背景:自从关于食道旁疝治疗的最新指南以来,出现了新的证据,指导方针开发方法已经发展起来。欧洲内镜手术协会的成员已优先考虑通过相关建议解决食道旁疝的管理。
目的:制定关于食管旁疝的循证临床实践建议,通过跨学科利益相关者小组的证据综合和结构化的证据到决策框架。
方法:我们进行了三次系统综述,我们使用等级方法对证据的确定性进行了总结和评估。一组普通和上消化道外科医生,胃肠病学家和患者倡导者讨论了益处和危害的背景下的证据,证据的确定性,可接受性,可行性,股本,资源的成本和使用,由指南国际网络认证的主指南开发人员和主席主持。我们在协商一致的会议上提出了这些建议,随后是修改后的德尔福调查。
结果:专家组建议手术治疗无症状/症状轻微的食管旁疝(有条件推荐),并建议对虚弱患者的无症状/症状轻微的食管旁疝进行保守治疗,而不是手术治疗(强烈推荐)。Further,该小组建议在食管旁疝修补术中缝合缝合裂孔,胃底折叠术在选择性食管旁疝修补术中,心肺不稳定并需要紧急食管旁疝修补术的患者的胃底折叠术(有条件的推荐)。强烈建议意味着建议的行动方案适合绝大多数患者。有条件的建议意味着大多数患者会选择拟议的行动方案,需要外科医生和患者的共同决策。在使用建议时,应阅读随附的证据摘要和决定证据框架。该指南适用于中度至大型II至IV型食管旁疝的成年患者,其中至少50%的胃突出到胸腔。具有用户友好的决策辅助工具的完整指南可在https://app中获得。magicapp.org/#/guideline/j7q7Gn。
结论:一个跨学科小组使用最高的方法学标准并遵循透明的过程,就食管旁疝的管理的关键主题提供建议。
■准备-2023CN018。
New evidence has emerged since latest guidelines on the management of paraesophageal hernia, and guideline development methodology has evolved. Members of the European Association for Endoscopic Surgery have prioritized the management of paraesophageal hernia to be addressed by pertinent recommendations.
To develop evidence-informed clinical practice recommendations on paraesophageal hernias, through evidence synthesis and a structured evidence-to-decision framework by an interdisciplinary panel of stakeholders.
We performed three systematic reviews, and we summarized and appraised the certainty of the evidence using the GRADE methodology. A panel of general and upper gastrointestinal surgeons, gastroenterologists and a patient advocate discussed the evidence in the context of benefits and harms, the certainty of the evidence, acceptability, feasibility, equity, cost and use of resources, moderated by a Guidelines International Network-certified master guideline developer and chair. We developed the recommendations in a consensus meeting, followed by a modified Delphi survey.
The panel suggests surgery over conservative management for asymptomatic/minimally symptomatic paraesophageal hernias (conditional recommendation), and recommends conservative management over surgery for asymptomatic/minimally symptomatic paraesophageal hernias in frail patients (strong recommendation). Further, the panel suggests mesh over sutures for hiatal closure in paraesophageal hernia repair, fundoplication over gastropexy in elective paraesophageal hernia repair, and gastropexy over fundoplication in patients who have cardiopulmonary instability and require emergency paraesophageal hernia repair (conditional recommendation). A strong recommendation means that the proposed course of action is appropriate for the vast majority of patients. A conditional recommendation means that most patients would opt for the proposed course of action, and joint decision-making of the surgeon and the patient is required. Accompanying evidence summaries and evidence-to-decision frameworks should be read when using the recommendations. This guideline applies to adult patients with moderate to large paraesophageal hernias type II to IV with at least 50% of the stomach herniated to the thoracic cavity. The full guideline with user-friendly decision aids is available in https://app.magicapp.org/#/guideline/j7q7Gn .
An interdisciplinary panel provides recommendations on key topics on the management of paraesophageal hernias using highest methodological standards and following a transparent process.
PREPARE-2023CN018.