Showing papers by "Guy J. Maddern published in 2009"

Liver failure after major hepatic resection.

Abstract: Introduction The consequence of excessive liver resection is the inexorable development of progressive liver failure characterised by the typical stigmata associated with this condition, including worsening coagulopathy, hyperbilirubinaemia and encephalopathy. The focus of this review will be to investigate factors contributing to hepatocyte loss and impaired regeneration.

Systematic review of endoscopic treatments for gastro-oesophageal reflux disease.

Abstract: Background: The aim of this review was to assess the safety and efficacy of endoscopic procedures for gastro-oesophageal reflux disease. Methods: Literature databases including Medline, Embase and PubMed were searched up to May 2006 without language restriction. Randomized controlled trials and non-randomized comparative studies with at least ten patients in each study arm, and case series studies of at least ten patients, were included. Results: A total of 33 studies examining seven endoscopic procedures (Stretta® procedure, Bard® EndoCinch™, Wilson-Cook Endoscopic Suturing Device, NDO Plicator™, Enteryx®, Gatekeeper™ Reflux Repair System and Plexiglas®) were included in the review. Of the three procedures that were tested against sham controls (Stretta® procedure, Bard® EndoCinch™ and Enteryx®), patient outcomes in the treatment group were either as good as, or significantly better than, those of control patients in terms of heartburn symptoms, quality of life and medication usage. However, for the two procedures that were tested against laparoscopic fundoplication (Stretta® procedure and Bard® EndoCinch™), outcomes for patients in the endoscopic group were either as good as, or inferior to, those for the laparoscopic group. Conclusion: At present there is insufficient evidence to determine the safety and efficacy of endoscopic procedures for gastro-oesophageal reflux disease, particularly in the long term. Copyright © 2009 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Laparoscopic ventral hernia repair: a systematic review

Abstract: Laparoscopic ventral hernia repair may be an alternative to open mesh repair as it avoids a large abdominal incision, and thus potentially reduces pain and hospital stay. This review aimed to assess the safety and efficacy of laparoscopic ventral hernia repair in comparison with open ventral hernia repair. A systematic review was conducted, with comprehensive searches identifying six randomised controlled trials (RCTs) and eight nonrandomised comparative studies. The laparoscopic approach may have a lower recurrence rate than the open approach and required a shorter hospital stay. Five RCTs (Barbaros et al., Hernia 11:51–56, 2007; Misra et al., Surg Endosc 20:1839–1845, 2006; Navarra et al., Surg Laparosc Endosc Percutan Tech 17:86–90, 2007; Moreno-Egea et al., Arch Surg 137:266–1268, 2002; Carbajo et al., Surg Endosc 13:250–252, 1999) reported no conversion (0%) to open surgery, and four nonrandomised studies reported conversions to open surgery ranging from 0% to 14%. Open approach complications generally were wound related, whereas the laparoscopic approach reported both wound- and procedure-related complications and these appeared to be less frequently reported. Based on current evidence, the relative safety and efficacy of the laparoscopic approach in comparison with the open approach remains uncertain. The laparoscopic approach may be more suitable for straightforward hernias, with open repair reserved for the more complex hernias. Laparoscopic ventral hernia repair appears to be an acceptable alternative that can be offered by surgeons proficient in advanced laparoscopic techniques.

Influence of resection margin on survival in hepatic resections for colorectal liver metastases.

Abstract: Background Traditionally a 1-cm margin has been accepted as the gold standard for resection of colorectal liver metastases. Evidence is emerging that a lesser margin may provide equally acceptable outcomes, but a critical margin, below which recurrence is higher and survival poorer, has not been universally agreed. In a recent publication, we reported peri-operative morbidity and clear margin as the two independent prognostic factors. The aim of the current study was to further analyse the effect of the width of the surgical margin on patient survival to determine whether a margin of 1 mm is adequate. Methods Two hundred and sixty-one consecutive primary liver resections for colorectal metastases were analysed from 1992 to 2007. The resection margins were assessed by microscopic examination of paraffin sections. The initial analysis was performed on five groups according to the resection margins: involved margin, 0–1 mm, >1– 1 mm. Results With a median follow-up of 4.7 years, the overall 5-year patient and disease-free survival were 38% and 22%, respectively. There was no significant difference in patient- or disease-free survival between the three groups with resection margins >1 mm. When a comparison was made between patients with resection margins ≤1 mm and patients with resection margins >1 mm, there was a significant 5-year patient survival difference of 25% versus 43% ( P P = 0.14). Conclusions In this cohort of patients, we have demonstrated that a resection margin of greater than 1 mm is associated with significantly improved 5-year overall survival, compared with involved margins or margins less than or equal to 1 mm. The possible beneficial effect of greater margins beyond 1 mm could not be demonstrated.

