The role of staging laparoscopy for intraabdominal cancers: an evidence-based review

Diagnostic laparoscopy is minimally invasive surgery for the diagnosis of intraabdominal diseases. The aim of this review is a critical examination of the available literature on the role of laparoscopy for the staging of intraabdominal cancers. A systematic literature search of English-language articles on MEDLINE, the Cochrane database of evidence-based reviews, and the Database of Abstracts of Reviews of Effects was performed for the period 1995–2006. The level of evidence in the identified articles was graded. The search identified and reviewed seven main categories that have received attention in the literature: esophageal cancer, gastric cancer, pancreatic cancer, hepatocellular carcinoma, biliary tract cancer, colorectal cancer, and lymphoma. The indications, contraindications, risks, benefits, diagnostic accuracy of the procedure, and its associated morbidity are discussed. The limitations of the available literature are highlighted, and evidence-based recommendations for the use of laparoscopy to stage intraabdominal cancers are provided.     

The role of diagnostic laparoscopy for acute abdominal conditions: an evidence-based review

Diagnostic laparoscopy is minimally invasive surgery for the diagnosis of intraabdominal diseases. This study aim was a critical examination of the available literature on the role of laparoscopy for the diagnosis and treatment of acute intraabdominal conditions. A systematic literature search of English-language articles on MEDLINE, the Cochrane database of evidence-based reviews, and the Database of Abstracts of Reviews of Effects was performed for the period 1995-2006. The level of evidence in the identified articles was graded. This review examines the role of diagnostic laparoscopy for acute nonspecific abdominal pain, trauma, and the acute abdomen experienced by the critically ill patient. The indications, contraindications, risks, benefits, diagnostic accuracy of the procedure, and associated morbidity are discussed. The limitations of the available literature are highlighted, and evidence-based recommendations for the use of diagnostic laparoscopy to determine acute intraabdominal conditions are provided.     

Laparoscopic entry techniques: clinical guideline, national survey, and medicolegal ramifications

Background  This study aimed to establish criteria for safe laparoscopic entry through a systematic literature search and evidence-based medicine appraisal, to determine surgeon preferences for laparoscopic entry in the United Kingdom, and to appraise the medicolegal ramifications of complications arising from laparoscopic entry. Methods  A systematic literature search of MEDLINE and EMBASE (1996–2007) was performed as well as a national surgeon survey by questionnaire (May–December 2006). Results  Laparoscopic entry criteria involving 10 steps were established based on the systematic literature search and evidence-based critical appraisal. The national survey had 226 respondents, with the majority aware of the Middlesbrough consensus or Royal College of Obstetricians and Gynaecologists [RCOG]-sourced guidance. There was considerable variation in preferred laparoscopic entry techniques. Currently, there is clear judicial guidance on the medicolegal stance toward laparoscopic entry-related complications. Conclusions  Despite widespread awareness of laparoscopic entry guidelines, there remains considerable variation in the techniques adopted in clinical practice. Unless practice concurs with recommended guidance, women undergoing laparoscopy will be exposed to increased unnecessary operative risk. Laparoscopic entry-related injury in an uncomplicated woman is considered negligent practice according to UK legal case law.     

Effect of pneumoperitoneum on renal perfusion and function: A systematic review

Background The precise physiologic consequences of insufflating carbon dioxide into the abdominal cavity during laparoscopy are not yet fully understood. This systematic review aimed to investigate whether pneumoperitoneum results in decreased renal blood flow (RBF) or renal function. Methods A literature search was conducted electronically using Medline, Embase, and the Cochrane libraries on 1 July 2005. Various combinations of the medical subject headings—renal blood flow, pneumoperitoneum, renal function, and laparoscopy—were searched in all three databases. Reference lists from articles fulfilling the search criteria were used to identify additional articles. Results The literature search retrieved 20 articles concerning RBF and 25 articles concerning renal function during pneumoperitoneum. It was found that 17 of the 20 studies identified a decrease in RBF, and 20 of the 25 studies identified a decrease in renal function during pneumoperitoneum. Conclusion There appears to be sufficient evidence to conclude that both renal function and RBF are decreased during pneumoperitoneum. The magnitude of the decrease is dependent on factors such as preoperative renal function, level of hydration, level of pneumoperitoneum, patient positioning, and duration of pneumoperitoneum.     

