To analyze the results of laparoscopic surgery in patients with perforated ulcers using evidence-based medicine approaches.
We compared the efficacy and effectiveness of laparoscopic and open surgeries in patients with perforated ulcers. Meta-analysis of mortality after laparoscopic surgeries (randomized controlled trials) and trial sequential analysis were carried out.
We clarified the differences between the efficacy and effectiveness of laparoscopic surgeries regarding postoperative mortality. In the Russian Federation, mortality after laparoscopic surgery is 9-11 times lower compared to open procedures. According to evidence-based researches (efficacy of laparoscopic interventions in 10 meta-analyses), these differences are less obvious (1.4-3.0 times) and not significant. The diversity-adjusted required information size to draw reasonable conclusions about differences in mortality in trial sequential analysis was 68 181 participants. Meta-analyses of RCTs also demonstrate lower incidence of wound complications (1.8-5.0% after laparoscopic surgery and 6.3-13.3% after laparotomy), shorter hospital-stay (mean difference from -0.13 to -2.84) and less severe pain syndrome (mean difference in VAS score from -2.08 to -2.45) after laparoscopic technologies.
The obvious advantage of laparoscopic surgery in patients with perforated ulcers is fast-truck recovery following shorter hospital-stay, mild pain and rarer wound complications. Comparison of postoperative mortality regarding efficacy and effectiveness is difficult due to insufficient introduction of laparoscopic technologies in clinical practice and diversity-adjusted required information size.
Динамические изменения в доказательной базе по хирургическому лечению прободной язвы требуют постоянного мониторинга с целью адаптации лучших мировых достижений в отечественные клинические Рекомендации.
Провести анализ результатов применения лапароскопических операций у пациентов с прободной язвой с использованием инструментов доказательной медицины.
Представлена сравнительная оценка действенности и эффективности лапароскопических и лапаротомных операций у пациентов с прободной язвой. Проведены метаанализ летальности после лапароскопических операций по данным рандомизированных исследований (РКИ) и последовательный экспертный анализ.
Установлены различия между действенностью и эффективностью лапароскопических операций в плане послеоперационной летальности. В общей популяции больных в РФ летальность после лапароскопических операций (эффективность) по сравнению с лапаротомными меньше в 9—11 раз. По данным доказательной медицины (действенность лапароскопических вмешательств по результатам 10 метаанализов), эти различия не столь существенны (1,4—3,0 раза) и статистически незначимы. Необходимый размер выборки метаанализа РКИ для получения обоснованных выводов о различиях в летальности по результатам проведенного в статье экспертного анализа составило 68181 наблюдение. Метаанализы РКИ также показывают меньшую частоту развития раневых осложнений (1,8—5,0% — после лапароскопических операций и 6,3—13,3% — после лапаротомных), снижение длительности стационарного лечения (разница средних от –0,13 до –2,84) и меньшую выраженность болевого синдрома (разница средних по визуальной аналоговой шкале от –2,08 до –2,45) при использовании лапароскопических технологий.
Доказанным преимуществом лапароскопических операций у пациентов с прободной язвой является ускоренная реабилитация за счет сокращения длительности стационарного лечения, меньшей выраженности болевого синдрома и снижения количества раневых осложнений. Сравнительные оценки послеоперационной летальности в рамках действенности и эффективности затруднены из-за недостаточного внедрения лапароскопических технологий в широкой клинической практике и расчетного порогового количества наблюдений метаанализа РКИ.

The Indian Society of Gastroenterology (ISG) felt the need to organize a consensus on Helicobacter pylori (H. pylori) infection and to update the current management of H. pylori infection; hence, ISG constituted the ISG\'s Task Force on Helicobacter pylori. The Task Force on H. pylori undertook an exercise to produce consensus statements on H. pylori infection. Twenty-five experts from different parts of India, including gastroenterologists, pathologists, surgeons, epidemiologists, pediatricians, and microbiologists participated in the meeting. The participants were allocated to one of following sections for the meeting: Epidemiology of H. pylori infection in India and H. pylori associated conditions; diagnosis; treatment and retreatment; H. pylori and gastric cancer, and H. pylori prevention/public health. Each group reviewed all published literature on H. pylori infection with special reference to the Indian scenario and prepared appropriate statements on different aspects for voting and consensus development. This consensus, which was produced through a modified Delphi process including two rounds of face-to-face meetings, reflects our current understanding and recommendations for the diagnosis and management of H. pylori infection. These consensus should serve as a reference for not only guiding treatment of H. pylori infection but also to guide future research on the subject.