Systematic review of the impact of volume of oesophagectomy on patient outcome

Abstract: Purpose: This systematic review aims to assess whether overall survival, mortality, morbidity, length of stay and cost of performing oesophagectomy are related to surgical volume. Methods: A systematic search strategy from 1997 until December 2006 was used to retrieve relevant studies. Inclusion of articles was established through application of a predetermined protocol, independent assessment by two reviewers and a final consensus decision. Results: A total of 55 studies were identified of which 27 studies, representing 68 882 patients, met the inclusion criteria. Twenty-one of these solely examined hospital volume, 5 examined both hospital and surgeon volume, and 1 examined surgeon volume in isolation. All but one of the studies were retrospective in nature, and because of the heterogeneity of the literature, no meta-analysis could be performed. Of the studies exploring the relationship between hospital volume and mortality, 20 reported a statistically significant benefit to large volume centres. Five of six included studies showed significant evidence for a reduced mortality risk with greater surgeon volume. Conclusions: Based on the evidence from these retrospective studies, oesophagectomy performed in high volume centres would appear to be associated with better outcome compared with low volume centres.

A systematic review of permanent and semipermanent dermal fillers for HIV-associated facial lipoatrophy

Abstract: The objective of this study was to assess the safety and efficacy of injectable semipermanent and permanent dermal fillers, compared to other facial augmentation techniques, for the management of facial lipoatrophy as a result of highly active antiretroviral therapy (HAART) for HIV infection through a systematic review of the literature. A systematic search strategy was used to retrieve relevant studies. Inclusion of articles was by the application of a predetermined protocol, independent assessment by two reviewers, and a final consensus decision. One randomized controlled trial (RCT), one pseudo-RCT, two nonrandomized comparative studies, and seven case series were included for review. Injections with permanent and semipermanent dermal fillers improved subjective ratings of appearance and resulted in high patient satisfaction. Although short-term safety appeared favorable, of the seven studies that reported lumps, three studies reported these events in more than 40% of patients. Long-term safet...

Palliation of Malignant Obstructive Jaundice

Abstract: Peri-ampullary and hepatic malignancies will frequently present with obstructive jaundice. For unresectable tumors, effective and lasting decompression of the biliary tree is essential to improve quality of life and survival. An overview of present treatment modalities for palliation of obstructive jaundice is provided, including a systematic review of the English literature regarding the optimum choice of palliation.

The current role of PET-CT in the characterization of hepatobiliary malignancies

Abstract: Background Surgery has become heavily dependent on accurate imaging in the assessment and treatment of suspected or confirmed intra-abdominal malignancy. Positron emission tomography-computed tomography (PET-CT) fuses uptake of a radiotracer combined with CT images to assess both functional tissue activity and anatomical detail. Since its introduction it has offered new ways of treating gastrointestinal cancers.

Russell Strong and the history of reduced-size liver transplantation.

Abstract: On the basis of their innovation and experience with reduced-size grafts in children, 20 years ago, Russell Strong and his team in Brisbane, Australia, performed the first successful living donor liver transplant in the world from a mother to her son. The mismatch between supply and demand for deceased donor organs has fueled the expansion of all forms of reduced-size grafts, including split-liver and living donor transplantation. This review outlines the story of Russell Strong, reduced-size liver transplantation techniques, and the development of living donor liver transplantation.

Sclerosing haemangiomas of the liver: two cases of mistaken identity.

Abstract: We describe two cases where patients undergoing hepatic resection for metastatic disease of colorectal origin were found to have concomitant sclerosing haemangiomas. The typical radiological and histological appearances of these lesions are discussed.

NOTES: progress or marketing?

