Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1519_Библиотеки_им_академика_М_И_Перельмана.pdf
467© Springer International Publishing Switzerland 2017
N. Hyman, K. Umanskiy (eds.), Difficult Decisions in Colorectal Surgery,
Difficult Decisions in Surgery: An Evidence-Based Approach,
DOI 10.1007/978-3-319-40223-9_41
Chapter 41
Quality Improvement: Where Are
We with Bowel Preps for Patients Undergoing
Colon Resection?
Anthony J. Senagore
Introduction
Colorectal surgeons have strived for reductions in postoperative septic complica-
tion rates and especially the incidence of anastomotic dehiscence since the incep-
tion of bowel surgery [1]. Bowel antisepsis as a means to this end was first advocated
by Poth in the 1940s [2]. Thirty years later, Barker and Everett advocated for MBP
because of their belief that gross fecal loading of the bowel was associated with an
increased incidence of wound infection [3, 4]. As a result of this work, MBP became
almost uniformly accepted as a dogma going forward [5]. The classic article which
codified the role of mechanical bowel prep with oral antibiotics was the three armed
study performed by Condon et al. They compared oral mechanical bowel prep with
either intravenous cephalothin alone; oral neomycin and erythromycin alone; or
both intravenous and oral regimens [6]. Although the intravenous antibiotic chosen
was limited in bacterial coverage, the combined strategy was superior nonetheless.
Coppa et al. studied 350 patients randomized to intravenous cefoxitin (broader
coverage gram negative and anaerobes) with or without oral neomycin and erythro-
mycin in conjunction with a mechanical bowel prep [7]. The dual regimen was
superior for superficial wound infection (11 % versus 5 %). Finally, Schoetz et al.
performed the reverse study, randomizing 190 patients to receive neomycin and
erythromycin orally with and without intravenous cefoxitin. Wound infection and
leak rates were higher in the group receiving only oral antibiotics [8]. These data led
to the era of combined mechanical bowel prep, with both oral and intravenous pro-
phylactic antibiotics. Over the last decade, the necessity for mechanical bowel prep
A.J. Senagore, MD, MBA
Department of Surgery, UTMB- Galveston, Galveston, TX, USA
e-mail: anthony.senagore@cmich.edu
www.ebook3000.com
468
has been questioned along with contemporaneous data reinvestigating the relative
role of mechanical prep with or without oral antibiotics.
Patients undergoing colon
resection
Bowel
prep
No bowel
prep
SSI, leak rate, dehiscence,
complications
Search Strategy
Search DATA SOURCES: Embase, PubMed, and the Cochrane Library were
searched using the terms oral, antibiotics/antimicrobial, colorectal/rectal/colon/rec-
tum, and surgery/operation. Time frame 2014–2016.
MAIN OUTCOME MEASURES: Anastomotic leakage, all-cause mortality,
wound infection, peritonitis/intra-abdominal abscess, reoperation, surgical site
infection, quality of life, length of stay, and adverse events were measured.
Patients Intervention Comparator Outcomes
Patients
undergoing
colectomy
No bowel
prep
Mechanical bowel
prep with or without
oral antibiotics
Anastomotic leak, mortality, wound
infection, surgical site infection,
ileus, reoperation, quality of life,
length of stay, and adverse events.
Results
Contant et al. studied 1431 patients undergoing open colorectal resection random-
ized to intravenous antibiotics (aerobic and anaerobic coverage) with or without
MBP [9]. The data demonstrated a significant increase in the rate of intra-abdominal
abscess without MBP (2.5 % vs 0.3 %), however there was no significant difference
in superficial wound infection (no-MBP-14 % vs MBP- 13.8 %) or anastomotic leak
(no-MBP-5.4 % vs MBP-4.8 %). The authors concluded that mechanical bowel
preparation can be safely avoided. Jungl et al. performed a similarly designed study
of 1505 open colectomy patients and also concluded that there was no significant
difference in wound infection (MBP- 7.8 % vs N-MBP- 6.4 %) or anastomotic leak
(MBP-2 % vs no-MBP 2.6 %) [10]. The recent meta-analysis by Bucher et al.
