A Double-Blinded Randomized Trial to Compare the Effectiveness of Minimally Invasive Procedures Using Patient-Reported Outcomes

Routine Implementation of Patient-Reported Outcomes Assessment Into Thoracic Surgery Practice

BACKGROUND

Patient-reported outcomes (PROs) assessment is a necessary component of surgical outcome assessment and patient care. This study examined the success of routine PROs assessment in an academic-based thoracic surgery practice.

METHODS

PROs, measuring pain intensity, physical function, and dyspnea, were routinely obtained using the National Institutes of Health-sponsored Patient-Reported Outcomes Measurement Information System (PROMIS) on all thoracic surgery patients beginning in April 2018 through January 2021. Questionnaires were administered electronically through a web-based platform at home or during the office visit. Completion rates and barriers were measured.

RESULTS

A total of 9725 thoracic surgery office visits occurred during this time frame. PROs data were obtained in 6899 visits from a total of 3551 patients. The mean number of questions answered per survey was 22.4 ± 2.2. Overall questionnaire completion rate was 65.7%. A significant decline in survey completion was noted in April 2020, after which adjustments were made to allow for questionnaire completion through a mobile health platform. Overall monthly questionnaire completion rates ranged from 20% (April 2020) to 90% (October 2018). Mean T scores were dyspnea, 41.6 ± 12.3; physical function, 42.7 ± 10.5; and pain intensity, 52.8 ± 10.3.

CONCLUSIONS

PROs can be assessed effectively in a thoracic surgery clinic setting, with minimal disruption of clinical activities. Future efforts should focus on facilitating PROs collection from disadvantaged patient populations and scaling implementation across programs.

OUP accepted manuscript

Background

Healthcare requires patient feedback to improve outcomes and experience. This study undertook a systematic review of the depth, variability, and digital suitability of current patient-reported outcome measures (PROMs) in patients undergoing laparoscopic cholecystectomy.

Methods

A PROSPERO-registered (registration number CRD42021261707) systematic review was undertaken for all relevant English language articles using PubMed version of MEDLINE, Scopus, and Web of Science electronic databases in June 2021. The search used Boolean operators and wildcards and included the keywords: laparoscopic cholecystectomy AND patient outcome OR patient-reported outcome OR patient-reported outcome measure OR PRO OR PROM. Medical Subjects Heading terms were used to search PubMed and Scopus. Articles published from 1 January 2011 to 2 June 2021 were included.

Results

A total of 4960 individual articles were reviewed in this study, of which 44 were found to evaluate PROMs in patients undergoing laparoscopic cholecystectomy and underwent methodological index for non-randomized studies (MINORS) grading. Twenty-one articles spanning 19 countries and four continents met all inclusion criteria and were included in the qualitative data synthesis. There was significant heterogeneity in PROMs identified with eight different comprehensive PROM tools used in the 21 studies. There was wide variation in the time points at which PROMs were recorded. Fourteen of 21 studies recorded PROMs before and after surgery, and 7 of 21 recorded PROMs only after surgery. Follow-up intervals ranged from 3 days to 2 years after surgery.

Conclusions

This study identified that while post-laparoscopic cholecystectomy PROMs are infrequently measured currently, tools are widely available to achieve this in clinical practice. PROMs may not capture all the outcomes but should be incorporated into future cholecystectomy outcome research. The EQ-5D™ (EuroQoL Group, Rotterdam, the Netherlands) provides a simple platform for the modern digital era.

Identification and categorisation of relevant outcomes for symptomatic uncomplicated gallstone disease: in-depth analysis to inform the development of a core outcome set

BACKGROUND

Many completed trials of interventions for uncomplicated gallstone disease are not as helpful as they could be due to lack of standardisation across studies, outcome definition, collection and reporting. This heterogeneity of outcomes across studies hampers useful synthesis of primary studies and ultimately negatively impacts on decision making by all stakeholders. Core outcome sets offer a potential solution to this problem of heterogeneity and concerns over whether the 'right' outcomes are being measured. One of the first steps in core outcome set generation is to identify the range of outcomes reported (in the literature or by patients directly) that are considered important.

OBJECTIVES

To develop a systematic map that examines the variation in outcome reporting of interventions for uncomplicated symptomatic gallstone disease, and to identify other outcomes of importance to patients with gallstones not previously measured or reported in interventional studies.