Abstract: and most convenient way to learn literature searching is from the hospital librarian. Hospital librarians spend much of their time performing searches for students and health workers, and most hospitals will provide one-on-one help, as well as introductory and advanced searching tutorials lasting an hour or two each. Some of the tools that are useful in searching Medline are: the use of Boolean terms (AND, OR, NOT); the use of suffixes (‘.ti’ to look for a particular word or phrase in the title, ‘.au’ to mean author, ‘.jn’ to mean journal, ‘.yr’ to indicate publication year etc.); the use of substitutes (e.g. ‘$’ to indicate any text string); the use of preprepared string searches; the use of ‘focus’ and ‘explode’ to broaden or refine a topic; ‘limiting’ searches (e.g. limiting a search to controlled trials, English language only, or to human studies only); and the use of combination searches. There are other databases apart from Medline, such as Embase, which is a European-based database of more than 10 million articles dating from 1980. Embase has a greater emphasis on pharmacology and a European bias and, because there is only 34% overlap between these two large databases, it is often recommended to include both databases for thorough searches. There are also many databases that focus on specific areas, for example CINAHL (nursing and allied health) and CancerLit (cancer). These other databases can also be searched using OVID and the other interfaces, but each one is structured differently, so that repeating a search strategy in a different database will often miss important articles. The literature search engines also provide automatically generated email alerts (to your selected accounts) that contain the table of contents of your selected journals as soon as a new issue is released. This electronic table of contents (eTOC) will contain the list of articles from the new issue, with direct links to the abstracts. You may be able to retrieve the full article, depending on the subscriptions of your provider. This service provides obvious cost and time advantages over traditional journal subscriptions. The Cochrane Library (www.thecochranelibrary.com) is an important site for systematic reviews. The Cochrane Collaboration is an independent group of volunteers that now provides, via the Cochrane Library, a large number of high-quality reviews, mainly of prevention and treatment, in health care. The methodology of a Cochrane Review is rigorous, and they are considered to be of higher quality than other systematic reviews. This website is easy to navigate, and the reviews can be viewed or saved free of charge. From my experience, as one who has studied literature searching, and who teaches literature searching through the college Critical Literature Evaluation and Research (CLEAR) courses, I have never failed to learn more about searching from my interactions with the librarians at my hospital and the courses that they run. I recommend that surgeons familiarize themselves with Medline and the sites listed here, but some formal tutoring is also necessary to be able to search the literature thoroughly. This can easily be provided by a hospital librarian, or by completing the college CLEAR course. The latter will also provide you with the tools necessary to critically appraise the articles you retrieve, because literature searching is only a part of practising evidence-based surgery.

Upper airway surgery for adult obstructive sleep apnoea: what is the evidence?