included 7 RCTs available in the literature. This meta-analysis revealed a higher
incidence of anastomotic dehiscence in patients receiving MBP, 5.6 % (36/642), vs
no MBP 2.8 % (18/655) (P = .03; OR, 1.85 [95 % CI, 1.06–3.22]) [11]. However,
using a number need to treat analysis (NNT) and an incidence of 5 % for anasto-
motic leaks, 32 patients (95 % CI, 19–306) would have to be operated on without
MBP to prevent one leak in a patient receiving MBP before surgery. The rate of
intra-abdominal infection (peritonitis or abscess) was similar in the MBP group,
3.7 % (17/458), compared with the no-MBP group, 2.0 % (9/461) (OR, 1.69 [95 %
A.J. Senagore
469
CI, 0.76–3.75]; P = .18). The rate of wound infection was slightly higher in patients
receiving MBP, 7.5 % (48/642), vs no MBP, 5.5 % (36/655) (OR, 1.38 [95 % CI,
0.89–2.15]; P = .15). General complication and extra-abdominal morbidity rates
were not significantly different in any of these studies; this finding was confirmed in
the meta-analysis. Because of the significant impact of anastomotic leaks, the
Bucher meta-analysis would favor the avoidance of MBP in terms of mortality rates
(OR, 1.42 [95 % CI, 0.37–5.45]; P = .60). The systematic review performed by
Wille-Jorgenson arrived at the same conclusion [12].
A major limitation of the “no bowel prep” philosophy was the failure to under-
stand that these data were obtained in the absence of the documented superior treat-
ment arm, mechanical bowel prep with oral antibiotics. Therefore, the more
accurate conclusion from these data is that bowel prep without oral antibiotics is
equivalent to no mechanical bowel prep. The recent report from the Michigan
Surgical Quality Consortium which analyzed 2062 elective colectomies between
January 2008 and June 2009 compared 49.6 % of patients with mechanical prep
only to 36.4 % with mechanical prep and oral antibiotics [13]. Patients receiving
oral antibiotics were less likely to have any SSI (4.5 % vs. 11.8 %, p = 0.0001), to
have an organ space infection (1.8 % vs. 4.2 %, p = 0.044) and to have a superficial
SSI (2.6 % vs. 7.6 %, p = 0.001). Interestingly, patients receiving bowel prep with
oral antibiotics were also less likely to have a prolonged ileus (3.9 % vs. 8.6 %,
p = 0.011). Fry recently reviewed the published literature and found MBP alone did
not reduce SSIs in nine prospective randomized trials between 2000 and 2010 [14].
He then performed a meta-analysis of nine randomized clinical trials of MBP
which showed the superiority of oral and intravenous antibiotics versus only intra-
venous antibiotics [odds ratio 0.47 (95 % CI: 0.16–0.77, p < 0.0001)]. Furthermore
the rate of SSIs decreased by 6.18 % (95 % CI: 3.43–8.94) with MBP using oral and
intravenous antibiotics [14].
More recently, there has been a concerted effort to revisit the impact of bowel
prep with antibiotics as part of quality improvement projects. Althumari performed
an analysis of the American College of Surgeons National Surgical Quality
Improvement Program Colectomy Targeted Participant Use Data File for 2012 and
2013 [15]. The analysis of 19,686 patients (25.7 % no bowel prep; 40.7 % received
MBP only; 3.3 % oral antibiotics only; 30.3 % received MBP plus oral antibiotics).
Patients who received MBP plus oral antibiotics had a lower incidence of superficial
SSI, deep SSI, organ space SSI, any SSI, anastomotic leak, postoperative ileus,
sepsis, readmission and reoperation compared with patients who received neither
(all P < 0.01). The reduction in SSI incidence was associated with a reduction in
wound dehiscence, anastomotic leak, pneumonia, prolonged requirement of
mechanical ventilator, sepsis, septic shock, readmission, and reoperation. Kiran
analyzed a portion of the same National Surgical Quality Improvement Program-
targeted colectomy data and also concluded that mechanical bowel prep with oral
antibiotics reduced the rates of SSI, anastomotic leak, and ileus by nearly half [16].
