No surgical innovation without evaluation: the IDEAL recommendations

Neurosurgical interventions for the treatment of classical trigeminal neuralgia

BACKGROUND

Surgical interventions are used for trigeminal neuralgia when drug treatment fails. Surgical treatments divide into two main categories, ablative (destructive) or non-ablative. These treatments can be done at three different sites: peripherally, at the Gasserian ganglion level, and within the posterior fossa of the skull.

OBJECTIVES

To assess the efficacy of neurosurgical interventions for classical trigeminal neuralgia in terms of pain relief, quality of life and any harms. To determine if there are defined subgroups of patients more likely to benefit.

SEARCH STRATEGY

We searched the Cochrane Neuromuscular Disease Group Specialized Register, (13 May 2010), CENTRAL (issue 2, 2010 part of the Cochrane Library), Health Technology Assessment (HTA) Database, NHS Economic Evaluation Database (NHSEED) and Database of Abstracts of Reviews of Effects (DARE) (issue 4, 2010 (HTA, NHSEED and DARE are part of the Cochrane Library)), MEDLINE (January 1966 to May 2010) and EMBASE (January 1980 to May 2010) with no language exclusion.

SELECTION CRITERIA

Randomised controlled trials and quasi-randomised controlled trials of neurosurgical interventions used in the treatment of classical trigeminal neuralgia.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. We contacted authors for clarification and missing information whenever possible.

MAIN RESULTS

Eleven studies involving 496 participants met some of the inclusion criteria stated in the protocol. One hundred and eighty patients in five studies had peripheral interventions, 229 patients in five studies had percutaneous interventions applied to the Gasserian ganglion, and 87 patients in one study underwent two modalities of stereotactic radiosurgery (Gamma Knife) treatment. No studies addressing microvascular decompression (which is the only non-ablative procedure) met the inclusion criteria. All but two of the identified studies had a high to medium risk of bias because of either missing data or methodological inconsistency. It was not possible to undertake meta-analysis because of differences in the intervention modalities and variable outcome measures. Three studies had sufficient outcome data for analysis. One trial, which involved 40 participants, compared two techniques of radiofrequency thermocoagulation (RFT) of the Gasserian ganglion at six months. Pulsed RFT resulted in return of pain in all participants by three months. When this group were converted to conventional (continuous) treatment these participants achieved pain control comparable to the group that had received conventional treatment from the outset. Sensory changes were common in the continuous treatment group. In another trial, of 87 participants, investigators compared radiation treatment to the trigeminal nerve at one or two isocentres in the posterior fossa. There were insufficient data to determine if one technique was superior to another. Two isocentres increased the incidence of sensory loss. Increased age and prior surgery were predictors for poorer pain relief. Relapses were nonsignificantly reduced with two isocentres (risk ratio (RR) 0.72, 95% confidence intervaI (CI) 0.30 to 1.71). A third study compared two techniques for RFT in 54 participants for 10 to 54 months. Both techniques produced pain relief (not significantly in favour of neuronavigation (RR 0.70, 95% CI 0.46 to 1.04) but relief was more sustained and side effects fewer if a neuronavigation system was used. The remaining eight studies did not report outcomes as predetermined in our protocol.

AUTHORS' CONCLUSIONS

There is very low quality evidence for the efficacy of most neurosurgical procedures for trigeminal neuralgia because of the poor quality of the trials. All procedures produced variable pain relief, but many resulted in sensory side effects. There were no studies of microvascular decompression which observational data suggests gives the longest pain relief. There is little evidence to help comparative decision making about the best surgical procedure. Well designed studies are urgently needed.

Surgical Videos for Accident Analysis, Performance Improvement, and Complication Prevention

Conventional audit of surgical records through review of surgical results provides useful knowledge but hardly helps identify the technical reasons lying behind specific outcomes or complications. Surgical teams not only need to know that a complication might happen but also how and when it is most likely to happen. Functional awareness is therefore needed to prevent complications, know how to deal with them, and improve overall surgical performance. The authors wish to argue that the systematic recording and reviewing of surgical videos, a “surgical black box,” might improve surgical care, help prevent complications, and allow accident analysis. A possible strategy to test this hypothesis is presented and discussed. Recording and reviewing surgical interventions, apart from helping us achieve functional awareness and increasing the safety profile of our performance, allows us also to effectively share our experience with colleagues. The authors believe that those potential implications make this hypothesis worth testing.

