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Surgery_Schwartz_13902
Surgery_Schwartz
B-cell lymphoma. Cancer Res. 1989;49:4163-4169. 102. Brandstrup B, Tonnesen H, Beier-Holgersen R, et al. Effects of intravenous fluid restriction on postoperative complications: comparison of two perioperative fluid regi-mens: a randomized assessor-blinded multicenter trial. Ann Surg. 2003;238:641-648. 103. Gonzalez-Fajardo JA, Mengibar L, Brizuela JA, et al. Effect of postoperative restrictive fluid therapy in the recovery of patients with abdominal vascular surgery. Eur J Vasc Endo-vasc Surg. 2009;37:538-543. 104. Holte K, Foss NB, Andersen J, et al. Liberal or restrictive fluid administration in fast-track colonic surgery: a randomized, double-blind study. Br J Anaesth. 2007;99:500-508. 105. Lobo DN, Bostock KA, Neal KR, et al. Effect of salt and water balance on recovery of gastrointestinal function after elective colonic resection: a randomised controlled trial. Lancet. 2002;359:1812-1818. 106. MacKay G, Fearon K, McConnachie A, et al. Randomized clinical trial of the effect of
Surgery_Schwartz. B-cell lymphoma. Cancer Res. 1989;49:4163-4169. 102. Brandstrup B, Tonnesen H, Beier-Holgersen R, et al. Effects of intravenous fluid restriction on postoperative complications: comparison of two perioperative fluid regi-mens: a randomized assessor-blinded multicenter trial. Ann Surg. 2003;238:641-648. 103. Gonzalez-Fajardo JA, Mengibar L, Brizuela JA, et al. Effect of postoperative restrictive fluid therapy in the recovery of patients with abdominal vascular surgery. Eur J Vasc Endo-vasc Surg. 2009;37:538-543. 104. Holte K, Foss NB, Andersen J, et al. Liberal or restrictive fluid administration in fast-track colonic surgery: a randomized, double-blind study. Br J Anaesth. 2007;99:500-508. 105. Lobo DN, Bostock KA, Neal KR, et al. Effect of salt and water balance on recovery of gastrointestinal function after elective colonic resection: a randomised controlled trial. Lancet. 2002;359:1812-1818. 106. MacKay G, Fearon K, McConnachie A, et al. Randomized clinical trial of the effect of
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Surgery_Schwartz_13903
Surgery_Schwartz
function after elective colonic resection: a randomised controlled trial. Lancet. 2002;359:1812-1818. 106. MacKay G, Fearon K, McConnachie A, et al. Randomized clinical trial of the effect of postoperative intravenous fluid restriction on recovery after elective colorectal surgery. Br J Surg. 2006;93:1469-1474. 107. McArdle GT, McAuley DF, McKinley A, et al. Preliminary results of a prospective randomized trial of restrictive versus Brunicardi_Ch50_p2113-p2136.indd 213001/03/19 9:39 AM 2131OPTIMIZING PERIOPERATIVE CARE: ENHANCED RECOVERY AND CHINESE MEDICINECHAPTER 50standard fluid regime in elective open abdominal aortic aneu-rysm repair. Ann Surg. 2009;250:28-34. 108. Vermeulen H, Hofland J, Legemate DA, et al. Intravenous fluid restriction after major abdominal surgery: a randomized blinded clinical trial. Trials. 2009;10:50. 109. Francis N, Kennedy RH, Ljunggvist O, Mythen M. Manual of Fast Track Recovery for Colorectal Surgery. London: Springer; 2012. 110. Walsh SR, Tang T,
Surgery_Schwartz. function after elective colonic resection: a randomised controlled trial. Lancet. 2002;359:1812-1818. 106. MacKay G, Fearon K, McConnachie A, et al. Randomized clinical trial of the effect of postoperative intravenous fluid restriction on recovery after elective colorectal surgery. Br J Surg. 2006;93:1469-1474. 107. McArdle GT, McAuley DF, McKinley A, et al. Preliminary results of a prospective randomized trial of restrictive versus Brunicardi_Ch50_p2113-p2136.indd 213001/03/19 9:39 AM 2131OPTIMIZING PERIOPERATIVE CARE: ENHANCED RECOVERY AND CHINESE MEDICINECHAPTER 50standard fluid regime in elective open abdominal aortic aneu-rysm repair. Ann Surg. 2009;250:28-34. 108. Vermeulen H, Hofland J, Legemate DA, et al. Intravenous fluid restriction after major abdominal surgery: a randomized blinded clinical trial. Trials. 2009;10:50. 109. Francis N, Kennedy RH, Ljunggvist O, Mythen M. Manual of Fast Track Recovery for Colorectal Surgery. London: Springer; 2012. 110. Walsh SR, Tang T,
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Surgery_Schwartz_13904
Surgery_Schwartz
blinded clinical trial. Trials. 2009;10:50. 109. Francis N, Kennedy RH, Ljunggvist O, Mythen M. Manual of Fast Track Recovery for Colorectal Surgery. London: Springer; 2012. 110. Walsh SR, Tang T, Bass S, et al. Doppler-guided intra-operative fluid management during major abdominal sur-gery: systematic review and meta-analysis. Int J Clin Pract. 2008;62:466-470. 111. Giglio MT, Marucci M, Testini M, et al. Goal-directed haemo-dynamic therapy and gastrointestinal complications in major surgery: a meta-analysis of randomized controlled trials. Br J Anaesth. 2009;103:637-646. 112. Gan TJ, Soppitt A, Maroof M, et al. Goal-directed intraopera-tive fluid administration reduces length of hospital stay after major surgery. Anesthesiology. 2002;97:820-826. 113. Noblett SE, Snowden CP, Shenton BK, et al. Randomized clinical trial assessing the effect of Doppler-optimized fluid management on outcome after elective colorectal resection. Br J Surg. 2006;93:1069-1076. 114. Pillai P, McEleavy I,
Surgery_Schwartz. blinded clinical trial. Trials. 2009;10:50. 109. Francis N, Kennedy RH, Ljunggvist O, Mythen M. Manual of Fast Track Recovery for Colorectal Surgery. London: Springer; 2012. 110. Walsh SR, Tang T, Bass S, et al. Doppler-guided intra-operative fluid management during major abdominal sur-gery: systematic review and meta-analysis. Int J Clin Pract. 2008;62:466-470. 111. Giglio MT, Marucci M, Testini M, et al. Goal-directed haemo-dynamic therapy and gastrointestinal complications in major surgery: a meta-analysis of randomized controlled trials. Br J Anaesth. 2009;103:637-646. 112. Gan TJ, Soppitt A, Maroof M, et al. Goal-directed intraopera-tive fluid administration reduces length of hospital stay after major surgery. Anesthesiology. 2002;97:820-826. 113. Noblett SE, Snowden CP, Shenton BK, et al. Randomized clinical trial assessing the effect of Doppler-optimized fluid management on outcome after elective colorectal resection. Br J Surg. 2006;93:1069-1076. 114. Pillai P, McEleavy I,
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Surgery_Schwartz_13905
Surgery_Schwartz
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Surgery_Schwartz. et al. Randomized clinical trial assessing the effect of Doppler-optimized fluid management on outcome after elective colorectal resection. Br J Surg. 2006;93:1069-1076. 114. Pillai P, McEleavy I, Gaughan M, et al. A double-blind ran-domized controlled clinical trial to assess the effect of Dop-pler optimized intraoperative fluid management on outcome following radical cystectomy. J Urol. 2011;186:2201-2206. 115. Sinclair S, James S, Singer M. Intraoperative intravascular volume optimisation and length of hospital stay after repair of proximal femoral fracture: randomised controlled trial. BMJ. 1997;315:909-912. 116. Wakeling HG, McFall MR, Jenkins CS, et al. Intraopera-tive oesophageal Doppler guided fluid management shortens postoperative hospital stay after major bowel surgery. Br J Anaesth. 2005;95:634-642. 117. Perel P, Roberts I, Ker K. Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database Syst Rev. 2013;CD000567. 118. McCluskey SA,
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Surgery_Schwartz_13906
Surgery_Schwartz
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Surgery_Schwartz_13907
Surgery_Schwartz
Enhanced Recovery After Surgery (ERAS): Protocol in Colorectal Surgery. Second Annual Monitoring Conference, UPMC Department of Anesthesiology. Pittsburgh, PA, 2014. 122. Chia YY, Liu K, Wang JJ, et al. Intraoperative high dose fen-tanyl induces postoperative fentanyl tolerance. Can J Anaesth. 1999;46:872-877. 123. Collard V, Mistraletti G, Taqi A, et al. Intraoperative esmolol infusion in the absence of opioids spares postoperative fen-tanyl in patients undergoing ambulatory laparoscopic chole-cystectomy. Anesth Analg. 2007;105:1255-1262. 124. Coloma M, Chiu JW, White PF, et al. The use of esmolol as an alternative to remifentanil during desflurane anesthesia for fast-track outpatient gynecologic laparoscopic surgery. Anesth Analg. 2001;92:352-357. 125. Crawford MW, Galton S, Naser B. Postoperative morphine consumption in children with sickle-cell disease. Paediatr Anaesth. 2006;16:152-157. 126. Gottschalk A, Durieux ME, Nemergut EC. Intraopera-tive methadone improves postoperative
Surgery_Schwartz. Enhanced Recovery After Surgery (ERAS): Protocol in Colorectal Surgery. Second Annual Monitoring Conference, UPMC Department of Anesthesiology. Pittsburgh, PA, 2014. 122. Chia YY, Liu K, Wang JJ, et al. Intraoperative high dose fen-tanyl induces postoperative fentanyl tolerance. Can J Anaesth. 1999;46:872-877. 123. Collard V, Mistraletti G, Taqi A, et al. Intraoperative esmolol infusion in the absence of opioids spares postoperative fen-tanyl in patients undergoing ambulatory laparoscopic chole-cystectomy. Anesth Analg. 2007;105:1255-1262. 124. Coloma M, Chiu JW, White PF, et al. The use of esmolol as an alternative to remifentanil during desflurane anesthesia for fast-track outpatient gynecologic laparoscopic surgery. Anesth Analg. 2001;92:352-357. 125. Crawford MW, Galton S, Naser B. Postoperative morphine consumption in children with sickle-cell disease. Paediatr Anaesth. 2006;16:152-157. 126. Gottschalk A, Durieux ME, Nemergut EC. Intraopera-tive methadone improves postoperative
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Surgery_Schwartz_13908
Surgery_Schwartz
morphine consumption in children with sickle-cell disease. Paediatr Anaesth. 2006;16:152-157. 126. Gottschalk A, Durieux ME, Nemergut EC. Intraopera-tive methadone improves postoperative pain control in patients undergoing complex spine surgery. Anesth Analg. 2011;112:218-223. 127. Guignard B, Bossard AE, Coste C, et al. Acute opioid toler-ance: intraoperative remifentanil increases postoperative pain and morphine requirement. Anesthesiology. 2000;93:409-417. 128. Mendel HG, Guarnieri KM, Sundt LM, et al. The effects of ketorolac and fentanyl on postoperative vomiting and analge-sic requirements in children undergoing strabismus surgery. Anesth Analg. 1995;80:1129-1133. 129. Sukhani R, Vazquez J, Pappas AL, et al. Recovery after propo-fol with and without intraoperative fentanyl in patients under-going ambulatory gynecologic laparoscopy. Anesth Analg. 1996;83:975-981. 130. Rorarius MG, Mennander S, Suominen P, et al. Gabapentin for the prevention of postoperative pain after vaginal
Surgery_Schwartz. morphine consumption in children with sickle-cell disease. Paediatr Anaesth. 2006;16:152-157. 126. Gottschalk A, Durieux ME, Nemergut EC. Intraopera-tive methadone improves postoperative pain control in patients undergoing complex spine surgery. Anesth Analg. 2011;112:218-223. 127. Guignard B, Bossard AE, Coste C, et al. Acute opioid toler-ance: intraoperative remifentanil increases postoperative pain and morphine requirement. Anesthesiology. 2000;93:409-417. 128. Mendel HG, Guarnieri KM, Sundt LM, et al. The effects of ketorolac and fentanyl on postoperative vomiting and analge-sic requirements in children undergoing strabismus surgery. Anesth Analg. 1995;80:1129-1133. 129. Sukhani R, Vazquez J, Pappas AL, et al. Recovery after propo-fol with and without intraoperative fentanyl in patients under-going ambulatory gynecologic laparoscopy. Anesth Analg. 1996;83:975-981. 130. Rorarius MG, Mennander S, Suominen P, et al. Gabapentin for the prevention of postoperative pain after vaginal
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Surgery_Schwartz_13909
Surgery_Schwartz
under-going ambulatory gynecologic laparoscopy. Anesth Analg. 1996;83:975-981. 130. Rorarius MG, Mennander S, Suominen P, et al. Gabapentin for the prevention of postoperative pain after vaginal hyster-ectomy. Pain. 2004;110:175-181. 131. Parikh HG, Dash SK, Upasani CB. Study of the effect of oral gabapentin used as preemptive analgesia to attenuate post-operative pain in patients undergoing abdominal surgery under general anesthesia. Saudi J Anaesth. 2010;4:137-141. 132. Pandey CK, Sahay S, Gupta D, et al. Preemptive gabapentin decreases postoperative pain after lumbar discoidectomy. Can J Anaesth. 2004;51:986-989. 133. Pandey CK, Priye S, Singh S, et al. Preemptive use of gaba-pentin significantly decreases postoperative pain and rescue analgesic requirements in laparoscopic cholecystectomy. Can J Anaesth. 2004;51:358-363. 134. Dirks J, Fredensborg BB, Christensen D, et al. A randomized study of the effects of single-dose gabapentin versus placebo on postoperative pain and
Surgery_Schwartz. under-going ambulatory gynecologic laparoscopy. Anesth Analg. 1996;83:975-981. 130. Rorarius MG, Mennander S, Suominen P, et al. Gabapentin for the prevention of postoperative pain after vaginal hyster-ectomy. Pain. 2004;110:175-181. 131. Parikh HG, Dash SK, Upasani CB. Study of the effect of oral gabapentin used as preemptive analgesia to attenuate post-operative pain in patients undergoing abdominal surgery under general anesthesia. Saudi J Anaesth. 2010;4:137-141. 132. Pandey CK, Sahay S, Gupta D, et al. Preemptive gabapentin decreases postoperative pain after lumbar discoidectomy. Can J Anaesth. 2004;51:986-989. 133. Pandey CK, Priye S, Singh S, et al. Preemptive use of gaba-pentin significantly decreases postoperative pain and rescue analgesic requirements in laparoscopic cholecystectomy. Can J Anaesth. 2004;51:358-363. 134. Dirks J, Fredensborg BB, Christensen D, et al. A randomized study of the effects of single-dose gabapentin versus placebo on postoperative pain and
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Surgery_Schwartz_13910
Surgery_Schwartz
Can J Anaesth. 2004;51:358-363. 134. Dirks J, Fredensborg BB, Christensen D, et al. A randomized study of the effects of single-dose gabapentin versus placebo on postoperative pain and morphine consumption after mas-tectomy. Anesthesiology. 2002;97:560-564. 135. Dierking G, Duedahl TH, Rasmussen ML, et al. Effects of gabapentin on postoperative morphine consumption and pain after abdominal hysterectomy: a randomized, double-blind trial. Acta Anaesthesiol Scand. 2004;48:322-327. 136. Bell RF, Dahl JB, Moore RA, et al. Peri-operative ketamine for acute post-operative pain: a quantitative and qualitative systematic review (Cochrane review). Acta Anaesthesiol Scand. 2005;49:1405-1428. 137. Celerier E, Rivat C, Jun Y, et al. Long-lasting hyperalgesia induced by fentanyl in rats: preventive effect of ketamine. Anesthesiology. 2000;92:465-472. 138. Seyhan TO, Tugrul M, Sungur MO, et al. Effects of three dif-ferent dose regimens of magnesium on propofol requirements, haemodynamic variables
Surgery_Schwartz. Can J Anaesth. 2004;51:358-363. 134. Dirks J, Fredensborg BB, Christensen D, et al. A randomized study of the effects of single-dose gabapentin versus placebo on postoperative pain and morphine consumption after mas-tectomy. Anesthesiology. 2002;97:560-564. 135. Dierking G, Duedahl TH, Rasmussen ML, et al. Effects of gabapentin on postoperative morphine consumption and pain after abdominal hysterectomy: a randomized, double-blind trial. Acta Anaesthesiol Scand. 2004;48:322-327. 136. Bell RF, Dahl JB, Moore RA, et al. Peri-operative ketamine for acute post-operative pain: a quantitative and qualitative systematic review (Cochrane review). Acta Anaesthesiol Scand. 2005;49:1405-1428. 137. Celerier E, Rivat C, Jun Y, et al. Long-lasting hyperalgesia induced by fentanyl in rats: preventive effect of ketamine. Anesthesiology. 2000;92:465-472. 138. Seyhan TO, Tugrul M, Sungur MO, et al. Effects of three dif-ferent dose regimens of magnesium on propofol requirements, haemodynamic variables
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Surgery_Schwartz_13911
Surgery_Schwartz
of ketamine. Anesthesiology. 2000;92:465-472. 138. Seyhan TO, Tugrul M, Sungur MO, et al. Effects of three dif-ferent dose regimens of magnesium on propofol requirements, haemodynamic variables and postoperative pain relief in gyn-aecological surgery. Br J Anaesth. 2006;96:247-252. 139. Dube L, Granry JC. The therapeutic use of magnesium in anesthesiology, intensive care and emergency medicine: a review. Can J Anaesth. 2003;50:732-746. 140. Vigneault L, Turgeon AF, Cote D, et al. Perioperative intra-venous lidocaine infusion for postoperative pain control: a meta-analysis of randomized controlled trials. Can J Anaesth. 2011;58:22-37. 141. Benyamin R, Trescot AM, Datta S, et al. Opioid complications and side effects. Pain Physician. 2008;11:S105-S120. 142. de Cosmo G. The use of NSAIDs in the postoperative perioid: advantage and disadvantages. J Anesth Crit Care. 2015;3(4). 143. Kurdi MS, Theerth KA, Deva RS. Ketamine: current applica-tions in anesthesia, pain, and critical care.
Surgery_Schwartz. of ketamine. Anesthesiology. 2000;92:465-472. 138. Seyhan TO, Tugrul M, Sungur MO, et al. Effects of three dif-ferent dose regimens of magnesium on propofol requirements, haemodynamic variables and postoperative pain relief in gyn-aecological surgery. Br J Anaesth. 2006;96:247-252. 139. Dube L, Granry JC. The therapeutic use of magnesium in anesthesiology, intensive care and emergency medicine: a review. Can J Anaesth. 2003;50:732-746. 140. Vigneault L, Turgeon AF, Cote D, et al. Perioperative intra-venous lidocaine infusion for postoperative pain control: a meta-analysis of randomized controlled trials. Can J Anaesth. 2011;58:22-37. 141. Benyamin R, Trescot AM, Datta S, et al. Opioid complications and side effects. Pain Physician. 2008;11:S105-S120. 142. de Cosmo G. The use of NSAIDs in the postoperative perioid: advantage and disadvantages. J Anesth Crit Care. 2015;3(4). 143. Kurdi MS, Theerth KA, Deva RS. Ketamine: current applica-tions in anesthesia, pain, and critical care.
