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.

[Organization of pain therapy in surgery--comparison of acute pain service and alternative concepts]. / Organisation der Schmerztherapie in der Chirurgie. Akutschmerzdienst und alternative Möglichkeiten im Vergleich.

An acute pain service done by surgeons is one possibility for organizing pain therapy in surgical wards. To do this successfully, some preconditions must be kept in mind, such as 24-h presence, an integrated system of documentation, and teamwork between medical and nursing staff. Comparison of differently structured pain therapy in three different hospitals (with and without acute pain service) showed high levels of patient satisfaction with the pain therapies in all three hospitals. One of the preconditions for effective pain therapy in surgery is to formulate a concept which takes into account the specific situation of each hospital.

Quality of life in patients with multiple injuries--basic issues, assessment, and recommendations.

BACKGROUND: While the primary goal of trauma care continues to be the preservation of life, interest has begun to focus on disability and quality of life of those who survive. Numerous instruments have been developed to measure personal well-being, impairment, or subjective life-satisfaction. But there is no consensus regarding which instruments are most appropriate to use in multiply injured patients, and comparison of results are difficult. OBJECTIVE: The objective of this multinational conference was to arrive at a consensus regarding the measurement of quality of life in survivors of multiple trauma. Specifically we sought to identify the best time intervals for measurement and a minimum set of instruments. METHOD: The group reviewed instruments currently in use for quality of life measurement in multiply injured patients. A structured discussion covered the following topics: definition of the population, the concept of quality of life, the importance of different domains of quality of life at different time points, the type of measures and their validity, consistency, and practicability, the mode of administration, subject burden, and availability of population norms. RESULTS: The group suggested three time points, after 3, 12 and 24 months, for the assessment of quality of life after multiple injury. The Glasgow Outcome Scale (GOS) was suggested as an overall global outcome measure including death and vegetative state. The EuroQol was proposed to permit economic analysis, and the SF-36 as a validated global quality of life measure. CONCLUSION: While most selected measures are psychometrically sound, many have had limited use in the setting of multiple injuries. Researchers and clinicians may use these suggestions as a source of information when developing a measurement strategy.

[Preventive and pre-emptive concepts in the acute hospital]. / Präventive und präemptive Konzepte im Akutkrankenhaus.

This study aimed at developing an efficient pain therapy with preventive conceptions for the clinical routine. Since 30-75% of all patients suffer from unbearably strong pain. Before establishing an efficient treatment, 100 patients were asked about efficiency of pain treatment. After establishing the actual state of matters, all medical collaborators and nursing personnel were trained an improved pain management. Afterwards, another 100 patients were questioned for comparison. The results showed significant improvements in the reduction of pain intensity and frequency. Higher satisfaction and efficiency of pain treatment were documented as well as the reduction of accompanying vegetative symptoms.

Laparoscopic fundoplication for gastro-oesophageal reflux disease - a consensus development conference and the evidence-based benefit.

The aim of this paper is to demonstrate an example of evidence-based medicine for a clinically relevant and frequent disease - gastro-oesophageal reflux disease - for which an increasing number of laparoscopic operations is performed. A consensus development conference was performed on this topic in 1996. During the following 3-year period, increase of knowledge shown by the number of publications was monitored and the consecutive changes of the consensus as well as its consequences and impact were analysed. The six published randomised clinical trials revealed important information about the technique of the laparoscopic operation focussing on the gastric fundic mobilisation and the modification of the anti-reflux wrap. Five consecutive consensus conferences were performed and published. Citations of the 1996 consensus conference could not be found in the major surgical journals - not even by participants of the conference. The responsibility of societies to run such conferences continues.

The individual patient and evidence-based medicine - a conflict?

The doctor-patient relationship is characterised by clinical situations that reflect different degrees of impairment of the patient's quality of life on the one hand and different degrees of threat to the patient's life on the other. Typical patterns of these situations from absent or minimal to severe impairment of well being or threat to life are described. With regard to this, the doctor-patient communication is still suffering from considerable deficits. For the latter, a possible philosophical framework and reason is given. The potential of evidence-based medicine to ease this conflict by bringing into the game the current best-available scientific evidence is discussed, and some inherent serious limitations of evidence-based medicine are shown. Besides these drawbacks, doctors are usually very reluctant and lazy to integrate evidence-based results into their daily practice. In the author's view, evidence-based medicine is a reasonably new tool. However, it should not yet be overestimated in its potential to influence and improve daily clinical practice.

Combined abdominal wall paresis and incisional hernia after laparoscopic cholecystectomy.