Abstract: Population studies from various countries have demonstrated that obstructive sleep apnoea (OSA) is becoming highly prevalent in adults; approximately one in five adults have at least mild OSA and one in 15 adults have moderate or severe OSA.1 A 1995 Australian survey of 2202 people aged 35–69 years estimated that the prevalence of OSA, based on an apnoea–hypopnoea index (AHI) of ‡15 (moderate–severe OSA), was at least 3.6% (5.7% for men, 1.2% for women).2 With the increase in obesity this estimate could now be higher. There has been recent controversy over the role of upper airway surgical procedures in the treatment of OSA. Upper airway surgery includes phase I procedures such as uvulopalatopharyngoplasty (UPPP), laser-assisted uvulopalatoplasty (LAUP), temperaturecontrolled radiofrequency tissue ablation (TCRFTA), palatal implants, and inferior sagittal mandibular osteotomy and genioglossus advancement with or without hyoid myotomy and suspension (ISMO and GA with or without HM); and more invasive phase II procedures such as maxillomandibular osteotomy and advancement (MMO), and mucosal sacrificing glossectomy techniques (laser midline glossectomy and lingualplasty). In line with the American Sleep Disorders Association (ASDA) guidelines, the role of upper airway surgery in adult OSA is generally accepted as appropriate only when less invasive treatments are ineffective, rejected or inappropriate.3 The critical issue is whether upper airway surgery should be offered in this context, or whether the patient should be left untreated, because the safety and effectiveness of surgery remain controversial. A systematic search of the literature indicated that there is a paucity of high-level evidence on the safety and effectiveness of upper airway surgery for treating OSA in comparison with conservative behavioural therapy, treatment with devices (continuous positive airway pressure (CPAP) or oral appliances), or no treatment. Five systematic reviews (which included four relevant randomized controlled trials (RCT)) were identified on this topic,4–8 as well as one additional RCT that was published too recently to be included in the systematic reviews.9 All reviews were restricted by the lack of RCT evidence. The available RCT included specific patient groups selected according to OSA severity, anatomy, or body mass index (BMI), and used different surgical procedures and comparators, precluding direct comparisons between studies. Results were generally limited by small sample sizes, short follow-up periods, and the inability to generalize results. The success of OSA surgery is usually measured by the level of improvement in polysomnography outcomes, but the systematic reviews and additional RCT provide insufficient evidence to determine the effect of upper airway surgery on polysomnography results. From limited short-term RCT evidence (follow up £1 year), it appears that UPPP and TCRFTA do not present significant benefits in mean polysomnography outcomes compared with conservative management or placebo, although one UPPP study reported a higher success rate in UPPP compared with conservative management.5,6 One RCT in LAUP and one in palatal implants found some benefit in surgery compared to no treatment or placebo in the short term (3 month follow up).5,6,9 Use of oral appliance therapy and CPAP produced better polysomnographic outcomes than surgery (follow up of 4 years for oral appliances vs surgery and 8 weeks for CPAP vs surgery);5,6 but unlike surgery any device has the additional issue of compliance. Higher level evidence was not available for any other procedures. Surgical success rates varied depending on the procedure, the patient population, and the actual definition of success. If the traditional definition of success is used (a 50% reduction in AHI and/or AHI £20), for phase I procedures approximately half of patients will achieve this level of success.7 From lower level (non-RCT) evidence the success rate of phase II procedures was approximately 85%.7 According to a recent review, the success rate after multi-level surgery (surgery to at least two of the frequently involved anatomic sites: nose, oropharynx and hypopharynx) was 66%.8 There has, however, been recent discussion on whether the traditional measure of surgical success (‡50% reduction in AHI, and a decrease in score to £20) represents clinically significant health outcomes.7 In addition, the long-term effectiveness of the various surgical techniques cannot be established from the available evidence. Polysomnography alone is not an ideal measure of treatment success because it is poorly correlated with health outcomes. There was also insufficient evidence from the systematic reviews and RCT, however, to determine the effect of upper airway surgery on the health outcomes of daytime sleepiness, snoring or quality of life. When compared with conservative management or no treatment/ placebo, two RCT showed benefit for UPPP and palatal implants for daytime sleepiness and snoring, while two other RCT found no benefit for LAUP and TCRFTA for daytime sleepiness.5,6,9 For quality of life measures, one RCT found no benefit for LAUP, while two others reported possible benefit after TCRFTA and palatal implant compared with no treatment/placebo.5,6,9 There was no difference between surgery and use of devices (such as the gold standard treatment of CPAP) for quality of life measures or sleepiness outcomes.5,6 There was also insufficient evidence to determine levels of patient satisfaction, or to make long-term survival comparisons between upper airway surgery and alternative treatments. It is also important to note that there are no long-term RCT studies on noninvasive measures such as CPAP and oral appliances that show efficacy in treating the morbidity or mortality associated with OSA. From limited safety evidence it would appear that UPPP had more adverse effects than the less invasive procedures of TCRFTA and palatal implants. LAUP had similar adverse effects to UPPP, at similar rates of occurrence. Long-term safety data were not available from the included studies.5,6,9 Perspectives 223

Pain or gain: new innovations and trends in hernia repair.