Recovery of erectile function after robotic prostatectomy: evidence-based outcomes

Several reported advantages of the robotic-assisted laparoscopic approach to the treatment of clinically localized prostate cancer include superior results for erectile function as one of the critical outcomes of radical prostate surgery. This article provides a critical assessment of the evidence that exists for erectile function outcomes based on a systematic literature review. We found that the low methodological and reporting quality of existing studies did not appear well suited to guide clinical practice. A new framework of prospective investigation using validated patient self-assessment instruments would seem critical to the future advancement of this field.

Extracts from The Cochrane Library

The “Cochrane Corner” is a quarterly section in the Journal that highlights systematic reviews relevant to otolaryngology–head and neck surgery, with invited commentary to aid clinical decision making. This installment features a Cochrane Review, titled “Functional Endoscopic Balloon Dilation of Sinus Ostia for Chronic Rhinosinusitis,” that finds no convincing evidence supporting balloon dilation compared to conventional surgical modalities for managing refractory disease.

Can evidence-based medicine and clinical quality improvement learn from each other?

The considerable gap between what we know from research and what is done in clinical practice is well known. Proposed responses include the Evidence-Based Medicine (EBM) and Clinical Quality Improvement. EBM has focused more on ‘doing the right things’—based on external research evidence—whereas Quality Improvement (QI) has focused more on ‘doing things right’—based on local processes. However, these are complementary and in combination direct us how to ‘do the right things right’. This article examines the differences and similarities in the two approaches and proposes that by integrating the bedside application, the methodological development and the training of these complementary disciplines both would gain.

Scientific production and impact of national registers: the example of orthopaedic national registers

OBJECTIVE

National arthroplasty registers are often cited as examples of a non-randomized design that have made an essential contribution to advances in assessing arthroplasty procedures. We aimed to compare national registers to randomized controlled trials (RCTs) and meta-analyses in the field of arthroplasty in terms of scientific production and impact.

METHOD

We systematically searched Medline via PubMed and the registers' websites to select all articles from national registers, RCTs and meta-analyses assessing hip and knee arthroplasty. The scientific production and impact were evaluated by number of publications, number of citations (total and the 3-year citation counts), and information on the 2008 journal impact factor (IF), for each design and identified articles. We also contacted representatives of all the selected registers to determine the availability of the data for external research projects.

RESULTS

We retrieved information on 13 active national hip or knee arthroplasty registers; for 9, data were available for research projects under specific conditions. Overall, 190 publications in peer-reviewed journals resulted from national arthroplasty registers, 476 from RCTs, and 40 from meta-analyses. We found 4,112 citations for national register reports, 7,328 for RCT reports and 552 for meta-analysis reports. The median [interquartile [IQR] range] number of citations for register, RCT and meta-analysis reports in the 3-year period after publication was 3.5 [1.0-6.0], 2.0 [1.0-6.0], and 2.5 [0.5-7.5], respectively.

CONCLUSION

Publications from national registers may have the highest impact among the 3 designs in terms of median citation counts, but data from RCTs remain the most productive evidence in the arthroplasty field. Because of the number of patients recruited by registers, the quality of data collected, and the potential availability of data, scientific production and impact from national registers should be improved.

Emerging ethical issues in pediatric surgery

With the rapid pace of technological advancement and changing political, social, and legal attitudes, physicians face new ethical dilemmas. For pediatric surgeons, these emerging issues affect our relationship with, and the care we provide, to our patients and their families. In this review, we explore issues related to professionalism in pediatric surgery practice, the value of apology, and the risks associated with sleep deprivation. Furthermore, we discuss how the imperative of patient safety presents an opportunity for specialty-driven effort to define standards for the surgical care of children and a responsible process for introducing surgical innovations. Finally, we remind pediatric surgeons of their ethical and professional duty to support clinical research, and advocate the acceptance of community equipoise as sufficient basis for enrolling children in clinical trials.

Introduction of a quality management system and outcome after hematopoietic stem-cell transplantation

PURPOSE

A comprehensive quality management system called JACIE (Joint Accreditation Committee International Society for Cellular Therapy and the European Group for Blood and Marrow Transplantation), was introduced to improve quality of care in hematopoietic stem-cell transplantation (HSCT). We therefore tested the hypothesis that the introduction of JACIE improved patient survival.

PATIENTS AND METHODS

Data on 41,623 allogeneic (39%) and 66,281 autologous (61%) HSCTs for an acquired hematologic disorder performed between 1999 and 2007 by 421 teams in Europe were used to assess the outcomes of patients who received a transplantation at baseline (> 3 years before application or no application), during preparation (3 years before application), during application (time from application to accreditation), and after JACIE accreditation. The analysis was clustered by team and stratified for year of HSCT, donor type, disease, conditioning, and gross national income per capita of the respective country. Patient's risks were adjusted for by their European Group for Blood and Marrow Transplantation score.

