and total extraperitoneal (TEP)--with various open mesh repairs were deemed to be suitable for a formal meta-analysis of the relevant parameters. These studies included data for 7,223 patients. Trials that used the Lichtenstein repair for the control group (23 of 34 trials) were analyzed-separately. RESULTS: Significant advantages for the endoscopic procedures compared with the Lichtenstein repair include a lower incidence of wound infection (Peto odds ratio, 0.39; 95% confidence interval, 0.26, 0.61), a reduction in hematoma formation (0.69 [0.54, 0.90]) and nerve injury (0.46 [0.35, 0.61]), an earlier return to normal activities or work (-1.35[-1.72, -0.97]), and fewer incidences of chronic pain syndrome (0.56[0.44, 0.70]). No difference was found in total morbidity or in the incidence of intestinal lesions, urinary bladder lesions, major vascular lesions, urinary retention and testicular problems. Significant advantages for the Lichtenstein repair include in a shorter operating time (5.45[1.18, 9.73]), a lower incidence of seroma formation (1.42[1.13, 1.79]), and fewer hernia recurrences (2.00[1.46, 2.74]). Similar results are seen when endoscopic procedures are compared with other open mesh repairs. However, in this comparison, total morbidity was lower with the endoscopic operations (0.73[0.61, 0.89]). The incidence of seroma formation, chronic pain syndromes, and hernia recurrence was not significantly different. CONCLUSION: Endoscopic repairs do have advantages interms of local complications and pain-associated parameters. For more detailed evaluation further well-structured trials with improved standardization of hernia type, operative technique, and surgeons' experience are necessary.
Digestive System Surgical Procedures↗
Obesity surgery: evidence-based guidelines of the European Association for Endoscopic Surgery (EAES).
BACKGROUND: The increasing prevalence of morbid obesity together with the development of laparoscopic approaches has led to a steep rise in the number of bariatric operations. These guidelines intend to define the comparative effectiveness and surrounding circumstances of the various types of obesity surgery. METHODS: A consensus panel representing the fields of general/endoscopic surgery, nutrition and epidemiology convened to agree on specific questions in obesity surgery. Databases were systematically searched for clinical trial results in order to produce evidence-based recommendations. Following two days of discussion by the experts and a plenary discussion, the final statements were issued. RECOMMENDATIONS: After the patient's multidisciplinary evaluation, obesity surgery should be considered in adults with a documented BMI greater than or equal to 35 and related comorbidity, or a BMI of at least 40. In addition to standard laboratory testing, chest radiography, electrocardiography, spirometry, and abdominal ultrasonography, the preoperative evaluation of obesity surgery patients also includes upper gastrointestinal endoscopy or radiologic evaluation with a barium meal. Psychiatric consultation and polysomnography can safely be restricted to patients with clinical symptoms on preoperative screening. Adjustable gastric banding (GB), vertical banded gastroplasty (VBG), Roux-en-Y gastric bypass (RYGB) and biliopancreatic diversion (BPD) are all effective in the treatment of morbid obesity, but differ in degree of weight loss and range of complications. The choice of procedure therefore should be tailored to the individual situation. There is evidence that a laparoscopic approach is advantageous for LAGB, VBG, and GB (and probably also for BPD). Antibiotic and antithromboembolic prophylaxis should be used routinely. Patients should be seen 3 to 8 times during the first postoperative year, 1 to 4 times during the second year and once or twice a year thereafter. Outcome assessment after surgery should include weight loss and maintainance, nutritional status, comorbidities and quality-of-life.
Adolescent↗
Laparoscopic versus open surgery for suspected appendicitis.
