BACKGROUND: The evidence for treatment decision-making in emergency general surgery has not been summarized previously. The aim of this overview was to review the quantity and quality of systematic review evidence for the most common emergency surgical conditions.
METHODS: Systematic reviews of the most common conditions requiring unplanned admission and treatment managed by general surgeons were eligible for inclusion. The Centre for Reviews and Dissemination databases were searched to April 2014. The number and type (randomized or non-randomized) of included studies and patients were extracted and summarized. The total number of unique studies was recorded for each condition. The nature of the interventions (surgical, non-surgical invasive or non-invasive) was documented. The quality of reviews was assessed using the AMSTAR checklist.
RESULTS: The 106 included reviews focused mainly on bowel conditions (42), appendicitis (40) and gallstone disease (17). Fifty-one (48·1 per cent) included RCTs alone, 79 (74·5 per cent) included at least one RCT and 25 (23·6 per cent) summarized non-randomized evidence alone. Reviews included 727 unique studies, of which 30·3 per cent were RCTs. Sixty-five reviews compared different types of surgical intervention and 27 summarized trials of surgical versus non-surgical interventions. Fifty-seven reviews (53·8 per cent) were rated as low risk of bias.
CONCLUSION: This overview of reviews highlights the need for more and better research in this field.
ANTECEDENTES: La infección por Clostridium difficile es la causa principal de diarrea nosocomial en los Estados Unidos; Sin embargo, son pocos los pacientes desarrollarán la enfermedad fulminante asociada a C. difficile (CDAD), lo que exige una intervención quirúrgica urgente. La mortalidad de los pacientes que requieren una intervención quirúrgica es muy alta, de hasta el 80% en algunas series. Puesto que no hay consenso en la literatura sobre el mejor tratamiento quirúrgico para esta enfermedad, hemos tratado de responder a la siguiente: PICO [población, intervención, comparación y resultados] Pregunta 1: En pacientes adultos con CDAD, hace la cirugía temprana en comparación con finales cirugía, tal como se define por la necesidad de vasopresores, disminuir la mortalidad?PICO Pregunta 2: En pacientes adultos con CDAD, no colectomía abdominal total (TAC) en comparación con otros tipos de intervención disminuir la mortalidad quirúrgica?
MÉTODOS: Un subcomité del Comité Directriz de gestión práctica de la Asociación Oriental para la Cirugía de Trauma realizaron una revisión sistemática y meta-análisis de las preguntas seleccionadas. Software RevMan se utilizó para generar diagramas de bosque. Grados de recomendación, evaluación, desarrollo y metodología de las evaluaciones se utilizó para evaluar la calidad de la evidencia, el uso de software GRADEpro para crear tablas de evidencia.
RESULTADOS: La reducción de la mortalidad se asoció significativamente con la cirugía temprana, con un riesgo relativo (RR) de 0,5 (intervalo de confianza del 95% [IC]: 0,35 hasta 0,72). La calidad de las pruebas fue "moderado". Teniendo en cuenta sólo el primer procedimiento realizado, la mortalidad parecía su tendencia alcista para TAC, con un RR de 1,11 (IC 95%, 0,69-1,80). Considerando sólo el procedimiento real realizado, la estimación puntual cambió de bando, que muestra una tendencia hacia la disminución de la mortalidad con TAC (RR, 0,86; IC del 95%, 0,56-1,31). La calidad de las pruebas fue "muy bajo".
CONCLUSIÓN: Es muy recomendable que los pacientes adultos con CDAD someten a la cirugía temprana, antes de que el desarrollo de shock y la necesidad de vasopresores. Nos condicionalmente recomendamos colectomía subtotal o total (frente a la colectomía parcial u otra cirugía) cuando se conoce el diagnóstico de los Centros para el Control y la Prevención de Enfermedades.
The evidence for treatment decision-making in emergency general surgery has not been summarized previously. The aim of this overview was to review the quantity and quality of systematic review evidence for the most common emergency surgical conditions.
METHODS:
Systematic reviews of the most common conditions requiring unplanned admission and treatment managed by general surgeons were eligible for inclusion. The Centre for Reviews and Dissemination databases were searched to April 2014. The number and type (randomized or non-randomized) of included studies and patients were extracted and summarized. The total number of unique studies was recorded for each condition. The nature of the interventions (surgical, non-surgical invasive or non-invasive) was documented. The quality of reviews was assessed using the AMSTAR checklist.
RESULTS:
The 106 included reviews focused mainly on bowel conditions (42), appendicitis (40) and gallstone disease (17). Fifty-one (48·1 per cent) included RCTs alone, 79 (74·5 per cent) included at least one RCT and 25 (23·6 per cent) summarized non-randomized evidence alone. Reviews included 727 unique studies, of which 30·3 per cent were RCTs. Sixty-five reviews compared different types of surgical intervention and 27 summarized trials of surgical versus non-surgical interventions. Fifty-seven reviews (53·8 per cent) were rated as low risk of bias.
CONCLUSION:
This overview of reviews highlights the need for more and better research in this field.
Síntesis amplia»Revisión panorámica de revisiones sistemáticas