Bias towards publishing positive results in orthopedic and general surgery: a patient safety issue?

Background  

Research articles reporting positive findings in the fields of orthopedic and general surgery appear to be represented at a considerably higher prevalence in the peer-reviewed literature, compared to published studies on negative or neutral data. This "publication bias" may alter the balance of the available evidence-based literature and may affect patient safety in surgery by depriving important information from unpublished negative studies.     

An evidence-based clinical guideline for antibiotic prophylaxis in spine surgery

Background context

The North American Spine Society's (NASS) Evidence-Based Clinical Guideline on Antibiotic Prophylaxis in Spine Surgery provides evidence-based recommendations to address key clinical questions regarding the efficacy and the appropriate antibiotic prophylaxis protocol to prevent surgical site infections in patients undergoing spine surgery. The guideline is intended to address these questions based on the highest quality clinical literature available on this subject as of June 2011.

Purpose

Provide an evidence-based educational tool to assist spine surgeons in preventing surgical site infections.

Study design

Systematic review and evidence-based clinical guideline.

Methods

This guideline is a product of the Antibiotic Prophylaxis in Spine Surgery Work Group of NASS Evidence-Based Guideline Development Committee. The work group consisted of neurosurgeons and orthopedic surgeons who specialize in spine surgery and are trained in the principles of evidence-based analysis. A literature search addressing each question and using a specific search protocol was performed on English language references found in MEDLINE (PubMed), ACP Journal Club, Cochrane Database of Systematic Reviews Database of Abstracts of Reviews of Effectiveness, Cochrane Central Register of Controlled Trials, EMBASE (Drugs and Pharmacology), and Web of Science to identify articles published since the search performed for the original guideline. The relevant literature was then independently rated using the NASS-adopted standardized levels of evidence. An evidentiary table was created for each of the questions. Final recommendations to answer each clinical question were developed via work group discussion, and grades were assigned to the recommendations using standardized grades of recommendation. In the absence of Levels I to IV evidence, work group consensus statements have been developed using a modified nominal group technique, and these statements are clearly identified as such in the guideline.

Results

Sixteen clinical questions were formulated and addressed, and the answers are summarized in this article. The respective recommendations were graded by the strength of the supporting literature, which was stratified by levels of evidence.

Conclusions

The clinical guideline for antibiotic prophylaxis in spine surgery has been created using the techniques of evidence-based medicine and best available evidence to aid practitioners in the care of patients undergoing spine surgery. The entire guideline document, including the evidentiary tables, suggestions for future research, and all the references, is available electronically on the NASS Web site at http://www.spine.org/Pages/PracticePolicy/ClinicalCare/ClinicalGuidlines/Default.aspx and will remain updated on a timely schedule.     

An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spinal stenosis (update)

