Evidence-based surgery

  • Miran Rems
Keywords: evidence-based surgery, surgeon, critical assessment, ethics


Background: Surgery is setting a new ground by the reign of evidence that was brought up by the Evidence Based Medicine (EBM). While experiences and opinion of an expert count the least by the principles of EBM, randomized controlled trials (RCT) and other comparative studies have gained their importance. Recommendations that were included in guidelines represent a demanding shift in surgeon’s professional thinking. Their thinking and classical education have not yet been completely based on the results of such studies and are still very very much master-pupil centred. Assessment of someone’s own experiences is threatened by objectivity as negative experiences get recorded in deeper memory. Randomized studies and meta-analyses do appear also in surgery. However, they demand an extra knowledge about critical assessment.

Conclusions: Setting a patient to the foreground brings a surgeon’s decision to the field of EBM. The process has already begun and cannot be avoided. Decision hierarchy moves from the experience field to the evidence territory but to a lesser extent when compared to the rest of medicine. There exist objective restrictions with approving a new paradigm. However, these should not stop the process of EBM implementation. Finally, there is an ethic issue to be considered. Too slow activities in research, education and critical assessment can bring the surgeon to the position when a well-informed patient loses his/her trust.


Download data is not yet available.


O’Flynn KJ, Irving M, Sackett D. Evidence-based approach to surgical decisions. In: Morris PJ,Wood WC, eds. Oxford Textbook of surgery. 2nd ed. Oxford: Oxford University Press; 2001. p. 187–96.

Čuk A. Na izsledkih temelječa medicina – I. Splošna načela. Zdrav Vestn 2003; 72: 695–9.

Drinovec J. Ali na izsledkih temelječa medicina s kliničnimi smernicami zdravnika omejuje? Zdrav Vestn 2006; 75: 653–7.

Michel L. Epistemology of evidence based medicine. Acta Gastroenterol Belg 2006; 69: 238–46.

Solomon MJ, McLeod RS. Should we be performing more randomized controlled trials in evaluating surgical procedures? Surgery 1995; 118: 459–67.

Goliger JC, Pulvertaft CN, Watkins G. Controlled trial of vagotomy and gastroenterostomy, vagotomy and antrectomy and subtotal gastrectomy in elective treatment of duodenal ulcer. Br Med J 1964; 1: 455–60.

Stirrat GM. Ethics and evidence based surgery. J Med Ethics 2004; 30: 160–5.

Wente MN, Seiler CM, Uhl W, Buechler MW. Perspectives of evidence- based surgery. Dig Surg 2003; 20: 263–9.

Dziri C, Fingerhut A. What surgeons know about evidencebased surgery. World J Surg 2005; 29: 545–6.

Abraham NS. Will the dilemma of evidence-based surgery ever be resolved? ANZ J Surg 2006; 76: 855–60.

Čuk A. Na izsledkih temelječa medicina – II. Klinična uporaba in kritike. Zdrav Vestn 2004; 73: 19–23.

Sackett DL, Strauss SE, Richardson WS, Rosenberg W, Hayness RB. Evidence-based medicine: how to practice and teach EBM. 2nd edition. London: Churchill Livingstone; 2000.

Fras Z (ur.). Slovenski priročnik za smernice. Ljubljana: Ministrstvo za zdravje; 2003. Dosegljivo na: http://www.mz.gov.si/fileadmin/ mz.gov.si/pageuploads/mz_dokumenti/delovna_ podrocja/zdravstveno_varstvo/kakovost/prirocniki_in_ publikacije/prirocnik_za_smernice_slo.pdf

Howes N, Chagla L, Thorpe M, McCulloch P. Surgical practice is evidence based. Br J Surg 1997; 84: 1220–3.

Kingston R, Barry M, Tierney S, Drum J, Grace P. Treatment of surgical patients is evidence based. Eur J Surg 2001; 167: 324–30.

Grol R. Success, failures in the implementation of evidence-based guidelines for clinical practice. Med Care 2001; 39: 46–54.

Ward JE, Gattelari M, Solomon MJ. Management of patients with colorectal cancer: do Australian surgeons know the scientific nevidence? Arch Surg 2002; 137: 1389–94.

Classen DC, Evans RS, Pestotnik SL, Horn SD, Menlove RL, Burke JP. The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. N Eng J Med 1992; 326: 337–9.

