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Cioffi SPB, Altomare M, Podda M, Spota A, Granieri S, Reitano E, Zamburlini B, Virdis F, Bini R, Gupta S, Torzilli G, Mingoli A, Chiara O, Cimbanassi S. The burden of the knowledge-to-action gap in acute appendicitis. Surg Endosc 2023; 37:9617-9632. [PMID: 37884735 PMCID: PMC10709474 DOI: 10.1007/s00464-023-10449-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 09/05/2023] [Indexed: 10/28/2023]
Abstract
BACKGROUND The burden of emergency general surgery (EGS) is higher compared to elective surgery. Acute appendicitis (AA) is one of the most frequent diseases and its management is dictated by published international clinical practice guidelines (CPG). Adherence to CPG has been reported as heterogeneous. Barriers to clinical implementation were not studied. This study explored barriers to adherence to CPG and the clinico-economic impact of poor compliance. METHODS Data were extracted from the three-year data lock of the REsiDENT-1 registry, a prospective resident-led multicenter trial. We identified 7 items from CPG published from the European Association of Endoscopic Surgery (EAES) and the World Society of Emergency Surgery (WSES). We applied our classification proposal and used a five-point Likert scale (Ls) to assess laparoscopic appendectomy (LA) difficulty. Descriptive analyses were performed to explore compliance and group comparisons to assess the impact on outcomes and related costs. We ran logistic regressions to identify barriers and facilitators to implementation of CPG. RESULTS From 2019 to 2022, 653 LA were included from 24 centers. 69 residents performed and coordinated data collection. We identified low compliance with recommendations on peritoneal irrigation (PI) (25.73%), abdominal drains (AD) (34.68%), and antibiotic stewardship (34.17%). Poor compliance on PI and AD was associated to higher infectious complications in uncomplicated AA. Hospitalizations were significantly longer in non-compliance except for PI in uncomplicated AA, and costs significantly higher, exception made for antibiotic stewardship in complicated AA. The strongest barriers to CPG implementation were complicated AA and technically challenging LA for PI and AD. Longer operative times and the use of PI negatively affected antibiotic stewardship in uncomplicated AA. Compliance was higher in teaching hospitals and in emergency surgery units. CONCLUSIONS We confirmed low compliance with standardized items influenced by environmental factors and non-evidence-based practices in complex LA. Antibiotic stewardship is sub-optimal. Not following CPG may not influence clinical complications but has an impact in terms of logistics, costs and on the non-measurable magnitude of antibiotic resistance. Structured educational interventions and institutional bundles are required.
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Affiliation(s)
- Stefano Piero Bernardo Cioffi
- Advanced Technologies in Surgery, Department of Surgical Sciences, University of Rome Sapienza, Rome, Italy.
- General Surgery Trauma Team, ASST GOM Niguarda, Viale Ettore Majorana, 20162, Milan, Italy.
| | - Michele Altomare
- Advanced Technologies in Surgery, Department of Surgical Sciences, University of Rome Sapienza, Rome, Italy
- General Surgery Trauma Team, ASST GOM Niguarda, Viale Ettore Majorana, 20162, Milan, Italy
| | - Mauro Podda
- Department of Surgical Sciences, Cagliari State University, Cagliari, Italy
| | - Andrea Spota
- General Surgery Trauma Team, ASST GOM Niguarda, Viale Ettore Majorana, 20162, Milan, Italy
| | - Stefano Granieri
- General Surgery Unit, ASST-Brianza, Vimercate Hospital, Vimercate, Italy
| | - Elisa Reitano
- Division of General Surgery, Department of Translational Medicine, Maggiore Della Carità Hospital, University of Eastern Piedmont, Novara, Italy
- Research Institute Against Digestive Cancer, IRCAD, Strasbourg, France
| | - Beatrice Zamburlini
- General Surgery Trauma Team, ASST GOM Niguarda, Viale Ettore Majorana, 20162, Milan, Italy
- General Surgery Residency Program, University of Milan, Milan, Italy
| | - Francesco Virdis
- General Surgery Trauma Team, ASST GOM Niguarda, Viale Ettore Majorana, 20162, Milan, Italy
| | - Roberto Bini
- General Surgery Trauma Team, ASST GOM Niguarda, Viale Ettore Majorana, 20162, Milan, Italy
| | | | | | - Andrea Mingoli
- Advanced Technologies in Surgery, Department of Surgical Sciences, University of Rome Sapienza, Rome, Italy