Background contextThe evidence-based clinical guideline on the diagnosis and treatment of degenerative lumbar spinal stenosis by the North American Spine Society (NASS) provides evidence-based recommendations to address key clinical questions surrounding the diagnosis and treatment of degenerative lumbar spinal stenosis. The guideline is intended to reflect contemporary treatment concepts for symptomatic degenerative lumbar spinal stenosis as reflected in the highest quality clinical literature available on this subject as of July 2010. The goals of the guideline recommendations are to assist in delivering optimum efficacious treatment and functional recovery from this spinal disorder.PurposeProvide an evidence-based educational tool to assist spine care providers in improving quality and efficiency of care delivered to patients with degenerative lumbar spinal stenosis.Study designSystematic review and evidence-based clinical guideline.MethodsThis report is from the Degenerative Lumbar Spinal Stenosis Work Group of the NASS's Evidence-Based Clinical Guideline Development Committee. The work group consisted of multidisciplinary spine care specialists trained in the principles of evidence-based analysis. The original guideline, published in 2006, was carefully reviewed. A literature search addressing each question and using a specific search protocol was performed on English language references found in MEDLINE, EMBASE (Drugs and Pharmacology), and four additional, evidence-based, databases to identify articles published since the search performed for the original guideline. The relevant literature was then independently rated by a minimum of three physician reviewers using the NASS-adopted standardized levels of evidence. An evidentiary table was created for each of the questions. Final recommendations to answer each clinical question were arrived at via work group discussion, and grades were assigned to the recommendations using standardized grades of recommendation. In the absence of Levels I to IV evidence, work group consensus statements have been developed using a modified nominal group technique, and these statements are clearly identified as such in the guideline.ResultsSixteen key clinical questions were assessed, addressing issues of natural history, diagnosis, and treatment of degenerative lumbar spinal stenosis. The answers are summarized in this document. The respective recommendations were graded by the strength of the supporting literature that was stratified by levels of evidence.ConclusionsA clinical guideline for degenerative lumbar spinal stenosis has been updated using the techniques of evidence-based medicine and using the best available clinical evidence to aid both practitioners and patients involved with the care of this condition. The entire guideline document, including the evidentiary tables, suggestions for future research, and all references, will be available electronically at the NASS Web site (www.spine.org) and will remain updated on a timely schedule.     

Fewer adhesions induced by laparoscopic surgery?

Background Laparoscopic surgery has potential theoretical advantages over open surgery in reducing the rate of adhesion formation, but very few comparative studies are available to prove this.Methods A literature search was performed within Medline and Cochrane databases using the key words: adhesion*, adhesiolysis, laparoscop*, laparotomy, open surgery. Further articles were identified from the reference lists of retrieved literature. Both clinical and experimental studies comparing laparoscopy and laparotomy with regard to adhesion formation were retained. In each article, the rates of adhesion formation were identified or deduced for the operative site, access wound site, and distant sites.Results Fifteen studies from 1987 to 2001 were identified. Most studies assessed the operative site. Thus, three clinical studies and six experimental ones found fewer adhesions following laparoscopy than laparotomy, while other five experimental studies found similar adhesion rates for the two surgical methods. There were fewer adhesions to trocar wounds than to the laparotomy wounds in seven studies and equal rates of adhesion in one study. The problem of distant adhesions is poorly represented in literature; three studies favored laparoscopy as being followed by fewer adhesions. Because of the important differences between studies with regard to the design, end points, and statistical calculations, a metaanalysis could not be achieved. The conclusion is based on the prevalence of evidence.Conclusions All clinical studies and most of the experimental studies found a reduction of adhesion formation after laparoscopic surgery compared to open surgery.     

An evidence-based clinical guideline for the diagnosis and treatment of lumbar disc herniation with radiculopathy