Abstract: follow-up was short in our series, there were already three patients who reported recurrent disease between 6 and 12 months, none, however, requiring surgery. Recurrence rates of up to 65% are reported with significant proportion of patients requiring further interventions. As a result, the risk involved in a short-term gain must be small and the benefits significant in order to justify the temporizing measure. This highlights the importance of appropriate patient selection in treating Dupuytren’s with PNF. It was pointed out at a meeting of the American Society of Surgery of the Hand by Keith Denkler MD who was discussing PNF that there is ‘no one operation for Dupuytren’s’ and that several smaller procedures may be the treatment of choice in many situations. This comment may soon extend to incorporate the use of clostridial collagenases currently being trailed with apparent success, but no published results to discuss. It is important to note that PNF can be repeated, and its previous use does not preclude in itself the use of any other procedure available. In the U.K., increasing popularity and demand for PNF has led to publication of official guidelines for its use. This review of the evidence by the National Institute for Clinical Excellence is summarized in Table 1. As yet, there is no Australian equivalent of this. With PNF gaining increasing popularity among the patient population, it is important to understand the technique and its place in the treatment of Dupuytren’s disease. With easy access to information via the Internet, an increasing number of patients present asking for this procedure. Many patients elect to travel overseas in order to avoid more invasive surgical procedures in the belief that PNF is not offered in Australia. Percutaneous needle fasciotomy is a safe and effective technique for treatment of Dupuytren’s disease in the appropriately selected patient. Patients undergoing PNF treatment need to be informed of the potential complications and the risk of early recurrence to allow them to make a decision on which treatment modality is best for them. We believe that needle fasciotomy (PNF) is a useful technique that can be used in these well-selected patients, and should be included in the armamentarium of the surgeon treating Dupuytren’s contracture.

Doctor displacement: a political agenda or a health care imperative?

Abstract: TO THE EDITOR: We read with interest the recent editorial by Van Der Weyden on the issue of doctor displacement. We agree completely that a transparent and evidencebased approach to health care roles is essential. In proposing a pilot program of physician assistants (PAs) in South Australia to examine the potential of “physician extenders”, we broadly used the model applied to the introduction of new the apies in medicine, including new drugs: • Evidence of an unmet need; • Evidence of safety and efficacy in another setting; • A monitored pilot/trial in practice; • Re-evaluation after a defined period with a defined process; and • An emphasis on any ongoing utilisation being a consistent and national process. This last point is noted in the Australian and New Zealand College of Anaesthetists’ submission to the National Health and Hospitals Reform Commission. We emphasised the need for any proposed future clinical role for PAs to be defined, followed by identification of the required knowledge base, training and education requirements, and certification. Not all new health care roles have followed such a pathway, and this provides potential challenges for ensuring quality, safety, consistency and “trademark definition” (widespread understanding of the role). In the case of PAs, it was evident at a recent International Forum for Physician Assistant Education in the United States that the definition of the term “physician assistant” varies greatly internationally, potentially confusing future debate on this topic in Australia. Hence, to develop a robust Australian model, any proposals for ongoing use and training of PAs would have to be discussed at a national level.

Abdominal adhesion prevention, time to change our everyday practice?

Abstract: engagement of the local medical staff. In some, there will be the primary goal of education of the local medical groups and in others it will be primarily service delivery. Each mission focus should be evaluated to determine the appropriateness of involvement of a RACS trainee. In order to involve trainees safely, the role of the trainee needs to be clearly delineated according to the specific situation in each mission. In Australia and New Zealand, the level of clinical responsibility assumed by a surgical trainee is delegated by his/her mentor. The trainee is closely supervised to ensure that a high standard of care is maintained in this training environment. Appropriate governance and guidelines would ensure that this standard of care is translated equally overseas. Local factors also need to be taken into account including the different cultural environment, the issue of teamwork in a different country where English may not be the first language and the different operating set ups. There is a high level of interest among trainees for surgical missions. The engagement of surgeons early in their career will give them a taste of the work involved, improve their knowledge and skills and motivate them to be involved in the future once they have finished training. This will in turn provide the manpower to allow long-term projects to continue and importantly, train the surgeon into a more competent and complete professional. References