Wick et al. evaluated the impact of the implementation of a pathway designed to
improve patient outcomes which adopted a mechanical bowel preparation with oral
antibiotics at their institution. Compared to a historical control group, there was a
41 Quality Improvement: Where Are We with Bowel Preps for Patients
www.ebook3000.com
470
significant reduction in SSI (18.8 % vs 7.3 %). Collins et al. analyzed long term data
from a 1999 to 2005 randomized study comparing mechanical bowel preparation
(no oral antibiotics) to no prep and demonstrated that prep was associated with sig-
nificantly fewer recurrences, and better cancer-specific and overall survival in the
MBP group after 10 years [17]. Finally, a more recent meta-analysis assessing seven
randomized controlled trials that consisted of 1769 cases determined that both total
surgical site infection and incisional surgical site infection were significantly reduced
in patients who received oral and systemic antibiotics with a mechanical bowel prep-
aration (total: 7.2 % vs 16.0 %, p < 0.00001; incisional: 4.6 % vs 12.1 %, p < 0.00001)
[18]. Therefore, the current body of data would support the re- introduction (or con-
tinued practice) of the combination of mechanical bowel prep with oral antibiotics
as well as prophylactic intravenous antibiotics for optimal outcomes including surgi-
cal site infection and the related secondary complications in colectomy patients.
Study Patients
Outcome
classification
Typical risk
No prep
Typical risk
MBP/oral
ABX
Quality of
evidence
Contant et al.
Lancet. 2007;
370(9605):
2112–2117
Elective
colorectal
surgical
resection
patients
Mechanical
prep with
either PEG or
magnesium
citrate vs no
Prep;
Anastomotic
leak
Leak 37/684
(5.4 %)
Leak-
32/670
(4.8 %)
High quality
PRCT;
however no
study arm
with prep
and oral
antibiotics
Jung et al.
British Journal
of Surgery
2007; 94:
689–695
Elective
colorectal
surgical
resection
patients
Primary end
point- SSI;
Secondary-
adverse
outcomes
SSI- 16.1 %
ND in other
periop
complications
SSI- 15.1 % HIgh quality
PRCT;
however no
study arm
with prep
and oral
antibiotics
Cochrane
Review –
Antimicrobial
prophylaxis
for colorectal
surgery
(Review)
2009- [19]
Colorectal
surgical
resection
patients
SSI Oral/IV vs IV RR 0.55
with
combination
High quality
comparison
of multiple
outcomes
favoring
MBP and
oral ABX
Fry DE.
American
Journal of
Surgery.
2011;202(2):
225–232
Meta-
analysis of
9 studies
comparing
MBP with
and
without
oral
antibiotics
SSI OR in favor
of combined
mechanical
prep and oral
abx for SSI
reduction
High quality
meta analysis
A.J. Senagore
471
Study Patients
Outcome
classification
Typical risk
No prep
Typical risk
MBP/oral
ABX
Quality of
evidence
Englesbe MJ.
Annals of
Surgery 2010;
252(3):
514–520.
Propensity
analysis
based on
quality
database of
colorectal
surgery
patients
SSI risk and
associated
complications
SSI- 11.8 %
Organ
Space- 4.2 %
Superficial-
7.2 %
Ileus- 8.6 %
SSI- 4.5 %
Organ
Space- 1.8 %
Superficial-
2.6 %
Ileus- 3.9 %
High quality
audited
database
Recommendations Based on Data
Based upon the available data, it appears that the initial rigorous work by Nichols
and Condon as well as other investigators regarding the efficacy of mechanical
bowel preparation, oral antibiotics, and broad spectrum prophylactic intravenous
antibiotics has been reaffirmed. The controversy over the need for mechanical
bowel preparation in recent years was, in retrospect, supported by incomplete stud-
ies which did not include an arm with oral antibiotics. These studies were conceived
on the incorrect assumption that modern, broad spectrum intravenous prophylactic
antibiotics were sufficient to reduce surgical site infection. The importance of selec-
tive GI decontamination is an important component of both enhanced recovery and
quality improvement in colorectal surgery.
Strength of
recommendation
Implications for
patients
Implications for
clinicians
Implications for
policy makers
Strong in favor of
combined
mechanical bowel
preparation and oral
antibiotics; The large
PRCT’s advocating
equipoise for prep/
no prep did not
include the
important
component of oral
antibiotics with the
prep
Most patients
undergoing colectomy
would desire a
combined MBP/oral
ABX prep when
offered the informed
consent discussion
regarding the risk of
SSI and associated
complications. This
approach should be
part of the patient
education within an
enhanced recovery
program.