RESULTS

The literature search identified 794 potentially relevant titles and abstracts of which 137 were deemed eligible for inclusion. A total of 129 randomised controlled trials, 4 gallstone disease specific patient-reported outcome measures (PROMs) and 8 qualitative studies were included. This was supplemented with data from 6 individual interviews, 1 focus group (n=5 participants) and analysis of 20 consultations. A total of 386 individual recorded outcomes were identified across the combined evidence: 330 outcomes (which were reported 1147 times) from trials evaluating interventions, 22 outcomes from PROMs, 17 outcomes from existing qualitative studies and 17 outcomes from primary qualitative research. Areas of overlap between the evidence sources existed but also the primary research contributed new, unreported in this context, outcomes.

CONCLUSIONS

This study took a rigorous approach to catalogue and map the outcomes of importance in gallstone disease to enhance the development of the COS 'long' list. A COS for uncomplicated gallstone disease that considers the views of all relevant stakeholders is needed.

Comparative outcomes of needlescopic, single-incision laparoscopic, standard laparoscopic, mini-laparotomy, and open cholecystectomy: A systematic review and network meta-analysis of 96 randomized controlled trials with 11,083 patients

BACKGROUND

Most randomized trials on minimally invasive cholecystectomy have been conducted with standard (3/4-port) laparoscopic or open cholecystectomy serving as the control group. However, there exists a dearth of head-to-head trials that directly compare different minimally invasive techniques for cholecystectomy (eg, single-incision laparoscopic cholecystectomy versus needlescopic cholecystectomy). Hence, it remains largely unknown how the different minimally invasive cholecystectomy techniques fare up against one another.

METHODS

To minimize selection and confounding biases, only randomized controlled trials were considered for inclusion. Perioperative outcomes were compared using frequentist network meta-analyses. The interpretation of the results was driven by treatment effects and surface under the cumulative ranking curve values. A sensitivity analysis was also undertaken focusing on a subgroup of randomized controlled trials, which recruited patients with only uncomplicated cholecystitis.

RESULTS

Ninety-six eligible randomized controlled trials comprising 11,083 patients were identified. Risk of intra-abdominal infection or abscess, bile duct injury, bile leak, and open conversion did not differ significantly between minimally invasive techniques. Needlescopic cholecystectomy was associated with the lowest rates of wound infection (surface under the cumulative ranking curve value = 0.977) with an odds ratio of 0.095 (95% confidence interval: 0.023-0.39), 0.32 (95% confidence interval: 0.11-0.98), 0.33 (95% confidence interval: 0.11-0.99), 0.36 (95% confidence interval: 0.14-0.98) compared to open cholecystectomy, single-incision laparoscopic cholecystectomy, mini-laparotomy, and standard laparoscopic cholecystectomy, respectively. Mini-laparotomy was associated with the shortest operative time (surface under the cumulative ranking curve value = 0.981) by a mean difference of 22.20 (95% confidence interval: 13.79-30.62), 12.17 (95% confidence interval: 1.80-22.54), 9.07 (95% confidence interval: 1.59-16.54), and 8.36 (95% confidence interval: -1.79 to 18.52) minutes when compared to single-incision laparoscopic cholecystectomy, needlescopic cholecystectomy, standard laparoscopic cholecystectomy, and open cholecystectomy, respectively. Needlescopic cholecystectomy appeared to be associated with the shortest hospitalization (surface under the cumulative ranking curve value = 0.717) and lowest postoperative pain (surface under the cumulative ranking curve value = 0.928).

CONCLUSION

Perioperative outcomes differed across minimally invasive techniques and, in some instances, afforded superior outcomes compared to standard laparoscopic cholecystectomy. These findings suggest that there may be equipoise for exploring further the utility of novel minimally invasive techniques and potentially incorporating them into the general surgery training curriculum.

Is single port laparoscopic cholecystectomy superior to standard cholecystectomy in post-operative pain?

A best evidence topic has been constructed using a described protocol. The three-part question addressed was: is single port laparoscopic cholecystectomy superior to standard cholecystectomy in post-operative pain? Using the reported search, 8083 papers were found. 8 studies were deemed to be suitable to answer the question. The outcomes assessed were post-operative pain differ in single or standard laparoscopic cholecystectomy, all study used VAS (visual analogue scale). The evidence showed no difference in post-operative pain for patients went for single laparoscopic in compared with standard laparoscopic cholecystectomy.