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Surgery_Schwartz_13912
Surgery_Schwartz
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Surgery_Schwartz_13913
Surgery_Schwartz
and Pain Medicine, and the American Society of Anesthesiologists’ Committee on Regional Anesthesia, Executive Committee, and Administrative Council. J Pain. 2016;17:131-157. 146. De Pinto M, Dagal A, O’Donnell B, et al. Regional anes-thesia for management of acute pain in the intensive care unit. Int J Crit Illn Inj Sci. 2015;5:138-143. 147. Fortier J, Chung F, Su J. Unanticipated admission after ambulatory surgery—a prospective study. Can J Anaesth. 1998;45:612-619. 148. Gold BS, Kitz DS, Lecky JH, et al. Unanticipated admis-sion to the hospital following ambulatory surgery. JAMA. 1989;262:3008-3010. 149. Hill RP, Lubarsky DA, Phillips-Bute B, et al. Cost-effectiveness of prophylactic antiemetic therapy with ondansetron, droperi-dol, or placebo. Anesthesiology. 2000;92:958-967. 150. Sinclair DR, Chung F, Mezei G. Can postoperative nausea and vomiting be predicted? Anesthesiology. 1999;91:109-118. 151. Koivuranta M, Laara E, Snare L, et al. A survey of postopera-tive nausea and
Surgery_Schwartz. and Pain Medicine, and the American Society of Anesthesiologists’ Committee on Regional Anesthesia, Executive Committee, and Administrative Council. J Pain. 2016;17:131-157. 146. De Pinto M, Dagal A, O’Donnell B, et al. Regional anes-thesia for management of acute pain in the intensive care unit. Int J Crit Illn Inj Sci. 2015;5:138-143. 147. Fortier J, Chung F, Su J. Unanticipated admission after ambulatory surgery—a prospective study. Can J Anaesth. 1998;45:612-619. 148. Gold BS, Kitz DS, Lecky JH, et al. Unanticipated admis-sion to the hospital following ambulatory surgery. JAMA. 1989;262:3008-3010. 149. Hill RP, Lubarsky DA, Phillips-Bute B, et al. Cost-effectiveness of prophylactic antiemetic therapy with ondansetron, droperi-dol, or placebo. Anesthesiology. 2000;92:958-967. 150. Sinclair DR, Chung F, Mezei G. Can postoperative nausea and vomiting be predicted? Anesthesiology. 1999;91:109-118. 151. Koivuranta M, Laara E, Snare L, et al. A survey of postopera-tive nausea and
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Surgery_Schwartz_13914
Surgery_Schwartz
DR, Chung F, Mezei G. Can postoperative nausea and vomiting be predicted? Anesthesiology. 1999;91:109-118. 151. Koivuranta M, Laara E, Snare L, et al. A survey of postopera-tive nausea and vomiting. Anaesthesia. 1997;52:443-449. 152. Apfel CC, Laara E, Koivuranta M, et al. A simplified risk score for predicting postoperative nausea and vomiting: con-clusions from cross-validations between two centers. Anesthe-siology. 1999;91:693-700. 153. Gan TJ, Diemunsch P, Habib AS, et al. Consensus guidelines for the management of postoperative nausea and vomiting. Anesth Analg. 2014;118:85-113. 154. Apfel CC, Korttila K, Abdalla M, et al. A factorial trial of six interventions for the prevention of postoperative nausea and vomiting. N Engl J Med. 2004;350:2441-2451. 155. Apfel CC, Philip BK, Cakmakkaya OS, et al. Who is at risk for postdischarge nausea and vomiting after ambulatory sur-gery? Anesthesiology. 2012;117:475-486. 156. Kranke P, Apefel CC, Papenfuss T, et al. An increased body mass
Surgery_Schwartz. DR, Chung F, Mezei G. Can postoperative nausea and vomiting be predicted? Anesthesiology. 1999;91:109-118. 151. Koivuranta M, Laara E, Snare L, et al. A survey of postopera-tive nausea and vomiting. Anaesthesia. 1997;52:443-449. 152. Apfel CC, Laara E, Koivuranta M, et al. A simplified risk score for predicting postoperative nausea and vomiting: con-clusions from cross-validations between two centers. Anesthe-siology. 1999;91:693-700. 153. Gan TJ, Diemunsch P, Habib AS, et al. Consensus guidelines for the management of postoperative nausea and vomiting. Anesth Analg. 2014;118:85-113. 154. Apfel CC, Korttila K, Abdalla M, et al. A factorial trial of six interventions for the prevention of postoperative nausea and vomiting. N Engl J Med. 2004;350:2441-2451. 155. Apfel CC, Philip BK, Cakmakkaya OS, et al. Who is at risk for postdischarge nausea and vomiting after ambulatory sur-gery? Anesthesiology. 2012;117:475-486. 156. Kranke P, Apefel CC, Papenfuss T, et al. An increased body mass
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Surgery_Schwartz_13915
Surgery_Schwartz
OS, et al. Who is at risk for postdischarge nausea and vomiting after ambulatory sur-gery? Anesthesiology. 2012;117:475-486. 156. Kranke P, Apefel CC, Papenfuss T, et al. An increased body mass index is no risk factor for postoperative nausea and vom-iting. A systematic review and results of original data. Acta Anaesthesiol Scand. 2001;45:160-166. 157. Scuderi PE, James RL, Harris L, et al. Multimodal antiemetic management prevents early postoperative vomiting after out-patient laparoscopy. Anesth Analg. 2000;91:1408-1414. 158. Tramer M, Moore A, McQuay H. Omitting nitrous oxide in general anaesthesia: meta-analysis of intraoperative aware-ness and postoperative emesis in randomized controlled trials. Br J Anaesth. 1996;76:186-193. 159. Tramer M, Moore A, McQuay H. Meta-analytic comparison of prophylactic antiemetic efficacy for postoperative nausea and vomiting: propofol anaesthesia vs omitting nitrous oxide vs total i.v. anaesthesia with propofol. Br J Anaesth.
Surgery_Schwartz. OS, et al. Who is at risk for postdischarge nausea and vomiting after ambulatory sur-gery? Anesthesiology. 2012;117:475-486. 156. Kranke P, Apefel CC, Papenfuss T, et al. An increased body mass index is no risk factor for postoperative nausea and vom-iting. A systematic review and results of original data. Acta Anaesthesiol Scand. 2001;45:160-166. 157. Scuderi PE, James RL, Harris L, et al. Multimodal antiemetic management prevents early postoperative vomiting after out-patient laparoscopy. Anesth Analg. 2000;91:1408-1414. 158. Tramer M, Moore A, McQuay H. Omitting nitrous oxide in general anaesthesia: meta-analysis of intraoperative aware-ness and postoperative emesis in randomized controlled trials. Br J Anaesth. 1996;76:186-193. 159. Tramer M, Moore A, McQuay H. Meta-analytic comparison of prophylactic antiemetic efficacy for postoperative nausea and vomiting: propofol anaesthesia vs omitting nitrous oxide vs total i.v. anaesthesia with propofol. Br J Anaesth.
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Surgery_Schwartz_13916
Surgery_Schwartz
comparison of prophylactic antiemetic efficacy for postoperative nausea and vomiting: propofol anaesthesia vs omitting nitrous oxide vs total i.v. anaesthesia with propofol. Br J Anaesth. 1997;78:256-259. 160. Tramer MR, Reynolds DJ, Moore RA, et al. Efficacy, dose-response, and safety of ondansetron in prevention of postop-erative nausea and vomiting: a quantitative systematic review of randomized placebo-controlled trials. Anesthesiology. 1997;87:1277-1289. 161. Schnabel A, Eberhart LH, Muellenbach R, et al. Efficacy of perphenazine to prevent postoperative nausea and vomit-ing: a quantitative systematic review. Eur J Anaesthesiol. 2010;27:1044-1051. 162. Gan TJ, Apfel CC, Kovac A, et al. A randomized, double-blind comparison of the NK1 antagonist, aprepitant, versus ondan-setron for the prevention of postoperative nausea and vomit-ing. Anesth Analg. 2007;104:1082-1089. 163. Wang JJ, Ho ST, Lee SC, et al. The use of dexamethasone for preventing postoperative nausea and vomiting in
Surgery_Schwartz. comparison of prophylactic antiemetic efficacy for postoperative nausea and vomiting: propofol anaesthesia vs omitting nitrous oxide vs total i.v. anaesthesia with propofol. Br J Anaesth. 1997;78:256-259. 160. Tramer MR, Reynolds DJ, Moore RA, et al. Efficacy, dose-response, and safety of ondansetron in prevention of postop-erative nausea and vomiting: a quantitative systematic review of randomized placebo-controlled trials. Anesthesiology. 1997;87:1277-1289. 161. Schnabel A, Eberhart LH, Muellenbach R, et al. Efficacy of perphenazine to prevent postoperative nausea and vomit-ing: a quantitative systematic review. Eur J Anaesthesiol. 2010;27:1044-1051. 162. Gan TJ, Apfel CC, Kovac A, et al. A randomized, double-blind comparison of the NK1 antagonist, aprepitant, versus ondan-setron for the prevention of postoperative nausea and vomit-ing. Anesth Analg. 2007;104:1082-1089. 163. Wang JJ, Ho ST, Lee SC, et al. The use of dexamethasone for preventing postoperative nausea and vomiting in
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Surgery_Schwartz_13917
Surgery_Schwartz
prevention of postoperative nausea and vomit-ing. Anesth Analg. 2007;104:1082-1089. 163. Wang JJ, Ho ST, Lee SC, et al. The use of dexamethasone for preventing postoperative nausea and vomiting in females undergoing thyroidectomy: a dose-ranging study. Anesth Analg. 2000;91:1404-1407. 164. Bailey PL, Streisand JB, Pace NL, et al. Transdermal scopol-amine reduces nausea and vomiting after outpatient laparos-copy. Anesthesiology. 1990;72:977-980. 165. Delaney CP, Senagore AJ, Viscusi ER, et al. Postoperative upper and lower gastrointestinal recovery and gastrointesti-nal morbidity in patients undergoing bowel resection: pooled analysis of placebo data from 3 randomized controlled trials. Am J Surg. 2006;191:315-319. 166. Asgeirsson T, El-Badawi KI, Mahmood A, et al. Postopera-tive ileus: it costs more than you expect. J Am Coll Surg. 2010;210:228-231. 167. Nelson R, Tse B, Edwards S. Systematic review of prophy-lactic nasogastric decompression after abdominal operations. Br J Surg.
Surgery_Schwartz. prevention of postoperative nausea and vomit-ing. Anesth Analg. 2007;104:1082-1089. 163. Wang JJ, Ho ST, Lee SC, et al. The use of dexamethasone for preventing postoperative nausea and vomiting in females undergoing thyroidectomy: a dose-ranging study. Anesth Analg. 2000;91:1404-1407. 164. Bailey PL, Streisand JB, Pace NL, et al. Transdermal scopol-amine reduces nausea and vomiting after outpatient laparos-copy. Anesthesiology. 1990;72:977-980. 165. Delaney CP, Senagore AJ, Viscusi ER, et al. Postoperative upper and lower gastrointestinal recovery and gastrointesti-nal morbidity in patients undergoing bowel resection: pooled analysis of placebo data from 3 randomized controlled trials. Am J Surg. 2006;191:315-319. 166. Asgeirsson T, El-Badawi KI, Mahmood A, et al. Postopera-tive ileus: it costs more than you expect. J Am Coll Surg. 2010;210:228-231. 167. Nelson R, Tse B, Edwards S. Systematic review of prophy-lactic nasogastric decompression after abdominal operations. Br J Surg.
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Surgery_Schwartz_13918
Surgery_Schwartz
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Surgery_Schwartz. it costs more than you expect. J Am Coll Surg. 2010;210:228-231. 167. Nelson R, Tse B, Edwards S. Systematic review of prophy-lactic nasogastric decompression after abdominal operations. Br J Surg. 2005;92:673-680. 168. Nelson R, Edwards S, Tse B. Prophylactic nasogastric decom-pression after abdominal surgery. Cochrane Database Syst Rev. 2005;CD004929. 169. Daryaei P, Vaghef Davari F, Mir M, et al. Omission of naso-gastric tube application in postoperative care of esophagec-tomy. World J Surg. 2009;33:773-777. 170. Chapuis PH, Bokey L, Keshava A, et al. Risk factors for prolonged ileus after resection of colorectal cancer: an observational study of 2400 consecutive patients. Ann Surg. 2013;257:909-915. 171. Lacy AM, Garcia-Valdecasas JC, Pique JM, et al. Short-term outcome analysis of a randomized study comparing laparo-scopic vs open colectomy for colon cancer. Surg Endosc. 1995;9:1101-1105. 172. Schwenk W, Bohm B, Haase O, et al. Laparoscopic versus conventional colorectal
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Surgery_Schwartz_13919
Surgery_Schwartz
of a randomized study comparing laparo-scopic vs open colectomy for colon cancer. Surg Endosc. 1995;9:1101-1105. 172. Schwenk W, Bohm B, Haase O, et al. Laparoscopic versus conventional colorectal resection: a prospective randomised study of postoperative ileus and early postoperative feeding. Langenbecks Arch Surg. 1998;383:49-55. 173. Shussman N, Brown MR, Johnson MC, et al. Does nasogastric tube decompression get used less often with laparoscopic and hand-assisted compared with open colectomy? Surg Endosc. 2013;27:4564-4568. 174. Uemura K, Tatewaki M, Harris MB, et al. Magnitude of abdominal incision affects the duration of postoperative ileus in rats. Surg Endosc. 2004;18:606-610. 175. Varadhan KK, Lobo DN. A meta-analysis of randomised con-trolled trials of intravenous fluid therapy in major elective open abdominal surgery: getting the balance right. Proc Nutr Soc. 2010;69:488-498. 176. Ho YM, Smith SR, Pockney P, et al. A meta-analysis on the effect of sham feeding following
Surgery_Schwartz. of a randomized study comparing laparo-scopic vs open colectomy for colon cancer. Surg Endosc. 1995;9:1101-1105. 172. Schwenk W, Bohm B, Haase O, et al. Laparoscopic versus conventional colorectal resection: a prospective randomised study of postoperative ileus and early postoperative feeding. Langenbecks Arch Surg. 1998;383:49-55. 173. Shussman N, Brown MR, Johnson MC, et al. Does nasogastric tube decompression get used less often with laparoscopic and hand-assisted compared with open colectomy? Surg Endosc. 2013;27:4564-4568. 174. Uemura K, Tatewaki M, Harris MB, et al. Magnitude of abdominal incision affects the duration of postoperative ileus in rats. Surg Endosc. 2004;18:606-610. 175. Varadhan KK, Lobo DN. A meta-analysis of randomised con-trolled trials of intravenous fluid therapy in major elective open abdominal surgery: getting the balance right. Proc Nutr Soc. 2010;69:488-498. 176. Ho YM, Smith SR, Pockney P, et al. A meta-analysis on the effect of sham feeding following
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Surgery_Schwartz_13920
Surgery_Schwartz
in major elective open abdominal surgery: getting the balance right. Proc Nutr Soc. 2010;69:488-498. 176. Ho YM, Smith SR, Pockney P, et al. A meta-analysis on the effect of sham feeding following colectomy: should gum chewing be included in enhanced recovery after surgery pro-tocols? Dis Colon Rectum. 2014;57:115-126. 177. Purkayastha S, Tilney HS, Darzi AW, et al. Meta-analysis of randomized studies evaluating chewing gum to enhance postoperative recovery following colectomy. Arch Surg. 2008;143:788-793. 178. Short V, Herbert G, Perry R, et al. Chewing gum for postop-erative recovery of gastrointestinal function. Cochrane Data-base Syst Rev. 2015;CD006506. 179. Atkinson C, Penfold CM, Ness AR, et al. Randomized clinical trial of postoperative chewing gum versus standard care after colorectal resection. Br J Surg. 2016;103:962-970. 180. Lim P, Morris OJ, Nolan G, et al. Sham feeding with chewing gum after elective colorectal resectional surgery: a random-ized clinical trial. Ann
Surgery_Schwartz. in major elective open abdominal surgery: getting the balance right. Proc Nutr Soc. 2010;69:488-498. 176. Ho YM, Smith SR, Pockney P, et al. A meta-analysis on the effect of sham feeding following colectomy: should gum chewing be included in enhanced recovery after surgery pro-tocols? Dis Colon Rectum. 2014;57:115-126. 177. Purkayastha S, Tilney HS, Darzi AW, et al. Meta-analysis of randomized studies evaluating chewing gum to enhance postoperative recovery following colectomy. Arch Surg. 2008;143:788-793. 178. Short V, Herbert G, Perry R, et al. Chewing gum for postop-erative recovery of gastrointestinal function. Cochrane Data-base Syst Rev. 2015;CD006506. 179. Atkinson C, Penfold CM, Ness AR, et al. Randomized clinical trial of postoperative chewing gum versus standard care after colorectal resection. Br J Surg. 2016;103:962-970. 180. Lim P, Morris OJ, Nolan G, et al. Sham feeding with chewing gum after elective colorectal resectional surgery: a random-ized clinical trial. Ann
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Surgery_Schwartz_13921
Surgery_Schwartz
resection. Br J Surg. 2016;103:962-970. 180. Lim P, Morris OJ, Nolan G, et al. Sham feeding with chewing gum after elective colorectal resectional surgery: a random-ized clinical trial. Ann Surg. 2013;257:1016-1024. 181. Delaney CP, Wolff BG, Viscusi ER, et al. Alvimopan, for post-operative ileus following bowel resection: a pooled analysis of phase III studies. 2007; Ann Surg 245:355-363. 182. Adam MA, Lee LM, Kim J, et al. Alvimopan provides addi-tional improvement in outcomes and cost savings in enhanced recovery colorectal surgery. Ann Surg. 2016;264:141-146. 183. Barletta JF, Asgeirsson T, El-Badawi KI, et al. Introduction of alvimopan into an enhanced recovery protocol for colectomy Brunicardi_Ch50_p2113-p2136.indd 213201/03/19 9:39 AM 2133OPTIMIZING PERIOPERATIVE CARE: ENHANCED RECOVERY AND CHINESE MEDICINECHAPTER 50offers benefit in open but not laparoscopic colectomy. J Lapa-roendosc Adv Surg Tech A. 2011;21:887-891. 184. Keller DS, Flores-Gonzalez JR, Ibarra S, et al. Is
Surgery_Schwartz. resection. Br J Surg. 2016;103:962-970. 180. Lim P, Morris OJ, Nolan G, et al. Sham feeding with chewing gum after elective colorectal resectional surgery: a random-ized clinical trial. Ann Surg. 2013;257:1016-1024. 181. Delaney CP, Wolff BG, Viscusi ER, et al. Alvimopan, for post-operative ileus following bowel resection: a pooled analysis of phase III studies. 2007; Ann Surg 245:355-363. 182. Adam MA, Lee LM, Kim J, et al. Alvimopan provides addi-tional improvement in outcomes and cost savings in enhanced recovery colorectal surgery. Ann Surg. 2016;264:141-146. 183. Barletta JF, Asgeirsson T, El-Badawi KI, et al. Introduction of alvimopan into an enhanced recovery protocol for colectomy Brunicardi_Ch50_p2113-p2136.indd 213201/03/19 9:39 AM 2133OPTIMIZING PERIOPERATIVE CARE: ENHANCED RECOVERY AND CHINESE MEDICINECHAPTER 50offers benefit in open but not laparoscopic colectomy. J Lapa-roendosc Adv Surg Tech A. 2011;21:887-891. 184. Keller DS, Flores-Gonzalez JR, Ibarra S, et al. Is
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Surgery_Schwartz_13922
Surgery_Schwartz
RECOVERY AND CHINESE MEDICINECHAPTER 50offers benefit in open but not laparoscopic colectomy. J Lapa-roendosc Adv Surg Tech A. 2011;21:887-891. 184. Keller DS, Flores-Gonzalez JR, Ibarra S, et al. Is there value in alvimopan in minimally invasive colorectal surgery? Am J Surg. 2016;212:851-856. 185. Hirsch CH, Sommers L, Olsen A, et al. The natural history of functional morbidity in hospitalized older patients. J Am Geriatr Soc. 1990;38:1296-1303. 186. Gillis C, Li C, Lee L, et al. Prehabilitation versus rehabilita-tion: a randomized control trial in patients undergoing colorec-tal resection for cancer. Anesthesiology. 2014;121:937-947. 187. Nygren J, Soop M, Thorell A, et al. An enhanced-recovery protocol improves outcome after colorectal resection already during the first year: a single-center experience in 168 con-secutive patients. Dis Colon Rectum. 2009;52:978-985. 188. Teeuwen PH, Bleichrodt RP, Strik C, et al. Enhanced recovery after surgery (ERAS) versus conventional