Background contextThe objective of the North American Spine Society's (NASS) Evidence-Based Clinical Guideline for the Diagnosis and Treatment of Lumbar Disc Herniation with Radiculopathy is to provide evidence-based recommendations to address key clinical questions surrounding the diagnosis and treatment of lumbar disc herniation with radiculopathy. The guideline is intended to reflect contemporary treatment concepts for symptomatic lumbar disc herniation with radiculopathy as reflected in the highest quality clinical literature available on this subject as of July 2011. The goals of the guideline recommendations are to assist in delivering optimum efficacious treatment and functional recovery from this spinal disorder.PurposeTo provide an evidence-based educational tool to assist spine specialists in the diagnosis and treatment of lumbar disc herniation with radiculopathy.Study designSystematic review and evidence-based clinical guideline.MethodsThis guideline is a product of the Lumbar Disc Herniation with Radiculopathy Work Group of NASS' Evidence-Based Guideline Development Committee. The work group consisted of multidisciplinary spine care specialists trained in the principles of evidence-based analysis. A literature search addressing each question and using a specific search protocol was performed on English-language references found in Medline, Embase (Drugs and Pharmacology), and four additional evidence-based databases to identify articles. The relevant literature was then independently rated using the NASS-adopted standardized levels of evidence. An evidentiary table was created for each of the questions. Final recommendations to answer each clinical question were developed via work group discussion, and grades were assigned to the recommendations using standardized grades of recommendation. In the absence of Level I to IV evidence, work group consensus statements have been developed using a modified nominal group technique, and these statements are clearly identified as such in the guideline.ResultsTwenty-nine clinical questions were formulated and addressed, and the answers are summarized in this article. The respective recommendations were graded by strength of the supporting literature, which was stratified by levels of evidence.ConclusionsThe clinical guideline has been created using the techniques of evidence-based medicine and best available evidence to aid practitioners in the care of patients with symptomatic lumbar disc herniation with radiculopathy. The entire guideline document, including the evidentiary tables, suggestions for future research, and all the references, is available electronically on the NASS Web site at http://www.spine.org/Pages/PracticePolicy/ClinicalCare/ClinicalGuidlines/Default.aspx and will remain updated on a timely schedule.     

History of thoracoscopic surgery in Japan and the world

Purpose  The aim of this study was to review articles to learn how current thoracoscopic surgery was developed to the present status. Materials and methods  The Internet literature search engines PubMed and Index Medicus were used to search for the published articles. Interpretation of the articles was reflected in the reviewer’s personal experience, who was closely associated with the developmental history. Results  Altogether, 49 articles were selected and reviewed. Conclusions  A variety of applications of thoracoscopy have been developed. It remains the major surgical technique in thoracic surgery. This review was submitted at the invitation of the editorial committee.     

The Importance of the Length of the Limbs for Gastric Bypass Patients—An Evidence-based Review

The ideal length of the gastric bypass limbs is debated. Recent evidence suggests that standard limb lengths used today have a limited impact on patient weight loss. Our objective was to appraise critically the available evidence on the influence of the length of gastric bypass limbs on weight loss outcomes. We systematically reviewed MEDLINE, the Cochrane database of evidence-based reviews, and the Database of Abstracts of Reviews of Effects for articles reporting the effect of gastric bypass length on outcomes published between 1987 and 2009. Four randomized controlled trials and several retrospective studies were identified and reviewed. Longer Roux limb lengths (at least 150 cm) were associated with a very modest weight loss advantage in the short term in superobese patients. No significant impact of alimentary limb length on weight loss for patients with body mass index (BMI) <50 was seen. When the length of the common channel approaches 100 cm, a significant impact on weight loss is observed. The currently available literature supports the notion that a longer Roux limb (at least 150 cm) may be associated with a very modest weight loss advantage in the short term in superobese patients but has no significant impact on patients with BMI ≤50. To achieve weight loss benefit due to malabsorption, bariatric surgeons should focus on the length of the common channel rather than the alimentary or biliopancreatic limbs when constructing a gastric bypass especially in the superobese population where failure rates after conventional gastric bypass are higher.     

Unruptured intracranial aneurysms: appraisal of the literature and suggested recommendations for surgery, using evidence-based medicine criteria

OBJECTIVE: The literature on unruptured intracranial aneurysms is reviewed, and an attempt is made to stratify it according to the weight of the evidence. Recommendations for surgery are suggested, using evidence-based criteria. METHODS: A MEDLINE search was performed for 1966 to 1999. The focus was restricted to surgical management rather than other types of management, such as endovascular treatments. Each article was classified as Class I, II, or III according to the weight of the evidence. Some articles, such as literature reviews and data analyses, did not fit this classification and were grouped separately. Recommendations are based on the evidence available. RESULTS: Forty-five articles were reviewed. Thirteen articles contained information on the natural history, 19 contained data on the risks of surgery, and 2 contained information on both. In addition, 11 contained analyses of costs and benefits. None met the criteria for Class I evidence. Seven articles on the natural history and 7 on the risks of surgery met the criteria for Class II evidence, and 6 and 12, respectively, met those for Class III evidence. The remainder of the articles were analyses or review articles. CONCLUSION: There is insufficient evidence to recommend a standard of management. As a therapeutic guideline, conservative treatment is recommended for small aneurysms (<10 mm) and asymptomatic nongiant aneurysms in older people, whereas surgery is recommended for larger aneurysms in younger people and symptomatic aneurysms in fit patients. Other recommendations can be justified only as therapeutic options, using evidence-based criteria. Areas for future investigation are discussed.     

