Levels of evidence in plastic surgery—bibliometric trends and comparison with five other surgical specialties

Level of evidence in high impact surgical literature: the way forward

Evidence-based medicine stipulates that clinical decision-making should revolve around scientific evidence. The goal of the present study is to evaluate the methodological quality of surgical research recently published in JAMA Surgery, International Journal of Surgery, and British Journal of Surgery, the three surgical journals with the highest impact factor. An electronic search of the PUBMED database was performed to retrieve all articles published in the JAMA Surgery, International Journal of Surgery, and British Journal of Surgery in the year 2022. Three authors independently reviewed all retrieved articles and methodological designs of the publications were analyzed and rated using a modification of the Oxford Centre for Evidence-Based Medicine Levels of Evidence (Oxford Levels of Evidence scale). The initial search identified 1236 articles of which 809 were excluded after title and abstract screening. The remaining 427 underwent full text/methods read, of which 164 did not meet the inclusion/exclusion criteria. A total of 273 studies were included in the analysis. The average level of evidence was 2.5 ± 0.8 across all studies assessed. The majority of study designs were comprised of retrospective cohorts (n = 119), prospective cohorts (n = 47), systematic reviews of non RCTs (n = 39), and RCTs (n = 37). There was no significant difference in the average level of evidence between the top three journals (p = 0.50). Most clinical studies in the highest impact factor surgical journals are of level III evidence, consistent with earlier literature. However, our analysis demonstrates a relatively higher percentage of LOE I and II compared to what was previously published in the literature.

Multiple primary tumors: Colorectal carcinoma and non-Hodgkin's lymphoma

•

The association of a solid tumor with a hematological malignancy is very uncommon.

•

We report the case of synchronous colorectal cancer and diffuse large B-cell non-Hodgkin’s lymphoma.

•

This particular scenario poses a great challenge with regards to the appropriate treatment sequence due to the scarce literature found on this topic.

•

Multidisciplinary management in a patient-oriented fashion is of utmost importance to decide the best therapeutic strategy for each individual.

Introduction

Colorectal cancer (CRC) is the third most commonly diagnosed cancer, whereas lymphoma is the sixth leading cause of cancer death, 90% of which corresponds to non-Hodgkin’s lymphoma (NHL). The association of these two primary tumors, a solid tumor with an hematological malignancy, is very uncommon.

Presentation of case

We report the case of a 47-year-old man who presented with abdominal pain, a right upper quadrant mass and 12 kg of weight loss in 9 months. The computed tomography (CT) showed a large intra-abdominal mass and a wall thickening at the rectosigmoid junction. A colonoscopic biopsy confirmed a colorectal adenocarcinoma and a laparoscopic biopsy of the intraabdominal mass confirmed a diffuse large B-cell NHL. After multidisciplinary discussion it was decided to treat first the NHL with 3 cycles of R-CHOP chemotherapy (cyclophosphamide, doxorubicin, vincristine and prednisone). The patient experienced a good response with a 70% decrease in the intraabdominal mass and a negative PET/CT. Four months after diagnosis an anterior rectal resection was performed. The patient recovered uneventfully and was discharged 5 days after surgery. The patient finally died 20 months after surgery due to disease progression.

Discussion

The association of CRC and NHL is an extremely rare scenario that represents a great multidisciplinary challenge with respect to treatment due to the scarce literature found on this topic.

Conclusion

When CRC and NHL are present, all the different disease patterns must be considered in a multidisciplinary and patient-oriented fashion, in order to decide the best therapeutic strategy for each individual.

The Suprapubic Dermoadipose Flap for Aesthetic Reshaping of the Postpregnancy Abdomen

BACKGROUND

Postpregnancy full-length diastasis of the recti abdominis muscles is a common condition occasionally associated with atrophy of the subcutaneous fat located at the midline above and below the umbilicus.

OBJECTIVES

The authors report a preliminary clinical experience with the suprapubic flap to prevent the late postoperative contour deformities of the postpregnancy abdomen.