Surgery_Schwartz. RECOVERY AND CHINESE MEDICINECHAPTER 50offers benefit in open but not laparoscopic colectomy. J Lapa-roendosc Adv Surg Tech A. 2011;21:887-891. 184. Keller DS, Flores-Gonzalez JR, Ibarra S, et al. Is there value in alvimopan in minimally invasive colorectal surgery? Am J Surg. 2016;212:851-856. 185. Hirsch CH, Sommers L, Olsen A, et al. The natural history of functional morbidity in hospitalized older patients. J Am Geriatr Soc. 1990;38:1296-1303. 186. Gillis C, Li C, Lee L, et al. Prehabilitation versus rehabilita-tion: a randomized control trial in patients undergoing colorec-tal resection for cancer. Anesthesiology. 2014;121:937-947. 187. Nygren J, Soop M, Thorell A, et al. An enhanced-recovery protocol improves outcome after colorectal resection already during the first year: a single-center experience in 168 con-secutive patients. Dis Colon Rectum. 2009;52:978-985. 188. Teeuwen PH, Bleichrodt RP, Strik C, et al. Enhanced recovery after surgery (ERAS) versus conventional
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Surgery_Schwartz_13923
Surgery_Schwartz
a single-center experience in 168 con-secutive patients. Dis Colon Rectum. 2009;52:978-985. 188. Teeuwen PH, Bleichrodt RP, Strik C, et al. Enhanced recovery after surgery (ERAS) versus conventional postoperative care in colorectal surgery. J Gastrointest Surg. 2010;14:88-95. 189. Zargar-Shoshtari K, Connolly AB, Israel LH, et al. Fast-track surgery may reduce complications following major colonic surgery. Dis Colon Rectum. 2008;51:1633-1640. 190. Ren L, Zhu D, Wei Y, et al. Enhanced Recovery After Sur-gery (ERAS) program attenuates stress and accelerates recov-ery in patients after radical resection for colorectal cancer: a prospective randomized controlled trial. World J Surg. 2012;36:407-414. 191. Delaney CP, Brady K, Woconish D, et al. Towards optimizing perioperative colorectal care: outcomes for 1,000 consecutive laparoscopic colon procedures using enhanced recovery path-ways. Am J Surg. 2012;203:353-355; discussion 355-356. 192. Keane C, Savage S, McFarlane K, et al. Enhanced
Surgery_Schwartz. a single-center experience in 168 con-secutive patients. Dis Colon Rectum. 2009;52:978-985. 188. Teeuwen PH, Bleichrodt RP, Strik C, et al. Enhanced recovery after surgery (ERAS) versus conventional postoperative care in colorectal surgery. J Gastrointest Surg. 2010;14:88-95. 189. Zargar-Shoshtari K, Connolly AB, Israel LH, et al. Fast-track surgery may reduce complications following major colonic surgery. Dis Colon Rectum. 2008;51:1633-1640. 190. Ren L, Zhu D, Wei Y, et al. Enhanced Recovery After Sur-gery (ERAS) program attenuates stress and accelerates recov-ery in patients after radical resection for colorectal cancer: a prospective randomized controlled trial. World J Surg. 2012;36:407-414. 191. Delaney CP, Brady K, Woconish D, et al. Towards optimizing perioperative colorectal care: outcomes for 1,000 consecutive laparoscopic colon procedures using enhanced recovery path-ways. Am J Surg. 2012;203:353-355; discussion 355-356. 192. Keane C, Savage S, McFarlane K, et al. Enhanced
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Surgery_Schwartz_13924
Surgery_Schwartz
outcomes for 1,000 consecutive laparoscopic colon procedures using enhanced recovery path-ways. Am J Surg. 2012;203:353-355; discussion 355-356. 192. Keane C, Savage S, McFarlane K, et al. Enhanced recovery after surgery versus conventional care in colonic and rectal surgery. ANZ J Surg. 2012;82:697-703. 193. Esteban F, Cerdan FJ, Garcia-Alonso M, et al. A multicen-tre comparison of a fast track or conventional postoperative protocol following laparoscopic or open elective surgery for colorectal cancer surgery. Colorectal Dis. 2014;16:134-140. 194. Gouvas N, Gogos-Pappas G, Tsimogiannis K, et al. Imple-mentation of fast-track protocols in open and laparoscopic sphincter-preserving rectal cancer surgery: a multicenter, comparative, prospective, non-randomized study. Dig Surg. 2012;29:301-309. 195. Greco M, Capretti G, Beretta L, et al. Enhanced recovery program in colorectal surgery: a meta-analysis of randomized controlled trials. World J Surg. 2014;38:1531-1541. 196. Vlug MS, Wind J,
Surgery_Schwartz. outcomes for 1,000 consecutive laparoscopic colon procedures using enhanced recovery path-ways. Am J Surg. 2012;203:353-355; discussion 355-356. 192. Keane C, Savage S, McFarlane K, et al. Enhanced recovery after surgery versus conventional care in colonic and rectal surgery. ANZ J Surg. 2012;82:697-703. 193. Esteban F, Cerdan FJ, Garcia-Alonso M, et al. A multicen-tre comparison of a fast track or conventional postoperative protocol following laparoscopic or open elective surgery for colorectal cancer surgery. Colorectal Dis. 2014;16:134-140. 194. Gouvas N, Gogos-Pappas G, Tsimogiannis K, et al. Imple-mentation of fast-track protocols in open and laparoscopic sphincter-preserving rectal cancer surgery: a multicenter, comparative, prospective, non-randomized study. Dig Surg. 2012;29:301-309. 195. Greco M, Capretti G, Beretta L, et al. Enhanced recovery program in colorectal surgery: a meta-analysis of randomized controlled trials. World J Surg. 2014;38:1531-1541. 196. Vlug MS, Wind J,
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Surgery_Schwartz_13925
Surgery_Schwartz
M, Capretti G, Beretta L, et al. Enhanced recovery program in colorectal surgery: a meta-analysis of randomized controlled trials. World J Surg. 2014;38:1531-1541. 196. Vlug MS, Wind J, van der Zaag E, et al. Systematic review of laparoscopic vs open colonic surgery within an enhanced recovery programme. Colorectal Dis. 2009;11:335-343. 197. Zhuang CL, Huang DD, Chen FF, et al. Laparoscopic versus open colorectal surgery within enhanced recovery after sur-gery programs: a systematic review and meta-analysis of ran-domized controlled trials. Surg Endosc. 2015;29:2091-2100. 198. Garulli G, Lucchi A, Berti P, et al. “Ultra” E.R.A.S. in laparoscopic colectomy for cancer: discharge after the first flatus? A prospective, randomized trial. Surg Endosc. 2017;31:1806-1813. 199. Gignoux B, Pasquer A, Vulliez A, et al. Outpatient colec-tomy within an enhanced recovery program. J Visc Surg. 2015;152:11-15. 200. Lawrence JK, Keller DS, Samia H, et al. Discharge within 24 to 72 hours of colorectal
Surgery_Schwartz. M, Capretti G, Beretta L, et al. Enhanced recovery program in colorectal surgery: a meta-analysis of randomized controlled trials. World J Surg. 2014;38:1531-1541. 196. Vlug MS, Wind J, van der Zaag E, et al. Systematic review of laparoscopic vs open colonic surgery within an enhanced recovery programme. Colorectal Dis. 2009;11:335-343. 197. Zhuang CL, Huang DD, Chen FF, et al. Laparoscopic versus open colorectal surgery within enhanced recovery after sur-gery programs: a systematic review and meta-analysis of ran-domized controlled trials. Surg Endosc. 2015;29:2091-2100. 198. Garulli G, Lucchi A, Berti P, et al. “Ultra” E.R.A.S. in laparoscopic colectomy for cancer: discharge after the first flatus? A prospective, randomized trial. Surg Endosc. 2017;31:1806-1813. 199. Gignoux B, Pasquer A, Vulliez A, et al. Outpatient colec-tomy within an enhanced recovery program. J Visc Surg. 2015;152:11-15. 200. Lawrence JK, Keller DS, Samia H, et al. Discharge within 24 to 72 hours of colorectal
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Surgery_Schwartz_13926
Surgery_Schwartz
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Surgery_Schwartz. A, Vulliez A, et al. Outpatient colec-tomy within an enhanced recovery program. J Visc Surg. 2015;152:11-15. 200. Lawrence JK, Keller DS, Samia H, et al. Discharge within 24 to 72 hours of colorectal surgery is associated with low readmission rates when using Enhanced Recovery Pathways. J Am Coll Surg. 2013;216:390-394. 201. Pawa N, Cathcart PL, Arulampalam TH, et al. Enhanced recovery program following colorectal resection in the elderly patient. World J Surg. 2012;36:415-423. 202. Anderin K, Gustafsson UO, Thorell A, et al. The effect of diverting stoma on postoperative morbidity after low anterior resection for rectal cancer in patients treated within an ERAS program. Eur J Surg Oncol. 2015;41:724-730. 203. Group EC: the impact of enhanced recovery protocol compli-ance on elective colorectal cancer resection: results from an international registry. Ann Surg. 2015;261:1153-1159. 204. Bakker N, Cakir H, Doodeman HJ, et al. Eight years of expe-rience with enhanced recovery after
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Surgery_Schwartz_13927
Surgery_Schwartz
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Surgery_Schwartz. colorectal cancer resection: results from an international registry. Ann Surg. 2015;261:1153-1159. 204. Bakker N, Cakir H, Doodeman HJ, et al. Eight years of expe-rience with enhanced recovery after surgery in patients with colon cancer: impact of measures to improve adherence. Surgery. 2015;157:1130-1136. 205. Boulind CE, Yeo M, Burkill C, et al. Factors predicting devia-tion from an enhanced recovery programme and delayed dis-charge after laparoscopic colorectal surgery. Colorectal Dis. 2012;14:e103-110. 206. Keller DS, Bankwitz B, Woconish D, et al. Predicting who will fail early discharge after laparoscopic colorectal surgery with an established enhanced recovery pathway. Surg Endosc. 2014;28:74-79. 207. Oh HK, Ihn MH, Son IT, et al. Factors associated with failure of enhanced recovery programs after laparoscopic colon can-cer surgery: a single-center retrospective study. Surg Endosc. 2016;30:1086-1093. 208. Smart NJ, White P, Allison AS, et al. Deviation and failure of enhanced
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Surgery_Schwartz_13928
Surgery_Schwartz
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Surgery_Schwartz_13929
Surgery_Schwartz
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Surgery_Schwartz. review of economic evaluations of enhanced recovery pathways for colorectal sur-gery. Ann Surg. 2014;259:670-676. 212. van Dam RM, Hendry PO, Coolsen MM, et al. Initial experience with a multimodal enhanced recovery pro-gramme in patients undergoing liver resection. Br J Surg. 2008;95:969-975. 213. Jones C, Kelliher L, Dickinson M, et al. Randomized clini-cal trial on enhanced recovery versus standard care following open liver resection. Br J Surg. 2013;100:1015-1024. 214. Ni TG, Yang HT, Zhang H, et al. Enhanced recovery after sur-gery programs in patients undergoing hepatectomy: a meta-analysis. World J Gastroenterol. 2015;21:9209-9216. 215. Wang C, Zheng G, Zhang W, et al. Enhanced recovery after surgery programs for liver resection: a meta-analysis. J Gas-trointest Surg. 2017;21:472-486. 216. Yang R, Tao W, Chen YY, et al. Enhanced recovery after surgery programs versus traditional perioperative care in laparoscopic hepatectomy: a meta-analysis. Int J Surg. 2016;
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Surgery_Schwartz_13930
Surgery_Schwartz
2017;21:472-486. 216. Yang R, Tao W, Chen YY, et al. Enhanced recovery after surgery programs versus traditional perioperative care in laparoscopic hepatectomy: a meta-analysis. Int J Surg. 2016; 36:274-282. 217. Xu X, Wang Y, Feng T, et al. Nonstrict and individual enhanced recovery after surgery (ERAS) in partial hepatec-tomy. Springerplus. 2016;5:2011. 218. Balzano G, Zerbi A, Braga M, et al. Fast-track recovery pro-gramme after pancreaticoduodenectomy reduces delayed gastric emptying. Br J Surg. 2008;95:1387-1393. 219. Zouros E, Liakakos T, Machairas A, et al. Improvement of gastric emptying by enhanced recovery after pancreaticoduo-denectomy. Hepatobiliary Pancreat Dis Int. 2016;15:198-208. 220. Abu Hilal M, Di Fabio F, Badran A, et al. Implementation of enhanced recovery programme after pancreatoduodenectomy: a single-centre UK pilot study. Pancreatology. 2013;13:58-62. 221. Braga M, Pecorelli N, Ariotti R, et al. Enhanced recovery after surgery pathway in patients undergoing
Surgery_Schwartz. 2017;21:472-486. 216. Yang R, Tao W, Chen YY, et al. Enhanced recovery after surgery programs versus traditional perioperative care in laparoscopic hepatectomy: a meta-analysis. Int J Surg. 2016; 36:274-282. 217. Xu X, Wang Y, Feng T, et al. Nonstrict and individual enhanced recovery after surgery (ERAS) in partial hepatec-tomy. Springerplus. 2016;5:2011. 218. Balzano G, Zerbi A, Braga M, et al. Fast-track recovery pro-gramme after pancreaticoduodenectomy reduces delayed gastric emptying. Br J Surg. 2008;95:1387-1393. 219. Zouros E, Liakakos T, Machairas A, et al. Improvement of gastric emptying by enhanced recovery after pancreaticoduo-denectomy. Hepatobiliary Pancreat Dis Int. 2016;15:198-208. 220. Abu Hilal M, Di Fabio F, Badran A, et al. Implementation of enhanced recovery programme after pancreatoduodenectomy: a single-centre UK pilot study. Pancreatology. 2013;13:58-62. 221. Braga M, Pecorelli N, Ariotti R, et al. Enhanced recovery after surgery pathway in patients undergoing
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Surgery_Schwartz_13931
Surgery_Schwartz
after pancreatoduodenectomy: a single-centre UK pilot study. Pancreatology. 2013;13:58-62. 221. Braga M, Pecorelli N, Ariotti R, et al. Enhanced recovery after surgery pathway in patients undergoing pancreaticoduodenec-tomy. World J Surg. 2014;38:2960-2966.Brunicardi_Ch50_p2113-p2136.indd 213301/03/19 9:39 AM 2134SPECIFIC CONSIDERATIONSPART II 222. Coolsen MM, van Dam RM, Chigharoe A, et al. Improving outcome after pancreaticoduodenectomy: experiences with implementing an enhanced recovery after surgery (ERAS) program. Dig Surg. 2014;31:177-184. 223. Dai J, Jiang Y, Fu D. Reducing postoperative complications and improving clinical outcome: enhanced recovery after surgery in pancreaticoduodenectomy—a retrospective cohort study. Int J Surg. 2017;39:176-181. 224. Morgan KA, Lancaster WP, Walters ML, et al. Enhanced recovery after surgery protocols are valuable in pancreas sur-gery patients. J Am Coll Surg. 2016;222:658-664. 225. Pecorelli N, Capretti G, Balzano G, et al. Enhanced
Surgery_Schwartz. after pancreatoduodenectomy: a single-centre UK pilot study. Pancreatology. 2013;13:58-62. 221. Braga M, Pecorelli N, Ariotti R, et al. Enhanced recovery after surgery pathway in patients undergoing pancreaticoduodenec-tomy. World J Surg. 2014;38:2960-2966.Brunicardi_Ch50_p2113-p2136.indd 213301/03/19 9:39 AM 2134SPECIFIC CONSIDERATIONSPART II 222. Coolsen MM, van Dam RM, Chigharoe A, et al. Improving outcome after pancreaticoduodenectomy: experiences with implementing an enhanced recovery after surgery (ERAS) program. Dig Surg. 2014;31:177-184. 223. Dai J, Jiang Y, Fu D. Reducing postoperative complications and improving clinical outcome: enhanced recovery after surgery in pancreaticoduodenectomy—a retrospective cohort study. Int J Surg. 2017;39:176-181. 224. Morgan KA, Lancaster WP, Walters ML, et al. Enhanced recovery after surgery protocols are valuable in pancreas sur-gery patients. J Am Coll Surg. 2016;222:658-664. 225. Pecorelli N, Capretti G, Balzano G, et al. Enhanced
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Surgery_Schwartz_13932
Surgery_Schwartz
WP, Walters ML, et al. Enhanced recovery after surgery protocols are valuable in pancreas sur-gery patients. J Am Coll Surg. 2016;222:658-664. 225. Pecorelli N, Capretti G, Balzano G, et al. Enhanced recovery pathway in patients undergoing distal pancreatectomy: a case-matched study. HPB (Oxford). 2017;19:270-278. 226. Richardson J, Di Fabio F, Clarke H, et al. Implementation of enhanced recovery programme for laparoscopic distal pancre-atectomy: feasibility, safety and cost analysis. Pancreatology. 2015;15:185-190. 227. Coolsen MM, van Dam RM, van der Wilt AA, et al. Sys-tematic review and meta-analysis of enhanced recovery after pancreatic surgery with particular emphasis on pancreatico-duodenectomies. World J Surg. 2013;37:1909-1918. 228. Kagedan DJ, Ahmed M, Devitt KS, et al. Enhanced recovery after pancreatic surgery: a systematic review of the evidence. HPB (Oxford). 2015;17:11-16. 229. Lei Q, Wang X, Tan S, et al. Application of enhanced recovery after surgery program in
Surgery_Schwartz. WP, Walters ML, et al. Enhanced recovery after surgery protocols are valuable in pancreas sur-gery patients. J Am Coll Surg. 2016;222:658-664. 225. Pecorelli N, Capretti G, Balzano G, et al. Enhanced recovery pathway in patients undergoing distal pancreatectomy: a case-matched study. HPB (Oxford). 2017;19:270-278. 226. Richardson J, Di Fabio F, Clarke H, et al. Implementation of enhanced recovery programme for laparoscopic distal pancre-atectomy: feasibility, safety and cost analysis. Pancreatology. 2015;15:185-190. 227. Coolsen MM, van Dam RM, van der Wilt AA, et al. Sys-tematic review and meta-analysis of enhanced recovery after pancreatic surgery with particular emphasis on pancreatico-duodenectomies. World J Surg. 2013;37:1909-1918. 228. Kagedan DJ, Ahmed M, Devitt KS, et al. Enhanced recovery after pancreatic surgery: a systematic review of the evidence. HPB (Oxford). 2015;17:11-16. 229. Lei Q, Wang X, Tan S, et al. Application of enhanced recovery after surgery program in
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Surgery_Schwartz_13933
Surgery_Schwartz
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Surgery_Schwartz_13934
Surgery_Schwartz
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Surgery_Schwartz_13935
Surgery_Schwartz
review and meta-analysis of enhanced recovery programmes in gas-tric cancer surgery. Int J Surg. 2015;19:46-54. 237. Chen ZX, Liu AH, Cen Y. Fast-track program vs traditional care in surgery for gastric cancer. World J Gastroenterol. 2014;20:578-583. 238. Makuuchi R, Sugisawa N, Kaji S, et al. Enhanced recov-ery after surgery for gastric cancer and an assessment of preoperative carbohydrate loading. Eur J Surg Oncol. 2017;43:210-217. 239. Mortensen K, Nilsson M, Slim K, et al. Consensus guidelines for enhanced recovery after gastrectomy: Enhanced Recov-ery After Surgery (ERAS[R]) Society recommendations. Br J Surg. 2014;101:1209-1229. 240. Gemmill EH, Humes DJ, Catton JA. Systematic review of enhanced recovery after gastro-oesophageal cancer surgery. Ann R Coll Surg Engl. 2015;97:173-179. 241. Ford SJ, Adams D, Dudnikov S, et al. The implementation and effectiveness of an enhanced recovery programme after oesophago-gastrectomy: a prospective cohort study. Int J Surg.
Surgery_Schwartz. review and meta-analysis of enhanced recovery programmes in gas-tric cancer surgery. Int J Surg. 2015;19:46-54. 237. Chen ZX, Liu AH, Cen Y. Fast-track program vs traditional care in surgery for gastric cancer. World J Gastroenterol. 2014;20:578-583. 238. Makuuchi R, Sugisawa N, Kaji S, et al. Enhanced recov-ery after surgery for gastric cancer and an assessment of preoperative carbohydrate loading. Eur J Surg Oncol. 2017;43:210-217. 239. Mortensen K, Nilsson M, Slim K, et al. Consensus guidelines for enhanced recovery after gastrectomy: Enhanced Recov-ery After Surgery (ERAS[R]) Society recommendations. Br J Surg. 2014;101:1209-1229. 240. Gemmill EH, Humes DJ, Catton JA. Systematic review of enhanced recovery after gastro-oesophageal cancer surgery. Ann R Coll Surg Engl. 2015;97:173-179. 241. Ford SJ, Adams D, Dudnikov S, et al. The implementation and effectiveness of an enhanced recovery programme after oesophago-gastrectomy: a prospective cohort study. Int J Surg.