Helicobacter pylori infection is one of the most common infectious diseases worldwide. Although the prevalence of H. pylori is gradually decreasing, approximately half of the world\'s population still becomes infected with this disease. H. pylori is responsible for substantial gastrointestinal morbidity worldwide, with a high disease burden. It is the most common cause of gastric and duodenal ulcers and gastric cancer. Since the revision of the H. pylori clinical practice guidelines in 2013 in Korea, the eradication rate of H. pylori has gradually decreased with the use of a clarithromycin-based triple therapy for 7 days. According to a nationwide randomized controlled study conducted by the Korean College of Helicobacter and Upper Gastrointestinal Research released in 2018, the intention-to-treat eradication rate was only 63.9%, which was mostly due to increased antimicrobial resistance, especially from clarithromycin. The clinical practice guidelines for the treatment of H. pylori were updated according to evidence-based medicine from a meta-analysis conducted on a target group receiving the latest level of eradication therapy. The draft recommendations developed based on the meta-analysis were finalized after an expert consensus on three recommendations regarding the indication for treatment and eight recommendations for the treatment itself. These guidelines were designed to provide clinical evidence for the treatment (including primary care treatment) of H. pylori infection to patients, nurses, medical school students, policymakers, and clinicians. These may differ from current medical insurance standards and will be revised if more evidence emerges in the future.

Peptic ulcer disease is common with a lifetime prevalence in the general population of 5-10% and an incidence of 0.1-0.3% per year. Despite a sharp reduction in incidence and rates of hospital admission and mortality over the past 30 years, complications are still encountered in 10-20% of these patients. Peptic ulcer disease remains a significant healthcare problem, which can consume considerable financial resources. Management may involve various subspecialties including surgeons, gastroenterologists, and radiologists. Successful management of patients with complicated peptic ulcer (CPU) involves prompt recognition, resuscitation when required, appropriate antibiotic therapy, and timely surgical/radiological treatment.
The present guidelines have been developed according to the GRADE methodology. To create these guidelines, a panel of experts was designed and charged by the board of the WSES to perform a systematic review of the available literature and to provide evidence-based statements with immediate practical application. All the statements were presented and discussed during the 5th WSES Congress, and for each statement, a consensus among the WSES panel of experts was reached.
The population considered in these guidelines is adult patients with suspected complicated peptic ulcer disease. These guidelines present evidence-based international consensus statements on the management of complicated peptic ulcer from a collaboration of a panel of experts and are intended to improve the knowledge and the awareness of physicians around the world on this specific topic. We divided our work into the two main topics, bleeding and perforated peptic ulcer, and structured it into six main topics that cover the entire management process of patients with complicated peptic ulcer, from diagnosis at ED arrival to post-discharge antimicrobial therapy, to provide an up-to-date, easy-to-use tool that can help physicians and surgeons during the decision-making process.

Computer-interpretable guidelines (CIGs) are based on clinical practice guidelines, which typically address a single morbidity. However, most of the aging population suffers from multiple morbidities. Currently, there is no demonstrated effective mechanism that integrates recommendations from multiple CIGs. We are developing a goal-based method that utilizes knowledge of drugs\' physiological effects and therapeutic usage to combine knowledge from CIGs. It incrementally detects interactions and plans non-contradicting therapies. Our algorithm uses patterns to check consistency and respond to events, including data enquiries, diagnoses, adverse events, recommended medications, tests, and goals. Our method utilizes existing standards and CIG tools, including the Fast Healthcare Interoperability Resources (FHIR) patient data model, SNOMED-CT, and the PROforma CIG formalism with its Alium knowledge-engineering environment and PROforma enactment engine. We demonstrate our approach using a case study involving two clinical guidelines with templates for responding to a new goal and to a medication request that causes an inconsistency which can be automatically detected and resolved based on the knowledge of the two CIGs.

