Comment to: analysing topics using different methods promotes constructive debates. Author's reply
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LETTER TO THE EDITOR
Comment to: analysing topics using different methods promotes constructive debates. Author’s reply U. Klinge1 Received: 6 April 2020 / Accepted: 30 April 2020 / Published online: 18 May 2020 © The Author(s) 2020
In November 2019 Gavriilidis et al. compared total extraperitoneal endoscopic hernioplasty (TEP) with Lichtenstein hernioplasty by updated traditional and cumulative metaanalysis of randomised controlled trials (RCT) [1]. They concluded that the data revealed significantly higher rates of recurrence and vascular injuries in the TEP cohort compared to the Lichtenstein cohort. In a letter to the editor Köckerling and Adolf pointed out that without the two largest studies (from 2004 and 2008) the remaining 12 of 14 RCTs in contrast showed a higher overall recurrence rate for the Lichtenstein operation. These two dominated the results of the meta-analysis because of the large sample size and number of recurrences [2]. Furthermore, in January 2020 Rosenberg and Andresen wrote that Gavriilidis et al. came to the wrong conclusion, not least because of the marked heterogeneity of the studies included, and that a conclusion based on the available data should be that there is no difference in the recurrence rates between the TEP and Lichtenstein repair [3]. In their subsequent reply Gavrilidis et al. admitted that their study was indeed inconclusive, and propose multicentre RCTs with predefined outcome estimation, size of hernial defects and size of mesh used, plus evaluation of cost effectiveness and the experience of the operator(s) to determine the possible superiority of one method over the other [4]. So, the solution to the question, which of the two procedures is better, once again is postponed to future, bigger RCTs. Even this may not be enough; it is a difficult problem to declare one procedure superior to another: 1. The studies used for the meta-analysis of Gavriilidis et al. include several without any complications. * U. Klinge [email protected] 1
Department of General‑, Visceral‑ and Transplant Surgery, University Hospital of the RWTH Aachen, Pauwelsstraße 30, 52070 Aachen, Germany
Obviously, in some hands TEP (n = 4 studies) as well as Lichtenstein (n = 3) can be performed without any recurrence or pain. Recurrence and pain therefore do not represent inherent and unavoidable risks. For some experts any attempt to define a “better” technique will be pointless, as both techniques can be regarded as “best”. 2. The focus on recurrence as the main for quality of a procedure is based on the assumption that all recurrences are caused by an inherent problem of the procedure, which certainly is not the case. Development of a recurrence may reflect the patients’ biology or immunology, the anatomy, a sufficient mesh overlap, and/or the experience of the surgeon, accordingly. Only a percentage of recurrence is strictly related to the procedure—and might have been avoided if another procedure had been used. Probably only 20% of recurrence cannot be related to individual risks, and theref
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