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Surgery_Schwartz_13936
Surgery_Schwartz
2015;97:173-179. 241. Ford SJ, Adams D, Dudnikov S, et al. The implementation and effectiveness of an enhanced recovery programme after oesophago-gastrectomy: a prospective cohort study. Int J Surg. 2014;12:320-324. 242. Schmidt HM, El Lakis MA, Markar SR, et al. accelerated recovery within standardized recovery pathways after esopha-gectomy: a prospective cohort study assessing the effects of early discharge on outcomes, readmissions, patient satisfac-tion, and costs. Ann Thorac Surg. 2016;102:931-939. 243. Tang J, Humes DJ, Gemmil E, et al. Reduction in length of stay for patients undergoing oesophageal and gastric resec-tions with implementation of enhanced recovery packages. Ann R Coll Surg Engl. 2013;95:323-328. 244. Findlay JM, Gillies RS, Millo J, et al. Enhanced recovery for esophagectomy: a systematic review and evidence-based guidelines. Ann Surg. 2014;259:413-431. 245. Markar SR, Karthikesalingam A, Low DE. Enhanced recovery pathways lead to an improvement in postoperative
Surgery_Schwartz. 2015;97:173-179. 241. Ford SJ, Adams D, Dudnikov S, et al. The implementation and effectiveness of an enhanced recovery programme after oesophago-gastrectomy: a prospective cohort study. Int J Surg. 2014;12:320-324. 242. Schmidt HM, El Lakis MA, Markar SR, et al. accelerated recovery within standardized recovery pathways after esopha-gectomy: a prospective cohort study assessing the effects of early discharge on outcomes, readmissions, patient satisfac-tion, and costs. Ann Thorac Surg. 2016;102:931-939. 243. Tang J, Humes DJ, Gemmil E, et al. Reduction in length of stay for patients undergoing oesophageal and gastric resec-tions with implementation of enhanced recovery packages. Ann R Coll Surg Engl. 2013;95:323-328. 244. Findlay JM, Gillies RS, Millo J, et al. Enhanced recovery for esophagectomy: a systematic review and evidence-based guidelines. Ann Surg. 2014;259:413-431. 245. Markar SR, Karthikesalingam A, Low DE. Enhanced recovery pathways lead to an improvement in postoperative
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Surgery_Schwartz_13937
Surgery_Schwartz
a systematic review and evidence-based guidelines. Ann Surg. 2014;259:413-431. 245. Markar SR, Karthikesalingam A, Low DE. Enhanced recovery pathways lead to an improvement in postoperative outcomes following esophagectomy: systematic review and pooled anal-ysis. Dis Esophagus. 2015;28:468-475. 246. Barreca M, Renzi C, Tankel J, et al. Is there a role for enhanced recovery after laparoscopic bariatric surgery? Preliminary results from a specialist obesity treatment center. Surg Obes Relat Dis. 2016;12:119-126. 247. Hahl T, Peromaa-Haavisto P, Tarkiainen P, et al. Outcome of laparoscopic gastric bypass (LRYGB) with a program for enhanced recovery after surgery (ERAS). Obes Surg. 2016;26:505-511. 248. Lemanu DP, Singh PP, Berridge K, et al. Randomized clinical trial of enhanced recovery versus standard care after laparo-scopic sleeve gastrectomy. Br J Surg. 2013;100:482-489. 249. Rickey J, Gersin K, Yang W, et al. Early discharge in the bar-iatric population does not increase
Surgery_Schwartz. a systematic review and evidence-based guidelines. Ann Surg. 2014;259:413-431. 245. Markar SR, Karthikesalingam A, Low DE. Enhanced recovery pathways lead to an improvement in postoperative outcomes following esophagectomy: systematic review and pooled anal-ysis. Dis Esophagus. 2015;28:468-475. 246. Barreca M, Renzi C, Tankel J, et al. Is there a role for enhanced recovery after laparoscopic bariatric surgery? Preliminary results from a specialist obesity treatment center. Surg Obes Relat Dis. 2016;12:119-126. 247. Hahl T, Peromaa-Haavisto P, Tarkiainen P, et al. Outcome of laparoscopic gastric bypass (LRYGB) with a program for enhanced recovery after surgery (ERAS). Obes Surg. 2016;26:505-511. 248. Lemanu DP, Singh PP, Berridge K, et al. Randomized clinical trial of enhanced recovery versus standard care after laparo-scopic sleeve gastrectomy. Br J Surg. 2013;100:482-489. 249. Rickey J, Gersin K, Yang W, et al. Early discharge in the bar-iatric population does not increase
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Surgery_Schwartz_13938
Surgery_Schwartz
versus standard care after laparo-scopic sleeve gastrectomy. Br J Surg. 2013;100:482-489. 249. Rickey J, Gersin K, Yang W, et al. Early discharge in the bar-iatric population does not increase post-discharge resource utilization. Surg Endosc. 2017;31:618-624. 250. Malczak P, Pisarska M, Piotr M, et al. Enhanced recovery after bariatric surgery: systematic review and meta-analysis. Obes Surg. 2017;27:226-235. 251. Singh PM, Panwar R, Borle A, et al. Efficiency and safety effects of applying ERAS protocols to bariatric surgery: a sys-tematic review with meta-analysis and trial sequential analysis of evidence. Obes Surg. 2017;27:489-501. 252. Fayezizadeh M, Petro CC, Rosen MJ, et al. Enhanced recov-ery after surgery pathway for abdominal wall reconstruction: pilot study and preliminary outcomes. Plast Reconstr Surg. 2014;134:151S-159S. 253. Jensen KK, Brondum TL, Harling H, et al. Enhanced recovery after giant ventral hernia repair. Hernia. 2016;20:249-256. 254. Majumder A, Fayezizadeh
Surgery_Schwartz. versus standard care after laparo-scopic sleeve gastrectomy. Br J Surg. 2013;100:482-489. 249. Rickey J, Gersin K, Yang W, et al. Early discharge in the bar-iatric population does not increase post-discharge resource utilization. Surg Endosc. 2017;31:618-624. 250. Malczak P, Pisarska M, Piotr M, et al. Enhanced recovery after bariatric surgery: systematic review and meta-analysis. Obes Surg. 2017;27:226-235. 251. Singh PM, Panwar R, Borle A, et al. Efficiency and safety effects of applying ERAS protocols to bariatric surgery: a sys-tematic review with meta-analysis and trial sequential analysis of evidence. Obes Surg. 2017;27:489-501. 252. Fayezizadeh M, Petro CC, Rosen MJ, et al. Enhanced recov-ery after surgery pathway for abdominal wall reconstruction: pilot study and preliminary outcomes. Plast Reconstr Surg. 2014;134:151S-159S. 253. Jensen KK, Brondum TL, Harling H, et al. Enhanced recovery after giant ventral hernia repair. Hernia. 2016;20:249-256. 254. Majumder A, Fayezizadeh
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Surgery_Schwartz_13939
Surgery_Schwartz
Plast Reconstr Surg. 2014;134:151S-159S. 253. Jensen KK, Brondum TL, Harling H, et al. Enhanced recovery after giant ventral hernia repair. Hernia. 2016;20:249-256. 254. Majumder A, Fayezizadeh M, Neupane R, et al. Ben-efits of multimodal enhanced recovery pathway in patients undergoing open ventral hernia repair. J Am Coll Surg. 2016;222:1106-1115. 255. Arumainayagam N, McGrath J, Jefferson KP, et al. Introduc-tion of an enhanced recovery protocol for radical cystectomy. BJU Int. 2008;101:698-701. 256. Cerruto MA, De Marco V, D’Elia C, et al. Fast track surgery to reduce short-term complications following radical cystectomy and intestinal urinary diversion with Vescica Ileale Padovana neobladder: proposal for a tailored enhanced recovery pro-tocol and preliminary report from a pilot study. Urol Int. 2014;92:41-49. 257. Mukhtar S, Ayres BE, Issa R, et al. Challenging boundaries: an enhanced recovery programme for radical cystectomy. Ann R Coll Surg Engl. 2013;95:200-206. 258. Campos
Surgery_Schwartz. Plast Reconstr Surg. 2014;134:151S-159S. 253. Jensen KK, Brondum TL, Harling H, et al. Enhanced recovery after giant ventral hernia repair. Hernia. 2016;20:249-256. 254. Majumder A, Fayezizadeh M, Neupane R, et al. Ben-efits of multimodal enhanced recovery pathway in patients undergoing open ventral hernia repair. J Am Coll Surg. 2016;222:1106-1115. 255. Arumainayagam N, McGrath J, Jefferson KP, et al. Introduc-tion of an enhanced recovery protocol for radical cystectomy. BJU Int. 2008;101:698-701. 256. Cerruto MA, De Marco V, D’Elia C, et al. Fast track surgery to reduce short-term complications following radical cystectomy and intestinal urinary diversion with Vescica Ileale Padovana neobladder: proposal for a tailored enhanced recovery pro-tocol and preliminary report from a pilot study. Urol Int. 2014;92:41-49. 257. Mukhtar S, Ayres BE, Issa R, et al. Challenging boundaries: an enhanced recovery programme for radical cystectomy. Ann R Coll Surg Engl. 2013;95:200-206. 258. Campos
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Surgery_Schwartz_13940
Surgery_Schwartz
Urol Int. 2014;92:41-49. 257. Mukhtar S, Ayres BE, Issa R, et al. Challenging boundaries: an enhanced recovery programme for radical cystectomy. Ann R Coll Surg Engl. 2013;95:200-206. 258. Campos PAC, Martinez JG, Fernandez PJG, et al. Periop-erative fast track program in intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC) after cytoreduc-tive surgery in advanced ovarian cancer. Eur J Surg Oncol. 2011;37:543-548.Brunicardi_Ch50_p2113-p2136.indd 213401/03/19 9:39 AM 2135OPTIMIZING PERIOPERATIVE CARE: ENHANCED RECOVERY AND CHINESE MEDICINECHAPTER 50 259. Chapman JS, Roddy E, Ueda S, et al. enhanced recovery path-ways for improving outcomes after minimally invasive gyne-cologic oncology surgery. Obstet Gynecol. 2016;128:138-144. 260. de Groot JJ, van Es LE, Maessen JM, et al. Diffusion of Enhanced Recovery principles in gynecologic oncology sur-gery: is active implementation still necessary? Gynecol Oncol. 2014;134:570-575. 261. Lindemann K, Kok PS, Stockler M, et al.
Surgery_Schwartz. Urol Int. 2014;92:41-49. 257. Mukhtar S, Ayres BE, Issa R, et al. Challenging boundaries: an enhanced recovery programme for radical cystectomy. Ann R Coll Surg Engl. 2013;95:200-206. 258. Campos PAC, Martinez JG, Fernandez PJG, et al. Periop-erative fast track program in intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC) after cytoreduc-tive surgery in advanced ovarian cancer. Eur J Surg Oncol. 2011;37:543-548.Brunicardi_Ch50_p2113-p2136.indd 213401/03/19 9:39 AM 2135OPTIMIZING PERIOPERATIVE CARE: ENHANCED RECOVERY AND CHINESE MEDICINECHAPTER 50 259. Chapman JS, Roddy E, Ueda S, et al. enhanced recovery path-ways for improving outcomes after minimally invasive gyne-cologic oncology surgery. Obstet Gynecol. 2016;128:138-144. 260. de Groot JJ, van Es LE, Maessen JM, et al. Diffusion of Enhanced Recovery principles in gynecologic oncology sur-gery: is active implementation still necessary? Gynecol Oncol. 2014;134:570-575. 261. Lindemann K, Kok PS, Stockler M, et al.
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Surgery_Schwartz_13941
Surgery_Schwartz
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Surgery_Schwartz. al. Diffusion of Enhanced Recovery principles in gynecologic oncology sur-gery: is active implementation still necessary? Gynecol Oncol. 2014;134:570-575. 261. Lindemann K, Kok PS, Stockler M, et al. enhanced recov-ery after surgery for advanced ovarian cancer: a system-atic review of interventions trialed. Int J Gynecol Cancer. 2017;27:1274-1282. 262. Marx C, Rasmussen T, Jakobsen DH, et al. The effect of accel-erated rehabilitation on recovery after surgery for ovarian malignancy. Acta Obstet Gynecol Scand. 2006;85:488-492. 263. Wijk L, Franzen K, Ljungqvist O, et al. Implementing a structured enhanced recovery after surgery (ERAS) protocol reduces length of stay after abdominal hysterectomy. Acta Obstet Gynecol Scand. 2014;93:749-756. 264. Khan SK, Malviya A, Muller SD, et al. Reduced short-term complications and mortality following enhanced recovery pri-mary hip and knee arthroplasty: results from 6,000 consecu-tive procedures. Acta Orthop. 2014;85:26-31. 265. Scott NB, McDonald
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Surgery_Schwartz_13943
Surgery_Schwartz
medicine: two kinds of philosophies and two different cultures of medicine. Journal of Zhengzhou University of Light Industry (Social Science). 2012;13:7-12. 269. Yue X. The Historical stages of the formation and develop-ment of traditional Chinese medicine. Guangming Journal of Chinese Medicine(CJGMCM). 2012;27:207-210. 270. Tong X, Zhang Z, Li A. The confusion of chinese medicine development and its countermeasures. Chinese Journal of Basic Medicine in Traditional Chinese Medicine. 2003;9:52-55. 271. Geng D. Research progress of shiquan dabu decoction. Chinese Traditional Patient Medicine. 2003;25:837-840. 272. Han D, Chen Z, Xing B. Therapeutic rules of analogous pre-scriptions for tonify and replenish the middle qi. Chinese Archives of Traditional Chinese Medicine. 2010;28:595-598. 273. Liu K, Wang B. Influences of Buzhong Yiqi Decoction on gastrointestinal feunction and nutrition status of gastric carcinoma after operation. Chinese Journal of Experimental Traditional Medical
Surgery_Schwartz. medicine: two kinds of philosophies and two different cultures of medicine. Journal of Zhengzhou University of Light Industry (Social Science). 2012;13:7-12. 269. Yue X. The Historical stages of the formation and develop-ment of traditional Chinese medicine. Guangming Journal of Chinese Medicine(CJGMCM). 2012;27:207-210. 270. Tong X, Zhang Z, Li A. The confusion of chinese medicine development and its countermeasures. Chinese Journal of Basic Medicine in Traditional Chinese Medicine. 2003;9:52-55. 271. Geng D. Research progress of shiquan dabu decoction. Chinese Traditional Patient Medicine. 2003;25:837-840. 272. Han D, Chen Z, Xing B. Therapeutic rules of analogous pre-scriptions for tonify and replenish the middle qi. Chinese Archives of Traditional Chinese Medicine. 2010;28:595-598. 273. Liu K, Wang B. Influences of Buzhong Yiqi Decoction on gastrointestinal feunction and nutrition status of gastric carcinoma after operation. Chinese Journal of Experimental Traditional Medical
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Surgery_Schwartz_13944
Surgery_Schwartz
K, Wang B. Influences of Buzhong Yiqi Decoction on gastrointestinal feunction and nutrition status of gastric carcinoma after operation. Chinese Journal of Experimental Traditional Medical Formulae. 2015;21:152-156. 274. Su P, Li W. The effect of Shiquan Dabu Decoction tegether with enteral nutrition for patients with lung cancer after sur-gery. Journal of Nanjing University of Traditional Chinese Medicine. 2015;31:17-20. 275. Yang A, Xiang F, Yang L. Effect of Shiquan Dabu Tang com-bined with Wuwei Xiaodu Yin on immune functions in post-operative Qi and blood deficiency patients with esophagus cancer. Chinese Journal of Experimental Traditional Medical Formulae. 2016;22:174-178. 276. Cui J. The effects of Shenmai injection on cellular immuno-logic function in the perioperative patients with gastroentero-logical tumors. Pract Clin Med. 2007;8:39-41. 277. Liang C. Clinical observation on the protective effect of huangqi injection on the myocardium of coronary heart dis-ease in the
Surgery_Schwartz. K, Wang B. Influences of Buzhong Yiqi Decoction on gastrointestinal feunction and nutrition status of gastric carcinoma after operation. Chinese Journal of Experimental Traditional Medical Formulae. 2015;21:152-156. 274. Su P, Li W. The effect of Shiquan Dabu Decoction tegether with enteral nutrition for patients with lung cancer after sur-gery. Journal of Nanjing University of Traditional Chinese Medicine. 2015;31:17-20. 275. Yang A, Xiang F, Yang L. Effect of Shiquan Dabu Tang com-bined with Wuwei Xiaodu Yin on immune functions in post-operative Qi and blood deficiency patients with esophagus cancer. Chinese Journal of Experimental Traditional Medical Formulae. 2016;22:174-178. 276. Cui J. The effects of Shenmai injection on cellular immuno-logic function in the perioperative patients with gastroentero-logical tumors. Pract Clin Med. 2007;8:39-41. 277. Liang C. Clinical observation on the protective effect of huangqi injection on the myocardium of coronary heart dis-ease in the
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Surgery_Schwartz_13945
Surgery_Schwartz
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Surgery_Schwartz_13946
Surgery_Schwartz
Journal of Surgery of Integrated Traditional and Western Medicine. 1996;2:355-357. 282. Li X. Flavored pure ginseng decoction treating 75 cases of traumatic shock. Journal of Emergency in Traditional Chinese Medicine. 2003;12:413. 283. Ji C, Liu J, Chen H. Effect of Qingdan Decoction combined with biliary decompression on the liver function and inflam-matory factors in acute cholangitis severe type rats. Journal of Traditional Chinese Medicine. 2013;54:512-515. 284. Wang X, Zhang X. The effect of Qingyi decoction on bacte-rial and endotoxin translocation from intestine in acute hem-orrhagic necrotizing pancreatitis in rat. Chinese Journal of General Surgery. 2010;19:255-258. 285. Yao G, Wu X. Clinical study of treatment of severe acute pancreatitis with Qingyi decoction. Chinese Journal of Surgery of Integrated Traditional and Western Medicine. 1997;3:244-246. 286. Han J. Research on acupuncture anesthesia-analgesia. Acupunct Res. 2016;41:377-387. 287. Arranz L, Guayerbas N, Siboni L.
Surgery_Schwartz. Journal of Surgery of Integrated Traditional and Western Medicine. 1996;2:355-357. 282. Li X. Flavored pure ginseng decoction treating 75 cases of traumatic shock. Journal of Emergency in Traditional Chinese Medicine. 2003;12:413. 283. Ji C, Liu J, Chen H. Effect of Qingdan Decoction combined with biliary decompression on the liver function and inflam-matory factors in acute cholangitis severe type rats. Journal of Traditional Chinese Medicine. 2013;54:512-515. 284. Wang X, Zhang X. The effect of Qingyi decoction on bacte-rial and endotoxin translocation from intestine in acute hem-orrhagic necrotizing pancreatitis in rat. Chinese Journal of General Surgery. 2010;19:255-258. 285. Yao G, Wu X. Clinical study of treatment of severe acute pancreatitis with Qingyi decoction. Chinese Journal of Surgery of Integrated Traditional and Western Medicine. 1997;3:244-246. 286. Han J. Research on acupuncture anesthesia-analgesia. Acupunct Res. 2016;41:377-387. 287. Arranz L, Guayerbas N, Siboni L.