New Swedish guidelines for the management of dyspepsia, H pylori, and duodenal and gastric ulcers The management of dyspepsia in Sweden differs between national county councils, and is often not in line with international recommendations. The Swedish Society of Gastroenterology has together with the Swedish College of General Practice (SFAM) developed new national guidelines for the management of uninvestigated dyspepsia, functional dyspepsia, Helicobacter pylori, and uncomplicated duodenal and gastric ulcers. The new Swedish guidelines emphasize that patients under 50 years of age with new onset of uninvestigated dyspepsia without any alarm symptoms or signs can be managed with the »Test and treat« strategy. Moreover, patients with a known H pylori infection and bothersome symptoms of functional dyspepsia shall be offered eradication therapy. The recommendations for triple therapy for H pylori eradication take into account the estimated average national antibiotic resistance patterns, environmental factors and potential effects on gut microbiota.

The Japanese Society of Gastroenterology (JSGE) revised the evidence-based clinical practice guidelines for peptic ulcer disease in 2014 and has created an English version. The revised guidelines consist of seven items: bleeding gastric and duodenal ulcers, Helicobacter pylori (H. pylori) eradication therapy, non-eradication therapy, drug-induced ulcer, non-H. pylori, non-nonsteroidal anti-inflammatory drug (NSAID) ulcer, surgical treatment, and conservative therapy for perforation and stenosis. Ninety clinical questions (CQs) were developed, and a literature search was performed for the CQs using the Medline, Cochrane, and Igaku Chuo Zasshi databases between 1983 and June 2012. The guideline was developed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. Therapy is initially provided for ulcer complications. Perforation or stenosis is treated with surgery or conservatively. Ulcer bleeding is first treated by endoscopic hemostasis. If it fails, surgery or interventional radiology is chosen. Second, medical therapy is provided. In cases of NSAID-related ulcers, use of NSAIDs is stopped, and anti-ulcer therapy is provided. If NSAID use must continue, the ulcer is treated with a proton pump inhibitor (PPI) or prostaglandin analog. In cases with no NSAID use, H. pylori-positive patients receive eradication and anti-ulcer therapy. If first-line eradication therapy fails, second-line therapy is given. In cases of non-H. pylori, non-NSAID ulcers or H. pylori-positive patients with no indication for eradication therapy, non-eradication therapy is provided. The first choice is PPI therapy, and the second choice is histamine 2-receptor antagonist therapy. After initial therapy, maintenance therapy is provided to prevent ulcer relapse.

This paper describes a new methodological approach to reconciling adverse and contradictory activities (called points of contention) occurring when a patient is managed according to two or more concurrently used clinical practice guidelines (CPGs). The need to address these inconsistencies occurs when a patient with more than one disease, each of which is a comorbid condition, has to be managed according to different treatment regimens. We propose an automatic procedure that constructs a mathematical guideline model using the Constraint Logic Programming (CLP) methodology, uses this model to identify and mitigate encountered points of contention, and revises the considered CPGs accordingly. The proposed procedure is used as an alerting mechanism and coupled with a guideline execution engine warns the physician about potential problems with the concurrent application of two or more guidelines. We illustrate the operation of our procedure in a clinical scenario describing simultaneous use of CPGs for duodenal ulcer and transient ischemic attack.

暂无摘要。

In accordance with our current understanding, infection with the pathogen Helicobacter pylori is an important, but readily diagnosable and treatable cause of various gastroduodenal diseases. A lasting cure is achieved when the bacterium is eradicated with the aid of an established therapeutic regimen. Furthermore, eradication is a rational preventive measure even in asymptomatic patients, since current clinical data show that it offers protection, in particular to high-risk groups, from gastric carcinoma, but also from other complications (e.g. peptic ulcer). The upgraded European Guidelines on the diagnosis and treatment of H. pylori infection put out by the European Helicobacter Pylori Study Group (EHPSG) in Maastricht take account of the present state of our knowledge of the significance of H. pylori eradication.