METHODS

Between January 2005 and January 2015, all female patients undergoing abdominoplasty with the suprapubic flap were included in the present study. Electronic clinical records were reviewed to analyze the patients' ages, body mass index (BMI) scores, pregnancies, risk factors, and operative times, followed by a telephone-based survey to measure patient satisfaction.

RESULTS

Twenty-two patients were included. Their ages ranged from 19 to 36 years (mean, 27 years) and their BMI ranged from 17.5 to 22.5 kg/m2 (mean, 20.5 kg/m2). Postoperative follow up ranged from 12 months to 10 years (mean, 89 months). All patients had experienced at least one pregnancy and many of them multiple or twin pregnancies. Umbilical hernias were present in 18 patients. There were 5 unusual cases: one hematoma, one seroma, and three cases of hypertrophic scarring. Thirteen additional minutes were required, on average, to associate the flap. All patients were satisfied or very satisfied with the results.

CONCLUSIONS

The suprapubic dermoadipose flap is an effective option to prevent the midline depression that would otherwise remain on the hypogastric region of postpregnant slim women with midline fat tissue atrophy.

LEVEL OF EVIDENCE 4

Modified Island Technique for Prominent Ears

There have been several methods described for the correction of prominent ears, including techniques that excise, bend, suture, score, or cut the auricular cartilage. The Island Technique, proposed by Pitanguy, is based on the creation of a cartilage island to define the antihelix and correct the conchoscaphal angle. Visibility of sharp edges has been the main criticism of this technique. To avoid them, we advise performing an internal bevel incision to round off the edges and achieve a more natural look. Also, sometimes prominent ears are asymmetric with different conchoscaphal angles, determining a residual but protruding upper pole, thus requiring different treatment on each side. For such cases, we propose the additional excision of a cartilage strip from the lower border of the auricular scapha, with a greater conchoscaphal angle. In this way, cartilage islands of similar width and identical antihelixes for both ears are created and a symmetric result is achieved. Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The STROCSS statement: Strengthening the Reporting of Cohort Studies in Surgery

INTRODUCTION

The development of reporting guidelines over the past 20 years represents a major advance in scholarly publishing with recent evidence showing positive impacts. Whilst over 350 reporting guidelines exist, there are few that are specific to surgery. Here we describe the development of the STROCSS guideline (Strengthening the Reporting of Cohort Studies in Surgery).

METHODS AND ANALYSIS

We published our protocol apriori. Current guidelines for case series (PROCESS), cohort studies (STROBE) and randomised controlled trials (CONSORT) were analysed to compile a list of items which were used as baseline material for developing a suitable checklist for surgical cohort guidelines. These were then put forward in a Delphi consensus exercise to an expert panel of 74 surgeons and academics via Google Forms.

RESULTS

The Delphi exercise was completed by 62% (46/74) of the participants. All the items were passed in a single round to create a STROCSS guideline consisting of 17 items.

CONCLUSION

We present the STROCSS guideline for surgical cohort, cross-sectional and case-control studies consisting of a 17-item checklist. We hope its use will increase the transparency and reporting quality of such studies. This guideline is also suitable for cross-sectional and case control studies. We encourage authors, reviewers, journal editors and publishers to adopt these guidelines.

A protocol for the development of the STROCSS guideline: Strengthening the Reporting of Cohort Studies in Surgery

•

No guidelines currently exist to support authors reporting on surgical cohort studies.

•

We hereby provide our protocol for the development of the STROCSS Guideline for surgical cohort studies.

•

Dissemination to interested parties and journals will be encouraged to endorse the reporting guideline.

Introduction

Strengthening the reporting of observational studies in epidemiology (STROBE) coined in 2007, highlighted the importance of improving the quality of observational research by providing an item checklist in order to avoid inadequate reporting of research. However, currently there are no reporting guidelines specific to surgical cohort studies, which have an extremely important role within the surgical literature. The recent development of surgery specific guidelines has underscored how surgical and procedural interventions require additional detail for readers to have a complete, clear, transparent and reproducible understanding. The objective of this research is to conduct a Delphi consensus exercise to develop the STROCSS guideline (Strengthening the Reporting of Cohort Studies in Surgery).