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No difference in post-operative pain for patients who had single laparoscopic compared with standard laparoscopic cholecystectomy.

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May differ in hospital stay and cosmesis but not for post-operative pain.

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If your main concern is post-operative pain evidence not supporting any technique over other.

During which period should we avoid cholecystectomy in patients who underwent endoscopic retrograde cholangiopancreatography?

OBJECTIVE

To determine the period during which we should avoid cholecystectomy after endoscopic retrograde cholangiopancreatography.

METHODS

A retrospective analysis of electronic medical charts of 532 patients undergoing endoscopic retrograde cholangiopancreatography, between March 2013 and December 2017.

RESULTS

Approximately one-third of patients underwent the procedure between 4 and 30 days after endoscopic retrograde cholangiopancreatography. The conversion rate was 3.8%. The need for abdominal drainage and the finding of biliary tract injury after surgery were observed in 15.1% and 1.9% of patients, respectively. The length of stay was significantly shorter among patients undergoing surgery more than 30 days after endoscopic retrograde cholangiopancreatography. These patients had a median length of stay of one day, whereas the median length of stay in the group undergoing the procedure between 4 and 30 days after endoscopic retrograde cholangiopancreatography was 2 days.

CONCLUSION

The period during which we should avoid cholecystectomy is between 4 and 30 days after endoscopic retrograde cholangiopancreatography.

Single-incision versus conventional multiport laparoscopic cholecystectomy: a current meta-analysis of randomized controlled trials

BACKGROUND

We performed this study to compare the safety and feasibility of single-incision laparoscopic cholecystectomy (SILC) with conventional multiple-port laparoscopic cholecystectomy (MPLC).

METHODS

We searched PubMed, Embase, Web of Science, the Cochrane Controlled Register of Trials (CENTRAL), and ClinicalTrials.gov for randomized controlled trials comparing SILC versus MPLC. We evaluated the pooled outcomes for complications, pain scores, and surgery-related events. This study was performed in accordance with PRISMA guidelines.

RESULTS

A total of 48 randomized controlled trials involving 2838 patients in the SILC group and 2956 patients in the MPLC group were included in this study. Our results showed that SILC was associated with a higher incidence of incisional hernia (relative risk = 2.51; 95% confidence interval = 1.23-5.12; p = 0.01) and longer operation time (mean difference = 15.27 min; 95% confidence interval = 9.67-20.87; p < 0.00001). There were no significant differences between SILC and MPLC regarding bile duct injury, bile leakage, wound infection, conversion to open surgery, retained common bile duct stones, total complication rate, and estimated blood loss. No difference was observed in postoperative pain assessed by a visual analogue scale between the two groups at four time points (6 h, 8 h, 12 h, and 24 h postprocedure).

CONCLUSIONS

Based on the current evidence, SILC did not result in better outcomes compared with MPLC and both were equivalent regarding complications. Considering the additional surgical technology and longer operation time, SILC should be chosen with careful consideration.

Systematic review of reporting benefits and harms of surgical interventions in randomized clinical trials

BACKGROUND

Standardized reporting methods facilitate comparisons between studies. Reporting of data on benefits and harms of treatments in surgical RCTs should support clinical decision-making. Correct and complete reporting of the outcomes of clinical trials is mandatory to appreciate available evidence and to inform patients properly before asking informed consent.

METHODS

RCTs published between January 2005 and January 2017 in 15 leading journals comparing a surgical treatment with any other treatment were reviewed systematically. The CONSORT checklist, including the extension for harms, was used to appraise the publications. Beneficial and harmful treatment outcomes, their definitions and their precision measures were extracted.

RESULTS

Of 1200 RCTs screened, 88 trials were included. For the differences in effect size of beneficial outcomes, 68 per cent of the trials reported a P value only but not a 95 per cent confidence interval. For harmful effects, this was 67 per cent. Only five of the 88 trials (6 per cent) reported a number needed to treat, and no study a number needed to harm. Only 61 per cent of the trials reported on both the beneficial and harmful outcomes of the intervention studied in the same paper.

CONCLUSION

Despite CONSORT guidelines, current reporting of benefits and harms in surgical trials does not facilitate clear communication of treatment outcomes with patients. Researchers, reviewers and journal editors should ensure proper reporting of treatment benefits and harms in trials.