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Surgery_Schwartz_13947
Surgery_Schwartz
Surgery of Integrated Traditional and Western Medicine. 1997;3:244-246. 286. Han J. Research on acupuncture anesthesia-analgesia. Acupunct Res. 2016;41:377-387. 287. Arranz L, Guayerbas N, Siboni L. Effect of acupuncture treat-ment on the immune function impairment found in anxious women. Am J Chinese Med. 2007;35:35-51. 288. Liu Y. The effect of transcutaneous electroacupuncture on serum level of glucocose and cortisol in patient underwent thyroidectomy. Chinese Journal of Traditional Medical Science and Technology. 2013;20:180-181. 289. Sun Y, Gan TJ, Dubose JW, et al. Acupuncture and related techniques for postoperative pain: a systematic review of randomized controlled trials. Br J Anaesth. 2008;101:151-160. 290. Zhang Q, Gao Z, Wang H, et al. The effect of pre-treatment with transcutaneous electrical acupoint stimulation on the quality of recovery after ambulatory breast surgery: a pro-spective, randomised controlled trial. Anaesthesia. 2014;69: 832-839. 291. Zou D, Chen WH,
Surgery_Schwartz. Surgery of Integrated Traditional and Western Medicine. 1997;3:244-246. 286. Han J. Research on acupuncture anesthesia-analgesia. Acupunct Res. 2016;41:377-387. 287. Arranz L, Guayerbas N, Siboni L. Effect of acupuncture treat-ment on the immune function impairment found in anxious women. Am J Chinese Med. 2007;35:35-51. 288. Liu Y. The effect of transcutaneous electroacupuncture on serum level of glucocose and cortisol in patient underwent thyroidectomy. Chinese Journal of Traditional Medical Science and Technology. 2013;20:180-181. 289. Sun Y, Gan TJ, Dubose JW, et al. Acupuncture and related techniques for postoperative pain: a systematic review of randomized controlled trials. Br J Anaesth. 2008;101:151-160. 290. Zhang Q, Gao Z, Wang H, et al. The effect of pre-treatment with transcutaneous electrical acupoint stimulation on the quality of recovery after ambulatory breast surgery: a pro-spective, randomised controlled trial. Anaesthesia. 2014;69: 832-839. 291. Zou D, Chen WH,
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Surgery_Schwartz_13948
Surgery_Schwartz
electrical acupoint stimulation on the quality of recovery after ambulatory breast surgery: a pro-spective, randomised controlled trial. Anaesthesia. 2014;69: 832-839. 291. Zou D, Chen WH, Iwakiri K, et al. Inhibition of transient lower esophageal sphincter relaxations by electrical acu-point stimulation. Am J Physiol Gastrointest Liver Physiol. 2005;289:G197-G201. 292. Shiotani A, Tatewaki M, Hoshino E, et al. Effects of elec-troacupuncture on gastric myoelectrical activity in healthy humans. Neurogastroenterol Motil. 2004;16:293-298. 293. Tatewaki M, Strickland C, Fukuda H, et al. Effects of acupuncture on vasopressin-induced emesis in con-scious dogs. Am J Physiol Regul Integr Comp Physiol. 2005;288:R401-R408. 294. Arnberger M, Stadelmann K, Alischer P, et al. Monitoring of neuromuscular blockade at the P6 acupuncture point reduces the incidence of postoperative nausea and vomiting. Anesthe-siology. 2007;107:903-908. 295. El-Deeb AM, Ahmady MS. Effect of acupuncture on nausea
Surgery_Schwartz. electrical acupoint stimulation on the quality of recovery after ambulatory breast surgery: a pro-spective, randomised controlled trial. Anaesthesia. 2014;69: 832-839. 291. Zou D, Chen WH, Iwakiri K, et al. Inhibition of transient lower esophageal sphincter relaxations by electrical acu-point stimulation. Am J Physiol Gastrointest Liver Physiol. 2005;289:G197-G201. 292. Shiotani A, Tatewaki M, Hoshino E, et al. Effects of elec-troacupuncture on gastric myoelectrical activity in healthy humans. Neurogastroenterol Motil. 2004;16:293-298. 293. Tatewaki M, Strickland C, Fukuda H, et al. Effects of acupuncture on vasopressin-induced emesis in con-scious dogs. Am J Physiol Regul Integr Comp Physiol. 2005;288:R401-R408. 294. Arnberger M, Stadelmann K, Alischer P, et al. Monitoring of neuromuscular blockade at the P6 acupuncture point reduces the incidence of postoperative nausea and vomiting. Anesthe-siology. 2007;107:903-908. 295. El-Deeb AM, Ahmady MS. Effect of acupuncture on nausea
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Surgery_Schwartz_13949
Surgery_Schwartz
blockade at the P6 acupuncture point reduces the incidence of postoperative nausea and vomiting. Anesthe-siology. 2007;107:903-908. 295. El-Deeb AM, Ahmady MS. Effect of acupuncture on nausea and/or vomiting during and after cesarean section in compari-son with ondansetron. J Anesth. 2011;25:698-703. 296. Feng C, Popovic J, Kline R, et al. auricular acupressure in the prevention of postoperative nausea and emesis a randomized controlled trial. Bull Hosp Jt Dis (2013). 2017;75:114-118. 297. Okuno S, Hirayama K, Inoue J. Effects of rikkunshito on the postoperative nausea and vomiting (PONV) after laparoscopic gynecological surgery. Masui. 2008;57:1502-1509.Brunicardi_Ch50_p2113-p2136.indd 213501/03/19 9:39 AM 2136SPECIFIC CONSIDERATIONSPART II 298. Zhang X, Zhang D, Yang Y. Effects of Houpupaiqi Heji on the gastrintestinal function of patients after gastric cancer surgery. Mod Oncol. 2015;23:1268-1270. 299. Zhang X, Yuan H, Qin W. Study on early enteral nutrition combined with
Surgery_Schwartz. blockade at the P6 acupuncture point reduces the incidence of postoperative nausea and vomiting. Anesthe-siology. 2007;107:903-908. 295. El-Deeb AM, Ahmady MS. Effect of acupuncture on nausea and/or vomiting during and after cesarean section in compari-son with ondansetron. J Anesth. 2011;25:698-703. 296. Feng C, Popovic J, Kline R, et al. auricular acupressure in the prevention of postoperative nausea and emesis a randomized controlled trial. Bull Hosp Jt Dis (2013). 2017;75:114-118. 297. Okuno S, Hirayama K, Inoue J. Effects of rikkunshito on the postoperative nausea and vomiting (PONV) after laparoscopic gynecological surgery. Masui. 2008;57:1502-1509.Brunicardi_Ch50_p2113-p2136.indd 213501/03/19 9:39 AM 2136SPECIFIC CONSIDERATIONSPART II 298. Zhang X, Zhang D, Yang Y. Effects of Houpupaiqi Heji on the gastrintestinal function of patients after gastric cancer surgery. Mod Oncol. 2015;23:1268-1270. 299. Zhang X, Yuan H, Qin W. Study on early enteral nutrition combined with
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Surgery_Schwartz_13951
Surgery_Schwartz
acupuncture or chewing gum alone on postop-erative ileus in colorectal cancer resection: a randomized trial. Sci Rep. 2017;7:37826. 303. Chen Z, Cao L, Wen Z, et al. Study of Evodia hot compress plus electro-acupuncture in patients who have undergone abdominal surgery. Int J Clin Exp Med. 2015;8:16167-16174. 304. Wu X. Practice of Abdominal Surgery. 3rd ed. Tianjin Science and Technology Press; 2004. 305. Cui Z, Kong D. 74 cases of biiliary liver abscess treated with integrated traditional and western medicine. Chinese Journal of Surgery of Integrated Traditional and Western Medicine. 2014;20:167-169. 306. Sun S, Xu W. Effects of TPN and immune regulator radix astragali on postoperative patients of obstructive jaundice. J Parenter Enteral Nutr. 2002;9:151-157. 307. Ma X, Yang W, Zhang X. The study of effect of shiquan dabu decoction in surgeical nutrition therapy. Beijing Journal of Traditional Chinese Medicine. 1991;4:31-32. 308. Dong Y, Cui Z. Acupuncture research on adhesive
Surgery_Schwartz. acupuncture or chewing gum alone on postop-erative ileus in colorectal cancer resection: a randomized trial. Sci Rep. 2017;7:37826. 303. Chen Z, Cao L, Wen Z, et al. Study of Evodia hot compress plus electro-acupuncture in patients who have undergone abdominal surgery. Int J Clin Exp Med. 2015;8:16167-16174. 304. Wu X. Practice of Abdominal Surgery. 3rd ed. Tianjin Science and Technology Press; 2004. 305. Cui Z, Kong D. 74 cases of biiliary liver abscess treated with integrated traditional and western medicine. Chinese Journal of Surgery of Integrated Traditional and Western Medicine. 2014;20:167-169. 306. Sun S, Xu W. Effects of TPN and immune regulator radix astragali on postoperative patients of obstructive jaundice. J Parenter Enteral Nutr. 2002;9:151-157. 307. Ma X, Yang W, Zhang X. The study of effect of shiquan dabu decoction in surgeical nutrition therapy. Beijing Journal of Traditional Chinese Medicine. 1991;4:31-32. 308. Dong Y, Cui Z. Acupuncture research on adhesive
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Surgery_Schwartz_13952
Surgery_Schwartz
X. The study of effect of shiquan dabu decoction in surgeical nutrition therapy. Beijing Journal of Traditional Chinese Medicine. 1991;4:31-32. 308. Dong Y, Cui Z. Acupuncture research on adhesive intestinal obstruction. Clin J Chinese Med. 2001;3:86-88. 309. Li G, Ma J, Shang H, et al. Application of Dechengqi decoc-tion in abdominal surgery. World Chinese Journal of Diges-tion. 2008;16:1672-1676. 310. Li H, Hong Y, Huang M. Clinical effect observation of Chinese herbal enema, external application and acupuncture in adhe-sive ileus. Journal of Guangzhou University of Traditional Chinese Medicine. 2007;24:282-285.Brunicardi_Ch50_p2113-p2136.indd 213601/03/19 9:39 AM
Surgery_Schwartz. X. The study of effect of shiquan dabu decoction in surgeical nutrition therapy. Beijing Journal of Traditional Chinese Medicine. 1991;4:31-32. 308. Dong Y, Cui Z. Acupuncture research on adhesive intestinal obstruction. Clin J Chinese Med. 2001;3:86-88. 309. Li G, Ma J, Shang H, et al. Application of Dechengqi decoc-tion in abdominal surgery. World Chinese Journal of Diges-tion. 2008;16:1672-1676. 310. Li H, Hong Y, Huang M. Clinical effect observation of Chinese herbal enema, external application and acupuncture in adhe-sive ileus. Journal of Guangzhou University of Traditional Chinese Medicine. 2007;24:282-285.Brunicardi_Ch50_p2113-p2136.indd 213601/03/19 9:39 AM
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Surgery_Schwartz_13953
Surgery_Schwartz
Understanding, Evaluating, and Using Evidence for Surgical PracticeAndrew J. Benjamin, Andrew B. Schneider, Jeffrey B. Matthews, and Gary An 51chapterINTRODUCTIONThe singular importance of this chapter rests on the following chain of reasoning:1. The state of surgical science and knowledge is constantly changing.2. The education of a surgeon is a continuous process.3. Surgeons need to know how to evaluate new surgical knowl-edge to maintain their education in order to best serve their patients.4. This chapter provides guidance as to how surgeons might navigate, interpret and apply this new knowledge.Notably, this reasoning also applies to the process of acquisition of new knowledge itself, which explains why this inaugural chapter on evidence-based medicine is occurring in the 11th edition of this book. Recognizing the impermanence and fluidity of knowledge is a critical insight for the responsible surgeon, but so too is realizing that “good practice” cannot occur without reference
Surgery_Schwartz. Understanding, Evaluating, and Using Evidence for Surgical PracticeAndrew J. Benjamin, Andrew B. Schneider, Jeffrey B. Matthews, and Gary An 51chapterINTRODUCTIONThe singular importance of this chapter rests on the following chain of reasoning:1. The state of surgical science and knowledge is constantly changing.2. The education of a surgeon is a continuous process.3. Surgeons need to know how to evaluate new surgical knowl-edge to maintain their education in order to best serve their patients.4. This chapter provides guidance as to how surgeons might navigate, interpret and apply this new knowledge.Notably, this reasoning also applies to the process of acquisition of new knowledge itself, which explains why this inaugural chapter on evidence-based medicine is occurring in the 11th edition of this book. Recognizing the impermanence and fluidity of knowledge is a critical insight for the responsible surgeon, but so too is realizing that “good practice” cannot occur without reference
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Surgery_Schwartz_13954
Surgery_Schwartz
of this book. Recognizing the impermanence and fluidity of knowledge is a critical insight for the responsible surgeon, but so too is realizing that “good practice” cannot occur without reference points as to what should be done given the current imperfect state of knowledge. These dual recognitions inform the organization of this chapter, which introduces and describes the currently accepted approach to evidence-based medicine, and then follows by noting a series of current issues that anticipate the likelihood that what is meant by “evidence-based medicine” will evolve over the coming years. Also note that this chapter is not intended to be a primer on statistics and clinical trial design; there are entire textbooks devoted to those subjects. Rather, this chapter will focus on how those tools are aggregated and presented in order to inform a surgeon how to keep abreast with current developments in practice.WHAT IS EVIDENCE-BASED MEDICINE?For centuries, the practice of medicine was
Surgery_Schwartz. of this book. Recognizing the impermanence and fluidity of knowledge is a critical insight for the responsible surgeon, but so too is realizing that “good practice” cannot occur without reference points as to what should be done given the current imperfect state of knowledge. These dual recognitions inform the organization of this chapter, which introduces and describes the currently accepted approach to evidence-based medicine, and then follows by noting a series of current issues that anticipate the likelihood that what is meant by “evidence-based medicine” will evolve over the coming years. Also note that this chapter is not intended to be a primer on statistics and clinical trial design; there are entire textbooks devoted to those subjects. Rather, this chapter will focus on how those tools are aggregated and presented in order to inform a surgeon how to keep abreast with current developments in practice.WHAT IS EVIDENCE-BASED MEDICINE?For centuries, the practice of medicine was
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Surgery_Schwartz_13955
Surgery_Schwartz
tools are aggregated and presented in order to inform a surgeon how to keep abreast with current developments in practice.WHAT IS EVIDENCE-BASED MEDICINE?For centuries, the practice of medicine was guided primarily by anecdotal experience, often based on rationales that did not arise from a rigorous scientific process and sustained by the fundamental barriers associated with being able to learn from one’s experience (e.g., cognitive bias). For example, treatments such as bloodletting and purging were based on ostensible prin-ciples of bodily humors originating from the Ancient Greeks, and persisted well into the 18th century despite repeated disas-trous outcomes. To a great degree, the goal of the Scientific Method, through its emphasis on skepticism and falsifiability, is predicated upon overriding observational/experiential bias by the application of rigorous methodology statistical analysis. The dangers of bias were recognized at the dawn of the Scien-tific Era, and continue to
Surgery_Schwartz. tools are aggregated and presented in order to inform a surgeon how to keep abreast with current developments in practice.WHAT IS EVIDENCE-BASED MEDICINE?For centuries, the practice of medicine was guided primarily by anecdotal experience, often based on rationales that did not arise from a rigorous scientific process and sustained by the fundamental barriers associated with being able to learn from one’s experience (e.g., cognitive bias). For example, treatments such as bloodletting and purging were based on ostensible prin-ciples of bodily humors originating from the Ancient Greeks, and persisted well into the 18th century despite repeated disas-trous outcomes. To a great degree, the goal of the Scientific Method, through its emphasis on skepticism and falsifiability, is predicated upon overriding observational/experiential bias by the application of rigorous methodology statistical analysis. The dangers of bias were recognized at the dawn of the Scien-tific Era, and continue to
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Surgery_Schwartz_13956
Surgery_Schwartz
overriding observational/experiential bias by the application of rigorous methodology statistical analysis. The dangers of bias were recognized at the dawn of the Scien-tific Era, and continue to manifest today (Box: The History and Sources of Bias in Biomedical Literature).Introduction2137What is Evidence-Based Medicine?2137Searching for Information: Patient/Population, Intervention, Comparison, and Outcome / 2139Types of Studies / 2139Hierarchies of Evidence / 2140Tools to Evaluate a Body of Evidence / 2140Synthesis of Evidence—Clinical Guidelines / 2142The Challenges of Applying EBM to Surgery2144Analysis of a Surgical Randomized Control Trial / 2144Internal Validity / 2144External Validity / 2146Additional Challenges to Conducting a Surgical RCT / 2146Use and Misuse of Statistical Significance2147Type I and Type II Errors / 2147P Values / 2147Alternative to P Values / 2148How do the Tools of EBM Perform?2148External Consistency / 2148Internal Consistency / 2148System
Surgery_Schwartz. overriding observational/experiential bias by the application of rigorous methodology statistical analysis. The dangers of bias were recognized at the dawn of the Scien-tific Era, and continue to manifest today (Box: The History and Sources of Bias in Biomedical Literature).Introduction2137What is Evidence-Based Medicine?2137Searching for Information: Patient/Population, Intervention, Comparison, and Outcome / 2139Types of Studies / 2139Hierarchies of Evidence / 2140Tools to Evaluate a Body of Evidence / 2140Synthesis of Evidence—Clinical Guidelines / 2142The Challenges of Applying EBM to Surgery2144Analysis of a Surgical Randomized Control Trial / 2144Internal Validity / 2144External Validity / 2146Additional Challenges to Conducting a Surgical RCT / 2146Use and Misuse of Statistical Significance2147Type I and Type II Errors / 2147P Values / 2147Alternative to P Values / 2148How do the Tools of EBM Perform?2148External Consistency / 2148Internal Consistency / 2148System
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Surgery_Schwartz_13957
Surgery_Schwartz
Significance2147Type I and Type II Errors / 2147P Values / 2147Alternative to P Values / 2148How do the Tools of EBM Perform?2148External Consistency / 2148Internal Consistency / 2148System Issues / 2148Validity / 2149Implications of EBM / 2149The Alternatives to EBM2149What can Researchers do to Improve the Validity of Research Findings?2149The History and Sources of Bias in Biomedical LiteratureIn Sir Francis Bacon’s initial description of the scientific method in his Novum Organum1 he notes what he terms the “idols of the mind,” in essence recognizing and classifying the sources of cognitive bias that limit the reliability of sub-jective observation and interpretation. These “idols” are:• Idols of the tribe (Idola tribus): A humans’ tendency to per-ceive more order and regularity in systems than truly exists, and arises from their preconceived ideas about things• Idols of the cave (Idola specus): Arising from an individ-ual’s personal limitations in reasoning due to particular
Surgery_Schwartz. Significance2147Type I and Type II Errors / 2147P Values / 2147Alternative to P Values / 2148How do the Tools of EBM Perform?2148External Consistency / 2148Internal Consistency / 2148System Issues / 2148Validity / 2149Implications of EBM / 2149The Alternatives to EBM2149What can Researchers do to Improve the Validity of Research Findings?2149The History and Sources of Bias in Biomedical LiteratureIn Sir Francis Bacon’s initial description of the scientific method in his Novum Organum1 he notes what he terms the “idols of the mind,” in essence recognizing and classifying the sources of cognitive bias that limit the reliability of sub-jective observation and interpretation. These “idols” are:• Idols of the tribe (Idola tribus): A humans’ tendency to per-ceive more order and regularity in systems than truly exists, and arises from their preconceived ideas about things• Idols of the cave (Idola specus): Arising from an individ-ual’s personal limitations in reasoning due to particular
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Surgery_Schwartz_13958
Surgery_Schwartz
systems than truly exists, and arises from their preconceived ideas about things• Idols of the cave (Idola specus): Arising from an individ-ual’s personal limitations in reasoning due to particular personalities, subjective likes and dislikesBrunicardi_Ch51_p2137-p2152.indd 213728/02/19 4:19 PM 2138• Idols of the marketplace (Idola fori): Arising from the con-fusion in the use of language and taking some words in sci-ence to have a different meaning than their common usage• Idols of the theatre (Idola theatri): Arising from the following of academic dogma and not asking questions about the worldThese descriptions still resonate today, illustrating just how long the dangers of cognitive bias have been recognized, and just how embedded those tendencies may be. For instance, the following are sources of bias in biomedical literature:• Publication bias: publishers incentivized to accept posi-tive results• Prevailing field bias: supporting entrenched opinions• Citation bias: tendency
Surgery_Schwartz. systems than truly exists, and arises from their preconceived ideas about things• Idols of the cave (Idola specus): Arising from an individ-ual’s personal limitations in reasoning due to particular personalities, subjective likes and dislikesBrunicardi_Ch51_p2137-p2152.indd 213728/02/19 4:19 PM 2138• Idols of the marketplace (Idola fori): Arising from the con-fusion in the use of language and taking some words in sci-ence to have a different meaning than their common usage• Idols of the theatre (Idola theatri): Arising from the following of academic dogma and not asking questions about the worldThese descriptions still resonate today, illustrating just how long the dangers of cognitive bias have been recognized, and just how embedded those tendencies may be. For instance, the following are sources of bias in biomedical literature:• Publication bias: publishers incentivized to accept posi-tive results• Prevailing field bias: supporting entrenched opinions• Citation bias: tendency
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Surgery_Schwartz_13959
Surgery_Schwartz
are sources of bias in biomedical literature:• Publication bias: publishers incentivized to accept posi-tive results• Prevailing field bias: supporting entrenched opinions• Citation bias: tendency to cite positive studies• Time-lag bias: delay the reporting of negative results• Reporting bias: emphasizing positive over negative resultsKey Points1 Cognitive bias is inescapable, and limits the ability of both individual practitioners and the surgical field in general, to advance and improve in a scientific fashion. Evidence Based Medicine is an attempt to codify the process of interpret-ing experience, assessing the literature and translating it into practice.2 Dealing with and interpreting the vast amount of surgical literature available on the Internet can be daunting, and this task can be aided by the application of identified formats for executing online search. The PICO (Patient/Population, Intervention, Comparison and Outcome) format is a com-monly used method for codifying online
Surgery_Schwartz. are sources of bias in biomedical literature:• Publication bias: publishers incentivized to accept posi-tive results• Prevailing field bias: supporting entrenched opinions• Citation bias: tendency to cite positive studies• Time-lag bias: delay the reporting of negative results• Reporting bias: emphasizing positive over negative resultsKey Points1 Cognitive bias is inescapable, and limits the ability of both individual practitioners and the surgical field in general, to advance and improve in a scientific fashion. Evidence Based Medicine is an attempt to codify the process of interpret-ing experience, assessing the literature and translating it into practice.2 Dealing with and interpreting the vast amount of surgical literature available on the Internet can be daunting, and this task can be aided by the application of identified formats for executing online search. The PICO (Patient/Population, Intervention, Comparison and Outcome) format is a com-monly used method for codifying online
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Surgery_Schwartz_13960
Surgery_Schwartz
aided by the application of identified formats for executing online search. The PICO (Patient/Population, Intervention, Comparison and Outcome) format is a com-monly used method for codifying online search.3 Not all literature or evidence is created equal. There exist various approaches, such as the Oxford Center for Evidence Based Medicine (CEBM) Levels of Evidence or the GRADE (Grading and Recommendations, Assessment, Development and Evaluation) system, that have been developed to provide guidance in assessing and reifying scientific literature.4 The conversion of evidence into clinical practice often mani-fests in the creation of clinical guidelines. As with all things related to evidence based medicine, not all guidelines are created equal, and therefore there are certain characteristics that can be used to evaluate the quality of a particular clini-cal guideline.5 There are specific challenges in the application of evidence based medicine to surgery, not least of which is the
Surgery_Schwartz. aided by the application of identified formats for executing online search. The PICO (Patient/Population, Intervention, Comparison and Outcome) format is a com-monly used method for codifying online search.3 Not all literature or evidence is created equal. There exist various approaches, such as the Oxford Center for Evidence Based Medicine (CEBM) Levels of Evidence or the GRADE (Grading and Recommendations, Assessment, Development and Evaluation) system, that have been developed to provide guidance in assessing and reifying scientific literature.4 The conversion of evidence into clinical practice often mani-fests in the creation of clinical guidelines. As with all things related to evidence based medicine, not all guidelines are created equal, and therefore there are certain characteristics that can be used to evaluate the quality of a particular clini-cal guideline.5 There are specific challenges in the application of evidence based medicine to surgery, not least of which is the
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Surgery_Schwartz_13961
Surgery_Schwartz
that can be used to evaluate the quality of a particular clini-cal guideline.5 There are specific challenges in the application of evidence based medicine to surgery, not least of which is the difficulty in performing a truly randomized clinical trial. The CONSORT (Consolidated Standard of Reporting Clinical Trials) guidelines were developed to serve as minimal rec-ommendations for reporting randomized clinical trials.6 The well-known saying “There are lies, damn lies and then statistics” points to the recognition that statistical tools can be prone to misuse, and emphasizes the need to understand the appropriate application, limits of and interpretation of reported statistics.7 Evidence based medicine has not thus far been held to its own standards of evidence. Recognizing that available “evidence” is a constantly shifting landscape should warn one against the dangers of epistemic certainty, and further emphasizes the fact that surgical education is an ongoing and perpetual