RESULTS

Patient outcome was systematically better when the transplantation center was at a more advanced phase of JACIE accreditation, independent of year of transplantation and other risk factors. Improvement was robust as quantified for relapse-free survival after allogeneic HSCT compared with baseline by a hazard ratio (HR) of 0.96 (95% CI, 0.90 to 1.03; P = .22) for preparation, 0.95 (95% CI, 0.88 to 1.03; P = .20) for application, and 0.86 (95% CI, 0.78 to 0.95; P = .01) for the accreditation (test for trend P = .01). Improvement from baseline was similar after autologous HSCT (HR for accreditation, 0.83; 95% CI, 0.74 to 0.93; P < .01).

CONCLUSION

Even with all the limitations of an observational study, these findings support the hypothesis that introduction of a comprehensive clinical quality management system is associated with improved outcome of patients after HSCT.

Anterior colporrhaphy versus transvaginal mesh for pelvic-organ prolapse

BACKGROUND

The use of standardized mesh kits for repair of pelvic-organ prolapse has spread rapidly in recent years, but it is unclear whether this approach results in better outcomes than traditional colporrhaphy.

METHODS

In this multicenter, parallel-group, randomized, controlled trial, we compared the use of a trocar-guided, transvaginal polypropylene-mesh repair kit with traditional colporrhaphy in women with prolapse of the anterior vaginal wall (cystocele). The primary outcome was a composite of the objective anatomical designation of stage 0 (no prolapse) or 1 (position of the anterior vaginal wall more than 1 cm above the hymen), according to the Pelvic Organ Prolapse Quantification system, and the subjective absence of symptoms of vaginal bulging 12 months after the surgery.

RESULTS

Of 389 women who were randomly assigned to a study treatment, 200 underwent prolapse repair with the transvaginal mesh kit and 189 underwent traditional colporrhaphy. At 1 year, the primary outcome was significantly more common in the women treated with transvaginal mesh repair (60.8%) than in those who underwent colporrhaphy (34.5%) (absolute difference, 26.3 percentage points; 95% confidence interval, 15.6 to 37.0). The surgery lasted longer and the rates of intraoperative hemorrhage were higher in the mesh-repair group than in the colporrhaphy group (P<0.001 for both comparisons). Rates of bladder perforation were 3.5% in the mesh-repair group and 0.5% in the colporrhaphy group (P=0.07), and the respective rates of new stress urinary incontinence after surgery were 12.3% and 6.3% (P=0.05). Surgical reintervention to correct mesh exposure during follow-up occurred in 3.2% of 186 patients in the mesh-repair group.

CONCLUSIONS

As compared with anterior colporrhaphy, use of a standardized, trocar-guided mesh kit for cystocele repair resulted in higher short-term rates of successful treatment but also in higher rates of surgical complications and postoperative adverse events. (Funded by the Karolinska Institutet and Ethicon; ClinicalTrials.gov number, NCT00566917.).

Development of a composite endpoint for randomized controlled trials in liver surgery

Background

The feasibility of randomized controlled trials (RCTs) in liver surgery using a single-component clinical endpoint is low as such endpoints require large sample sizes owing to their low incidence. A liver surgery-specific composite endpoint (CEP) could solve this problem. The aim of this study was to develop a liver surgery-specific CEP with well-defined components.

Methods

Components of a liver surgery-specific CEP were selected based on a systematic literature search and consensus among 28 international hepatopancreatobiliary (HPB) surgeons. As an example, two prospective cohorts of patients who had undergone liver surgery in high-volume HPB centres were used to assess the event rate and effect of implementing a liver surgery-specific CEP.

Results

Components selected for the liver surgery-specific CEP were ascites, postresectional liver failure, bile leakage, intra-abdominal haemorrhage, intra-abdominal abscess and operative mortality, all with a Clavien–Dindo grade of at least 3 and occurring within 90 days after initial surgery. The incidence of this liver surgery-specific CEP was 19·2 per cent in one cohort and 10·7 per cent in the other. These rates led to an approximately twofold reduction in the theoretical sample size required for an adequately powered RCT in liver surgery using the CEP as primary endpoint.

Conclusion

The proposed liver surgery-specific CEP consists of ascites, postresectional liver failure, bile leakage, intra-abdominal haemorrhage, intra-abdominal abscess and operative mortality. It has a considerably higher event rate than any of its components. Its use as the primary endpoint will increase the feasibility and comparability of RCTs in liver surgery.

