Confirmation based solution in laparoscopic day surgery: the European point of view

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The general point of surgery. The right patient ought to get the right operation, done in the right center, performed by the right specialist.. Laparoscopic or traditional?. In a healing center or wandering?. Essential idea of confirmation based medication. . . . Sackett D et al., Br Med J 1996; 312: 71-72Haynes RB, et al., ACP Journal Club 1996;125:A-14-16.

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Prove based pharmaceutical in laparoscopic day surgery: the European point of view Evoluzione della Chirurgia Mini-invasiva: La Day Surgery Vittorio Veneto, March 31, 2006 Dr. Stefan Sauerland, MD MPH Institute for Research in Operative Medicine, University of Witten/Herdecke, Ostmerheimer Str. 200, D 51109 Cologne stefan.sauerland@ifom-uni-wh.de

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The general point of surgery The correct patient ought to receive the correct operation , done in the correct center , performed by the correct specialist . Laparoscopic or ordinary? In a healing facility or mobile?

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Basic idea of confirmation based pharmaceutical Doctor Patient (Experience, ability, costs, morals) (Experience, desires, culture, values) Evidence (Medical and methodological significance) Sackett D et al., Br Med J 1996; 312: 71-72 Haynes RB, et al., ACP Journal Club 1996;125:A-14-16

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How much in medication is proof based? Autor Discipline Evidence Number of RCT Other None Treatm. Pat. Baraldini Paed. Surg. 26% 71% 3% 70 49 Djulbegovic Oncology 24% 21% 55% 154 n.a. Ellis General Med. 53% 29% 18% 108 108 Galloway Haematology 70% 30% n.a. 83 Geddes Psychiatry 65% 40 40 Gill General Med 30% 51% 19% 101 122 Howes General Surg. 24% 71% 5% 100 100 Jemec Dermatology 38% 33% 23% n.a. 115 Kenny Paed. Surg. 11% 66% 23% 281 281 Lee General Surg. 14% 64% 22% 50 n.a. Michaud Internal Med. 65% 150 150 Myles Anaesthes. 32% 65% 3% n.a. n.a. Nordin-J. Internal Med. 50% 34% 12% 369 197 Rudolf Paediatrics 40% 7% 1149 247 Slim Variable discipl. 50% 28% 428 n.a. Suarez-V. General Med. 38% 4% 58% 2341 1990 Summers Psychiatry 53% 10% 37% 160 158 Tsuruoka General Med. 21% 60% 19% 53 49

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We simply found a review saying that you can go home now quickly.

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What impacts surgical conduct? A study of 418 Australian specialists: Surgical training 71% Published study results 46% Congress visits 44% Quality administration data 27% Practice guidelines 24% Mass media <1% Young JM et al., Arch Surg 2003; 138: 785-791

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Evidence-based Guidelines Evidence-based rules as an extension amongst science and practice Clinical reviews Patient Care Animal reviews Basic sciences Science Practice

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Guidelines of the European Association for Endoscopic Surgery (EAES) Cholecystolithiasis Appendicitis Inguinal hernia Gastrooesophageal reflux disease Common bile channel stones Diverticular ailment The pneumoperitoneum Lap surgery in colonic malignancy Measuring personal satisfaction in lap surgery Obesity surgery Acute stomach torment

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Levels of Evidence and Grades of Recommendation A B C 1a Systematic audit of randomized controlled trials 1b Individual randomized controlled trial 1c All or none arrangement 2a Systematic survey of accomplice studies 2b Individual simultaneous partner concentrate 2c Outcomes research 3a Systematic survey of case-control-concentrates 3b Individual case-control-contemplate 4 Case-arrangement (uncontrolled trials) 5 Expert assessment without express basic examination, animal thinks about, seat explore Center for Evidence-based Medicine Oxford: http://www.cebm.net/levels_of_evidence.asp

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Inguinal hernia repair in grown-ups: Choice of endoscopic and control gather Ventral work: Lichten-stein Dorsal work: Stoppa Shoul-dice Other open sutures TAPP TEP

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What's the confirmation? Latest meta-examinations

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Main consequences of meta-investigation Meta-examination of 34 trials with 7223 patients Schmedt CG, Sauerland S, Bittner R: Comparison of endoscopic methodology versus Lichtenstein and other open work procedures for inguinal hernia repair. A meta-examination of randomized controlled trials. Surg Endosc 2005;19:188-199