A case of combined abdominal wall paresis and incisional hernia after laparoscopic cholecystectomy is reported. The paresis possibly occurred by a lesion of the N. intercostalis when extending the incision for stone extraction. Possibly the paresis was a predisposing factor for the development of an incisional hernia. The causes of abdominal wall paresis are explored with a review of the literature. In spite of minimal trauma to the anterior abdominal wall in laparoscopic procedures, the risk of iatrogenic lesions remains.

Quality of life more than 20 years after repair of esophageal atresia.

PURPOSE: To examine the quality of life after repair of esophageal atresia, follow-up studies were performed in 58 of 71 surviving patients (81.7%). METHODS: Fifty patients with primary anastomosis and all eight surviving patients with colon interposition were seen. The mean age was 25.3 years (range, 20 to 31). Symptoms were evaluated by a standardized interview. Quality of life assessment was performed using a visual analogue scale (0 to 100 points), the Spitzer Index (5 dimensions, 10 points), and the Gastrointestinal Quality of Life Index (GIQLI, 5 dimensions, 128 points). RESULTS: After primary anastomosis the estimated meal capacity was unrestricted in 46 patients (92%), but numerous symptoms such as recidivating cough (60%), hold up (48%), and short breath (30%) were reported. All symptoms except cough were seen more frequently in patients with colon interposition, and all of these patients suffered from periods of short breath. Quality of life scores were higher in patients with primary anastomosis compared with colon interposition. The difference in the visual analogue scale score did not reach statistical significance, but the mean Spitzer Index was 9.7 compared with 8.8 after colon interposition (P < .05). The GIQLI after primary anastomosis was similar to that in healthy controls and was significantly lower in patients with colon interposition. This was because of specific symptoms, which scored 49.3 after colon interposition compared with 61.7 after primary anastomosis (P < .05) and to 54.8 (SD 5) in healthy controls (P < .05). Physical and social functions, emotions, and inconvenience of a medical treatment scored similar in patients with primary anastomosis, colon interposition, and healthy volunteers. CONCLUSIONS: The long-term quality of life after primary anastomosis was excellent. Patients with colon interposition suffer more frequently from various gastrointestinal and respiratory symptoms, but they lead an otherwise normal life.

Long-term results after laparoscopic cholecystotomy in a child with symptomatic gallstone disease.

Cholecystotomy has been suggested for symptomatic gallstone disease in selected children. This suggestion is supported by a potential reduction in the frequency of the so-called postcholecystotomy syndrome. To our knowledge, laparoscopic cholecystotomy has not been reported yet. However, gallstone recurrence has been reported up to 4 years after conventional cholecystotomy and therefore we waited to publish our results for that period of time. A 12-year-old girl with idiopathic symptomatic gallstone disease and a normal kinetic of the gallbladder underwent laparoscopic cholecystotomy. The laparoscopic technique was similar to laparoscopic cholecystectomy but the gallbladder was left in place and multiple gallstones were removed. Intraoperative cholecystoscopy revealed three additional small stones. They were removed by subsequent lavage of the gallbladder. Choledocholithiasis was excluded by intraoperative cholangiography and the gallbladder was closed using an Endo GIA. There were no intraoperative or postoperative events. The patient is free of complaints without recurrent gallstones on ultrasound examination today, 4 years after the operation. Laparoscopic cholecystotomy represents a feasible alternative to laparoscopic cholecystectomy.

[Viscerosynthesis in laparoscopic interventions--concepts and cost benefit relations]. / Viszerosynthesen bei laparoskopischen Eingriffen--Konzepte und Kosten-Nutzen-Relation.

Viscerosyntheses represent an unrenouncable component of several endoscopic procedures. The extra cost for a laparoscopic viscerosynthesis of approximately 2000 DM in the year 1994 are economically well invested with regard to a reduced postoperative pain, a reduced amount of postoperative analgesics, a faster recovery, and most of all drastically reduced morbidity of the abdominal wall. The unfortunate structure of the healthcare system burdens the hospital with additional financial expenditures, thus shifting the profits to the insurance companies. A change in this profit structure would allow for a faster spread of efficient and promising therapies. Economical studies including patients, physicians, hospital administrations and insurance companies are considered to be imperative in order to promote the development of efficient therapies.

[Technology assessment of ultrasound in acute diagnosis of blunt abdominal trauma]. / Technologiebewertung des Ultraschalls in der Akutdiagnostik des stumpfen Bauchtraumas.