Enhancing safety of laparoscopic vascular control for neonatal sacrococcygeal teratoma

Life-threatening bleeding is a hazard of major tumor excision in children. However, fatalities from inadvertent arterial ligation should not be overlooked. Sacrococcygeal teratoma is the commonest neonatal tumor. Laparotomy to ligate the median sacral artery has been used to preempt potentially fatal resectional bleeding. Use of laparoscopy to achieve the same is an evolving technique, with only 7 neonatal cases described. As such, the Idea, Development, Exploration, Assessment, Long-term study (IDEAL) guidelines on surgical innovation recommend case reports addressing proof of concept, technical factors and safety tips. Fortunately, mistaken arterial division is so far unreported during laparoscopic median sacral artery ligation. However, as uptake widens, anatomical distortion by tumor and surgeon disorientation at endosurgery are risk factors for even such inconceivable complications. We report a successful case of laparoscopic vascular control for neonatal sacrococcygeal teratoma and demonstrate an observation that serves as a useful safety check for this procedure (as well as the open alternative).

Surgical evaluation and knowledge transfer--methods of clinical research in surgery

PURPOSE

This article aims to outline the framework of surgical evaluation and knowledge transfer. Therefore, special design issues affecting surgical clinical research will be discussed. Moreover, principles and challenges of knowledge transfer from research into practice will be addressed.

BACKGROUND

The ultimate goal of academic surgery is to improve surgical and perioperative care in order to achieve the best outcomes for patients. Randomized controlled trials and reviews with and without meta-analyses are fundamental requirements for evidence-based decision making.

DISCUSSION

Despite calls for more rigorous research methods in surgery, the frequency of high-quality randomized controlled trials and systematic reviews is low. Specific methodological and design issues have to be implemented for valid evaluation of surgical procedures. Thus, general catchwords of clinical epidemiology such as timing, randomization, registration, and reporting standards demand special appraisal. Moreover, blinding methods, placebo controls, learning curves, standardized outcome assessment, and generalizability are critical design issues in surgical trials. Moreover, systematic reviews and meta-analyses are desirable for answering clinical issues or defining new research questions.

CONCLUSION

For a rigorous evaluation of surgical procedures, a basic understanding of research methodology is urgently needed, and to improve methodological expertise, collaboration between surgeons and methodologists is encouraged.

Key issues in recruitment to randomised controlled trials with very different interventions: a qualitative investigation of recruitment to the SPARE trial (CRUK/07/011)

Background

Recruitment to randomised controlled trials (RCTs) with very different treatment arms is often difficult. The ProtecT (Prostate testing for cancer and Treatment) study successfully used qualitative research methods to improve recruitment and these methods were replicated in five other RCTs facing recruitment difficulties. A similar qualitative recruitment investigation was undertaken in the SPARE (Selective bladder Preservation Against Radical Excision) feasibility study to explore reasons for low recruitment and attempt to improve recruitment rates by implementing changes suggested by qualitative findings.

Methods

In Phase I of the investigation, reasons for low levels of recruitment were explored through content analysis of RCT documents, thematic analysis of interviews with trial staff and recruiters, and conversation analysis of audio-recordings of recruitment appointments. Findings were presented to the trial management group and a plan of action was agreed. In Phase II, changes to design and conduct were implemented, with training and feedback provided for recruitment staff.

Results

Five key challenges to trial recruitment were identified in Phase I: (a) Investigators and recruiters had considerable difficulty articulating the trial design in simple terms; (b) The recruitment pathway was complicated, involving staff across different specialties/centres and communication often broke down; (c) Recruiters inadvertently used 'loaded' terminology such as 'gold standard' in study information, leading to unbalanced presentation; (d) Fewer eligible patients were identified than had been anticipated; (e) Strong treatment preferences were expressed by potential participants and trial staff in some centres. In Phase II, study information (patient information sheet and flowchart) was simplified, the recruitment pathway was focused around lead recruiters, and training sessions and 'tips' were provided for recruiters. Issues of patient eligibility were insurmountable, however, and the independent Trial Steering Committee advised closure of the SPARE trial in February 2010.

Conclusions

The qualitative investigation identified the key aspects of trial design and conduct that were hindering recruitment, and a plan of action that was acceptable to trial investigators and recruiters was implemented. Qualitative investigations can thus be used to elucidate challenges to recruitment in trials with very different treatment arms, but require sufficient time to be undertaken successfully.

Trial Registration

CRUK/07/011; ISRCTN61126465

The IDEAL recommendations and urological innovation

PURPOSE

Like other branches of surgery, Urology has encountered major challenges in aligning the research processes by which new interventions are assessed with the principles of Evidence-Based Medicine. This article explains the IDEAL framework and recommendations and illustrates how they might affect the evaluation of current controversial urological procedures.

