Towards evidence-based medicine in surgical practice: Best BETs

This best evidence topic was investigated according to a described protocol. We asked the question: what is the minimal vein diameter that can successfully predict maturation of an arteriovenous fistula (AVF) in patients undergoing dialysis. Using the reported search 804 papers were found, of which five represented the best evidence to answer the clinical question. All studies assessed the association between successful AVF maturation and the size of vein used. The strongest evidence came from a nonrandomised controlled follow-up study in which 76% of fistulas created using >2 mm cephalic vein successfully matured compared to 16% when the vein measured ≤2 mm. Another prospective, multicentre study showed 65% successful maturation using veins >4 mm compared to 45% with veins <3 mm. Vein diameter was found to be an independent predictor of maturation in multivariate regression analysis in two retrospective observational studies. Another retrospective observational study found that using venous measurements of ≥2.5 mm following tourniquet application resulted in more fistulas been created that would have otherwise been denied based on venous ultrasound mapping. A large multicentre randomised clinical trial assessing the use of different vein sizes both with and without tourniquet application using proper statistical tools - such as receiver operating characteristic - is required to make a final recommendation. Until then, a vein diameter of <2.5 mm should be considered inadequate for formation of an AVF, particularly if those measurements remain unchanged following the use of tourniquet.

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“…This best evidence topic was generated according to the structure outlined in the International Journal of Surgery [1].…”

Section: Introductionmentioning

confidence: 99%

The role of venous diameter in predicting arteriovenous fistula maturation: When not to expect an AVF to mature according to pre-operative vein diameter measurements? A best evidence topic

Bashar

Moloney

Burke

et al. 2015

International Journal of Surgery

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“…The search strategy used was highly sensitive and ensured retrieval of all relevant papers. As a result, this study succeeded in providing a practical answer of immediate use to surgeons in their daily practice [1]. It shows that RP is not only feasible and safe for carefully selected patients (a low BMI and a preoperatively localised parathyroid adenoma being the most important selection criteria) but also superior to all existing parathyroidectomy techniques with regards to the cosmetic result achieved.…”

Section: Discussionmentioning

confidence: 69%

Is robotic parathyroidectomy a feasible and safe alternative to targeted open parathyroidectomy for the treatment of primary hyperparathyroidism?

Garas

Holsinger

Grant

et al. 2015

International Journal of Surgery

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A best evidence topic was written according to a structured protocol. The question addressed was whether robotic parathyroidectomy (RP) is a feasible and safe alternative to targeted open parathyroidectomy for the treatment of primary hyperparathyroidism (pHPT). A total of 36 papers were identified using the reported searches of which 5 represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results are tabulated. Targeted parathyroidectomy constitutes the co-gold-standard procedure for pHPT with results equivalent to bilateral cervical exploration. This has led to the proliferation of minimally invasive parathyroidectomy (MIP) techniques for pre-operatively localised adenomas. None has been shown to be overwhelmingly superior. RP constitutes the most recent addition. RP overcomes the limitations of conventional endoscopic surgery and simultaneously avoids a neck scar by concealing it in the axilla or infraclavicular area. The evidence from the present review shows that RP is feasible and leads to a superior cosmetic result compared to targeted open parathyroidectomy (TOP) with an equivalent safety profile. As with every surgical technique, appropriate patient selection is crucial. Long-term data are currently awaited on RP especially in view of its high cost and long operative time compared to TOP and other MIP techniques. Hence, RP offers a viable but costly alternative to other forms of MIP in patients where even the smallest and most cosmetic neck scar is not an option.

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“…We therefore sought to review the routine use of radiological assessment of the integrity of cervical anastomoses formed following oesophagectomy by constructing a best evidence search according to a structured protocol, as has been outlined within an article published within the International Journal of Surgery [4].…”

Section: Introductionmentioning

confidence: 99%

Should routine radiological assessment of anastomotic integrity be performed after oesophagectomy with cervical anastomosis? Best evidence topic (BET)

Jones

Heah

Clarke

et al. 2015

International Journal of Surgery

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Rates of anastomotic leak in patients who undergo oesophagectomy with cervical anastomosis formation are reported within the literature to surpass those of patients undergoing thoracic anastomosis formation. Though preferred by a number of surgeons, cervical anastomosis is associated with higher rates of anastomotic leak, the consequences of which can be severe. Routine contrast oesophagograms are therefore utilised in a number of institutions as a means of recognising leaks early. They are not without potential complications, however, and the predictive value of contrast imaging has previously been debated. This best evidence topic reviews the use of contrast oesophagograms in screening for cervical anastamotic leak, concluding that their inherent risk of aspiration combined with poor sensitivity should preclude their use as a screening tool. High rates of specificity nevertheless indicate the potential utility of these studies in patients for whom there is clinical suspicion of a leak.

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Towards evidence-based medicine in surgical practice: Best BETs

Cited by 93 publications

References 16 publications

The role of venous diameter in predicting arteriovenous fistula maturation: When not to expect an AVF to mature according to pre-operative vein diameter measurements? A best evidence topic

The role of venous diameter in predicting arteriovenous fistula maturation: When not to expect an AVF to mature according to pre-operative vein diameter measurements? A best evidence topic

Is robotic parathyroidectomy a feasible and safe alternative to targeted open parathyroidectomy for the treatment of primary hyperparathyroidism?

Should routine radiological assessment of anastomotic integrity be performed after oesophagectomy with cervical anastomosis? Best evidence topic (BET)

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