The robust quality data
base studies comparing
historical approaches to
broad implementation of
MBP/oral ABX prep are
consistent with single
center studies
performing quality
improvement. The
consistent and
significant decrease in
SSI and related
complications is
compelling and should
be widely adopted.
This single
component (MBP/
oral ABX prep) is
the most important
single aspect of any
strategy for
reducing SSI in
colectomy. It is low
cost and high
reward and should
be strongly
advocated as a
process measure
within a greater
enhanced recovery
protocol for
colectomy.
41 Quality Improvement: Where Are We with Bowel Preps for Patients
www.ebook3000.com
472
A Personal View of the Literature
The journey of initial adoption of a MBP/oral antibiotic strategy based on high qual-
ity prospective randomized studies, followed by the subsequent refutation of that
strategy also based on high quality prospective randomized studies is a an excellent
object lesson for future quality initiatives. If one looks back at the Nichols/Condon
era, all combinations were assessed: no mechanical bowel prep; no prep/oral antibi-
otics; prep alone; and prep with oral antibiotics. Interestingly, the more modern high
quality studies failed to appreciate the strength of the prior research and the need to
at least compare the study arm (i.e., no prep) to the gold standard (prep with oral
antibiotics). The data describes both the journey away from the successful practice
of prep with oral antibiotics with a resulting increase in SSI to the journey back with
improved outcomes. At least for my practice, I have maintained this successful pro-
cess measure as part of a global enhanced recovery protocol with excellent out-
comes. This should be a platform for future quality studies where the gold standard
should be put up against a comparator with a clear definition of the outcomes to be
impacted. Innovation is important but it should be structured in a way that the new
approach is at least equal, if not superior both from an outcome and cost
perspective.
References
1. Halsted W. Circular suture of the intestine: an experimental study. Am J Med Sci.
1887;94:436–61.
2. Poth E. Historical development of intestinal antisepsis. World J Surg. 1982;6:153–9.
3. Barker K, Graham NG, Mason FT, Dombal FT, Goligher JC. The relative significance of pre-
operative oral antibiotics, mechanical bowel preparation, and preoperative peritoneal contami-
nation in the avoidance of sepsis after radical surgery for ulcerative colitis and Crohn’s disease
of the large bowel. Br J Surg. 1971;58:270–3.
4. Everett MT, Brogan TD, Nettleton J. The place of antibiotics in colonic surgery: a clinical
study. Br J Surg. 1969;56:679–84.
5. Nichols RL, Condon RE. Preoperative preparation of the colon. Surg Gynecol Obstet.
1971;132:323–37. Condon RE, Bartlett JG, Nichols RL, et al. Preoperative prophylactic ceph-
alothin fails to control septic complications of colorectal operations: results of a controlled
clinical trial. A Veterans Administration cooperative study. Am J Surg. 1979;137(1):68–74.
6. Coppa GF, Eng KE. Factors involved in antibiotic selection in elective colon and rectal sur-
gery. Surgery. 1988;104(5):853–8.
7. Schoetz DJ, Roberts PL, Murray JJ, et al. Addition of parenteral cefoxitin to regimen of oral
antibiotics for elective oral colorectal operations. A randomized prospective study. Ann Surg.
1990;212(2):209–12.
8. Caroline ME, Contant CME, Hop WCJ, van’t Sant HP, Oostvogel JM, Smeets HJ, Stassen
LPS, Neijenhuis PA, et al. Mechanical bowel preparation for elective colorectal surgery: a
multicentre randomised trial. Lancet. 2007;370:2112–7.
9. Jung B, Påhlman L, Nystrom PO, Nilsson E, Mechanical Bowel Preparation Study Group.
Multicentre randomized clinical trial of mechanical bowel preparation in elective colonic
resection. Br J Surg. 2007;94:689–95.
A.J. Senagore
473
10. Bucher P, Mermillod BS, Gervaz P, Morel P. Mechanical bowel preparation for elective
colorectal surgery. A meta-analysis. Arch Surg. 2004;139:1359–64.
11. Wille-Jorgensen P, Guenaga K, Castor A, Matos D. Clinical value of preoperative mechanical
bowel cleansing in elective colorectal surgery: a systematic review. Dis Colon Rectum.
2003;46:1013–20.