METHODS

From an inside perspective, we provide an overview of the efforts of the IDEAL Working Group to date with special emphasis on the field of Urology.

RESULTS

There are clear differences between drugs and interventions in the natural history of innovations. Since the conventional framework for conducting trials of new treatments is largely based on the former, the evaluation of surgical innovations using the same template can encounter significant problems. Difficulties in performing randomized controlled trials of surgical techniques and the persistence of the case series as an important feature of the scientific literature have been the two most controversial aspects of this mismatch between the subject of research and the methodology used. The IDEAL framework provides a description of the process of innovation and development for surgical trials, and the associated recommendations provide a suggested alternative approach to developing study designs, which are appropriate for the specific problems of new techniques.

CONCLUSIONS

IDEAL provides a new framework for surgical innovation that was developed with broad stakeholder input from the surgical community and is expected to have a transformative impact on the way that urologists perform clinical research.

Demonstration of the IDEAL recommendations for evaluating and reporting surgical innovation in minimally invasive oesophagectomy

Background

The Idea, Development, Evaluation, Assessment and Long term study (IDEAL) framework makes recommendations for evaluating and reporting surgical innovation and adoption, but remains untested.

Methods

A prospective database was created for the introduction of minimally invasive techniques for oesophagectomy. IDEAL stages of development and evaluation were examined retrospectively in a series of patients undergoing laparoscopically assisted oesophagectomy (LAO), two- or three-phase minimally invasive oesophagectomy (MIO) and open oesophagectomy.

Results

A total of 192 patients were involved. In IDEAL stages 1 and 2a, LAO in 16 patients was uneventful, but two-phase MIO in six patients was abandoned following consecutive technical complications. Two-phase MIO was modified to a three-phase MIO procedure, and the results of LAO (67 patients), three-phase MIO (35) and open techniques (68) were studied in IDEAL stage 2b. Major complications (Clavien–Dindo grades III and IV) occurred in 12 (18 per cent), nine (26 per cent) and 14 (21 per cent) LAO, three-phase MIO and open procedures respectively. There were four in-hospital deaths (2 LAO and 2 open).

Conclusion

The IDEAL framework is a feasible method for documenting the development and implementation of a procedure. MIO should now be compared with open surgery in a randomized controlled trial (IDEAL stage 3).

Fate of the peer review process at the ESA: long-term outcome of submitted studies over a 5-year period

OBJECTIVE

To critically evaluate the outcome of the peer review process of the European Surgical Association (ESA) and its contribution to Annals of Surgery.

BACKGROUND

The ESA was created in 1993 as an equivalent of the well-established American Surgical Association. Submitted abstracts and manuscripts were subjected to a stringent multistep peer review process to offer only the best studies for publication in the special issue of Annals of Surgery. A critical evaluation was felt necessary to identify factors that favored the acceptance of abstracts and manuscripts, respectively. The citations of the manuscripts published in Annals of Surgery and the outcome of the rejected studies were also researched.

METHODS

All submissions to the ESA between 2002 and 2007 were analyzed and followed over a period of 2 years. A database was established to identify factors favoring acceptance. A comprehensive search was undertaken to identify plagiarisms and the 2-year citations of all accepted manuscripts and later publications of the rejected studies in Annals of Surgery or elsewhere.

RESULTS

Altogether, 545 abstracts were submitted to the ESA during the study period. About one-third was accepted for presentation at the annual meeting, and, of those, 40% were published in Annals of Surgery. The majority of these studies originated from 4 European Countries. The only independent factors favoring presentation were randomized controlled trials and a sample size of more than 100 patients. All plagiarisms were identified before acceptance. Only 4% and 2% of the rejected abstracts and manuscripts, respectively, were published in higher impact factor journals than in Annals of Surgery. Twelve percent of the rejected manuscripts were eventually published in a later issue of Annals of Surgery, whereas more than two-thirds of the rejected studies appeared in a journal with a lower impact factor. The 2-year citations of the ESA manuscripts were in the range of all the other types of manuscripts published in Annals of Surgery. Only manuscripts originating from the American Surgical Association had slightly higher citations.

CONCLUSIONS

The ESA successfully spent its early years, providing high-quality manuscripts to Annals of Surgery. Only few rejected manuscripts reached higher-ranked journals. The focus should now turn toward stimulating other European countries to submit their best studies and attract more well-designed randomized controlled trials.

