Indications for Surgery Need to Be Assessed in a Differentiated Way
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Baum et al. presented data on mortality and complications after visceral surgery that are based on all inpatient cases in Germany (1). As they quite rightly stated, this data set in principle allows patients to make an informed decision in favor of or against a procedure. To enable patients to balance the risks and benefits of a surgical procedure in a valid way, the disease course that is to be expected without surgery also needs to be outlined in an objective fashion. The authors refer to our meta-analysis of randomized controlled trials of surgical versus antibiotic treatment of uncomplicated acute appendicitis (2) when they define this pathology as a vital indication for surgery. Our results do not support this statement. Over a follow-up period of 12 months, the effectiveness of surgical therapy was 96.3% versus 62.6% for antibiotic treatment; we found no indications signs of a higher incidence of complications or deaths in patients who did not have surgery. However, many surgeons still regard uncomplicated acute appendicitis as an absolute indication for surgery. A similar attitude applied for the longest time to diverticulitis of the sigmoid colon. Only in recent years the evidence-based conception has become established that defined forms of acute diverticulitis of the sigmoid colon can successfully be treated conservatively (3).
Both pathological entities show in an exemplary fashion that realistic, evidence-based assessment of a therapeutic success or disease course is essential for surgical as well as conservative therapy. Considered together with the expected incidence of perioperative complications and death, this assessment enables a differentiated evaluation of indications for surgery and shared decision-making with regard to any possible surgical procedure (4).
PD Dr. med. Ulrich Ronellenfitsch
Universitätsklinik und Poliklinik für Viszerale
Gefäß- und Endokrine Chirurgie, Universitätsklinikum Halle (Saale)
Thoraxchirurgisches Zentrum München
Asklepios Lungenfachklinik München-Gauting/
Thoraxchirurgische Klinik Großhadern, Gauting
Maurizio Grilli, M.A.L.I.S.
Fachinformation Medizin und Gesundheitsberufe
Medizinische Fakultät Heidelberg
Conflict of interest statement
The authors declare that no conflict of interest exists.
|1.||Baum P, Diers J, Lichthardt S, et al.: Mortality and complications following visceral surgery—a nationwide analysis based on the diagnostic categories used in German hospital invoicing data. Dtsch Arztebl Int 2019; 116: 739–46 VOLLTEXT|
|2.||Prechal D, Damirov F, Grilli M, Ronellenfitsch U: Antibiotic therapy for acute uncomplicated appendicitis: a systematic review and meta-analysis. Int J Colorectal Dis 2019; 34: 963–71 CrossRef MEDLINE|
|3.||Leifeld L, Germer CT, Bohm S, et al.: S2k-Leitlinie Divertikelkrankheit/Divertikulitis. Z Gastroenterol 2014; 52: 663–710 CrossRef MEDLINE|
|4.||Ubbink DT, Hageman MG, Legemate DA: Shared decision-making in surgery. Surg Technol Int 2015; 26: 31–6 CrossRef MEDLINE|