Risk of herpes/herpes zoster during anti-tumor necrosis factor therapy in patients with rheumatoid arthritis. Systematic review and meta-analysis

BackgroundTNF blockers have demonstrated efficacy in inflammatory rheumatic diseases (IRDs). The drugs are associated with a moderate but definite risk of bacterial infection, but risk of viral infection is not clearly known.ObjectiveTo assess the risk of herpes zoster (HZ) reactivation in patients with rheumatoid arthritis (RA) receiving TNF blockers as compared with DMARDs.MethodsA systematic search of literature up to March 2013 was performed, in MEDLINE, EMBASE, the Cochrane library and abstracts from the ACR and EULAR congresses from 2008 to 2011. Studies were included if they reported the incidence of HZ, respectively, in patients receiving anti-TNF and conventional DMARDs.ResultsThe literature search identified 3446 articles and 88 congress abstracts; a manual search retrieved seven articles. Finally, 26 articles and nine abstracts were included; six articles and one abstract were of meta-analyses estimating the relative risk of HZ in patients with RA with a total follow-up of 163,077 patient-years. From the meta-analyses of data for seven registries, the pooled risk ratio for HZ with TNF blockers was 1.61 [95%CI 1.16–2.23] (P = 0.004). Proportions of severe HZ ranged from 4.9% to 20.9% with TNF-blockers and from 2.0% to 5.5% with conventional DMARDs, in the different registries.ConclusionsThis meta-analysis revealed a significantly increased risk of HZ, up to 61%, in patients with IRD receiving TNF blockers. These data raise the issue of systematic prophylactic treatment with known history of HZ or vaccination without this history.     

Capture-mark-recapture to estimate the number of missed articles for systematic reviews in surgery

Background

Systematic reviews are an important knowledge synthesis tool, but with new literature available each day, reviewers must balance identifying all relevant literature against timely synthesis.

Methods

This study tested capture-mark-recapture (CMR), an ecology-based technique, to estimate the total number of articles in the literature identified in a systematic review of adult trauma care quality indicators.

Results

The systematic review included 40 articles identified from online searches and citation references. The CMR model suggested that 3 (95% confidence interval [CI]: 0 to 6) articles were missed and the database search provided 93% (one-sided 95% CI: ≥83%) of known articles for inclusion in the systematic review. The search order used for identifying the articles was optimal among the 24 that could have been used.

Conclusions

The CMR technique can be used in systematic reviews in surgery to estimate the closeness to capturing the total body of literature for a specific topic.     

Análise bibliométrica no campo da anestesiologia no período de 2009‐2018

ObjectiveThe limited number of bibliometric studies in the literature have generally focused on the top‐cited studies in the field of anesthesia, however, there is a lack of studies that made a holistic bibliometric evaluation of these works. The purpose of this study is to make a contemporary summary of the articles published in the field of anesthesia within the last 10 years through detailed bibliometric methods.MethodsThe articles published between the years 2009 and 2018 were downloaded from the Web of Science (WoS) database and analyzed using bibliometric methods. The literature review was conducted using the keyword “Anesthesiology” in the “Research Area” category via the advanced search option available in WoS. The relation between the number of publications of the countries and the Gross Domestic Products and Human Development Index values were analyzed using Spearman's correlation coefficient. The number of articles between the years 2019 and 2021 was estimated through linear regression analysis.ResultsA review of the literature indicated 41,003 articles in the Web of Science database. Estimations included 4,910 (3,971‐5,849) articles for the year 2019. There was a high‐level, positive significant correlation between the number of publications and Gross Domestic Product (r = 0.776, p < 0.001).ConclusionThe findings show that countries with high income are effective in the field of anesthesia, which indicates a strong association between research productivity and economic development. Undeveloped and developing countries should be encouraged to conduct research in the field of anesthesia.     

