Evidence Review Process - ESRA
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Video-Assisted Thoracoscopic Surgery 2021

Evidence Review Process

An explanation of PROSPECT methodology and Working Group processes can be found at the following link: https://esraeurope.org/prospect-methodology

For the VATS review, the Subgroup members were:

  • Sarah Feray1
  • Jelle Lubach2
  • Girish P. Joshi3
  • Francis Bonnet4
  • Marc Van de Velde5
  1. Assistant Professor of Anaesthesiology, Department of Anaesthesia, Intensive Care & Perioperative Medicine, Hôpital Tenon, Assistance Publique Hôpitaux de Paris / Medecine Sorbonne Université, Paris, France
  2. Resident Anaesthesiology, KU Leuven and University Hospital Leuven, Belgium
  3. Professor of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas, USA
  4. Professor of Anaesthesiology, Department of Anaesthesiology, Intensive Care & Perioperative Medicine, Hôpital Tenon, APHP, Paris, France / Médecine Sorbonne Université, Paris, France
  5. Professor and Chair, Department Cardiovascular Sciences, Section Anesthesiology, KULeuven and UZ Leuven, Leuven, Belgium.

Video-assisted thoracoscopic surgery (VATS) literature search

  • Systematic review of the literature associated with analgesia after VATS between 1st January 2010 and 1st January 2021. VATS was not commonly performed for lung resection before this period, as thoracotomy was the standard of care.
  • The following databases were searched: EMBASE, MEDLINE, PubMed and Cochrane Databases Central Register of Controlled Trials, Cochrane Database of Abstracts or Reviews of Effects and Cochrane Database of Systematic Reviews (Search strategy).
  • Included studies were RCTs and systematic reviews of analgesic, anaesthetic or surgical interventions, in English, assessing pain management for patients undergoing VATS for lung resection. Included studies were also required to report pain scores (VAS or NRS).
  • Exclusions: studies with patients who underwent a thoracotomy and studies in which more than 75% of the included patients underwent surgery for pneumothorax.
  • From 1070 records retrieved, 129 full-text articles were reviewed in more detail.
  • 69 RCTs and 2 systematic reviews met the inclusion criteria (Summary of literature selection; Included studies).
  • 58 studies were excluded after full-text screening.
  • The reasons for exclusion were: full article not in English (n=11); retrospective/not randomised (n=24); review (n=4); letter (n=6); only VATS for pneumothorax (n=3); retracted publication (n=1); miscellaneous (n=9).

Assessments of the quality of study methodology and reporting

All included studies were assessed for quality according to PROSPECT methodology (Joshi 2019, https://esraeurope.org/prospect-methodology). The study quality assessments for video-assisted thoracoscopic surgery are summarised here: Quality assessments and level of evidence assigned to included trials.

  • Data extraction and data analysis for video-assisted thoracoscopic surgery adhered to the PROSPECT methodology (Joshi 2019, https://esraeurope.org/prospect-methodology).
  • Pain intensity scores were used as the primary outcome measure. In this study, we defined a change of more than 10 on a scale of 0–100 as clinically relevant (Myles 2017).

The methodology of the PROSPECT group is unique in that it aims to critically evaluate the available literature, considering the analgesic benefit of interventions against the backdrop of basic analgesics (i.e. paracetamol and NSAIDs or COX-2-selective inhibitors), the degree of pain after surgery, and balancing the procedure-specific efficacy and benefits of an intervention against its general risks and invasiveness.

For recommending an analgesic, at least two RCTs have to show efficacy. Recommendations were made according to PROSPECT methodology (Joshi 2019, https://esraeurope.org/prospect-methodology). This involved a grading of A–D according to the overall level of evidence, as determined by the quality of studies included, consistency of evidence and study design: Relationship between quality of the study and levels of evidence and grades of recommendation.

A subgroup developed draft recommendations, which were then circulated amongst all the Working Group members for review and comments. A modified Delphi approach was utilised as previously described (Joshi 2019). This included obtaining feedback from PROSPECT members via e-mail, followed by revised drafts of recommendations. This was followed by face-to-face discussions with the aim of developing a consensus. The lead authors drafted the final manuscript, which was ultimately approved by the full PROSPECT group.

The limitations of this review are related to those of the included studies:

  • Most studies reported no multimodal analgesia strategies. Few RCTs used paracetamol and NSAIDs as standard analgesia.
  • Control and intervention groups were commonly small in size and the studies were at a high risk of bias.
  • There was significant heterogeneity between the studies regarding the methods, dosing regimens, and administration.
  • Only qualitative assessments were used, with no quantitative analyses. Effect sizes were not highlighted and qualitative assessment relied on statistical significance of included studies.
  • In thoracic surgery, accelerated rehabilitation is very important. Postoperative outcomes depend on the patient’s ability to get out of bed and participate in physical respiratory therapy exercises. However, very few studies had a primary endpoint related to rehabilitation, such as time to resume walking, time to get out of bed, number of steps by day, or pain scores during physiotherapy. Only a few studies looked at length of stay as a secondary outcome. Time in hospital and time to ambulation were rarely described.
  • It is known that thoracic surgery is associated with chronic pain (Bayman 2017). However, few studies included chronic pain as an outcome.

The AGREE II instrument (Brouwers 2010) is used internationally to assess the methodological rigour and transparency of practice guidelines. As far as possible, the methodology of the PROSPECT video-assisted thoracoscopic surgery review meets the requirements of ‘Domain 3: Rigour of development’ of the AGREE II instrument:

  • Systematic methods were used to search for evidence
  • The criteria for selecting the evidence are clearly described
  • The strengths and limitations of the body of evidence are clearly described
  • The methods for formulating the recommendations are clearly described
  • The health benefits, side effects, and risks have been considered in formulating the recommendations
  • There is an explicit link between the recommendations and the supporting evidence
  • The guideline has been externally reviewed by experts prior to its publication. (The evidence and recommendations are made available on the website after peer review and publication)
  • A procedure for updating the guideline is provided. (Methodology is provided so that the systematic review can be updated as required)