|Year : 2019 | Volume
| Issue : 3 | Page : 75-77
Guidelines in hernia surgery – friend or foe
M Pawlak1, B East2, H Gok3, AC de Beaux1
1 Department of General Surgery, Royal Infirmary of Edinburgh, Edinburgh, Scotland, UK
2 3rd Department of Surgery, Motol University Hospital; 1st Faculty of Medicine, 2nd Faculty of Medicine, Charles University, Prague, Czech Republic
3 Hernia Istanbul, Sisli, Istanbul, Turkey
|Date of Submission||14-Jul-2019|
|Date of Acceptance||15-Jul-2019|
|Date of Web Publication||30-Aug-2019|
Dr. A C de Beaux
Department of General Surgery, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, Scotland
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Pawlak M, East B, Gok H, de Beaux A C. Guidelines in hernia surgery – friend or foe. Int J Abdom Wall Hernia Surg 2019;2:75-7
The definition of a medical guideline is a document with the aim of guiding decisions and criteria regarding diagnosis, management, and treatment in specific areas of medicine.
Over the last 15 years, the hernia world has woken up to the idea of guidelines, and a number of such documents relating to hernia practice have been published.,,,,,,,,,,, While medical guidelines have been in use for thousands of years, they have, until recently, been based on tradition and authority. Modern medical guidelines are based on an examination of current evidence, so-called evidence-based medicine, and created using guideline methodology, which is in itself an evolving science. Indeed, two important pieces of evidence are necessary for worthwhile guideline development in any area: (1) evidence of good practice and (2) evidence that variation in practice exists in the region that the guideline is written for. A number of recent guidelines,, have highlighted lack of evidence of good practice, but they can still have value, as a consensus statement, highlighting important areas for further research.
Evidence itself is going through its own development. Many papers published in years past would not be accepted for publication today, because of their methodology failings, bias, lack of patient follow-up and the definitions of any complications reported not given. Indeed, one of the most cited papers relating to hernia surgery would have unlikely been published in its current form today. Yet, the Lichtenstein inguinal hernia repair is now in use worldwide and sometimes referred to as the “gold standard.” Many guidelines based the strength of their recommendations on the so-called hierarchy of clinical evidence, from systematic review of randomized controlled trials at the top to expert opinion at the bottom. However, this approach has been questioned and in many cases superseded by other ways of assessing medical knowledge which will be discussed further below. Indeed, Sir Michael Rawlins, then Head of the National Institute for Health and Care Excellence (NICE), commented in 2008 that “randomised controlled trials, long regarded as the 'gold standard' of evidence, have been put on an undeserved pedestal. Their appearance at the top of 'hierarchies' of evidence is inappropriate; and hierarchies, themselves, are illusory tools for assessing evidence. They should be replaced by a diversity of approaches that involve analysing the totality of the evidence-base.” Indeed, his 2008 Harveian Oration on the subject makes very interesting reading. In hernia surgery, registries are becoming an important part of patient care, and they are an important source of information to inform on guideline development. However, there are inherent risks and bias to registry data also. A recent paper on the subject articulates these pitfalls well.
Guideline methodology is evolving as already mentioned. The current standards of guideline development involve Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) methodology and the Appraisal for Guidelines, Research, and Evaluation (AGREE II) instrument. GRADE is a process that places at its core the members of the guideline development group. This group should be made up of interested parties relating to the subject of the guideline, including doctors, healthcare professionals, patients, and laypersons. Guidelines are not textbooks but start with identifying the key questions in the management of a condition, which are worthy of a guideline. The available evidence is examined, graded, and brought together by the group to result in statements and recommendations. Analysis of the evidence is an active process. The quality of evidence can be graded down based on the quality relating to a number of factors, including bias, inconsistency, indirectness, imprecision, and publication bias. In contrast, some evidence may be graded up, due to their outcome having a large effect or large dose–response. From this evidence base will come the recommendations. However, again, the guideline group is important in writing such recommendations. A recommendation will be a consideration of the balance of consequences. Quality of evidence remains a key to this, but also the balance of benefit versus harm, value and preferences, feasibility, equity and acceptability, and resource use and resource availability, for example, all influence the final guideline. Based on this process, the guideline will “recommend” or “suggest” that treatment should or should not be undertaken. Further knowledge of GRADE methodology is available on their website. Finally, the AGREE II instrument is a tool that assesses the methodological rigor and transparency in which a guideline is developed.(Further information on this can be obtained from their website.) Guidelines must be transparent, clear, and actionable. Many guidelines now will include future research topics to inform on key questions where evidence is lacking. However, an important step once a guideline is live is to have a dissemination and implementation strategy to encourage clinicians to use the guideline in practice and also inform the relevant patient groups discussed in the guideline.
It has been interesting to note the behavior of herniologists, both in medical journals and on social media platforms, as recent guidelines have been published. This was predicted by Prof. Feder in 1993 when he commented in a lecture, “One day soon medical sociologists will discover that the clinical guidelines industry is a microcosm of medicine worthy of close study. When guidelines are being developed, bloody struggles are waged over medical knowledge, all protagonists claim that 'evidence' supports their views, and final recommendations always require fine judgements and compromise.”
Guidelines – friend or foe? Guidelines that conform to current development standards should be our friend. There seems to be a fear among many herniologists that guidelines set a standard of care. And deviation from them will thus become ammunition for patients and their lawyers to trip us up. This is a view that is very wrong, both for what guidelines are for and what they mean. We end this editorial with the words of John Kinsella, recently retired Chair of the Scottish Intercollegiate Guidelines Network (SIGN). “In the era of realistic medicine, SIGN guidelines should be the starting point for decision-making at the clinician-patient interface, and should inform the joint decision, not dictate a particular course of action.”
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