Enhancing recovery after minimally invasive surgery in children: A systematic review of the literature and meta-analysis

ObjectiveEnhanced recovery after surgery (ERAS) has been widely implemented after minimally invasive surgeries (MIS) in adults. The aim of this study was to evaluate the current evidence available on ERAS after MIS in children.MethodsUsing a defined search strategy (PubMed, Cochrane, Scopus), we performed a systematic review of the literature, searching for studies reporting on ERAS after MIS (thoracoscopy, laparoscopy, retroperitoneoscopy) in children (1975–2019). This study was registered with PROSPERO-international prospective register of systematic reviews. A meta-analysis was conducted using comparative studies for length of stay (LOS), complication rates, and readmission rates.ResultsOf 180 abstracts screened, 20 full-text articles were analyzed, and 9 were included in our systematic review (1 randomized controlled trial, 3 prospective, and 5 retrospective studies), involving a total number of 531 patients. ERAS has been applied to laparoscopy for digestive (n = 7 studies) or urologic surgeries (n = 1), as well as thoracoscopy (n = 1). Mean LOS was decreased in ERAS children compared to controls (6 studies, −1.12 days, 95%IC: −1.5 to −0.82, p < 0.00001). There was no difference in complication rates between ERAS children and control children (5 studies, 13% vs 14%, OR = 0.84, 95%CI: 0.49–1.44, p = 0.52). The 30-day readmission rate was decreased in ERAS children compared to controls (6 studies, 4% vs 10%, OR = 0.34, 95%CI: 0.18–0.66, p = 0.001).ConclusionsAlthough the evidence regarding ERAS in MIS is scarce, these protocols seem safe and effective, by decreasing LOS and 30-day readmission rate, without increasing post-operative complication rates.     

Laparoscopy in the Management of Impalpable Testis: Series of 64 Cases

Background  The undescended testis represents one of the most common disorders of childhood. Laparoscopy has been widely used for the diagnosis and treatment of non-palpable testis. In this study, we investigated and evaluated the usefulness of laparoscopy in the diagnosis and treatment of the non-palpable testis. Methods  From January 2003 to January 2008, we used laparoscopy in the management of 64 patients with 75 impalpable testes. The patients’ ages varied from 1 to 15 years (median 4.6 years). The sites and sizes of the testes were localized by abdominopelvic ultrasonography (US) in all 64 children. One-stage laparoscopic orchiopexy was performed for 26 testes, staged Fowler Stephens orchiopexy for 17 testes, and laparoscopic orchidectomy for five testes. Follow-up by clinical examination and color Doppler US was performed in every patient who underwent orchiopexy. Results  There were 11 patients with bilateral non-palpable testes. The overall diagnostic agreement of US with laparoscopy was seen for only 16 of 75 testes (21.3%). The results of diagnostic laparoscopy were varied and showed various pathologic conditions and positions of the testes, such as 20 low intraabdominal testes (26.6%), 17 high intraabdominal testes (22.7%), and 18 testes (24%) that had entered the inguinal canal. Associated inguinal hernia was present in four patients. After a mean follow-up period of 26 months (6 months–5 years) all testes were seen to be located in the bottom of the scrotum, with the exception of three testes that had retracted to the neck of the scrotum and two testes that had atrophied (2.7%). Conclusions  Laparoscopy has proven to be the only diagnostic modality where the findings provide a clear, dependable direction for definitive management of impalpable testes. It allows an accurate diagnosis and simultaneous definitive treatment.     