Bile duct injuries associated with cholecystectomy

Abstract: control. Curr. Opin. Nephrol. Hypertens 2008; 17: 1–10. 15 Hihi AK, Michalik L, Wahli W. PPARs: transcriptional effectors of fatty acids and their derivatives. Cell. Mol. Life Sci. 2002; 59: 790–8. 16 Sun Y, Alexander SP, Garle MJ et al. Cannabinoid activation of PPAR alpha; a novel neuroprotective mechanism. Br. J. Pharmacol. 2007; 152: 734–43. 17 Gremlich S, Nolan C, Roduit R et al. Pancreatic islet adaptation to fasting is dependent on peroxisome proliferator-activated receptor alpha transcriptional up-regulation of fatty acid oxidation. Endocrinology 2005; 146: 375–82. 18 Lockridge JB, Sailors ML, Durgan DJ et al. Bioinformatic profiling of the transcriptional response of adult rat cardiomyocytes to distinct fatty acids. J. Lipid. Res. 2008; 49: 1395–408. 19 Prentki M, Nolan CJ. Islet beta cell failure in type 2 diabetes. J. Clin. Invest. 2006; 116: 1802–12. 20 Laybutt DR, Preston AM, Akerfeldt MC et al. Endoplasmic reticulum stress contributes to beta cell apoptosis in type 2 diabetes. Diabetologia 2007; 50: 752–63. 21 Moffitt JH, Fielding BA, Evershed R, Berstan R, Currie JM, Clark A. Adverse physicochemical properties of tripalmitin in beta cells lead to morphological changes and lipotoxicity in vitro. Diabetologia 2005; 48: 1819–29. 22 Cnop M, Hannaert JC, Hoorens A, Eizirik DL, Pipeleers DG. Inverse relationship between cytotoxicity of free fatty acids in pancreatic islet cells and cellular triglyceride accumulation. Diabetes 2001; 50: 1771–7. 23 Busch AK, Gurisik E, Cordery DV et al. Increased fatty acid desaturation and enhanced expression of stearoyl coenzyme A desaturase protects pancreatic beta-cells from lipoapoptosis. Diabetes 2005; 54: 2917–24. 24 Peter A, Weigert C, Staiger H et al. Induction of stearoyl-CoA desaturase protects human arterial endothelial cells against lipotoxicity. Am. J. Physiol. Endocrinol. Metab. 2008; 295: E339–49. 25 Arsov T, Larter CZ, Nolan CJ et al. Adaptive failure to high-fat diet characterizes steatohepatitis in Alms1 mutant mice. Biochem. Biophys. Res. Commun. 2006; 342: 1152–9.

Painless Obstructive Jaundice Secondary to a Common Bile Duct Abscess: A Delayed Sequela of Cholecystectomy

Abstract: Complications related to cholecystectomy are well described. Most occur in the early postoperative period and are recognised either at the time of, or shortly after surgery. Clinical sequelae occurring years following cholecystectomy are rare and infrequently reported. In addition, most delayed complications are related to the continuing presence or new formation of gallstones. In this paper we present a unique case of an abscess of the common bile duct wall, presenting with painless obstructive jaundice more than 30 years following an open cholecystectomy, without the presence of gallstones. The clinical presentation, investigations, and treatment are discussed with a review of other relevant reported cases in the literature.

Traitement des varices : revue générale

Abstract: Cette revue generale compare la securite et l'efficacite des traitements des varices, comprenant le traitement conservateur, la phlebectomie, le laser endoveineux, l'ablation par radiofrequence et la chirurgie de ligature et eveinage de la saphene. Des recherches systematiques dans les bases de donnees bibliographiques medicales ont ete effectuees en fevrier 2008 pour identifier les etudes pertinentes publiees depuis janvier 1988. Afin d'etre inclus dans cette revue, les articles ont ete soumis a l'application d'un protocole predefini. Les donnees comparant securite et efficacite d'au moins deux methodes de traitement des varices en ont ete extraites et analysees. Dix-sept etudes publiees entre 2003 et 2007 ont ete incluses dans cette revue. Les evenements indesirables graves etaient rares. Les evenements indesirables mineurs etaient plus frequents mais generalement spontanement resolutifs. Tous les traitements ont montre des niveaux d'efficacite variables selon l'etendue de la veine traitee. Des avantages a court terme ont ete associes a la sclerotherapie et aux traitements endoveineux, tandis que la chirurgie conventionnelle procurait une meilleure efficacite a long terme. L'analyse des donnees suggere que le traitement conservateur des varices est moins efficace que la sclerotherapie et la chirurgie. La ligature avec stripping puis phlebectomie est generalement consideree comme le traitement « gold standard » de la grande veine saphene. La sclerotherapie et la chirurgie ont toutes deux une place dans le traitement des varices. La sclerotherapie et la phlebectomie peuvent egalement etre plus appropriees chez les patients ayant des varices superficielles mineures non liees au reflux dans le reseau saphene ou comme traitement adjuvant a d'autres procedures comme la chirurgie. Des donnees actuelles suggerent que les traitements par laser endoveineux ou par radiofrequence sont aussi surs et efficaces que la chirurgie, en particulier dans le traitement des varices saphenes. Le plus important est de choisir une technique selon le type de varice consideree et de ne pas employer une methode unique.