Surgery_Schwartz. that can be used to evaluate the quality of a particular clini-cal guideline.5 There are specific challenges in the application of evidence based medicine to surgery, not least of which is the difficulty in performing a truly randomized clinical trial. The CONSORT (Consolidated Standard of Reporting Clinical Trials) guidelines were developed to serve as minimal rec-ommendations for reporting randomized clinical trials.6 The well-known saying “There are lies, damn lies and then statistics” points to the recognition that statistical tools can be prone to misuse, and emphasizes the need to understand the appropriate application, limits of and interpretation of reported statistics.7 Evidence based medicine has not thus far been held to its own standards of evidence. Recognizing that available “evidence” is a constantly shifting landscape should warn one against the dangers of epistemic certainty, and further emphasizes the fact that surgical education is an ongoing and perpetual
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Surgery_Schwartz_13962
Surgery_Schwartz
available “evidence” is a constantly shifting landscape should warn one against the dangers of epistemic certainty, and further emphasizes the fact that surgical education is an ongoing and perpetual process.In the medical field, the transition from accumulated anec-dote to true statistical analysis can be seen in the emergence of clinical epidemiology as a field in 1938, which began to shift the focus from descriptions of individual patients to trends affect-ing entire populations. This shift, however, was accompanied by new challenges, as different means of turning anecdotal experience into statistics (e.g., case series, observational stud-ies, retrospective studies, prospective studies) meant that now practitioners needed to be able to compare these “scientific” presentations against each other in order to best establish their practices. The processes and methods of aggregating, compar-ing, and translating these different types of data from the medi-cal literature into clinical
Surgery_Schwartz. available “evidence” is a constantly shifting landscape should warn one against the dangers of epistemic certainty, and further emphasizes the fact that surgical education is an ongoing and perpetual process.In the medical field, the transition from accumulated anec-dote to true statistical analysis can be seen in the emergence of clinical epidemiology as a field in 1938, which began to shift the focus from descriptions of individual patients to trends affect-ing entire populations. This shift, however, was accompanied by new challenges, as different means of turning anecdotal experience into statistics (e.g., case series, observational stud-ies, retrospective studies, prospective studies) meant that now practitioners needed to be able to compare these “scientific” presentations against each other in order to best establish their practices. The processes and methods of aggregating, compar-ing, and translating these different types of data from the medi-cal literature into clinical
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Surgery_Schwartz_13963
Surgery_Schwartz
each other in order to best establish their practices. The processes and methods of aggregating, compar-ing, and translating these different types of data from the medi-cal literature into clinical practice were explicitly established in the latter part of the 20th century, particularly arising from efforts at McMaster University, which eventually led to a fun-damental framework for literature-informed medical decision-making known as evidence-based medicine (EBM).EBM is defined as the “conscientious, explicit and judi-cious use of current best evidence in making decisions about treating individual patients.”2,3 This term was coined by Gordon Guyatt in 1991, focusing on assessing the credibility of the medical literature, understanding the presented results, and applying the information to individual practice. EBM is defined by three epistemological principles4:• Principle 1: Not all evidence is created equal, and the practice of medicine should be based on the best available
Surgery_Schwartz. each other in order to best establish their practices. The processes and methods of aggregating, compar-ing, and translating these different types of data from the medi-cal literature into clinical practice were explicitly established in the latter part of the 20th century, particularly arising from efforts at McMaster University, which eventually led to a fun-damental framework for literature-informed medical decision-making known as evidence-based medicine (EBM).EBM is defined as the “conscientious, explicit and judi-cious use of current best evidence in making decisions about treating individual patients.”2,3 This term was coined by Gordon Guyatt in 1991, focusing on assessing the credibility of the medical literature, understanding the presented results, and applying the information to individual practice. EBM is defined by three epistemological principles4:• Principle 1: Not all evidence is created equal, and the practice of medicine should be based on the best available
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Surgery_Schwartz_13964
Surgery_Schwartz
to individual practice. EBM is defined by three epistemological principles4:• Principle 1: Not all evidence is created equal, and the practice of medicine should be based on the best available evidence• Principle 2: The pursuit of truth is best accomplished by evaluation of the totality of the evidence, and not selecting evidence that favors a particular claim• Principle 3: Clinical decision-making requires consideration of patients’ values and preferenceThe adoption of EBM in the discipline of surgery has lagged compared to nonsurgical specialties. To a great extent, this is due to the challenges of achieving the highest level of evidence noted in principle 1: definitive conclusions from a randomized controlled trial (RCT). A literature analysis of MEDLINE from 1966 to 2000 demonstrated that only 15.1% of the 134,689 RCTs evaluated a surgical topic.5 In the early days of EBM during the 1990s, surgical RCTs accounted for only 7% of published articles in surgical journals; most of the
Surgery_Schwartz. to individual practice. EBM is defined by three epistemological principles4:• Principle 1: Not all evidence is created equal, and the practice of medicine should be based on the best available evidence• Principle 2: The pursuit of truth is best accomplished by evaluation of the totality of the evidence, and not selecting evidence that favors a particular claim• Principle 3: Clinical decision-making requires consideration of patients’ values and preferenceThe adoption of EBM in the discipline of surgery has lagged compared to nonsurgical specialties. To a great extent, this is due to the challenges of achieving the highest level of evidence noted in principle 1: definitive conclusions from a randomized controlled trial (RCT). A literature analysis of MEDLINE from 1966 to 2000 demonstrated that only 15.1% of the 134,689 RCTs evaluated a surgical topic.5 In the early days of EBM during the 1990s, surgical RCTs accounted for only 7% of published articles in surgical journals; most of the
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Surgery_Schwartz_13965
Surgery_Schwartz
that only 15.1% of the 134,689 RCTs evaluated a surgical topic.5 In the early days of EBM during the 1990s, surgical RCTs accounted for only 7% of published articles in surgical journals; most of the articles were retrospective studies and case series,6 which are essentially aggregated anecdotes. Over the next decade, the rela-tive frequency of RCTs in surgery further decreased, account-ing for 3.4% of all publications in 2003.5 As a result, most of the available evidence to guide surgical practice today remains based on retrospective reviews, nonrandomized trials, and expert opinion. The barriers to performing prospective RCTs in surgery remain substantial: standardization of clinical pre-sentation and, of course, accounting for variations in operative technique and the ability to blind studies to reduce experimental bias. The relative paucity in RCTs in surgery make it even more 1Brunicardi_Ch51_p2137-p2152.indd 213828/02/19 4:19 PM 2139UNDERSTANDING, EVALUATING, AND USING
Surgery_Schwartz. that only 15.1% of the 134,689 RCTs evaluated a surgical topic.5 In the early days of EBM during the 1990s, surgical RCTs accounted for only 7% of published articles in surgical journals; most of the articles were retrospective studies and case series,6 which are essentially aggregated anecdotes. Over the next decade, the rela-tive frequency of RCTs in surgery further decreased, account-ing for 3.4% of all publications in 2003.5 As a result, most of the available evidence to guide surgical practice today remains based on retrospective reviews, nonrandomized trials, and expert opinion. The barriers to performing prospective RCTs in surgery remain substantial: standardization of clinical pre-sentation and, of course, accounting for variations in operative technique and the ability to blind studies to reduce experimental bias. The relative paucity in RCTs in surgery make it even more 1Brunicardi_Ch51_p2137-p2152.indd 213828/02/19 4:19 PM 2139UNDERSTANDING, EVALUATING, AND USING
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Surgery_Schwartz_13966
Surgery_Schwartz
studies to reduce experimental bias. The relative paucity in RCTs in surgery make it even more 1Brunicardi_Ch51_p2137-p2152.indd 213828/02/19 4:19 PM 2139UNDERSTANDING, EVALUATING, AND USING EVIDENCE FOR SURGICAL PRACTICECHAPTER 51important that surgeons understand the best-practice methods to critically appraise available evidence, while recognizing the limitations and potential pitfalls of those methods, in order to optimize their practice and decision-making regarding patient care when high quality evidence may not be available. Herein we present the steps of such a workflow, starting with an initial search for information, identification of the classes of informa-tion that such a search can return, and then guidelines by which that information is evaluated, compared, and aggregated.Searching for Information: Patient/Population, Intervention, Comparison, and OutcomeTechnology has substantively changed how information can be sought and retrieved. Online search engines such as
Surgery_Schwartz. studies to reduce experimental bias. The relative paucity in RCTs in surgery make it even more 1Brunicardi_Ch51_p2137-p2152.indd 213828/02/19 4:19 PM 2139UNDERSTANDING, EVALUATING, AND USING EVIDENCE FOR SURGICAL PRACTICECHAPTER 51important that surgeons understand the best-practice methods to critically appraise available evidence, while recognizing the limitations and potential pitfalls of those methods, in order to optimize their practice and decision-making regarding patient care when high quality evidence may not be available. Herein we present the steps of such a workflow, starting with an initial search for information, identification of the classes of informa-tion that such a search can return, and then guidelines by which that information is evaluated, compared, and aggregated.Searching for Information: Patient/Population, Intervention, Comparison, and OutcomeTechnology has substantively changed how information can be sought and retrieved. Online search engines such as
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Surgery_Schwartz_13967
Surgery_Schwartz
for Information: Patient/Population, Intervention, Comparison, and OutcomeTechnology has substantively changed how information can be sought and retrieved. Online search engines such as MEDLINE via PubMed, which contains over 26 million citations, have dramatically enhanced the ability to access bio-medical literature.7 However, there is a very real potential for such access to become overwhelming. Effective and efficient use of search engines can be enhanced by framing the clinical question in a format designed to improve the relevancy of search results. PICO is one such format, where the acronym stands for Patient/Population, Intervention, Comparison, and Outcome.8• Patient or population is the specific group of individuals for which the questions is being asked.• Intervention is the treatment or technique of interest for the defined patient or population. Intervention might be a proce-dure, such as “laparoscopic appendectomy” or be defined as an exposure of interest, such as
Surgery_Schwartz. for Information: Patient/Population, Intervention, Comparison, and OutcomeTechnology has substantively changed how information can be sought and retrieved. Online search engines such as MEDLINE via PubMed, which contains over 26 million citations, have dramatically enhanced the ability to access bio-medical literature.7 However, there is a very real potential for such access to become overwhelming. Effective and efficient use of search engines can be enhanced by framing the clinical question in a format designed to improve the relevancy of search results. PICO is one such format, where the acronym stands for Patient/Population, Intervention, Comparison, and Outcome.8• Patient or population is the specific group of individuals for which the questions is being asked.• Intervention is the treatment or technique of interest for the defined patient or population. Intervention might be a proce-dure, such as “laparoscopic appendectomy” or be defined as an exposure of interest, such as
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Surgery_Schwartz_13968
Surgery_Schwartz
the treatment or technique of interest for the defined patient or population. Intervention might be a proce-dure, such as “laparoscopic appendectomy” or be defined as an exposure of interest, such as “smoking.”• Comparison is the alternative treatment or technique to which you are comparing the intervention. Terms might include, for example, “open appendectomy” or “observation.”• Outcome of interest is the final step of the PICO format. Examples include “mortality,” “operative time,” and “wound infection.”As with all online search strategies, there is a trade-off between the specificity of the search and the breadth of the returned items. When using PICO to inform clinical decision-making, it is generally advantageous to be as precise and specific as possible when initiating a search: this increases the likelihood the search will return information most germane to the particular clinical scenario. This is accomplished by the use of “AND” in the framing of the search to encompass the
Surgery_Schwartz. the treatment or technique of interest for the defined patient or population. Intervention might be a proce-dure, such as “laparoscopic appendectomy” or be defined as an exposure of interest, such as “smoking.”• Comparison is the alternative treatment or technique to which you are comparing the intervention. Terms might include, for example, “open appendectomy” or “observation.”• Outcome of interest is the final step of the PICO format. Examples include “mortality,” “operative time,” and “wound infection.”As with all online search strategies, there is a trade-off between the specificity of the search and the breadth of the returned items. When using PICO to inform clinical decision-making, it is generally advantageous to be as precise and specific as possible when initiating a search: this increases the likelihood the search will return information most germane to the particular clinical scenario. This is accomplished by the use of “AND” in the framing of the search to encompass the
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Surgery_Schwartz_13969
Surgery_Schwartz
increases the likelihood the search will return information most germane to the particular clinical scenario. This is accomplished by the use of “AND” in the framing of the search to encompass the set of questions of interest. For example, one could construct a query consisting of a particular procedure, with a particular method, with a particular outcome metric, such as “(distal pancreatectomy) AND splenectomy AND (splenic preservation) AND morbidity” to frame a PICO question.Types of StudiesPrinciple 1 of EBM states that not all evidence is created equal; therefore, evaluating the evidentiary quality of the results of an online search requires classifying the returned search items by type of study. As noted earlier, acknowledging that the “gold standard” level of evidence, RCTs, are rare in the surgical literature, the application of EBM to surgery requires increased familiarity with the types of alternative studies available, with their relative strengths and weaknesses. These
Surgery_Schwartz. increases the likelihood the search will return information most germane to the particular clinical scenario. This is accomplished by the use of “AND” in the framing of the search to encompass the set of questions of interest. For example, one could construct a query consisting of a particular procedure, with a particular method, with a particular outcome metric, such as “(distal pancreatectomy) AND splenectomy AND (splenic preservation) AND morbidity” to frame a PICO question.Types of StudiesPrinciple 1 of EBM states that not all evidence is created equal; therefore, evaluating the evidentiary quality of the results of an online search requires classifying the returned search items by type of study. As noted earlier, acknowledging that the “gold standard” level of evidence, RCTs, are rare in the surgical literature, the application of EBM to surgery requires increased familiarity with the types of alternative studies available, with their relative strengths and weaknesses. These
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Surgery_Schwartz_13970
Surgery_Schwartz
rare in the surgical literature, the application of EBM to surgery requires increased familiarity with the types of alternative studies available, with their relative strengths and weaknesses. These types are listed below:• Meta-analysis: A meta-analysis is a technique to combine similarly published data in order to increase the overall 2statistical power compared to each study individually. The amount of interstudy heterogeneity (methods, study popula-tion, endpoints, etc.) should be limited to allow for the gen-eration of informative conclusions. The pooling of similar studies enables researchers to generate a new statistical con-clusion based on a substantially larger sample size. These approaches, though useful, have their limitations: the inclu-sion of inappropriate studies and the mislabeling of a meta-analysis leading to inaccurate conclusions. Attention should be directed toward this type of evidence when clinical guide-lines do not exist.• Systematic Review: Like
Surgery_Schwartz. rare in the surgical literature, the application of EBM to surgery requires increased familiarity with the types of alternative studies available, with their relative strengths and weaknesses. These types are listed below:• Meta-analysis: A meta-analysis is a technique to combine similarly published data in order to increase the overall 2statistical power compared to each study individually. The amount of interstudy heterogeneity (methods, study popula-tion, endpoints, etc.) should be limited to allow for the gen-eration of informative conclusions. The pooling of similar studies enables researchers to generate a new statistical con-clusion based on a substantially larger sample size. These approaches, though useful, have their limitations: the inclu-sion of inappropriate studies and the mislabeling of a meta-analysis leading to inaccurate conclusions. Attention should be directed toward this type of evidence when clinical guide-lines do not exist.• Systematic Review: Like
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Surgery_Schwartz_13971
Surgery_Schwartz
and the mislabeling of a meta-analysis leading to inaccurate conclusions. Attention should be directed toward this type of evidence when clinical guide-lines do not exist.• Systematic Review: Like meta-analyses, systematic reviews use standardized methods to search for and appraise studies in order to attempt to reduce bias. However, systematic reviews do not utilize quantitative methods to summarize the results. For this reason, systematic reviews are often not considered to provide the same strength of evidence as a meta-analysis.• Cross-Sectional Studies: In a cross-sectional study, expo-sures and outcomes are measured at a single point in time. The prevalence of the outcome is then compared in patients who did and did not have the exposure. Multiple exposures and outcomes can be measured at the same time, which is an advantage; however, there are important limitations. One significant limitation is that a temporal relationship cannot be determined between exposure and outcome
Surgery_Schwartz. and the mislabeling of a meta-analysis leading to inaccurate conclusions. Attention should be directed toward this type of evidence when clinical guide-lines do not exist.• Systematic Review: Like meta-analyses, systematic reviews use standardized methods to search for and appraise studies in order to attempt to reduce bias. However, systematic reviews do not utilize quantitative methods to summarize the results. For this reason, systematic reviews are often not considered to provide the same strength of evidence as a meta-analysis.• Cross-Sectional Studies: In a cross-sectional study, expo-sures and outcomes are measured at a single point in time. The prevalence of the outcome is then compared in patients who did and did not have the exposure. Multiple exposures and outcomes can be measured at the same time, which is an advantage; however, there are important limitations. One significant limitation is that a temporal relationship cannot be determined between exposure and outcome
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Surgery_Schwartz_13972
Surgery_Schwartz
at the same time, which is an advantage; however, there are important limitations. One significant limitation is that a temporal relationship cannot be determined between exposure and outcome because they are measured simultaneously. These studies will often form the foundation for more definitive studies.• Case Control Study: In a case-control study, cohorts are determined by the presence or absence of a particular out-come of interest. This is in contrast to a cross-sectional study where samples are determined by the presence or absence of an exposure. Once the samples have been identi-fied based upon outcome, then possible prior exposures are identified, and the odds of those exposures are compared between cohorts.• Case Series: A Case Series involves a report of a small group of patients that share specified clinical features; this gener-ally does not include description of a control group. Case series are prevalent in the field of surgery, and some of the most famous eponymous
Surgery_Schwartz. at the same time, which is an advantage; however, there are important limitations. One significant limitation is that a temporal relationship cannot be determined between exposure and outcome because they are measured simultaneously. These studies will often form the foundation for more definitive studies.• Case Control Study: In a case-control study, cohorts are determined by the presence or absence of a particular out-come of interest. This is in contrast to a cross-sectional study where samples are determined by the presence or absence of an exposure. Once the samples have been identi-fied based upon outcome, then possible prior exposures are identified, and the odds of those exposures are compared between cohorts.• Case Series: A Case Series involves a report of a small group of patients that share specified clinical features; this gener-ally does not include description of a control group. Case series are prevalent in the field of surgery, and some of the most famous eponymous
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Surgery_Schwartz_13973
Surgery_Schwartz
that share specified clinical features; this gener-ally does not include description of a control group. Case series are prevalent in the field of surgery, and some of the most famous eponymous procedures originated from case series, including the Whipple procedure9 and Nissen fundo-plication.10 This type of study provides weak evidence due to issues with patient selection, biases, and confounding factors. However, the findings from a case series can be used to gen-erate hypotheses for a randomized control trial.• Expert Opinion: Expert opinions represent the lowest level of evidence and is representative of a clinician’s individual experience and anecdotes. Prior to evidence-based medicine, expert opinion was the primary means of teaching medicine and shaping the field. However, the opinions of clinicians can vary substantially leading to a wide range of potential unproven treatments for a medical issue. Thus, expert opinion should only be solicited in the complete absence of
Surgery_Schwartz. that share specified clinical features; this gener-ally does not include description of a control group. Case series are prevalent in the field of surgery, and some of the most famous eponymous procedures originated from case series, including the Whipple procedure9 and Nissen fundo-plication.10 This type of study provides weak evidence due to issues with patient selection, biases, and confounding factors. However, the findings from a case series can be used to gen-erate hypotheses for a randomized control trial.• Expert Opinion: Expert opinions represent the lowest level of evidence and is representative of a clinician’s individual experience and anecdotes. Prior to evidence-based medicine, expert opinion was the primary means of teaching medicine and shaping the field. However, the opinions of clinicians can vary substantially leading to a wide range of potential unproven treatments for a medical issue. Thus, expert opinion should only be solicited in the complete absence of
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Surgery_Schwartz_13974
Surgery_Schwartz
opinions of clinicians can vary substantially leading to a wide range of potential unproven treatments for a medical issue. Thus, expert opinion should only be solicited in the complete absence of evidence in the literature.It should also be noted that irrespective of the type of study or recommendation, there are additional factors that can contribute to bias in publication. To a great degree these are extrapolations of the sources of individual cognitive bias, but writ large across an entire community (see Box: The History and Sources of Bias in Biomedical Literature).Brunicardi_Ch51_p2137-p2152.indd 213928/02/19 4:19 PM 2140SPECIFIC CONSIDERATIONSPART IIHierarchies of EvidenceThe original architects of EBM codified the notion that certain types of evidence are superior to others based on charac-teristics of study design, depicting this concept as a “pyra-mid,” with expert opinion comprising the base of the pyramid and randomized controlled trials at the peak (Fig. 51-1).
Surgery_Schwartz. opinions of clinicians can vary substantially leading to a wide range of potential unproven treatments for a medical issue. Thus, expert opinion should only be solicited in the complete absence of evidence in the literature.It should also be noted that irrespective of the type of study or recommendation, there are additional factors that can contribute to bias in publication. To a great degree these are extrapolations of the sources of individual cognitive bias, but writ large across an entire community (see Box: The History and Sources of Bias in Biomedical Literature).Brunicardi_Ch51_p2137-p2152.indd 213928/02/19 4:19 PM 2140SPECIFIC CONSIDERATIONSPART IIHierarchies of EvidenceThe original architects of EBM codified the notion that certain types of evidence are superior to others based on charac-teristics of study design, depicting this concept as a “pyra-mid,” with expert opinion comprising the base of the pyramid and randomized controlled trials at the peak (Fig. 51-1).