12. Englesbe MJ, Luchtefeld MA, Kubus J, Lynch J, Velanovich V, Senagore AJ, Eggenberger JC,
Brooks L, Campbell DA. A statewide assessment of surgical site infection (SSI) following
colectomy: the role of oral antibiotics. Ann Surg. 2010;252(3):514–20.
13. Fry DE. Colon preparation and surgical site infection. Am J Surg. 2011;202(2):225–32.
14. Althumairi AA, Canner JK, Gearhart SL, Safar B, Sacks J, Efron JE. Predictors of perineal
wound complications and prolonged time to perineal wound healing after abdominoperineal
resection. World J Surg. 2016;40(7):1755–62.
15. Kiran RP, Murray AC, Chiuzan C, Estrada D, Forde K. Combined preoperative mechanical
bowel preparation with oral antibiotics significantly reduces surgical site infection, anasto-
motic leak, and ileus after colorectal surgery. Ann Surg. 2015;262(3):416–25.
16. Wick EC, Galante DJ, Hobson DB, Benson AR, Lee KH, Berenholtz SM, Efron JE, Pronovost
PJ, Wu CL. Organizational culture changes result in improvement in patient-centered out-
comes: implementation of an integrated recovery pathway for surgical patients. J Am Coll
Surg. 2015;221(3):669–77.
17. Collin Å, Jung B, Nilsson E, Påhlman L, Folkesson J. Impact of mechanical bowel preparation
on survival after colonic cancer resection. Br J Surg. 2014;101(12):1594–600.
18. Chen M, Song X, Chen LZ, Lin ZD, Zhang XL. Benefits of bowel preparation beyond surgical
site infection: a retrospective study. Comparing mechanical bowel preparation with both oral
and systemic antibiotics versus mechanical bowel preparation and systemic antibiotics alone
for the prevention of surgical site infection after elective colorectal surgery: a meta-analysis of
randomized controlled clinical trials. Dis Colon Rectum. 2016;59(1):70–8.
19. Nelson RL, Glenny AM, Song F. Antimicrobial prophylaxis for colorectal surgery (Review)
2009. The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. London, United
Kingdom
41 Quality Improvement: Where Are We with Bowel Preps for Patients
www.ebook3000.com
475© Springer International Publishing Switzerland 2017
N. Hyman, K. Umanskiy (eds.), Difficult Decisions in Colorectal Surgery,
Difficult Decisions in Surgery: An Evidence-Based Approach,
DOI 10.1007/978-3-319-40223-9_42
Chapter 42
Quality Improvement: Are Fast Track
Pathways for Laparoscopic Surgery Needed?
Avery S. Walker, Michael Keating, and Scott R. Steele
Introduction
Multiple studies have been performed demonstrating the benefits of an enhanced
recovery program following a wide breadth of surgical disciplines, including more
recent reports showing significant benefits of enhanced recovery protocols for
patients undergoing a laparoscopic colectomy. This has held true in both compari-
sons of an open versus minimally invasive approach, as well as when comparing
enhanced recovery pathways to traditional perioperative care strategies. While most
providers are now well versed in the concept of enhanced recovery, the individual
practice and components often vary in number and nature. However, the basic prin-
ciples of ensuring this program spans the preoperative, intraoperative, and postop-
erative settings, along with a multidisciplinary mandated “buy-in”, are necessary to
ensure maximal effectiveness regardless of the institution or procedure.
While enhanced recovery protocols may include anywhere from 8 to 26 different
components, almost all begin with detailed patient education on expectations and
outcomes in the outpatient setting prior to pursuing optimal perioperative tech-
niques, early enteral nutrition, and early mobilization. Initially described by
Disclaimers The results and opinions expressed in this article are those of the authors, and do not
reflect the opinions or official policy of the United States Army or the Department of Defense.
A.S. Walker, MD
Department of Surgery, Brian Allgood Army Community Hospital, Yongsan, South Korea
M. Keating, BA
Case Western Reserve University School of Medicine, Cleveland, OH, USA
S.R. Steele, MD (
*)
Department of Colon and Rectal Surgery, Case Western University, Cleveland, OH, USA
e-mail: harkersteele@mac.com
476
Professor Kehlet in the setting of open abdominal surgery, the impact that this “fast
track” protocol in the setting of a minimally invasive/laparoscopic approach has
also been questioned. To answer this latter question, this chapter focuses on patients
who undergo laparoscopic colectomy under the tenets of an enhanced recovery
pathway compared to those patients who progress through traditional perioperative
management strategies following a laparoscopic approach. The outcomes we pri-
marily evaluated within these programs include overall length of stay, morbidity,
and readmission rates--all in an effort to accelerate recovery without compromising
patient safety.