Maximizing health outcomes from government investment in surgical interventions

Abstract: In Australia today, the introduction of new interventional procedures into the health system is managed by a variety of processes, involving advisory committees at the state and national level, as well as hospitalor health service-based committees. The majority of these processes, which involve the evidence-based assessment of a new procedure’s safety and clinicaland cost-effectiveness, have been instituted over the last decade. Therefore, ineffective interventional procedures that diffused into clinical practice prior to the establishment of these assessment processes may still be in use today. However, changing clinical practice in relation to such procedures is challenging because of a number of factors, including a lack of formal processes for their identification and evaluation. ASERNIP-S, a program of the Royal Australasian College of Surgeons (RACS), recently completed a pilot project aimed at strengthening the evidence base of clinical practice and improving clinical outcomes in relation to government funding of surgical interventions. Specifically, this project was focused on developing a process for identifying and reviewing surgical items currently listed on the Medicare Benefits Schedule (MBS) that may be of questionable clinical benefit. Throughout the course of the project, a range of key stakeholders were consulted (Table 1). Initially, a systematic search of the international peer-reviewed literature was conducted to identify processes used to evaluate existing interventional procedures that may be of questionable clinical benefit, and change clinical practice in relation to these procedures. These searches revealed a paucity of information on such processes in the published literature. Currently, the majority of work in this area is being conducted by National Institute for Health and Clinical Excellence (NICE) in the UK, which is expanding its remit from evaluating the safety and clinical effectiveness of new interventional procedures, to include identifying and evaluating established interventions that are now considered unsafe, unnecessary or ineffective. A range of criteria has been suggested for use in identifying and prioritizing such procedures for further evaluation, including: • There is evidence of little or no health gain or significant budget impact. • Clinicians strongly support restriction or removal. • There are clinicallyand cost-effective yet underused alternative procedures. • A reduction in the use of the procedure may reduce risks to patient safety. • The impact of restricting or removing the procedure will not be borne largely by specific vulnerable groups such as children, the disabled or the elderly. The next stage of the project involved identifying and prioritizing for further evaluation those surgical items currently listed on the MBS that may be of questionable clinical benefit. The systematic review of the literature completed in the first stage of the project provided a number of such procedures which are no longer routinely funded within some National Health Service primary care trusts in the UK. In addition, key stakeholders were asked to nominate surgical procedures that they considered to be of questionable clinical benefit. A total of 11 procedures were put forward for further consideration. In order to determine which of these would be most appropriate to examine further, preliminary scoping searches of the published literature were conducted for each procedure, focusing mainly on the availability of high-level evidence (systematic reviews and randomized controlled trials). The scoping searches helped to establish whether there was any evidence in the peer-reviewed literature to suggest that these procedures were in fact of questionable clinical benefit or presented significant safety issues for patients. The information gathered from these searches was then presented to key stakeholders, who, in consultation with ASERNIP-S and using criteria identified from the literature, short-listed five procedures for further evaluation. The safety and clinical effectiveness of each of the five surgical procedures were then evaluated using a rapid review of the published literature. A rapid review is a systematic review in which the methodology has been limited in one or more areas to shorten the timeline for its completion. It may be used to answer a specific clinical question, and is often used to inform policy decisions in a timely manner, without losing any of the key information that may be expected from a full systematic review. The findings from each rapid review were presented to, and discussed with, key stakeholders. The outcomes of these consultations were then used to formulate options for further action, which constituted the final stage of the project. The key stakeholder group suggested that a summary of current clinical practice guidelines for each of the five procedures would be useful to further inform the discussion. The group also suggested that any implications that the clinical practice guidelines and the findings of the rapid reviews had for current MBS item descriptors should be highlighted. In the case of two of the reviewed procedures,