Risk of suicide after long-term follow-up from bariatric surgery

PURPOSE

Bariatric surgery is recognized as the treatment of choice for class III obesity (body mass index ≥40) and has been increasingly recommended for obese patients. Prior research has suggested an excess of deaths due to suicide following bariatric surgery, but few large long-term follow-up studies exist. We examined postbariatric surgery suicides by time since operation, sex, age, and suicide death rates as compared with US suicide rates.

METHODS

Medical data following bariatric operations performed on Pennsylvania residents between January 1, 1995 and December 31, 2004 were obtained from the Pennsylvania Health Care Cost and Containment Council. Matching mortality data from suicides between September 1, 1996 and December 28, 2006 were obtained from the Division of Vital Records, Pennsylvania State Department of Health.

RESULTS

There were 31 suicides (16,683 operations), for an overall rate of 6.6/10,000; 13.7 per 10,000 among men and 5.2 per 10,000 among women. About 30% of suicides occurred within the first 2 years following surgery, with almost 70% occurring within 3 years. For every age category except the youngest, suicide rates were higher among men than women. Age- and sex-matched suicide rates in the US population (ages 35-64 years) were 2.4/10,000 (men) and 0.7/10,000 (women).

CONCLUSIONS

Compared with age and sex-matched suicide rates in the US, there was a substantial excess of suicides among all patients who had bariatric surgery in Pennsylvania during a 10-year period. These data document a need to develop more comprehensive longer-term surveillance and follow-up methods in order to evaluate factors associated with postbariatric surgery suicide.

Systematic review of the efficacy and safety of high-intensity focussed ultrasound for the primary and salvage treatment of prostate cancer

CONTEXT

High-intensity focussed ultrasound (HIFU) is an emerging minimally invasive treatment option for prostate cancer.

OBJECTIVE

Our aim was to assess the efficacy and safety of HIFU in both primary treatment of men with localised and locally advanced prostate cancer as well as salvage treatment of men with recurrent prostate cancer following treatment failure of radical prostatectomy or external-beam radiation therapy.

EVIDENCE ACQUISITION

We conducted a systematic literature search for studies conducted on humans and published in either English or German in several databases from 2000 to 2010. In addition, we screened several Web sites for assessments on HIFU in prostate cancer and contacted the manufacturers of the two currently available HIFU devices for supplemental information on HIFU. We included all prospective studies with >50 study participants and assessed their quality using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach.

EVIDENCE SYNTHESIS

We identified 20 uncontrolled prospective case series, each of which treated between 58 and 517 patients. These studies were all conducted within the past decade. In total, 3018 patients were treated with HIFU, 93% for primary therapy and 7% for salvage HIFU. For all HIFU procedures, the biochemical disease-free survival rate at 1, 5, and 7 yr, respectively, was 78-84%, 45-84%, and 69%. The negative biopsy rate was 86% at 3 mo and 80% at 15 mo. Overall survival rates and prostate cancer-specific survival rates were 90% and 100% at 5 yr and 83% and 98% at 8 yr, respectively. Adverse events concerned the urinary tract (1-58%), potency (1-77%), the rectum (0-15%), and pain (1-6%). Quality-of-life assessment yielded controversial results.

CONCLUSIONS

Applying the GRADE approach, the available evidence on efficacy and safety of HIFU in prostate cancer is of very low quality, mainly due to study designs that lack control groups. More research is needed to explore the use of HIFU in prostate cancer.

Endoscopic minimally invasive thyroidectomy (eMIT): some clarifications regarding the idea, development, preclinical studies, and application in humans

BACKGROUND: The transoral endoscopic approach for thyroid surgery was based on a previous attempt to reach the thyroid gland by an axilloscope. In contrast to this single-port access, endoscopic minimally invasive thyroidectomy (eMIT) uses three access points (sublingual and bivestibular). This results in a sufficient triangulation of instruments, making surgical procedures in the anterior neck region possible. METHODS: The idea and development of the eMIT technique are described in detail. Anatomic studies, the development of the surgical access in a cadaver study, and the animal study for safety and feasibility of this transoral endoscopic approach for surgery of the anterior neck are outlined. Also, the foundations and ethical aspects are addressed in the context of developing a surgical innovation, which resulted in the first clinical application of this technique in humans. RESULTS: The preclinical studies regarding endoscopic minimally invasive thyroidectomy proofed feasibility in a human cadaver studies as well as safety in a short-time survival animal study. The first clinical application in a 53-year old patient was successful without any significant complications; expected benefits (no postoperative pain or dysphagia, no visible scar) could be demonstrated. CONCLUSIONS: The eMIT technique represents a promising new surgical approach for endoscopic surgery in the anterior neck region. The whole development was based on principles for surgical innovation published after the authors' preclinical studies. At this writing, after an initial clinical study with humans, the time has come to compare this new technique with other endoscopic and minimally invasive approaches in a prospective randomized multicenter trial.

