The evidence on which to base practice: different tools for different times

Treasure, Tom

doi:10.1016/j.ejcts.2006.10.008

Cited by 12 publications

(9 citation statements)

References 33 publications

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“…The Cochrane Database of Systematic Reviews [3] reveals serious limitations as far as thoracic surgical aspects are concerned. Conclusions of a previous small RCT [4] had to be revaluated by a recent report with a diagonally opposite outcome [5], which makes thoracic empyema an eminent example of the complexities Tom Treasure detailed in our speciality [6].…”

Section: Introductionmentioning

confidence: 96%

Current surgical treatment of thoracic empyema in adults

Molnár¹

2007

European Journal of Cardio-Thoracic Surgery

205

182

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A review of the recent literature on treatment modalities of adult thoracic empyema was conducted in order to expose the controversies and verify where consensus exists. Critical reading filtered through clinical experience was the method followed. The roles of surgical drainage, lavage techniques, debridement via VATS, decortication, thoracoplasty and open window thoracostomy were considered using the Oxford Center of Evidence Based Medicine criteria. The roles of the different therapeutical modalities were interpreted in the light of the triphasic nature of empyema thoracis. The randomised controlled trials came up with conflicting results. With two exceptions all of the papers reviewed provide level (2b) or below evidences. The lack of a single ideal treatment modality or policy reflects the complexity of the diagnosis and staging of this heterogeneous disease. Basic elements of intervention--drainage, different evacuation techniques, decortication, thoracoplasty and open window thoracostomy--are well-established technical modalities; however, neither a universally acceptable primary modality nor the gold standard of their sequence is available. Drainage remains to be the initial treatment modality in Phase I disease. Debridement via VATS is a safe, reliable and efficient method in the fibrinopurulent phase. Organised pleural callus requires formal decortication. Open window thoracostomy is a simple and safe procedure for high-risk patients and results in quick detoxication. Thoracoplasty kept its final role in pleural space management. Acute postoperative bronchial stump insufficiency requires immediate surgery. Evacuation of toxic material is mandatory. No single-stage procedure offers a solution. An optimised agressivity treatment modality should be tailored to the condition of the patient and to the potential of the persisting cavity. Decision-making involves a triad consisting of the aetiology of empyema (i.e. primary vs secondary), general condition of the patient and stage of disease, while considering the triphasic nature of development of thoracic empyema. The current attitudes show that the present concepts are based mainly on expert opinion. Flexibility and patience on behalf of the surgeon and nursing staff, the patient and the hospital management, as well as a good understanding of the complexity of this condition are the cornerstones of the treatment. No exclusive sequence of procedures leading to a uniformly predictable successful outcome is available. Individualised approaches can be recommended based on institutional practice and local protocols. Thoracic empyema in general seems to remain resilient to fit completely into the categories of evidence-based medical approach.

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Section: Introductionmentioning

confidence: 96%

Current surgical treatment of thoracic empyema in adults

Molnár¹

2007

European Journal of Cardio-Thoracic Surgery

205

182

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“…In drawing conclusions about surgical practice, it is necessary to use all the available evidence, since there is usually insufficient RCT evidence to underpin every aspect of surgical practice. 9 Bringing all the strands together, there appears to be good reason to advocate VATS in the management of pneumothorax. The evidence base presented, including RCTs, the systematic review and an expertise-based study, all points in that direction.…”

Section: Discussionmentioning

confidence: 99%

Minimally invasive surgery for pneumothorax: The evidence, changing practice and current opinion

Treasure

2007

J R Soc Med

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Spontaneous pneumothorax is a common problem and in patients at risk of recurrence, excision of the source of the air leak and pleurodesis is very effective in reducing further episodes. In the 15 years since the introduction of video assisted thoracic surgery (VATS), practice has changed towards this much less invasive procedure and away from thoracotomy. The evidence from randomized trials, non-randomized comparative studies, the consensus of surgeons and the documented change in practice from registry data are concordant. Unless there are specific clinical indications for more invasive surgery, it would seem reasonable for VATS to become the recommended approach.

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“…EBM is now taught in virtually all US and Canadian medical schools and many others world wide and is practiced at most teaching hospitals (more so than in private practice) [2]. However, many formidable obstacles, objections and criticisms to EBM remain [3–6]. We reviewed the English literature of EBM and its application to the young discipline of transfusion medicine (TM).…”

Section: Introductionmentioning

confidence: 99%