Discussion

The scope of this CDC was broad since we wanted to evaluate QoL after laparoscopic compared to open surgery for many different conditions. We have tried to include the most important diseases in laparoscopic surgery, for which evidence on QoL assessment is available. Although there are a large number of studies reporting QoL after laparoscopic surgery, only one third have compared laparoscopic with open surgery.

Here we provide some general remarks on QoL assessment in clinical and research settings. First, it should be kept in mind that no single QoL measure is ideal for all diseases or patient groups or settings. This implies that all instruments must be checked carefully for the psychometric properties in the context of endoscopic surgery. Occasionally, it may be necessary to extend existing instruments to fit the scope of a specific clinical problem or patient group, but only the reporting of standard measures allows readers to compare results across studies. Any modification of existing measures requires a new validation of the new measure. Second, it is often recommended to combine a generic instrument and a disease-specific instrument. For most diseases, the generic instruments have lower responsiveness compared to specific ones [145], but the generic measures are useful to compare the patient cohort against cohorts with other diseases or with the normal population. Third, the proof of superior QoL after one type of surgery is a strong but not a sufficient argument to use this type of surgery. Although QoL is a broad construct, it does not necessarily include all aspects that are relevant for clinical decision making. Therefore, we did not use grades of recommendations for the key statements.

With regard to choosing a QoL instrument, there is no hierarchy for grading the quality of QoL assessment tools. Since the different psychometric properties of an instrument are not a unidimensional issue, the choice of an instrument depends on the various practical and theoretical aspects of a study. Some projects on the development of such classifications are in progress and are the focus of experts in that field. A further methodologic problem is the difference between choosing a valid study design and a valid outcome measure: We think that a RCT should not automatically be considered high-level evidence, if the study does not report clinically relevant outcomes such as QoL via the use of standardized measures.

The overall quality of QoL research in endoscopic surgery compares well with other fields. In 1989, Guyatt et al. [46] found that less than half the RCTs in major journals examined QoL as an outcome, and two-thirds of these QoL measures had not been validated. Similarly, Gill and Feinstein [44] criticized that most clinical studies of QoL failed to define QoL, lacked a reliable QoL measure, and mixed up symptom checklists, proxy outcomes, QoL, and health-related QoL measures. Nevertheless, surgical researchers should increase the use of QoL measures in clinical trials. Since many validated instruments are obtainable free of charge from the primary investigators, there are no real obstacles to conduction more patient-centered research. For the well-known general instruments, further information can be found on the Internet.

Again, the importance of QoL assessment in laparoscopic surgery should be noted. QoL as an outcome is much more important to the patient than, for example, laboratory values and other traditional clinical end points. After biliary duct injury and successful repair of the injury, patients can have normal laboratory findings but permanently impaired QoL [45, 82], This reinforces the question as to whether we are measuring what is relevant for the patients, Furthermore, the experts pointed out the importance of the preop-erative QoL assessment for patient selection for laparoscopic surgery in specific diseases, This is especially true for GERD, for example, when deciding on surgery for depressed patients [55],

Evidence on QoL after laparoscopic compared to open surgery reported in this article represents all relevant data regarding this issue, Suggestions made for QoL assessment in different conditions are universal and can be used in every European country, We believe that the use of these suggestions will increase the quality of care in everyday practice as well as the quality of research, Implementation strategies and the evaluation of the impact of these guidelines need further discussion and will present a basis for further research,

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