An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spondylolisthesis

Background ContextThe objective of the North American Spine Society (NASS) evidence-based clinical guideline on the diagnosis and treatment of degenerative lumbar spondylolisthesis is to provide evidence-based recommendations on key clinical questions concerning the diagnosis and treatment of degenerative lumbar spondylolisthesis. The guideline is intended to address these questions based on the highest quality clinical literature available on this subject as of January 2007. The goal of the guideline recommendations is to assist the practitioner in delivering optimum, efficacious treatment of and functional recovery from this common disorder.PurposeTo provide an evidence-based, educational tool to assist spine care providers in improving the quality and efficiency of care delivered to patients with degenerative lumbar spondylolisthesis.Study DesignSystematic review and evidence-based clinical guideline.MethodsThis report is from the Degenerative Lumbar Spondylolisthesis Work Group of the NASS Evidence-Based Clinical Guideline Development Committee. The work group was comprised of multidisciplinary spine care specialists, all of whom were trained in the principles of evidence-based analysis. Each member participated in the development of a series of clinical questions to be addressed by the group. The final questions agreed on by the group are the subject of this report. A literature search addressing each question and using a specific search protocol was performed on English language references found in MEDLINE, EMBASE (Drugs and Pharmacology) and four additional, evidence-based, databases. The relevant literature was then independently rated by at least three reviewers using the NASS-adopted standardized levels of evidence. An evidentiary table was created for each of the questions. Final grades of recommendation for the answer to each clinical question were arrived at via face-to-face meetings among members of the work group using standardized grades of recommendation. When Level I–IV evidence was insufficient to support a recommendation to answer a specific clinical question, expert consensus was arrived at by the work group through the modified nominal group technique and is clearly identified as such in the guideline.ResultsNineteen clinical questions were formulated, addressing issues of prognosis, diagnosis, and treatment of degenerative lumbar spondylolisthesis. The answers to these 19 clinical questions are summarized in this document. The respective recommendations were graded by the strength of the supporting literature that was stratified by levels of evidence.ConclusionsA clinical guideline for degenerative lumbar spondylolisthesis has been created using the techniques of evidence-based medicine and using the best available evidence as a tool to aid practitioners involved with the care of this condition. The entire guideline document, including the evidentiary tables, suggestions for future research, and all references, is available electronically at the NASS Web site (www.spine.org) and will remain updated on a timely schedule.     

Preoperative risk factors for intraabdominal adhesions should not contraindicate surgical laparoscopy for infertility

OBJECTIVE: Abdominal wall adhesions at laparoscopy may predispose infertile patients to access-related injuries and increase the complexity of the procedure. We have observed concern from referring physicians regarding the safety of surgical laparoscopy in infertile patients who previously underwent surgery because of the risk of abdominal adhesions. To assess the risk of intraabdominal adhesions at laparoscopy, a retrospective cohort study was performed. METHODS: All infertile patients who underwent a reproductive laparoscopic procedure in a 6-year period at our institution were included in this study. A chart review was performed to obtain demographic/surgical data and identify preoperative risk factors for intraabdominal adhesions. Operative videotapes were reviewed to determine the presence and location of adhesions. Standard statistical analyses were performed. RESULTS: During the study period, 254 infertile patients underwent reproductive surgical laparoscopy, and videotapes on 164 (65%) were available for review. A total of 88 patients (54%) were identified with preoperative risk factors for intraabdominal adhesions (group 1), while 76 (46%) had no risk factors (group 2). The relative risk of adhesions was 1.34 (95% CI, range 0.89 to 2.01, P=0.18) when risk factors were identified. There were no differences in the groups regarding patient age, operative time, access technique, conversion to open surgery, or complications. Estimated blood loss was significantly higher in group 2, likely due to the predominance of laparoscopic surgery for ovarian endometriomata and complexity of the cases rather than the presence or absence of intraabdominal adhesion risk factors. CONCLUSIONS: No difference existed in the risk of intraabdominal adhesions in infertile patients with and without identifiable preoperative risk factors. Preoperative risk factors for intraabdominal adhesions should not contraindicate the surgical laparoscopic approach for reproductive procedures.