Methods and analysis

Current guidelines for case series (PROCESS), Cohort Studies (STROBE) and randomised controlled trials (CONSORT) will be analysed to compile items to form baseline material for developing cohort guidelines in the Delphi consensus exercise. The Delphi questionnaire will be administered via Google Forms and conducted using standard Delphi Methodology. Surgeons and individuals with significant experience of reviewing cohort studies as well as those with experience in developing reporting guidelines will be invited to participate. In the first round, existing items from PROCESS and STROBE will be put forward and participants will be invited to augment them or contribute further items for consideration. The provisional guidelines will then be updated in successive rounds using the nine-point Likert scale as proposed by the Grading Recommendations, Assessment, Development, and Evaluations (GRADE) working group. This process will be used to agree Standard definitions for the outcomes.

Dissemination

The work will be published in a peer-reviewed journal and presented at national and international meetings. Findings will be disseminated to interested parties, and journals will be encouraged to endorse the reporting guidelines.

Impact of the PROCESS guideline on the reporting of surgical case series: A before and after study

INTRODUCTION

The PROCESS guideline was developed in 2016 through expert Delphi consensus. It aimed to improve the quality of reporting of surgical case series. This study assessed the impact of the introduction of the PROCESS guideline on reporting for surgical case series submitted to three journals.

METHODS

20 case series published in the International Journal of Surgery Case Reports (IJSCR), the International Journal of Surgery (IJS) or the Annals of Medicine and Surgery (AMS) in September to December 2016, prior to the introduction of the PROCESS guideline (the pre-PROCESS period), were randomly identified and scored against the PROCESS criteria. Two authors independently scored each article a total score out of 29, the 'PROCESS score' (expressed as a percentage). Scores for the two researchers were compared and consensus was reached to achieve a final score set. The process was repeated for the January 2017 to April 2017 issues of the three journals, post PROCESS implementation (the post-PROCESS period).

RESULTS

The mean PROCESS score was 80% (range 66-90%) for the pre-PROCESS period and 84% (range 72-95%) for the post-PROCESS period, a 4% relative increase [STATS]. The Cohen's Kappa score between researchers was 0.907 implying very substantial agreement.

CONCLUSION

Implementation of the PROCESS guideline resulted in a 5% improvement in the reporting quality of surgical case series published in three journals. Further research is needed to identify and successfully navigate existing barriers to greater compliance. Authors, reviewers and editors should adhere to the guidelines to boost reporting quality. Journals should develop their policies and guide for authors to incorporate the guideline and mandate compliance.

Preferred reporting of case series in surgery; the PROCESS guidelines

INTRODUCTION

Case series have been a long held tradition within the surgical literature and are still frequently published. Reporting guidelines can improve transparency and reporting quality. No guideline exists for reporting case series, and our recent systematic review highlights the fact that key data are being missed from such reports. Our objective was to develop reporting guidelines for surgical case series.

METHODS

A Delphi consensus exercise was conducted to determine items to include in the reporting guideline. Items included those identified from a previous systematic review on case series and those included in the SCARE Guidelines for case reports. The Delphi questionnaire was administered via Google Forms and conducted using standard Delphi methodology. Surgeons and others with expertise in the reporting of case series were invited to participate. In round one, participants voted to define case series and also what elements should be included in them. In round two, participants voted on what items to include in the PROCESS guideline using a nine-point Likert scale to assess agreement as proposed by the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) working group.

RESULTS

In round one, there was a 49% (29/59) response rate. Following adjustment of the guideline with incorporation of recommended changes, round two commenced and there was an 81% (48/59) response rate. All but one of the items were approved by the participants and Likert scores 7-9 were awarded by >70% of respondents. The final guideline consists of an eight item checklist.

CONCLUSION

We present the PROCESS Guideline, consisting of an eight item checklist that will improve the reporting quality of surgical case series. We encourage authors, reviewers, editors, journals, publishers and the wider surgical and scholarly community to adopt these.