Burke JP. Maximising appropriate antibiotic prophylaxis for surgical patients: an update from LDS Hospital, Salt Lake City. Clin Infect Dis 2001; 33: S78–83.

Wasey N, Baughan J, de Gara CJ. Prophylaxis in elective colorectal surgery: the cost of ignoring the evidence. Can J Surg 2003; 46: 251–2.

Petrowsky H, Demartines N, Rousson V, Clavien PA. Evidencebased value of prophylactic drainage in gastrointestinal surgery: a systematic review and meta-analysis. Ann Surg 2004; 240: 1074– 85.

Nelson R, Tse B, Edwards S. Systematic review of prophylactic nasogastric decompression after abdominal operations. Br J Surg 2005; 92: 673–80.

Rems M, Kern A. Standardna kirurška oskrba raka debelega črevesa v Sloveniji 2004. Zdrav Vestn 2005; 74: 701–5.

Launay-Savary MV, Slim K. Evidence-based analysis of prohylactic abdominal drainage. Ann Chir 2006; 131: 302–5.

Khan AT, Mehr MN, Gaynor AM, Bowcock M, Khan KS. Is general inpatient obstetrics and gynecology evidence based? A survey of practice with critical review of methodological issues. BMC Womens Health 2006; 6: 5.

Lee JS, Urschel DM, Urschel JD. Is general thoracic surgical practice evidence based? Ann Thorac Surg 2000; 70: 429–31.

Myles PS, Bain DL, Johnson F, McMahon R. Is anaesthesia evidence- based? A survey of anaesthetic practice. Br J Anasth 1999; 82: 591–5.

Yan RT, Yan AT, Tan M, McGuire DK, Leiter L, Fitchet DH, et al. Underuse of evidence-based treatment partly explains the worse clinical outcomes in diabetic patients with acute coronary syndrom. Am Heart J 2006; 152: 676–83.

Bogaty P, Brophy JM. Acute ischaemic heart disease and interventional cardiology: a time to pause. BMC Med 2006; 4: 25.

Bohnen JMA. Why do the surgeons not comply with »best practice «? Can J Surg 2003; 46: 251–2.

Leape L, Berwick DM. Five years after »To err is human: what have we learned?« JAMA 2005; 293: 2384–90.

Meakins JL. Evidence-based surgery. Surg Clin N Am 2006; 86: 1– 16.

Slim K. Limits of evidence-based surgery. World J Surg 2005; 29: 606–9.

Dale W, Hemmerich J, Ghini EA, Schwarze ML. Can induced anxiety from a negative earlier experience influenced vascular surgeon’s statistical decision-making? A randomized field experiment with an abdominal aortic aneurysm analog. J Am J Surg 2006; 203: 642–52.

Timmermans D, van Boeckel H, Kievit J. Improving the quality of surgeons’ treatment decisions: a comparison of clinical decision making with a computerised evidence based decision analitycal model. Qual Health Care 2001; 10: 4–9.

Bonchek LI. Randomized trials of new procedures: problems and pitfalls. Heart 1997; 78: 535–6.

Tenery R, Rakatansky H, Riddick FA Jr, Goldrich MS, Morse LJ, O’Bannon JM 3rd, et al. Surgical »placebo« controls. Ann Surg 2002; 235: 303–7.

Macklin R. The ethical problems with sham surgery in clinical research. N Eng J Med 1999; 341: 992–6.

Cobb LA. Evaluation of internal mammary artery ligation by double-blind technique. N Eng J Med 1995; 260: 1115–8.

Moseley JB, O’Malley K, Petersen NJ, Menke TJ, Brody BA, Kuykendall DH, et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Eng J Med 2002; 347: 81–8.

Edward SJ, Stevens AJ, Braunholtz DA, Lilford RJ, Swift T. The ethics of placebo-controlled trials: a comparisson of inert and active placebo controls. World J Surg 2005; 29: 610–4.

Horng S, Miller FG. Ethical framework for the use of sham procedures in clinical trials. Crit Care Med 2003; 31: 126–30.

How to Cite
Rems M. Evidence-based surgery. ZdravVestn [Internet]. 1 [cited 3Apr.2020];76(4). Available from: https://vestnik.szd.si/index.php/ZdravVest/article/view/1706
Quality in health service