[NOTES. History and current situation of natural orifice transluminal endoscopic surgery in Spain]

Natural orifice transluminal endoscopic surgery (NOTES), involves a group of new endoscopic approaches to the abdominal cavity, with potential advantages over conventional laparoscopic surgery. It is based on the possibility of performing intra-peritoneal surgical techniques through natural orifices by entering the peritoneal cavity through natural orifices perforating the organ that allows direct access to that cavity (stomach, vagina, rectum, bladder). The possibility of using this same route to access the retroperitoneum and mediastinum has subsequently been postulated. Comments are made on how the technique has been developed, as well as how it has been applied in our country, attempting to give a general view on the risks and benefits of NOTES and the basic requirements to be able to start in this new surgery.

Neonatal endosurgical congenital diaphragmatic hernia repair: a systematic review and meta-analysis

OBJECTIVE

To compare outcomes of open and endosurgical neonatal congenital diaphragmatic hernia (CDH) repairs.

BACKGROUND

Historically a surgical emergency, neonatal CDH repair is now deferred pending stabilization of characteristically labile cardiopulmonary physiology. Usually accomplished via laparotomy, surgical repair may acutely worsen lung function; conversely, by reducing the visceral hernia, surgery might improve it. Theoretically, endosurgical repair could minimize deleterious effects of surgery while garnering benefits from decompressing the CDH lung. As endosurgical repair gains popularity, it is important to investigate whether or not minimally-invasive neonatal CDH repair has benefits.

METHODS

We searched Medline, Embase, and Cochrane Trials databases for studies comparing open with endosurgical CDH repair. Non-neonatal series and reports without comparison groups were excluded. References from papers and conference proceedings were also hand searched. Meta-analysis used a fixed effects model and was reported in accordance with PRISMA.

RESULTS

We included 3 studies (1 unpublished; none randomized); all compared thoracoscopic and open CDH repair and together described 143 patients. All studies had limitations, including use of historical controls. Demographics, CDH sidedness, APGAR and associated anomaly prevalence were similar between groups. For endosurgical repair, recurrence was higher (RR: 3.2 [1.1, 9.3], P = 0.03) and operative time longer (WMD 50 minutes [32, 69], P < 0.00001). Survival and patch usage were not different between open and endosurgical groups.

CONCLUSIONS

Neonatal thoracoscopic CDH repair has greater recurrence rates and operative times but similar survival and patch usage compared with open surgery. A prospective registry for all such cases would guide development of trials (Stage 2b; IDEAL recommendations).

[Impact of clinical trials for surgery]

Clinical trials play a key role in patient care, academic education and research in surgery. Without valid studies the practice of evidence-based medicine is limited. Surgery is supported through funding by the German Ministry of Education and Research to establish an infrastructure for clinical trials. So far seven universities have worked together in a network since 2007 and successfully obtained funding for six large randomized trials from a program existing since 2004. Until now 2,249 patients have been randomized within 11 trials and 910 patients have been treated at local hospitals without academic responsibilities. An increase in the interest in clinical trials in daily practice has resulted through the certification of hospitals for special treatment that specifies that at least 5% of all patients are included in clinical trials.

Capsule endoscopy in Italy: An unbalanced review of the literature. Authors' response

The comments by Spada et al. (which are similar in style and content to the ones already made by the authors on the Italian Ministry of Health Web site) are based on misunderstandings and manipulations. The essence of systematic reviews is to sum up available knowledge and minimize bias. The latter is done by a priori stating study inclusion criteria both in the protocol and in the full HTA report (see Fig. 1, p. 299) and assessing methodological quality of included studies using an instrument which was specified in the protocol text and never changed (the Quality Assessment Diagnostic Accuracy Studies checklist or QUADAS). The purpose of inclusion criteria and bias minimization efforts is to ensure that what is included in a review is both relevant and contributes evidence weighted by its reliability to answer the study question (in our case the diagnostic performance of WCE in the small bowel). The high number of excluded studies is thus irrelevant, although it is a common feature of systematic reviews. What matters is what the included studies tell us.

Endovascular versus open repair of abdominal aortic aneurysm

BACKGROUND

Few data are available on the long-term outcome of endovascular repair of abdominal aortic aneurysm as compared with open repair.