Surgical team workload comparison for 4-port and single-port laparoscopic cholecystectomy procedures

Advanced minimally invasive procedures may cause postural constraints and increased workload and stress for providers. This study compared workload and stress across surgical team roles for 48 laparoscopic cholecystectomies (4-port vs single-port) using a task load index (NASA-TLX), a procedural difficulty question, and salivary stress hormones. Statistical analyses were performed based on the presence intra-cluster correlation within team roles, at α=0.05. The single-port technique resulted in an 89% increase in physical workload for the surgeon and 63% increase for the assistant (both p<0.05). The surgeon had significantly higher salivary stress hormones during single-port surgeries. The degree of procedural difficulty was positively correlated between the surgeon and most roles: resident (r=0.67), assistant (r=0.81), and technician (r=0.81). There was a statistically significant positive correlation between the surgeon and assistant for all selfreported workload measures (p<0.05). The single-port technique requires further improvement to balance surgical team workload for optimal patient safety and satisfaction.

A systematic review of patient reported outcome measures (PROMs) and quality of life reporting in patients undergoing laparoscopic cholecystectomy

Patient reported outcome measures (PROMs) provide a valuable means of measuring outcomes subjectively from a patient's perspective, facilitating the assessment of service quality across healthcare providers, and assisting patients and clinicians in shared decision making. The primary aim of this systematic review was to critically appraise all historic studies evaluating patient reported quality of life, in adult patients undergoing laparoscopic cholecystectomy for symptomatic gallstones. The secondary aim was to perform a quality assessment of cholecystectomy-specific PROM-validation studies. A literature review was performed in PubMed, Google ScholarTM, the Cochrane Library, Medline, CINAHL, EMBASE and PsychINFO databases up to September 2017. Study characteristics, PROM-specific details and a bias assessment were summarised for non-validation studies. A COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) analysis was performed to assess the methodological quality of identified PROM-validation studies. Fifty one studies were found to evaluate health-related quality of life (HRQoL) after laparoscopic cholecystectomy. Although 94.1% of these studies included PROMs as a primary outcome measure, <20% provided level 1 evidence through randomised controlled trials (RCTs). There was significant variation in the selection and reporting of PROMs, with no studies declaring patient involvement in PROM selection, and 88.2% of studies failing to document the management of missing data points, or non-returned surveys (33.3%). In the 6 PROM-validation studies identified, only 5 psychometric properties were evaluated, the findings of which were limited due to the small number of studies. This systematic review identifies a lack in consistency of study design and PRO reporting in clinical trials. Whilst an increasing number of studies are being performed to evaluate PROs, a lack of adherence to existing PRO administration and reporting guidelines is continuing to negatively affect study quality. We recommend that future clinical trials utilizing PROs should adhere to established comprehensive guidelines as described.

Quality of life after single-incision laparoscopic cholecystectomy: A randomized, clinical trial

BACKGROUND

Controversy continues as to whether single-incision laparoscopic cholecystectomy, with the somewhat larger incision at the umbilicus, may lead to a worse postoperative quality of life and more pain compared with the more classic 4-port laparoscopic cholecystectomy. The aim of this study was to compare single-incision and 4-port laparoscopic cholecystectomy from the perspective of quality of life.

METHODS

This study was a multicenter, parallel-group, open-label, randomized clinical trial. A total of 120 patients who were scheduled to undergo elective cholecystectomy were randomly assigned 1:1 into the single-incision laparoscopic cholecystectomy or the 4-port laparoscopic cholecystectomy group and then assessed continuously for 2 weeks during the postoperative period. The primary outcome was quality of life, defined as the time to resume normal daily activities. Postoperative pain was also assessed. To explore the heterogeneity of treatment effects, we assessed the interactions of sex, age, and working status on recovery time.

RESULTS

A total of 58 patients in the single-incision group and 53 in the 4-port group (n = 111, 47 male, mean age 57 years) were analyzed. The mean time to resume daily activities was 10.2 days and 8.8 days, respectively, for single-incision and 4-port laparoscopic cholecystectomy (95% confidence interval -0.4 to 3.2, P = .12). Similarly, the time to relief from postoperative pain did not differ significantly between the groups. Statistically insignificant but qualitative interactions were noted; in the subgroups of women, full-time workers, and patients younger than 60 years, recovery tended to be slower after single-incision laparoscopic cholecystectomy.