In this article a systematic technology assessment was used for ultrasound in blunt abdominal trauma. We found sonography to be a simple, fast and complication-free method with high sensitivity and specificity. Ruptures of the small bowel seemed to be extremely difficult to detect, especially in the early phase after blunt abdominal trauma. No basic definitions of significant free fluid and maximal limit for non-operative treatment are found in the international literature. Only the combination of prognostic factors such as mechanism of the accident, clinical examination, and the intuition of the surgeon leads to a decision.

[Allocation of resources in surgery--the role of waiting lists and scoring systems]. / Allokation von Ressourcen in der Chirurgie--Die Rolle von Wartelisten und Scoringsystemen.

International authors who have applied scoring systems to reduce waiting lists conclude that the hope that scoring systems will help is an illusion. Data on queue management are extremely rare.

[Abdominal wall hernias: epidemiology, economics and surgical technique--an overview]. / Bauchwandhernien: Epidemiologie, Okonomie und chirurgische Technik--Ein Uberblick.

Surgery of the abdominal wall is a chronically neglected field in general surgery. In fact subcutaneous wound infections and incisional hernias are the most frequent events while wound rupture and laparostomy are the most dangerous complications in abdominal surgery. Based on epidemiological data, a classification of adverse events for the abdominal wall is presented. The various currently used techniques for the treatment of incisional hernias are discussed. The described enormous economic consequences of surgical trauma to the abdominal wall alone are already a good reason to improve this kind of surgery in the near future.

[Current practice of incisional hernia reconstruction in Germany]. / Gegenwärtige Praxis der Narbenhernienrekonstruktion in der Bundesrepublik Deutschland.

The results of a nationwide survey regarding the treatment of incisional hernias following open laparotomy revealed that the Mayo-duplication is the surgical technique preferred by the majority of surgeons. However, in exceptional situations alloplastic material is implanted by up to 50% of the surgeons asked. More than one forth of the departments performed more than 30 incisional hernia repairs per year. Even for complicated cases the surgeons' own estimation of their recurrence rates was 11.7%. Compared with the data (recurrence rate of the Mayo-duplication of 30%-50%) published in the literature there seems to be a quantitative and qualitative underestimation of the treatment of incisional hernias.

[Mayo duplication in treatment of incisional hernia of the abdominal wall after conventional laparotomy. Results of a retrospective analysis and comparison with the literature]. / Die Mayo-Dopplung zur Behandlung des Narbenbruchs der Bauchdecken nach konventioneller Laparotomie. Ergebnisse einer retrospektiven Analyse und ein Literaturvergleich.

About 10% of patients undergoing conventional laparotomy will develop incisional hernias. Traditionally these hernias are in this country most often repaired by a Mayo-duplication. In this retrospective analysis we investigated a consecutive series of 114 patients (mean age: 53 (11-87) years, gender ratio m:f 1.2:1.97% electively operated) with 135 hernias, operated between 1/1985 and 12/1992 by a standard Mayo-procedure. Recurrence-rates and quality of life were evaluated by clinical examination. The mean follow-up time was 5.7 (2.5-10.2) years with a follow-up rate of 84.4%. The overall recurrence rate was 53.5%. Further uni- and multi-variate analysis was unable to find any clinically relevant risk factors for hernia development. Health related quality of life was evaluated with a validated index at the time of their follow-up visit. There were no differences in patients without a hernia recurrence (n = 52) when compared to those with an actually present recurrence (n = 36). However, physical function of all patients was significantly impaired when compared to healthy individuals. According to our results and those reported by others the Mayo-duplication when applied to all patients leads to non-acceptable results and implantation of auto- or alloplastic material should be considered more frequently.

[Auto-dermal hernioplasty--a rare and unknown technique]. / Autodermale Hernioplastik--eine seltene und unbekannte Technik.

The recurrence rates following the "simple" incisional hernia repair procedures (Mayo-procedure or direct adaptation) are unacceptably high, in literature up to 50%. In order to reduce the recurrence rates alternative procedures are necessary, e.g. the additional support of the anterior abdominal wall by implantation of a non resorbable mesh or autodermal plasty. Our national inquiry of 669 hospitals showed that the technique of autodermal hernioplasty is almost unknown among the German surgeons. In this article a comparison of the history, morphology, healing process and possibilities of cutis implantation as well as technical aspects of different types of autodermal hernioplasty (cutis lacing plasty, onlay and sublay corium mesh plasty) are described. By literature analysis the results of autodermal hernioplasty are compared with the results of mesh implantation. The autodermal hernioplasty is discussed as an alternative operative procedure to the implantation of artificial meshs.