METHODS

From 1999 through 2004 at 37 hospitals in the United Kingdom, we randomly assigned 1252 patients with large abdominal aortic aneurysms (> or = 5.5 cm in diameter) to undergo either endovascular or open repair; 626 patients were assigned to each group. Patients were followed for rates of death, graft-related complications, reinterventions, and resource use until the end of 2009. Logistic regression and Cox regression were used to compare outcomes in the two groups.

RESULTS

The 30-day operative mortality was 1.8% in the endovascular-repair group and 4.3% in the open-repair group (adjusted odds ratio for endovascular repair as compared with open repair, 0.39; 95% confidence interval [CI], 0.18 to 0.87; P=0.02). The endovascular-repair group had an early benefit with respect to aneurysm-related mortality, but the benefit was lost by the end of the study, at least partially because of fatal endograft ruptures (adjusted hazard ratio, 0.92; 95% CI, 0.57 to 1.49; P=0.73). By the end of follow-up, there was no significant difference between the two groups in the rate of death from any cause (adjusted hazard ratio, 1.03; 95% CI, 0.86 to 1.23; P=0.72). The rates of graft-related complications and reinterventions were higher with endovascular repair, and new complications occurred up to 8 years after randomization, contributing to higher overall costs.

CONCLUSIONS

In this large, randomized trial, endovascular repair of abdominal aortic aneurysm was associated with a significantly lower operative mortality than open surgical repair. However, no differences were seen in total mortality or aneurysm-related mortality in the long term. Endovascular repair was associated with increased rates of graft-related complications and reinterventions and was more costly. (Current Controlled Trials number, ISRCTN55703451.)

[Single incision laparoscopic surgery]

One of the aims of the new technologies and techniques in minimally invasive surgery (MIS) is to achieve a surgery without or with minimal visible scars. Natural orifice transluminal endoscopic surgery (NOTES) might be considered to be a paradigm of this development but it has not yet been possible to implement this universally. Nevertheless, the resultant innovation of research into NOTES has enabled "bridge technologies" to be introduced that allow MIS to be developed with the required standards of efficiency and safety. The aim of this paper is to review the concept of single incision surgery and to classify the available tools for its development and implementation.

EAES recommendations on methodology of innovation management in endoscopic surgery

BACKGROUND

Under the mandate of the European Association for Endoscopic Surgery (EAES) a guideline on methodology of innovation management in endoscopic surgery has been developed. The primary focus of this guideline is patient safety, efficacy, and effectiveness.

METHODS

An international expert panel was invited to develop recommendations for the assessment and introduction of surgical innovations. A consensus development conference (CDC) took place in May 2009 using the method of a nominal group process (NGP). The recommendations were presented at the annual EAES congress in Prague, Czech Republic, on June 18th, 2009 for discussion and further input. After further Delphi processes between the experts, the final recommendations were agreed upon.

RESULTS

The development and implementation of innovations in surgery are addressed in five sections: (1) definition of an innovation, (2) preclinical and (3) clinical scientific development, (4) scientific approval, and (5) implementation along with monitoring. Within the present guideline each of the sections and several steps are defined, and several recommendations based on available evidence have been agreed within each category. A comprehensive workflow of the different steps is given in an algorithm. In addition, issues of health technology assessment (HTA) serving to estimate efficiency followed by ethical directives are given.

CONCLUSIONS

Innovations into clinical practice should be introduced with the highest possible grade of safety for the patient (nil nocere: do no harm). The recommendations can contribute to the attainment of this objective without preventing future promising diagnostic and therapeutic innovations in the field of surgery and allied techniques.

Evaluation and stages of surgical innovations

Surgical innovation is an important part of surgical practice. Its assessment is complex because of idiosyncrasies related to surgical practice, but necessary so that introduction and adoption of surgical innovations can derive from evidence-based principles rather than trial and error. A regulatory framework is also desirable to protect patients against the potential harms of any novel procedure. In this first of three Series papers on surgical innovation and evaluation, we propose a five-stage paradigm to describe the development of innovative surgical procedures.

Challenges in evaluating surgical innovation

Research on surgical interventions is associated with several methodological and practical challenges of which few, if any, apply only to surgery. However, surgical evaluation is especially demanding because many of these challenges coincide. In this report, the second of three on surgical innovation and evaluation, we discuss obstacles related to the study design of randomised controlled trials and non-randomised studies assessing surgical interventions. We also describe the issues related to the nature of surgical procedures-for example, their complexity, surgeon-related factors, and the range of outcomes. Although difficult, surgical evaluation is achievable and necessary. Solutions tailored to surgical research and a framework for generating evidence on which to base surgical practice are essential.