BACKGROUND: Laparoscopic surgery for acute appendicitis has been proposed to have advantages over conventional surgery. OBJECTIVES: To compare the diagnostic and therapeutic effects of laparoscopic and conventional 'open' surgery. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, SciSearch, the congress proceedings of endoscopic surgical societies. SELECTION CRITERIA: We included randomized clinical trials comparing laparoscopic (LA) versus open appendectomy (OA) in adults or children. Studies comparing immediate OA versus diagnostic laparoscopy (followed by LA or OA if necessary) were separately identified. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality. Missing information or data was requested from the authors. We used odds ratios (OR), relative risks (RR), and 95% confidence intervals (CI) for analysis. MAIN RESULTS: We included 54 studies, of which 45 compared LA (with or without diagnostic laparoscopy) vs. OA in adults. Wound infections were less likely after LA than after OA (OR 0.45; CI 0.35 to 0.58), but the incidence of intraabdominal abscesses was increased (OR 2.48; CI 1.45 to 4.21). The duration of surgery was 12 minutes (CI 7 to 16) longer for LA. Pain on day 1 after surgery was reduced after LA by 9 mm (CI 5 to 13 mm) on a 100 mm visual analogue scale. Hospital stay was shortened by 1.1 day (CI 0.6 to 1.5). Return to normal activity, work, and sport occurred earlier after LA than after OA. While the operation costs of LA were significantly higher, the costs outside hospital were reduced. Five studies on children were included, but the result do not seem to be much different when compared to adults. Diagnostic laparoscopy reduced the risk of a negative appendectomy, but this effect was stronger in fertile women (RR 0.20; CI 0.11 to 0.34) as compared to unselected adults (RR 0.37; CI 0.13 to 1.01). REVIEWERS' CONCLUSIONS: In those clinical settings where surgical expertise and equipment are available and affordable, diagnostic laparoscopy and LA (either in combination or separately) seem to have various advantages over OA. Some of the clinical effects of LA, however, are small and of limited clinical relevance. In spite of the mediocre quality of the available research data, we would generally recommend to use laparoscopy and LA in patients with suspected appendicitis unless laparoscopy itself is contraindicated or not feasible. Especially young female, obese, and employed patients seem to benefit from LA.
Acute Disease↗
Evaluation of quality of life after laparoscopic surgery: evidence-based guidelines of the European Association for Endoscopic Surgery.
BACKGROUND: Measuring health-related quality of life (QoL) after surgery is essential for decision making by patients, surgeons, and payers. The aim of this consensus conference was twofold. First, it was to determine for which diseases endoscopic surgery results in better postoperative QoL than open surgery. Second, it was to recommend QoL instruments for clinical research. METHODS: An expert panel selected 12 conditions in which QoL and endoscopic surgery are important. For each condition, studies comparing endoscopic and open surgery in terms of QoL were identified. The expert panel reached consensus on the relative benefits of endoscopic surgery and recommended generic and disease-specific QoL instruments for use in clinical research. RESULTS: Randomized trials indicate that QoL improves earlier after endoscopic than open surgery for gastroesophageal reflux disease (GERD), cholecystolithiasis, colorectal cancer, inguinal hernia, obesity (gastric bypass), and uterine disorders that require hysterectomy. For spleen, prostate, malignant kidney, benign colorectal, and benign non-GERD esophageal diseases, evidence from nonrandomized trials supports the use of laparoscopic surgery. However, many studies failed to collect long-term results, used nonvalidated questionnaires, or measured QoL components only incompletely. The following QoL instruments can be recommended: for benign esophageal and gallbladder disease, the GIQLI or the QOLRAD together with SF-36 or the PGWB; for obesity surgery, the IWQOL-Lite with the SF-36; for colorectal cancer, the FACT-C or the EORTC QLQ-C30/CR38; for inguinal and renal surgery, the VAS for pain with the SF-36 (or the EORTC QLQ-C30 in case of malignancy); and after hysterectomy, the SF-36 together with an evaluation of urinary and sexual function. CONCLUSIONS: Laparoscopic surgery provides better postoperative QoL in many clinical situations. Researchers would improve the quality of future studies by using validated QoL instruments such as those recommended here.
Cholecystectomy, Laparoscopic↗