| | - Osvaldo Chiara
- General Surgery Trauma Team, ASST GOM Niguarda, Viale Ettore Majorana, 20162, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Stefania Cimbanassi
- General Surgery Trauma Team, ASST GOM Niguarda, Viale Ettore Majorana, 20162, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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Pitak-Arnnop P, Meningaud JP, Neff A. Supramuscular upper blepharoplasty approach to orbital roof and/or lower anterior table frontal sinus fractures: A meta-narrative review. J Stomatol Oral Maxillofac Surg 2022; 123:645-654. [PMID: 35605961 DOI: 10.1016/j.jormas.2022.05.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 05/11/2022] [Accepted: 05/18/2022] [Indexed: 01/03/2023]
Abstract
BACKGROUND An approach to orbital roof fractures (ORFs) and/or lower anterior table frontal sinus fractures (LATFSFs) is a challenging task. The conventional coronal approach (CCA) appears to suit multiple/complex fractures of the upper face, while periorbital transcutaneous incisions (PTIs), e.g. gull wing, open sky, butterfly, and Lynch incisions, often impair aesthetic outcomes. The aims of this paper were to provide an overview of the supramuscular upper blepharoplasty approach (SUBA) to ORFs/LATFSFs. METHODS Using a meta-narrative review study design, the investigators enrolled published data extracted from PubMed/Medline, Embase, Cochrane Library, and Google Scholar concerning SUBA to ORFs/LATFSFs. Only publications with the highest and most recent level of evidence (LoE) in English, French or German available until 6 May 2022 were included. The LoE were evaluated using the 2011 Oxford Centre for Evidence-Based Medicine (OCEBM)'s classification. RESULTS In total, 70 articles were included; however, most contained low LoE. Under general and local anaesthesia, SUBA to ORFs/LATFSFs can be performed safely and appeared to be superior to its submuscular counterpart in terms of fewer risks of adjacent tissue injuries, and speedy operative time (maximal 5 min. in experienced hands). CONCLUSIONS In contrast to CCA and PTIs, the SUBA is a minimally invasive approach to the ORF/LATFSF with favourable aesthetic outcomes, direct visualisation of the fracture, quick operative time, rare complications, and easy learning.
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Affiliation(s)
- Poramate Pitak-Arnnop
- Department of Oral and Craniomaxillofacial Plastic Surgery, University Hospital of Giessen and Marburg, UKGM GmbH, Campus Marburg, Faculty of Medicine, Philipps-University of Marburg, Marburg, Germany.
| | - Jean-Paul Meningaud
- Department of Plastic, Reconstructive, Esthetic, Aesthetic and Maxillofacial Surgery, Henri Mondor University Hospital, AP-HP, Faculty of Medicine, University Paris-Est Créteil Val de Marne (Paris XII), Créteil, France
| | - Andreas Neff
- Department of Oral and Craniomaxillofacial Plastic Surgery, University Hospital of Giessen and Marburg, UKGM GmbH, Campus Marburg, Faculty of Medicine, Philipps-University of Marburg, Marburg, Germany
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Husnoo N, Johnston J, Harikrishnan A. Incorporation of Evidence-Based Surgery into the Curriculum. Indian J Surg 2021;:1-4. [PMID: 34334975 DOI: 10.1007/s12262-021-03038-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 07/09/2021] [Indexed: 11/30/2022] Open
Abstract
Surgeons have historically learned their craft through the apprenticeship model from their mentors. Knowledge and practices acquired this way can rapidly become outdated. Providing high-quality care to patients requires surgeons to keep their knowledge up to date in line with evolving new evidence. The principles of evidence-based medicine (EBM) and its application to surgery, evidence-based surgery (EBS), are pivotal in updating and refining surgical practice. Changing from the conventional practice of surgical education to a structured evidence-based format requires a transformative process in all the levels of surgical practice encompassing trainees and trainers. Equally important is providing an optimal environment to review the evidence and deliver the surgical teaching and incorporate effective assessment tools to monitor the process. In this article, we revisit the levels of evidence and explore the different issues related to EBS such as barriers to EBS, incorporation of EBS to the surgical curriculum and discuss practical ways to implement EBS in the surgical curriculum.