CONCLUSION

Postoperative quality of life did not differ substantially between single-incision laparoscopic cholecystectomy and 4-port laparoscopic cholecystectomy. Patients younger than 60 years, women, and full-time workers tended to have a somewhat slower recovery after single-incision laparoscopic cholecystectomy.

SINGLE PORT LAPAROSCOPIC CHOLECYSTECTOMY: TECHNICAL ASPECTS AND RESULTS

Background:

The search for less traumatic surgical procedures without compromising efficacy and safety, together with the technological advances and greater experience of the teams, led to the development of operative techniques with increasingly smaller incisions, the so-called “minimally invasive surgeries”.

Aim:

To evaluate the technical aspects and results of single port cholecystectomy.

Method:

Were analyzed 170 patients between 18-74 years submitted to videolaparoscopic cholecystectomies by single port, regardless of elective or urgent indication, without restriction of patient selection.

Results:

Among the 170 operations, 158 were exclusively performed by single port, and the conversion rate was 7% (inclusion of other accessory trocars or conversion to multiportal). Conversion to open surgery occurred in three cases (1.76%). The mean surgical time was 67.97 min, showing a marked decrease when was reached close to 50 cases and a stabilization after 100 surgeries. The overall complication rate was 10%, with minor complications such as: incisional pain, hematomas, granulomas, port access hernias (9.41%).

Conclusion:

Single port cholecystectomy can, after standardization and surgical team training, be a safe surgical procedure associated with a recognized aesthetic advantage.

Single-incision laparoscopic cholecystectomy is responsible for increased adverse events: results of a meta-analysis of randomized controlled trials

BACKGROUND

Over the last decade, single-incision laparoscopic cholecystectomy (SLC) has gained popularity, although it is not evident if benefits of this procedure overcome the potential increased risk. Aim of the study is to compare the outcome of SLC with conventional multi-incision laparoscopic cholecystectomy (MLC) in a meta-analysis of randomized controlled trials only.

METHODS

A systematic Medline, Embase, and Cochrane Central Register of Controlled Trials literature search of articles on SLC and MLC for any indication was performed in June 2017. The main outcomes measured were overall adverse events, pain score (VAS), cosmetic results, quality of life, and incisional hernias. Linear regression was used to model the effect of each procedure on the different outcomes.

RESULTS

Forty-six trials were included and data from 5141 participants were analysed; 2444 underwent SLC and 2697 MLC, respectively. Mortality reported was nil in both treatment groups. Overall adverse events were higher in the SLC group (RR 1.41; p < 0.001) compared to MLC group, as well severe adverse events (RR 2.06; p < 0.001) and even mild adverse events (RR 1.23; p = 0.041). This was confirmed also when only trials including 4-port techniques (RR 1.37, p = 0.004) or 3-port techniques were considered (RR 1.89, p = 0.020). The pain score showed a standardized mean difference (SMD) of - 0.36 (p < 0.001) in favour of SLC. Cosmetic outcome by time point scored a SMD of 1.49 (p < 0.001) in favour of SLC. Incisional hernias occurred more frequently (RR 2.97, p = 0.005) in the SLC group.

CONCLUSIONS

Despite SLC offers a better cosmetic outcome and reduction of pain, the consistent higher rate of adverse events, both severe and mild, together with the higher rate of incisional hernias, should suggest to reconsider the application of single incision techniques when performing cholecystectomy with the existing technology.

Kinematic and ergonomic assessment of laparoendoscopic single-site surgical instruments during simulator training tasks

While laparoendoscopic single-site surgery (LESS) appears to be feasible and safe, instrument triangulation, tissue handling, and other bimanual tasks are difficult even for experienced surgeons. Novel technologies emerged to overcome LESS' procedural and ergonomic difficulties of "tunnel vision" and "instrument clashing." Surgeon kinematics, self-reported workload and upper body discomfort were used to compare straight, bent and two articulating instruments while performing two basic surgical tasks in a LESS simulator. All instruments resulted in bilateral elevation and rotation of the shoulders, excessive forearm motion and flexion and ulnar deviation of wrists. Surgeons' adopted non-neutral upper extremity postures and performed excessive joint excursions to compensate for reduced freedom of movement at the single insertion site and to operate the instrument mechanisms. LESS' cosmetic benefits continue to impact laparoscopic surgery and by enabling performance through improved instruments, ergonomic improvement for LESS can reduce negative impact on surgeon well-being and patient safety.