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Surgery_Schwartz_13975
Surgery_Schwartz
based on charac-teristics of study design, depicting this concept as a “pyra-mid,” with expert opinion comprising the base of the pyramid and randomized controlled trials at the peak (Fig. 51-1). Although conceptually appealing, this initial attempt to “rank” the evidence was relatively simplistic and rested on unproven assumptions that RCT were inherently superior to observational studies. While RCTs theoretically provide higher quality evi-dence compared to observational studies, RCTs can also have significant limitations and biases (see later section, “The Chal-lenges of Applying EBM to Surgery”). Furthermore, translating the results from well-crafted RCTs can be challenging, where the specific restrictive criteria for executing a high-quality RCT can inherently limit its applicability to clinical scenarios not specifically noted or tested in the RCT. Therefore, one could find oneself in the situation of trying to compare an RCT on a related but clearly distinct use case with a
Surgery_Schwartz. based on charac-teristics of study design, depicting this concept as a “pyra-mid,” with expert opinion comprising the base of the pyramid and randomized controlled trials at the peak (Fig. 51-1). Although conceptually appealing, this initial attempt to “rank” the evidence was relatively simplistic and rested on unproven assumptions that RCT were inherently superior to observational studies. While RCTs theoretically provide higher quality evi-dence compared to observational studies, RCTs can also have significant limitations and biases (see later section, “The Chal-lenges of Applying EBM to Surgery”). Furthermore, translating the results from well-crafted RCTs can be challenging, where the specific restrictive criteria for executing a high-quality RCT can inherently limit its applicability to clinical scenarios not specifically noted or tested in the RCT. Therefore, one could find oneself in the situation of trying to compare an RCT on a related but clearly distinct use case with a
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Surgery_Schwartz_13976
Surgery_Schwartz
to clinical scenarios not specifically noted or tested in the RCT. Therefore, one could find oneself in the situation of trying to compare an RCT on a related but clearly distinct use case with a well performed obser-vational study that more closely approximated the clinical sce-nario in question. This led to the subsequent development of more refined frameworks to assess the quality of evidence in order to try and address these issues, although there is currently no consensus on a single framework. The current situation is that while many newer systems have devised ways in which studies can move up and down the pyramid, for well-designed studies, the pyramid largely remains intact.The initial hierarchies of evidence were limited because they entangled the method of evidence collection with underly-ing study design. They failed to recognize principle 2 of EBM: “the pursuit of truth is best accomplished by evaluation of the totality of evidence” and the principle that “health claims be
Surgery_Schwartz. to clinical scenarios not specifically noted or tested in the RCT. Therefore, one could find oneself in the situation of trying to compare an RCT on a related but clearly distinct use case with a well performed obser-vational study that more closely approximated the clinical sce-nario in question. This led to the subsequent development of more refined frameworks to assess the quality of evidence in order to try and address these issues, although there is currently no consensus on a single framework. The current situation is that while many newer systems have devised ways in which studies can move up and down the pyramid, for well-designed studies, the pyramid largely remains intact.The initial hierarchies of evidence were limited because they entangled the method of evidence collection with underly-ing study design. They failed to recognize principle 2 of EBM: “the pursuit of truth is best accomplished by evaluation of the totality of evidence” and the principle that “health claims be
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Surgery_Schwartz_13977
Surgery_Schwartz
underly-ing study design. They failed to recognize principle 2 of EBM: “the pursuit of truth is best accomplished by evaluation of the totality of evidence” and the principle that “health claims be based upon systematic reviews which summarize the best avail-able evidence.”4 The earliest hierarchies positioned systematic reviews at the top of the pyramid followed by RCTs; how-ever, this classification failed to acknowledge that systematic reviews can summarize any type of evidence. Cohort studies, case-control studies, and even case reports can be the subject of systematic review. The importance of systematic review in EBM cannot be understated: systematic reviews are the most 3cited type of study, and these studies are essential for the devel-opment of clinical guidelines and influencing the direction of future studies.2,11 When applied in a timely manner, systematic reviews have resulted in major practice changes, for example, encouraging early postoperative enteral feeding compared
Surgery_Schwartz. underly-ing study design. They failed to recognize principle 2 of EBM: “the pursuit of truth is best accomplished by evaluation of the totality of evidence” and the principle that “health claims be based upon systematic reviews which summarize the best avail-able evidence.”4 The earliest hierarchies positioned systematic reviews at the top of the pyramid followed by RCTs; how-ever, this classification failed to acknowledge that systematic reviews can summarize any type of evidence. Cohort studies, case-control studies, and even case reports can be the subject of systematic review. The importance of systematic review in EBM cannot be understated: systematic reviews are the most 3cited type of study, and these studies are essential for the devel-opment of clinical guidelines and influencing the direction of future studies.2,11 When applied in a timely manner, systematic reviews have resulted in major practice changes, for example, encouraging early postoperative enteral feeding compared
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Surgery_Schwartz_13978
Surgery_Schwartz
the direction of future studies.2,11 When applied in a timely manner, systematic reviews have resulted in major practice changes, for example, encouraging early postoperative enteral feeding compared to parenteral nutrition to prevent sepsis.12Tools to Evaluate a Body of EvidenceBy 2002, over 100 unique evidence rating systems existed,2 and the differences among them may be nontrivial. Depending upon the specific criteria used, the “strength” of evidence might dif-fer widely from system to system. For example, the American Association of Orthopedic Surgeons (AAOS) published guide-lines in 2009 for prevention of venous thromboembolism (VTE) in patients undergoing hip or knee surgery that conflicted with the widely used American College of Chest Physician (ACCP) guidelines, despite having access to the same data. While the ACCP considered VTE prophylaxis to be a grade 1 recommen-dation with level A evidence, the AAOS recommendation var-ied based upon risk of pulmonary embolism and
Surgery_Schwartz. the direction of future studies.2,11 When applied in a timely manner, systematic reviews have resulted in major practice changes, for example, encouraging early postoperative enteral feeding compared to parenteral nutrition to prevent sepsis.12Tools to Evaluate a Body of EvidenceBy 2002, over 100 unique evidence rating systems existed,2 and the differences among them may be nontrivial. Depending upon the specific criteria used, the “strength” of evidence might dif-fer widely from system to system. For example, the American Association of Orthopedic Surgeons (AAOS) published guide-lines in 2009 for prevention of venous thromboembolism (VTE) in patients undergoing hip or knee surgery that conflicted with the widely used American College of Chest Physician (ACCP) guidelines, despite having access to the same data. While the ACCP considered VTE prophylaxis to be a grade 1 recommen-dation with level A evidence, the AAOS recommendation var-ied based upon risk of pulmonary embolism and
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Surgery_Schwartz_13979
Surgery_Schwartz
access to the same data. While the ACCP considered VTE prophylaxis to be a grade 1 recommen-dation with level A evidence, the AAOS recommendation var-ied based upon risk of pulmonary embolism and bleeding, with no recommendation being greater than B and all recommenda-tions being based upon level III evidence.13 In the following section we present a few of the most widely accepted tools for assessing the quality of evidence.CEBM Levels of Evidence. One of the most widely adopted systems for grading evidence is the Oxford Center for Evi-dence Based Medicine (CEBM) Levels of Evidence. The origi-nal CEBM system was released in 2000 and was subsequently updated in 2011. Earlier systems of evidence ranking were criti-cized because they categorically placed randomized trials above observational studies, although observational studies and even anecdotes can occasionally give the “best” evidence in certain clinical situations. CEBM was therefore developed to not only improve the ranking of
Surgery_Schwartz. access to the same data. While the ACCP considered VTE prophylaxis to be a grade 1 recommen-dation with level A evidence, the AAOS recommendation var-ied based upon risk of pulmonary embolism and bleeding, with no recommendation being greater than B and all recommenda-tions being based upon level III evidence.13 In the following section we present a few of the most widely accepted tools for assessing the quality of evidence.CEBM Levels of Evidence. One of the most widely adopted systems for grading evidence is the Oxford Center for Evi-dence Based Medicine (CEBM) Levels of Evidence. The origi-nal CEBM system was released in 2000 and was subsequently updated in 2011. Earlier systems of evidence ranking were criti-cized because they categorically placed randomized trials above observational studies, although observational studies and even anecdotes can occasionally give the “best” evidence in certain clinical situations. CEBM was therefore developed to not only improve the ranking of
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Surgery_Schwartz_13980
Surgery_Schwartz
studies, although observational studies and even anecdotes can occasionally give the “best” evidence in certain clinical situations. CEBM was therefore developed to not only improve the ranking of evidence but also to aid clinicians in quickly searching for the best evidence available for a given clinical question (Table 51-1). It is designed as both a tool for traditional critical appraisal as well as a pragmatic system that clinicians can use to answer clinical questions in real time. It can be used as a heuristic that clinicians and patients can utilize to answer clinical questions quickly and without resorting to preap-praised sources.14 The CEBM Levels of Evidence system begins with choosing a clinical question from the first column of the table provided by the creators (see Table 51-1) (for example, “How common is the problem?”, “Does this intervention help?”, or “Is this test worthwhile?”). Therefore, each row of the CEBM Levels of Evidence represents a series of steps one
Surgery_Schwartz. studies, although observational studies and even anecdotes can occasionally give the “best” evidence in certain clinical situations. CEBM was therefore developed to not only improve the ranking of evidence but also to aid clinicians in quickly searching for the best evidence available for a given clinical question (Table 51-1). It is designed as both a tool for traditional critical appraisal as well as a pragmatic system that clinicians can use to answer clinical questions in real time. It can be used as a heuristic that clinicians and patients can utilize to answer clinical questions quickly and without resorting to preap-praised sources.14 The CEBM Levels of Evidence system begins with choosing a clinical question from the first column of the table provided by the creators (see Table 51-1) (for example, “How common is the problem?”, “Does this intervention help?”, or “Is this test worthwhile?”). Therefore, each row of the CEBM Levels of Evidence represents a series of steps one
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Surgery_Schwartz_13981
Surgery_Schwartz
51-1) (for example, “How common is the problem?”, “Does this intervention help?”, or “Is this test worthwhile?”). Therefore, each row of the CEBM Levels of Evidence represents a series of steps one should fol-low to find the best evidence for the question chosen. Strong evidence is likely to be found in columns to the left of the table, while weak evidence will be found in columns to the right. After completing a clinical query using the table, a final “level” of evidence is assigned on a scale from 1 to 5 based upon the types of studies found to answer the initial question (1 = highest rated evidence; 5 = lowest rated evidence). However, the levels are not intended to provide one with a definitive judgment regarding the quality of evidence. There may be cases where “lower level” evi-dence—for example, an observational study with a large treat-ment effect—provides stronger evidence than a “higher level” study, such as a systematic review with an inconclusive result.CEBM should be
Surgery_Schwartz. 51-1) (for example, “How common is the problem?”, “Does this intervention help?”, or “Is this test worthwhile?”). Therefore, each row of the CEBM Levels of Evidence represents a series of steps one should fol-low to find the best evidence for the question chosen. Strong evidence is likely to be found in columns to the left of the table, while weak evidence will be found in columns to the right. After completing a clinical query using the table, a final “level” of evidence is assigned on a scale from 1 to 5 based upon the types of studies found to answer the initial question (1 = highest rated evidence; 5 = lowest rated evidence). However, the levels are not intended to provide one with a definitive judgment regarding the quality of evidence. There may be cases where “lower level” evi-dence—for example, an observational study with a large treat-ment effect—provides stronger evidence than a “higher level” study, such as a systematic review with an inconclusive result.CEBM should be
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Surgery_Schwartz_13982
Surgery_Schwartz
example, an observational study with a large treat-ment effect—provides stronger evidence than a “higher level” study, such as a systematic review with an inconclusive result.CEBM should be thought of as a hierarchy of the likely best evidence. An advantage of CEBM is that it allows the potential of resorting to individual studies for the best evidence, while other systems generally assume that there is a systematic RCTCohort studyCase control studyCase seriesCase reportsAnimal researchIn-vitro researchExpert experience/opinionFigure 51-1. Evidence-based hierarchy.Brunicardi_Ch51_p2137-p2152.indd 214028/02/19 4:19 PM 2141UNDERSTANDING, EVALUATING, AND USING EVIDENCE FOR SURGICAL PRACTICECHAPTER 51Table 51-1Oxford center for evidence-based medicine 2011 levels of evidenceQUESTIONSTEP 1 (LEVEL 1*)STEP 2 (LEVEL 2*)STEP 3 (LEVEL 3*)STEP 4 (LEVEL 4*)STEP 5 (LEVEL 5)How common is the problem?Local and current random sample surveys (or censuses)Systematic review of surveys that allow
Surgery_Schwartz. example, an observational study with a large treat-ment effect—provides stronger evidence than a “higher level” study, such as a systematic review with an inconclusive result.CEBM should be thought of as a hierarchy of the likely best evidence. An advantage of CEBM is that it allows the potential of resorting to individual studies for the best evidence, while other systems generally assume that there is a systematic RCTCohort studyCase control studyCase seriesCase reportsAnimal researchIn-vitro researchExpert experience/opinionFigure 51-1. Evidence-based hierarchy.Brunicardi_Ch51_p2137-p2152.indd 214028/02/19 4:19 PM 2141UNDERSTANDING, EVALUATING, AND USING EVIDENCE FOR SURGICAL PRACTICECHAPTER 51Table 51-1Oxford center for evidence-based medicine 2011 levels of evidenceQUESTIONSTEP 1 (LEVEL 1*)STEP 2 (LEVEL 2*)STEP 3 (LEVEL 3*)STEP 4 (LEVEL 4*)STEP 5 (LEVEL 5)How common is the problem?Local and current random sample surveys (or censuses)Systematic review of surveys that allow
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Surgery_Schwartz_13983
Surgery_Schwartz
1 (LEVEL 1*)STEP 2 (LEVEL 2*)STEP 3 (LEVEL 3*)STEP 4 (LEVEL 4*)STEP 5 (LEVEL 5)How common is the problem?Local and current random sample surveys (or censuses)Systematic review of surveys that allow matching to local circumstances**Local non-random sample**Case-series**n/aIs this diagnostic or monitoring test accurate? (Diagnosis)Systematic review of cross-sectional studies with consistently applied reference standard and blindingIndividual cross-sectional studies with consistently applied reference standard and blindingNon-consecutive studies, or studies without consistently applied reference standards**Case-control studies, or “poor or non-independent reference standard**Mechanism-based reasoningWhat will happen if we do not add a therapy? (Prognosis)Systematic review of inception cohort studiesInception cohort studiesCohort study or control arm of randomized trial*Case-series or case-control studies, or poor quality prognostic cohort study**n/aDoes this intervention help? (Treatment
Surgery_Schwartz. 1 (LEVEL 1*)STEP 2 (LEVEL 2*)STEP 3 (LEVEL 3*)STEP 4 (LEVEL 4*)STEP 5 (LEVEL 5)How common is the problem?Local and current random sample surveys (or censuses)Systematic review of surveys that allow matching to local circumstances**Local non-random sample**Case-series**n/aIs this diagnostic or monitoring test accurate? (Diagnosis)Systematic review of cross-sectional studies with consistently applied reference standard and blindingIndividual cross-sectional studies with consistently applied reference standard and blindingNon-consecutive studies, or studies without consistently applied reference standards**Case-control studies, or “poor or non-independent reference standard**Mechanism-based reasoningWhat will happen if we do not add a therapy? (Prognosis)Systematic review of inception cohort studiesInception cohort studiesCohort study or control arm of randomized trial*Case-series or case-control studies, or poor quality prognostic cohort study**n/aDoes this intervention help? (Treatment
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Surgery_Schwartz_13984
Surgery_Schwartz
studiesInception cohort studiesCohort study or control arm of randomized trial*Case-series or case-control studies, or poor quality prognostic cohort study**n/aDoes this intervention help? (Treatment Benefits)Systematic review of randomized trials or n-of-1 trialsRandomized trial or observational study with dramatic effectNon-randomized controlled cohort/follow-up study**Case-series, case-control studies, or historically controlled studies**Mechanism-based reasoningWhat are the COMMON harms? (Treatment Harms)Systematic review of randomized trials, systematic review of nested case-control studies n-of-1 trial with the patient you are raising the question about, or observational study with dramatic effectIndividual randomized trial or (exceptionally) observational study with dramatic effectNon-randomized controlled cohort/follow-up study (post-marketing surveillance) provided there are sufficient numbers to rule out a common harm. (For long-term harms the duration of follow-up must be
Surgery_Schwartz. studiesInception cohort studiesCohort study or control arm of randomized trial*Case-series or case-control studies, or poor quality prognostic cohort study**n/aDoes this intervention help? (Treatment Benefits)Systematic review of randomized trials or n-of-1 trialsRandomized trial or observational study with dramatic effectNon-randomized controlled cohort/follow-up study**Case-series, case-control studies, or historically controlled studies**Mechanism-based reasoningWhat are the COMMON harms? (Treatment Harms)Systematic review of randomized trials, systematic review of nested case-control studies n-of-1 trial with the patient you are raising the question about, or observational study with dramatic effectIndividual randomized trial or (exceptionally) observational study with dramatic effectNon-randomized controlled cohort/follow-up study (post-marketing surveillance) provided there are sufficient numbers to rule out a common harm. (For long-term harms the duration of follow-up must be
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Surgery_Schwartz_13985
Surgery_Schwartz
controlled cohort/follow-up study (post-marketing surveillance) provided there are sufficient numbers to rule out a common harm. (For long-term harms the duration of follow-up must be sufficient.)**Case-series, case-control, or historically controlled studies**Mechanism-based reasoningWhat are the RARE harms? (Treatment Harms)Systematic review of randomized trials or n-of-1 trialRandomized trial or (exceptionally) observational study with dramatic effect Is this (early detection) test worthwhile? (Screening)Systematic review of randomized trialsRandomized trialNon-randomized controlled cohort/follow-up study**Case-series, case-control, or historically controlled studies**Mechanism-based reasoning*Level may be graded down on the basis of study quality, Imprecision, Indirectness (study PICO does not match questions PICO), because of inconsistency between studies, or because the absolute effect size is very small; Level may be graded up if there is a large or very large effect
Surgery_Schwartz. controlled cohort/follow-up study (post-marketing surveillance) provided there are sufficient numbers to rule out a common harm. (For long-term harms the duration of follow-up must be sufficient.)**Case-series, case-control, or historically controlled studies**Mechanism-based reasoningWhat are the RARE harms? (Treatment Harms)Systematic review of randomized trials or n-of-1 trialRandomized trial or (exceptionally) observational study with dramatic effect Is this (early detection) test worthwhile? (Screening)Systematic review of randomized trialsRandomized trialNon-randomized controlled cohort/follow-up study**Case-series, case-control, or historically controlled studies**Mechanism-based reasoning*Level may be graded down on the basis of study quality, Imprecision, Indirectness (study PICO does not match questions PICO), because of inconsistency between studies, or because the absolute effect size is very small; Level may be graded up if there is a large or very large effect
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Surgery_Schwartz_13986
Surgery_Schwartz
PICO does not match questions PICO), because of inconsistency between studies, or because the absolute effect size is very small; Level may be graded up if there is a large or very large effect size.**As always, a systematic review is generally better than an individual study.How to cite the Levels of Evidence TableOCEBM Levels of Evidence Working Group*. “The Oxford 2011 Levels of Evidence”.Oxford Centre for Evidence-Based Medicine. http://www.cebm.net/index.aspx?o=5653*OCEBM Table of Evidence Working Group = Jeremy Howick, Iain Chalmers (James Lind Library), Paul Glasziou, Trish Greenhaigh, Carl Heneghan, Alessandro Liberati, Ivan Moschetti, Bob Phillips, Hazel Thornton, Olive Goddard, and Mary HodgkinsanBrunicardi_Ch51_p2137-p2152.indd 214128/02/19 4:19 PM 2142SPECIFIC CONSIDERATIONSPART IIDefinitions of GRADE Evidence QualityHigh quality – Further research is very unlikely to change confidence in the estimate of effect.Moderate quality – Further research is likely to have an
Surgery_Schwartz. PICO does not match questions PICO), because of inconsistency between studies, or because the absolute effect size is very small; Level may be graded up if there is a large or very large effect size.**As always, a systematic review is generally better than an individual study.How to cite the Levels of Evidence TableOCEBM Levels of Evidence Working Group*. “The Oxford 2011 Levels of Evidence”.Oxford Centre for Evidence-Based Medicine. http://www.cebm.net/index.aspx?o=5653*OCEBM Table of Evidence Working Group = Jeremy Howick, Iain Chalmers (James Lind Library), Paul Glasziou, Trish Greenhaigh, Carl Heneghan, Alessandro Liberati, Ivan Moschetti, Bob Phillips, Hazel Thornton, Olive Goddard, and Mary HodgkinsanBrunicardi_Ch51_p2137-p2152.indd 214128/02/19 4:19 PM 2142SPECIFIC CONSIDERATIONSPART IIDefinitions of GRADE Evidence QualityHigh quality – Further research is very unlikely to change confidence in the estimate of effect.Moderate quality – Further research is likely to have an
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Surgery_Schwartz_13987
Surgery_Schwartz
of GRADE Evidence QualityHigh quality – Further research is very unlikely to change confidence in the estimate of effect.Moderate quality – Further research is likely to have an important impact confidence in the estimate of effect and may change the estimate.Low quality – Further research is very likely to have an important impact on confidence in the estimate of effect and is likely to change the estimate.Very low quality – Any estimate of effect is very uncertain.review available. Additionally, other systems are built around considering the strength of evidence for therapeutic effects and harms, while CEBM allows appraisal of evidence for prevalence of disease, accuracy of diagnostic tests, prognosis, therapeutic effects, rare harms, common harms, and usefulness of screening.Grading and Recommendations, Assessment, Development, and Evaluation. Alternatively, the Grading and Recommendations, Assessment, Development and Evaluation (GRADE) system classifies the quality of evidence
Surgery_Schwartz. of GRADE Evidence QualityHigh quality – Further research is very unlikely to change confidence in the estimate of effect.Moderate quality – Further research is likely to have an important impact confidence in the estimate of effect and may change the estimate.Low quality – Further research is very likely to have an important impact on confidence in the estimate of effect and is likely to change the estimate.Very low quality – Any estimate of effect is very uncertain.review available. Additionally, other systems are built around considering the strength of evidence for therapeutic effects and harms, while CEBM allows appraisal of evidence for prevalence of disease, accuracy of diagnostic tests, prognosis, therapeutic effects, rare harms, common harms, and usefulness of screening.Grading and Recommendations, Assessment, Development, and Evaluation. Alternatively, the Grading and Recommendations, Assessment, Development and Evaluation (GRADE) system classifies the quality of evidence
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Surgery_Schwartz_13988
Surgery_Schwartz
and Recommendations, Assessment, Development, and Evaluation. Alternatively, the Grading and Recommendations, Assessment, Development and Evaluation (GRADE) system classifies the quality of evidence into one of four levels: high, moderate, low, and very low15 (Box: Definitions of GRADE Evidence Quality). Evidence quality in the GRADE system is not assigned solely on study design. For example, a randomized controlled trial begins at “high quality,” but may be demoted due to one or more of the following: study limitations, inconsistent results, indirectness of evidence, imprecision, or reporting bias. Alternatively, observational studies (cohort or case-control studies) start as “low quality” but may be upgraded if there is a large magnitude of the treatment effect, evidence of a dose-response relationship, or if all plausible biases would decrease the magnitude of a treatment effect. Thus, the GRADE system of evaluating the quality of evidence provides more granularity than the