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Franceschini G, Masetti R. Evidence-based surgery to realize a successful extreme oncoplastic breast conservation. Eur J Surg Oncol 2020; 46:924-925. [PMID: 32070642 DOI: 10.1016/j.ejso.2020.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 02/06/2020] [Indexed: 10/25/2022] Open
Affiliation(s)
- Gianluca Franceschini
- Division of Breast Surgery, Department of Woman, Child and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8, 00168, Rome, Italy.
| | - Riccardo Masetti
- Division of Breast Surgery, Department of Woman, Child and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8, 00168, Rome, Italy
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Roberts DJ, Zygun DA, Ball CG, Kirkpatrick AW, Faris PD, James MT, Mrklas KJ, Hemmelgarn BD, Manns B, Stelfox HT. Challenges and potential solutions to the evaluation, monitoring, and regulation of surgical innovations. BMC Surg 2019; 19:119. [PMID: 31455337 PMCID: PMC6712595 DOI: 10.1186/s12893-019-0586-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 08/18/2019] [Indexed: 01/09/2023] Open
Abstract
Background As it may be argued that many surgical interventions provide obvious patient benefits, formal, staged assessment of the efficacy and safety of surgical procedures has historically been and remains uncommon. The majority of innovative surgical procedures have therefore often been developed based on anatomical and pathophysiological principles in an attempt to better manage clinical problems. Main Body In this manuscript, we sought to review and contrast the models for pharmaceutical and surgical innovation in North America, including their stages of development and methods of evaluation, monitoring, and regulation. We also aimed to review the present structure of academic surgery, the role of methodological experts and funding in conducting surgical research, and the current system of regulation of innovative surgical procedures. Finally, we highlight the influence that evidence and surgical history, education, training, and culture have on elective and emergency surgical decision-making. The above discussion is used to support the argument that the model used for assessment of innovative pharmaceuticals cannot be applied to that for evaluating surgical innovations. It is also used to support our position that although the evaluation and monitoring of innovative surgical procedures requires a rigorous, fit-for-purpose, and formal system of assessment to protect patient safety and prevent unexpected adverse health outcomes, it will only succeed if it is supported and championed by surgical practice leaders and respects surgical history, education, training, and culture. Conclusion We conclude the above debate by providing a recommended approach to the evaluation, monitoring, and regulation of surgical innovations, which we hope may be used as a guide for all stakeholders involved in interpreting and/or conducting future surgical research.
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Affiliation(s)
- Derek J Roberts
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, The Ottawa Hospital, Civic Campus, Room A280, 1053 Carling Avenue, Ottawa, Ontario, K1Y 4E9, Canada.
| | - David A Zygun
- Division of Critical Care Medicine, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Chad G Ball
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada.,Department of Oncology, University of Calgary, Calgary, Alberta, Canada
| | | | - Peter D Faris
- Alberta Health Sciences Research - Research Analytics, University of Calgary and the Foothills Medical Centre, Calgary, Alberta, Canada
| | - Matthew T James
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Kelly J Mrklas
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.,Strategic Clinical Networks, System Programs, and Innovation, Alberta Health Services, Calgary, Alberta, Canada
| | - Brenda D Hemmelgarn
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Braden Manns
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Henry T Stelfox
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.,Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
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Giulianotti PC, Mangano A, Bustos RE, Gheza F, Fernandes E, Masrur MA, Gangemi A, Bianco FM. Operative technique in robotic pancreaticoduodenectomy (RPD) at University of Illinois at Chicago (UIC): 17 steps standardized technique : Lessons learned since the first worldwide RPD performed in the year 2001. Surg Endosc 2018; 32:4329-4336. [PMID: 29766304 PMCID: PMC6132886 DOI: 10.1007/s00464-018-6228-7] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 05/09/2018] [Indexed: 12/21/2022]
Abstract
Background Minimally invasive pancreaticoduodenectomy (MIPD) was introduced in the attempt to improve the outcomes of the open approach. Laparoscopic pancreaticoduodenectomy (LPD) was first reported by Gagner and Pomp (Surg Endosc 8:408–410, 1994). Unfortunately, due to its complexity and technical demand, LPD never reached widespread popularity. Since it was first performed by P. C. Giulianotti in 2001, Robotic PD (RPD) has been gaining ground among surgeons. MIPD is included as a surgical option in the latest NCCN Guidelines. However, lack of surgical standardization, however, has limited the reproducibility of MIPD and made the acquisition of the technique by other surgeons difficult. We provide an accurate description of our standardized step-by-step RDP technique. Methods We took advantage of our 15-year long experience and > 150 cases performed to provide a step-by-step guidance of our RPD standardized technique. The description includes practical “tips and tricks” to facilitate the learning curve and assist with the teaching/evaluation process. Results 17 surgical steps were identified as key components of the RPD procedure. The steps reflect the subdivision of the RPD into several parts which help to understand a strategy that takes into accounts specific anatomical landmarks and the demands of the robotic platform. Conclusions Standardization is a key element of the learning curve of RPD. It can potentially provide consistent, reproducible results that can be more easily evaluated. Despite promising results, full acceptance of RPD as the ‘gold standard’ is still work in progress. Randomized-controlled trials with the application of a standardized technique are necessary to better define the role of RPD.