Search Strategy
A systematic database search utilizing the Cochrane Collaborative Library, OVID,
and PubMed databases was performed to identify all trials of interest from January
2009 to December 2015. This time period was selected in an effort to provide the
most up-to-date information balanced with allowing enough time from the initiation
and evolution of enhanced recovery programs in the early 2000s. Randomized con-
trolled trials (RCTs) and observational studies were provided the most weight,
though not the sole inclusionary criteria. The following keyword combinations were
used: “fast track”; “enhanced recovery”; “laparoscopic”; “colorectal”; “colon”;
“rectal”; “traditional open surgery”; and “laparotomy”. MeSH terms included “min-
imally invasive”; “laparoscopy*”; “treatment outcome”; “colonic/surgery”; “colec-
tomy/rehabilitation”; “length of stay”; “outcome assessment”; “postoperative care”;
“preoperative care”; “patient readmission”; “laparoscopic colectomy” and
“enhanced recovery pathway”. In addition, we hand-searched reference lists of
related systematic reviews since 2001 to identify relevant additional studies. Final
studies were selected based on the PICO (Population, Intervention, Comparator,
Outcomes) framework as listed in Table 42.1. Although not exclusionary, primary
authors focused on all English language manuscripts and studies of adults. The
primary authors formulated recommendations with the final grade of recommenda-
tion selected using the GRADE system (Table 42.2).
Table 42.1 PICO chart
P (patients) I (intervention) C (comparator) O (outcomes)
Patients
undergoing
colorectal
surgery
1. Laparoscopic-
assisted approach
or
2. Enhanced recovery
program/fast track
pathway
1. Traditional open
surgery
or
2. Conventional
postoperative care
Total hospital stay,
postoperative stay,
complications,
readmissions
Note: Studies were included where either (1) a fast track pathway was in place and they compared
open vs. laparoscopic approach or (2) laparoscopic colorectal surgery was being performed and the
analysis focused whether or not the addition of a fast track pathway changed outcomes
A.S. Walker et al.
www.ebook3000.com
477
Table 42.2 The GRADE system – grading recommendations
Description
Benefit vs. risk
and burdens
Methodologic quality
of supporting
evidence Implications
1A Strong
recommendation,
High quality
evidence
Benefits
clearly
outweigh risk
and burdens or
vice versa
RCTs without
important limitations
or overwhelming
evidence
from observational
studies
Strong recommendation,
can apply to most
patients in most
circumstances without
reservation
1B Strong
recommendation,
Moderate quality
evidence
Benefits
clearly
outweigh risk
and burdens or
vice versa
RCTs with important
limitations
(inconsistent results,
methodologic flaws,
indirect or imprecise)
or exceptionally
strong evidence
from observational
studies
Strong recommendation,
can apply to most
patients in most
circumstances without
reservation
1C Strong
recommendation,
Low or very low
quality evidence
Benefits
clearly
outweigh risk
and burdens or
vice versa
Observational studies
or case series
Strong recommendation
but may change when
higher quality evidence
becomes available
2A Weak
recommendation,
High quality
evidence
Benefits
closely
balanced with
risks and
burdens
RCTs without
important limitations
or overwhelming
evidence from
observational studies
Weak recommendation,
best action may differ
depending on
circumstances or
patients’ or societal
values
2B Weak
recommendations,
Moderate quality
evidence
Benefits
closely
balanced with
risks and
burdens
RCTs with important
limitations
(inconsistent results,
methodologic flaws,
indirect or imprecise)
or exceptionally
strong evidence
from observational
studies
Weak recommendation,
best action may differ
depending on
circumstances or
patients’ or societal
values
2C Weak
recommendation,
Low or very low
quality evidence
Uncertainty in
the estimates
of benefits,
risks and
burden;
benefits, risk
and burden
may be closely
balanced
Observational studies
or case series
Very weak
recommendations; other
alternatives may be
equally reasonable
Adapted from Guyatt et al. [1]
42 Quality Improvement: Are Fast Track Pathways for Laparoscopic Surgery Needed?