Surgery_Schwartz. and Recommendations, Assessment, Development, and Evaluation. Alternatively, the Grading and Recommendations, Assessment, Development and Evaluation (GRADE) system classifies the quality of evidence into one of four levels: high, moderate, low, and very low15 (Box: Definitions of GRADE Evidence Quality). Evidence quality in the GRADE system is not assigned solely on study design. For example, a randomized controlled trial begins at “high quality,” but may be demoted due to one or more of the following: study limitations, inconsistent results, indirectness of evidence, imprecision, or reporting bias. Alternatively, observational studies (cohort or case-control studies) start as “low quality” but may be upgraded if there is a large magnitude of the treatment effect, evidence of a dose-response relationship, or if all plausible biases would decrease the magnitude of a treatment effect. Thus, the GRADE system of evaluating the quality of evidence provides more granularity than the
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Surgery_Schwartz_13989
Surgery_Schwartz
relationship, or if all plausible biases would decrease the magnitude of a treatment effect. Thus, the GRADE system of evaluating the quality of evidence provides more granularity than the traditional hierarchy system, which assigns quality based upon study design alone. Although the GRADE system has significant advantages, it is more complex and has a steeper learning curve than traditional systems. Finally, GRADE is intended for appraising a body of evidence, such as in a systematic review.In addition to providing a transparent approach to grading evidence quality, the GRADE system outlines an approach to the development and assignment of strength to clinical recommendations. GRADE’s sophisticated hierarchy of evidence allows the system to protect against both superficial assessment and unwarranted confidence in all classes of study design. Since its development, the increasing use of GRADE has resulted in higher quality and rigor of systematic reviews due to standards outlined by
Surgery_Schwartz. relationship, or if all plausible biases would decrease the magnitude of a treatment effect. Thus, the GRADE system of evaluating the quality of evidence provides more granularity than the traditional hierarchy system, which assigns quality based upon study design alone. Although the GRADE system has significant advantages, it is more complex and has a steeper learning curve than traditional systems. Finally, GRADE is intended for appraising a body of evidence, such as in a systematic review.In addition to providing a transparent approach to grading evidence quality, the GRADE system outlines an approach to the development and assignment of strength to clinical recommendations. GRADE’s sophisticated hierarchy of evidence allows the system to protect against both superficial assessment and unwarranted confidence in all classes of study design. Since its development, the increasing use of GRADE has resulted in higher quality and rigor of systematic reviews due to standards outlined by
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Surgery_Schwartz_13990
Surgery_Schwartz
unwarranted confidence in all classes of study design. Since its development, the increasing use of GRADE has resulted in higher quality and rigor of systematic reviews due to standards outlined by the system.15 In creating a recommendation regarding a body of evidence, GRADE allows experts to account for limitations in bodies of evidence comprising of RCTs, while also allowing for the rating of observational studies as high quality in cases where RCTs are not feasible (i.e., an RCT cannot ethically be performed). GRADE therefore potentially allows for observational studies to provide definitive evidence of causal association (e.g., alcohol causing cirrhosis or asbestos causing mesothelioma) where RCTs may not be ethical or necessary.One of the major advantages of GRADE is that it specifi-cally addresses the process of moving from evidence to recom-mendations. The process begins with the creation of a summary of findings table. A summary of findings table consists of a presentation
Surgery_Schwartz. unwarranted confidence in all classes of study design. Since its development, the increasing use of GRADE has resulted in higher quality and rigor of systematic reviews due to standards outlined by the system.15 In creating a recommendation regarding a body of evidence, GRADE allows experts to account for limitations in bodies of evidence comprising of RCTs, while also allowing for the rating of observational studies as high quality in cases where RCTs are not feasible (i.e., an RCT cannot ethically be performed). GRADE therefore potentially allows for observational studies to provide definitive evidence of causal association (e.g., alcohol causing cirrhosis or asbestos causing mesothelioma) where RCTs may not be ethical or necessary.One of the major advantages of GRADE is that it specifi-cally addresses the process of moving from evidence to recom-mendations. The process begins with the creation of a summary of findings table. A summary of findings table consists of a presentation
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Surgery_Schwartz_13991
Surgery_Schwartz
addresses the process of moving from evidence to recom-mendations. The process begins with the creation of a summary of findings table. A summary of findings table consists of a presentation not only of evidence quality but also estimates of the relative and absolute effects of patient-centered outcomes (Fig. 51-2). The summary of findings format was created to min-imize framing effects, where different raters may come to varied conclusions based upon identical information due to the infor-mation having a contrasting presentation in terms of gain versus loss.16 GRADE and similar EBM systems specifically takes into consideration judgement of risk versus benefit, resource use, feasibility, and equity to attempt to make decision-making as consistent as possible across a range of reviewers.2 Despite all of the aforementioned considerations when constructing a guide-line, it is important to realize that patient values or preferences may immediately invalidate any recommendation. Evidence
Surgery_Schwartz. addresses the process of moving from evidence to recom-mendations. The process begins with the creation of a summary of findings table. A summary of findings table consists of a presentation not only of evidence quality but also estimates of the relative and absolute effects of patient-centered outcomes (Fig. 51-2). The summary of findings format was created to min-imize framing effects, where different raters may come to varied conclusions based upon identical information due to the infor-mation having a contrasting presentation in terms of gain versus loss.16 GRADE and similar EBM systems specifically takes into consideration judgement of risk versus benefit, resource use, feasibility, and equity to attempt to make decision-making as consistent as possible across a range of reviewers.2 Despite all of the aforementioned considerations when constructing a guide-line, it is important to realize that patient values or preferences may immediately invalidate any recommendation. Evidence
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Surgery_Schwartz_13992
Surgery_Schwartz
Despite all of the aforementioned considerations when constructing a guide-line, it is important to realize that patient values or preferences may immediately invalidate any recommendation. Evidence is often constructed based upon measurement of outcomes such as morbidity, mortality, or survival; however, patients may be more concerned with quality of life or avoiding invasive inter-ventions. GRADE attempts to acknowledges this intrinsic vari-ability within its system of grading.In terms of the overall strength of a recommendation that GRADE can assign, two grades are possible: “strong” and “weak.” A strong recommendation is one where positive effects of an intervention clearly outweigh the negative effects or vice versa. A weak recommendation is one where the asso-ciation is less clear, either because of low quality evidence or because the evidence clearly suggests that the positive and negative effects are similar. However, quality of evidence is not the only factor that affects the
Surgery_Schwartz. Despite all of the aforementioned considerations when constructing a guide-line, it is important to realize that patient values or preferences may immediately invalidate any recommendation. Evidence is often constructed based upon measurement of outcomes such as morbidity, mortality, or survival; however, patients may be more concerned with quality of life or avoiding invasive inter-ventions. GRADE attempts to acknowledges this intrinsic vari-ability within its system of grading.In terms of the overall strength of a recommendation that GRADE can assign, two grades are possible: “strong” and “weak.” A strong recommendation is one where positive effects of an intervention clearly outweigh the negative effects or vice versa. A weak recommendation is one where the asso-ciation is less clear, either because of low quality evidence or because the evidence clearly suggests that the positive and negative effects are similar. However, quality of evidence is not the only factor that affects the
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Surgery_Schwartz_13993
Surgery_Schwartz
because of low quality evidence or because the evidence clearly suggests that the positive and negative effects are similar. However, quality of evidence is not the only factor that affects the strength of a recommenda-tion (Table 51-2). Factors such as uncertainty of patient values or whether an intervention is an appropriate use of resources can play a role in the strength of a recommendation as well. Therefore, it is important to note that a “strong” or “weak” rec-ommendation may be given regardless of the classification of the evidence. For example, there is a strong recommendation that patients with Zollinger-Ellison syndrome be treated with PPI. This recommendation is made despite weak evidence to support this practice because the potential benefits far out-weigh the potential risks.17Although the systems for grading evidence are well devel-oped, it is important to remember that the studies used for evi-dence are judged based on their internal validity, or the extent to which a
Surgery_Schwartz. because of low quality evidence or because the evidence clearly suggests that the positive and negative effects are similar. However, quality of evidence is not the only factor that affects the strength of a recommenda-tion (Table 51-2). Factors such as uncertainty of patient values or whether an intervention is an appropriate use of resources can play a role in the strength of a recommendation as well. Therefore, it is important to note that a “strong” or “weak” rec-ommendation may be given regardless of the classification of the evidence. For example, there is a strong recommendation that patients with Zollinger-Ellison syndrome be treated with PPI. This recommendation is made despite weak evidence to support this practice because the potential benefits far out-weigh the potential risks.17Although the systems for grading evidence are well devel-oped, it is important to remember that the studies used for evi-dence are judged based on their internal validity, or the extent to which a
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Surgery_Schwartz_13994
Surgery_Schwartz
the systems for grading evidence are well devel-oped, it is important to remember that the studies used for evi-dence are judged based on their internal validity, or the extent to which a causal conclusion is warranted based upon applica-tion of the results to the study population. This means that care must be exercised when applying a recommendation to a given patient, as the external validity of a recommendation, or gener-alizability of a causal conclusion to populations outside of the scope of the original studies, may not be appropriate. Therefore, all evidence must be applied within the context of the patient in front of you.Synthesis of Evidence—Clinical GuidelinesThe Institute of Medicine defines a clinical guideline as “state-ments that include recommendations, intended to optimize patient care, that are informed by a systematic review of evidence and an assessment of the benefits and harms of alterna-tive care options.”18 Clinical guidelines may reflect previous published
Surgery_Schwartz. the systems for grading evidence are well devel-oped, it is important to remember that the studies used for evi-dence are judged based on their internal validity, or the extent to which a causal conclusion is warranted based upon applica-tion of the results to the study population. This means that care must be exercised when applying a recommendation to a given patient, as the external validity of a recommendation, or gener-alizability of a causal conclusion to populations outside of the scope of the original studies, may not be appropriate. Therefore, all evidence must be applied within the context of the patient in front of you.Synthesis of Evidence—Clinical GuidelinesThe Institute of Medicine defines a clinical guideline as “state-ments that include recommendations, intended to optimize patient care, that are informed by a systematic review of evidence and an assessment of the benefits and harms of alterna-tive care options.”18 Clinical guidelines may reflect previous published
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Surgery_Schwartz_13995
Surgery_Schwartz
patient care, that are informed by a systematic review of evidence and an assessment of the benefits and harms of alterna-tive care options.”18 Clinical guidelines may reflect previous published studies of varying design and quality, as well as expert opinion, and often represent the highest level of applied clinical evidence. Numerous guidelines have been published; however, like individual studies, even guidelines can vary in quality. The highest quality and most clinically useful guide-lines tend to have the following qualities:4Brunicardi_Ch51_p2137-p2152.indd 214228/02/19 4:19 PM 2143UNDERSTANDING, EVALUATING, AND USING EVIDENCE FOR SURGICAL PRACTICECHAPTER 51Summary of findings:Compression stockings compared with no compression stockings for people taking long flightsPatients or population: Anyone taking a long flight (lasting more than 6 hours)Settings: International air travelIntervention: Compression stockings1Comparison: Without stockingsOutcomesIllustrative comparative
Surgery_Schwartz. patient care, that are informed by a systematic review of evidence and an assessment of the benefits and harms of alterna-tive care options.”18 Clinical guidelines may reflect previous published studies of varying design and quality, as well as expert opinion, and often represent the highest level of applied clinical evidence. Numerous guidelines have been published; however, like individual studies, even guidelines can vary in quality. The highest quality and most clinically useful guide-lines tend to have the following qualities:4Brunicardi_Ch51_p2137-p2152.indd 214228/02/19 4:19 PM 2143UNDERSTANDING, EVALUATING, AND USING EVIDENCE FOR SURGICAL PRACTICECHAPTER 51Summary of findings:Compression stockings compared with no compression stockings for people taking long flightsPatients or population: Anyone taking a long flight (lasting more than 6 hours)Settings: International air travelIntervention: Compression stockings1Comparison: Without stockingsOutcomesIllustrative comparative
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Surgery_Schwartz_13996
Surgery_Schwartz
population: Anyone taking a long flight (lasting more than 6 hours)Settings: International air travelIntervention: Compression stockings1Comparison: Without stockingsOutcomesIllustrative comparative risks* (95% CI)Relativeeffect(95% CI)Number ofparticipants(studies)Qualityof theevidence(GRADE)Comments Assumed riskCorresponding riskWithout stockingsWith stockingsSymptomaticdeep vein thrombosis (DVT)See comment See comment Not estimable2821(9 studies)See comment0 participants developed symptomatic DVT in these studies.Symptom-lessdeep vein thrombosis Low risk population2RR 0.10(0.04 to 0.26) 2637(9 studies) ++++High10 per 10001 per 1000 (0 to 3)High risk population230 per 10003 per 1000(1 to 8)Superficial vein thrombosis13 per 10006 per 1000(2 to 15)RR 0.45(0.18 to 1.13)1804(8 studies)+++OModerate3 OedemaPost-flight values measured on a scale from 0, no oedema, to 10, maximum oedema.The mean oedema score ranged across control groups from6 to 9.The mean oedema score in the
Surgery_Schwartz. population: Anyone taking a long flight (lasting more than 6 hours)Settings: International air travelIntervention: Compression stockings1Comparison: Without stockingsOutcomesIllustrative comparative risks* (95% CI)Relativeeffect(95% CI)Number ofparticipants(studies)Qualityof theevidence(GRADE)Comments Assumed riskCorresponding riskWithout stockingsWith stockingsSymptomaticdeep vein thrombosis (DVT)See comment See comment Not estimable2821(9 studies)See comment0 participants developed symptomatic DVT in these studies.Symptom-lessdeep vein thrombosis Low risk population2RR 0.10(0.04 to 0.26) 2637(9 studies) ++++High10 per 10001 per 1000 (0 to 3)High risk population230 per 10003 per 1000(1 to 8)Superficial vein thrombosis13 per 10006 per 1000(2 to 15)RR 0.45(0.18 to 1.13)1804(8 studies)+++OModerate3 OedemaPost-flight values measured on a scale from 0, no oedema, to 10, maximum oedema.The mean oedema score ranged across control groups from6 to 9.The mean oedema score in the
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Surgery_Schwartz_13997
Surgery_Schwartz
studies)+++OModerate3 OedemaPost-flight values measured on a scale from 0, no oedema, to 10, maximum oedema.The mean oedema score ranged across control groups from6 to 9.The mean oedema score in the intervention groups was on average4.7 lower(95% CI –4.9 to –4.5). 1246(6 studies)++OOLow4 Pulmonary embolusSee commentSee commentNot estimable2821(9 studies)See comment0 participants developed pulmonary embolus in these studies.5DeathSee commentSee commentNot estimable2821(9 studies)See comment0 participants died in these studies.Adverse effectsSee commentSee commentNot estimable1182(4 studies)See commentThe tolerability of the stockings was described as very good with no complaints of side effects in 4 studies.6*The basis for the assumed risk is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the intervention group and the relative effect of the intervention (and its 95% CI).CI: Confidence interval; RR: Risk ratio GRADE:
Surgery_Schwartz. studies)+++OModerate3 OedemaPost-flight values measured on a scale from 0, no oedema, to 10, maximum oedema.The mean oedema score ranged across control groups from6 to 9.The mean oedema score in the intervention groups was on average4.7 lower(95% CI –4.9 to –4.5). 1246(6 studies)++OOLow4 Pulmonary embolusSee commentSee commentNot estimable2821(9 studies)See comment0 participants developed pulmonary embolus in these studies.5DeathSee commentSee commentNot estimable2821(9 studies)See comment0 participants died in these studies.Adverse effectsSee commentSee commentNot estimable1182(4 studies)See commentThe tolerability of the stockings was described as very good with no complaints of side effects in 4 studies.6*The basis for the assumed risk is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the intervention group and the relative effect of the intervention (and its 95% CI).CI: Confidence interval; RR: Risk ratio GRADE:
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Surgery_Schwartz_13998
Surgery_Schwartz
(and its 95% confidence interval) is based on the assumed risk in the intervention group and the relative effect of the intervention (and its 95% CI).CI: Confidence interval; RR: Risk ratio GRADE: GRADE Working Group grades of evidence (see explanations)11 All the stockings in the 9 trials included in this review were below-knee compression stockings. In four trials the compression strength was 20–30 mmHg at the ankle. It was 10–20 mmHg in the other four trials. Stockings come in different sizes. If a stocking is too tight around the knee it can prevent essential venous return causing the blood to pool around the knee. Compression stockings should be fitted properly. A stocking that is too tight could cut into the skin on a long flight and potentially cause ulceration and increased risk of DVT. Some stockings can be slightly thicker than normal leg covering and can be potentially restrictive with tight foot wear. It is a good idea to wear stockings around the house prior to travel to
Surgery_Schwartz. (and its 95% confidence interval) is based on the assumed risk in the intervention group and the relative effect of the intervention (and its 95% CI).CI: Confidence interval; RR: Risk ratio GRADE: GRADE Working Group grades of evidence (see explanations)11 All the stockings in the 9 trials included in this review were below-knee compression stockings. In four trials the compression strength was 20–30 mmHg at the ankle. It was 10–20 mmHg in the other four trials. Stockings come in different sizes. If a stocking is too tight around the knee it can prevent essential venous return causing the blood to pool around the knee. Compression stockings should be fitted properly. A stocking that is too tight could cut into the skin on a long flight and potentially cause ulceration and increased risk of DVT. Some stockings can be slightly thicker than normal leg covering and can be potentially restrictive with tight foot wear. It is a good idea to wear stockings around the house prior to travel to
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Surgery_Schwartz_13999
Surgery_Schwartz
DVT. Some stockings can be slightly thicker than normal leg covering and can be potentially restrictive with tight foot wear. It is a good idea to wear stockings around the house prior to travel to ensure a good, comfortable fitting. Stockings were put on 2 to 3 hours before the flight in most of the trials. The availability and cost of stockings can vary.2Two trials recruited high risk participants defined as those with previous episodes of DVT, coagulation disorders, severe obesity, limited mobility due to bone or joint problems, neoplastic disease within the previous two years, large varicose veins or, in one of the studies, participants taller than 190 cm and heavier than 90 kg. The incidence for 7 trials that excluded high risk participants was 1.45% and the incidence for the 2 trials that recruited high-risk participants (with at least one risk factor) was 2.43%. We have rounded these off to 10 and 30 per 1000 respectively.3The confidence interval crosses no difference and does
Surgery_Schwartz. DVT. Some stockings can be slightly thicker than normal leg covering and can be potentially restrictive with tight foot wear. It is a good idea to wear stockings around the house prior to travel to ensure a good, comfortable fitting. Stockings were put on 2 to 3 hours before the flight in most of the trials. The availability and cost of stockings can vary.2Two trials recruited high risk participants defined as those with previous episodes of DVT, coagulation disorders, severe obesity, limited mobility due to bone or joint problems, neoplastic disease within the previous two years, large varicose veins or, in one of the studies, participants taller than 190 cm and heavier than 90 kg. The incidence for 7 trials that excluded high risk participants was 1.45% and the incidence for the 2 trials that recruited high-risk participants (with at least one risk factor) was 2.43%. We have rounded these off to 10 and 30 per 1000 respectively.3The confidence interval crosses no difference and does
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Surgery_Schwartz_14000
Surgery_Schwartz
that recruited high-risk participants (with at least one risk factor) was 2.43%. We have rounded these off to 10 and 30 per 1000 respectively.3The confidence interval crosses no difference and does not rule out a small increase.4The measurement of oedema was not validated or blinded to the intervention. All of these studies were conducted by the same investigators.5If there are very few or no events and the number of participants is large, judgement about the quality of evidence (particularly judgements about precision) may be based on the absolute effect. Here the quality rating may be considered “high” if the outcome was appropriately assessed and the event, in fact, did not occur in 2821 studied participants.6None of the other trials reported adverse effects, apart from 4 cases of superficial vein thrombosis in varicose veins in the knee region that were compressed by the upper edge of the stocking in one trial.Figure 51-2. Example of a “summary of findings”
Surgery_Schwartz. that recruited high-risk participants (with at least one risk factor) was 2.43%. We have rounded these off to 10 and 30 per 1000 respectively.3The confidence interval crosses no difference and does not rule out a small increase.4The measurement of oedema was not validated or blinded to the intervention. All of these studies were conducted by the same investigators.5If there are very few or no events and the number of participants is large, judgement about the quality of evidence (particularly judgements about precision) may be based on the absolute effect. Here the quality rating may be considered “high” if the outcome was appropriately assessed and the event, in fact, did not occur in 2821 studied participants.6None of the other trials reported adverse effects, apart from 4 cases of superficial vein thrombosis in varicose veins in the knee region that were compressed by the upper edge of the stocking in one trial.Figure 51-2. Example of a “summary of findings”
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Surgery_Schwartz_14001
Surgery_Schwartz
from 4 cases of superficial vein thrombosis in varicose veins in the knee region that were compressed by the upper edge of the stocking in one trial.Figure 51-2. Example of a “summary of findings” table.Brunicardi_Ch51_p2137-p2152.indd 214328/02/19 4:19 PM 2144SPECIFIC CONSIDERATIONSPART IITable 51-2Factors that affect the strength of a recommendationFACTOREXAMPLES OF STRONG RECOMMENDATIONSEXAMPLES OF WEAK RECOMMENDATIONSQuality of evidenceMany high quality randomized trials have shown the benefit of inhaled steroids in asthmaOnly case series have examined the utility of pleurodesis in pneumothoraxUncertainty about the balance between desirable and undesirable effectsAspirin in myocardial infarction reduces mortality with minimal toxicity, inconvenience, and costWarfarin in low risk patients with atrial fibrillation results in small stroke reduction but increased bleeding risk and substantial inconvenienceUncertainty or variability in values and preferencesYoung patients with
Surgery_Schwartz. from 4 cases of superficial vein thrombosis in varicose veins in the knee region that were compressed by the upper edge of the stocking in one trial.Figure 51-2. Example of a “summary of findings” table.Brunicardi_Ch51_p2137-p2152.indd 214328/02/19 4:19 PM 2144SPECIFIC CONSIDERATIONSPART IITable 51-2Factors that affect the strength of a recommendationFACTOREXAMPLES OF STRONG RECOMMENDATIONSEXAMPLES OF WEAK RECOMMENDATIONSQuality of evidenceMany high quality randomized trials have shown the benefit of inhaled steroids in asthmaOnly case series have examined the utility of pleurodesis in pneumothoraxUncertainty about the balance between desirable and undesirable effectsAspirin in myocardial infarction reduces mortality with minimal toxicity, inconvenience, and costWarfarin in low risk patients with atrial fibrillation results in small stroke reduction but increased bleeding risk and substantial inconvenienceUncertainty or variability in values and preferencesYoung patients with
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