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Affiliation(s)
- Pier Cristoforo Giulianotti
- Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, 840 S Wood Street, Suite 435 E, Clinical Sciences Building, Chicago, IL, 60612, USA
| | - Alberto Mangano
- Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, 840 S Wood Street, Suite 435 E, Clinical Sciences Building, Chicago, IL, 60612, USA.
| | - Roberto E Bustos
- Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, 840 S Wood Street, Suite 435 E, Clinical Sciences Building, Chicago, IL, 60612, USA
| | - Federico Gheza
- Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, 840 S Wood Street, Suite 435 E, Clinical Sciences Building, Chicago, IL, 60612, USA
| | - Eduardo Fernandes
- Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, 840 S Wood Street, Suite 435 E, Clinical Sciences Building, Chicago, IL, 60612, USA
| | - Mario A Masrur
- Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, 840 S Wood Street, Suite 435 E, Clinical Sciences Building, Chicago, IL, 60612, USA
| | - Antonio Gangemi
- Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, 840 S Wood Street, Suite 435 E, Clinical Sciences Building, Chicago, IL, 60612, USA
| | - Francesco M Bianco
- Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, 840 S Wood Street, Suite 435 E, Clinical Sciences Building, Chicago, IL, 60612, USA
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Slim K, Martin G. Does routine intra-operative cholangiography reduce the risk of biliary injury during laparoscopic cholecystectomy? An evidence-based approach. J Visc Surg 2013; 150:321-4. [PMID: 23911201 DOI: 10.1016/j.jviscsurg.2013.06.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
The role of routine intra-operative cholangiography (IOC) during cholecystectomy remains controversial. The purpose of this evidence-based review was to analyze the role of IOC in the prevention and detection of biliary ductal injury during cholecystectomy. The relative rarity of biliary complications means that the randomized trials and meta-analyses that include fewer than 12,000 patients cannot answer the question. Therefore, only six comparative studies were included in this review. The conclusions of these studies were conflicting, half showing a protective effect of routine IOC and the other half showing no effect. Nevertheless, the U.S. and Swedish studies that included the largest number of patients suggested that, while not a panacea, routine IOC could prevent major biliary injuries (one ductal injury per 500 cholecystectomies). Finally, in the context of risk management, we must also emphasize the educational value of teaching young (and not so young) surgeons how to correctly interpret the operative cholangiogram.
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Affiliation(s)
- K Slim
- Service de chirurgie digestive et Unité de chirurgie ambulatoire, CHU Estaing, 1, place Lucie-Aubrac, 63003 Clermont-Ferrand, France.
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Rausei S, Dionigi G, Rovera F, Boni L, Valerii C, Giavarini L, Frattini F, Dionigi R. A decade in gastric cancer curative surgery: Evidence of progress (1999-2009). World J Gastrointest Surg 2012; 4:45-54. [PMID: 22530078 PMCID: PMC3332221 DOI: 10.4240/wjgs.v4.i3.45] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2011] [Revised: 11/04/2011] [Accepted: 11/12/2011] [Indexed: 02/06/2023] Open
Abstract
To investigate the progress in evidence-based surgical treatment of non-metastatic gastric cancer, we reviewed the last ten years’ literature. The data used in this review were identified by searches made on MEDLINE, Current Contents, PubMed, and other references taken from relevant original articles (on prospective and retrospective studies) concerning gastric cancer surgery. Only papers published in English between January 1999 and December 2009 were selected. Data from ongoing studies were obtained in December 2009, from the trials registry of the United States National Institutes of Health (http://www.clinicaltrial.gov). The citations list was presented according to evidence based relevance (i.e., randomized controlled trials, prospective studies, retrospective series). In the last ten years, many challenges have been faced relating to the extension of gastric resection and nodal dissection as well as surgical timing, but we found only limited evidence, regardless of latitude of study. The ongoing phase-III trials may provide answers that will be valid for the coming decades, and which may bring definitive answers for the currently unresolved questions.
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Affiliation(s)
- Stefano Rausei
- Stefano Rausei, Gianlorenzo Dionigi, Francesca Rovera, Luigi Boni, Caterina Valerii, Luisa Giavarini, Francesco Frattini, Renzo Dionigi, Department of Surgical Sciences, University of Insubria, 21100 Varese, Italy
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