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Cost-adequacy Higher in-healing center cost, however comparable expenses on the general public level because of prior come back to work Study Laparoscopic Open SMD (settled) or sub-classification N Mean (SD) N Mean (SD) 95% CI Heikkinen 1997 20 4796(4796) 18 5360(5360) Liem 1997 134 4918(3350) 139 4665(4352) Beets 1998 42 2004(2004) 37 2045(2045) Dirksen 1998 86 5750(5750) 88 6678(6678) Total (95% CI) 282 Test for heterogeneity: Chi² = 1.27, df = 3 (P = 0.74), I² = 0% Test for general impact: Z = 0.29 (P = 0.77) - 1 - 0.5 0 0.5 1 Favors treatment Favors control Sauerland S, Eypasch E: Kosten. In: Bittner R "laparoskopische/Endoskopische Chirurgie der Leistenhernie". Karger, Stuttgart, 2005 [in press] Gholghesaei M et al.: Costs and personal satisfaction after endoscopic repair of inguinal hernia versus open strain free repair: a survey. Surg Endosc 2005 [in press]

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Appendectomy: Choice of laparoscopic approach and control amass Lap attach ectomy Dia-gnostic laparo-scopy with or without Open appendectomy

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Results: Operation time Difference +12 Minutes [95%KI 7 bis 16] - 50 min 0 +50 min Pro laparoskopisch Pro konventionell

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Wound contamination Intraabd. Abszess

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Lap appendectomy: Pain on day 1 Difference 0.9 cm VAS [0.5 to 1.3] - 4 - 2 0 2 4 Pro laparoskopisch Pro konventionell

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Lap appendectomy: Length of stay Difference 1.1 Days [95%CI 0.6 to 1.5] - 10 - 5 0 5 10 Pro laparoskopisch Pro konventionell

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Laparoscopic stomach surgery Medical viewpoints Less surgical injury: Shorter length of remain General anesthesia: Day surgery troublesome Patients' points of view Organizational and repayment issues Longer span of surgery: Less wage every day Reduction of doctor's facility bed limit "Cherry-picking" by choosing simple patients

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Day surgery in the U.S.A. also, Europe: Overall rates of utilization Country, Year All elective Cholecyst- Inguinal operations ectomy hernia U.S.A. ~75% 50% 88% Sweden, 1996 ~50% ? 68% Great Britain, 2004 ~45% 1% 39% Germany, 2006 ~37% 2% 3% France, 1999 13% <1% 6% Portugal, 2003 15% ? ? Switzerland, 2000 ~20% ? ? http://www.audit-scotland.gov.uk/distributions/pdf/2004/04pf04ag.pdf http://www.irdes.fr/En_ligne/Rapport/rap2000/rap1303.pdf http://www.mao-bao.de/artikel/2005JB_ZahlOperationen.htm

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Day surgery in the U.S.A. furthermore, Europe: Inguinal hernia repair in France http://www.irdes.fr/En_ligne/Rapport/rap2000/rap1303.pdf

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Day surgery in Germany: Who isn't that right? Doctor's facility surgery 7.965.000 operations Ambulatory surgery 4.700.000 operations In a clinic setting 239.000 operations In a practice setting 3.831.000 operations In private practice 352.000 operations Cosmetic surgery 270.000 operations Total 12.665.000 operations http://www.mao-bao.de/artikel/2005JB_ZahlOperationen.htm

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Day surgery versus healing center confirmation: randomized controlled trials Author, Year Operation N ASA Discharge Costs Ruckley, 1978 Hernia, Vein 360 ? 100% -30£ Favretti, 1990 Hernia 73 NA 100% NA Keulemans, 1998 Cholec. 80 I - II 92% -75% Dirksen, 2001 Cholec. 86 I - II 74% -22% Young, 2001 Cholec. 28 Hollington, 1999 Cholec. 131 I - II 82% -4% Johansson, 2006 Cholec. 100 I - II 92% -9% Ruckley et al., Br J Surg 1978;65:456-9; Favretti et al., Trop Doct 1990;20:18-20; Keulemans Y et al., Ann Surg 1998;228:734-40; Dirksen CD et al., Ned Tijdschr Geneeskd 2001;145:2434-9; Hollington P et al., Aust NZ J Surg 1999;69:841-3; Young & O'Connell, J Qual Clin Pract. 2001;21:2-8; Johansson M et al., Br J Surg 2006;93:40-5

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The part of surgical preparing The impacts of surgical ability is frequently bigger than those of surgical strategy. EBM is supplementing as opposed to clashing with surgical preparing and instinct. Preparing techniques itself can (and ought to) be proof based. The time limitations of day surgery regularly forestall powerful surgical instructing of inhabitants.

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Summary Day surgery is to a great extent prove based, yet at the same time not a typical in most European nations. A great deal less information is accessible on day surgery agent methods and patient after-care. The fate of stomach day surgery will now depend for the most part on authoritative and money related conditions.

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