Research ReviewAnalysis of National Presentations of Surgical Case Series Discussions: What Matters to Surgeons?
Introduction
In the established hierarchy of research study designs, the randomized controlled trial (RCT) is considered the gold standard study design for hypothesis testing.1, 2, 3, 4 Although RCTs reduce bias through randomization and control for potential confounding factors when testing the effect of a treatment, their execution has proven difficult for some areas of medicine.5 Historically, there has been a dearth of surgical RCTs.6, 7, 8 Multiple factors contribute to this deficit in surgery and weaken the internal validity of surgical RCTs: low case volume at individual centers, learning curve of new surgical techniques, difficulty with standardization of surgical procedures, changes in surgeon preferences over time, and limitations in surgeon blinding.9, 10, 11, 12 In addition, randomized testing of accepted gold standard surgical treatments against proposed alternative surgical measures generates ethical concerns.13
A case series is a descriptive study that samples groups of patients in an uncontrolled fashion.14, 15 In surgery, the case series is largely used by surgeons to report their experience with a particular surgical technique. Although the case series is lower in the hierarchy of clinical evidence, physicians—and surgeons in particular—recognize the value and importance of learning from collective clinical experience of experts in a real-world setting.16 In addition, surgical case series are able to provide insights into the mechanism of disease, disease management, and complication management. As such, surgical case series continue to be quite commonly published across a variety of surgical fields. Although standardized guidelines for reporting RCTs have been in wide use since the release in 1996 of the Consolidated Standards of Reporting Trials guidelines,17 the publication of surgical case series has been limited by a lack of standardized reporting guidelines. The recent development of the Surgical Case Report guideline for case reports and, more pointedly, the Preferred Reporting of Case Series in Surgery (PROCESS) guideline for case series may help improve reporting quality if more widely implemented.18, 19 At present, however, the presentation of case series is still quite varied and may not include information considered important to the surgeon audience.
We aimed to inductively determine which core elements surgeons deem important for evaluating the findings from surgical case series. To do this, we performed a qualitative analysis of the questions surgeon discussants asked after oral presentations of case series at national surgical meetings that were published in high-impact surgical journals.
Section snippets
Conventional content analysis and thematic analysis
All items listed in the table of contents of the online databases of three high-impact surgical journals—Annals of Surgery, Journal of the American College of Surgeons, and JAMA Surgery—were reviewed from January 2010 to April 2015 to identify case series. Because there are no established thresholds for case series sizes, and we particularly wanted to evaluate large case series, we arbitrarily decided to include any study of a consecutive series of at least 100 patients at a single or at most
Emerged categories and subcategories
The process of identification of surgical case series articles is outlined in Figure 1. From a total of 6307 items listed in the table of contents, 221 case series in Annals of Surgery, Journal of the American College of Surgeons, and JAMA Surgery were identified. This exclusion of case series published without postpresentation discussions and case series published with invited critique and commentary resulted in the exclusion of all JAMA Surgery case series. From the final 56 case series, 476
Discussion
Case series are routinely published in surgical journals but have not been historically subjected to guidelines that ensure they address elements that are important for their surgical audience. To identify what surgeons are largely interested in knowing when evaluating a case series, our analysis focused on questions raised by surgeons during discussions after oral presentations of surgical case series at national meetings. Interestingly, although the case series included in this analysis
Acknowledgment
Authors' contributions: E.R.W. and A.B.S. designed the study, performed the literature search and data collection, and performed the qualitative content analysis. A.B.S. and V.R.R. prepared the initial article. All authors contributed to data analysis and interpretation as well as critical revision of the article.
References (41)
Observational versus experimental studies: what’s the evidence for a hierarchy?
NeuroRx
(2004)- et al.
Randomized versus historical controls for clinical-trials
Am J Med
(1982) - et al.
Randomized controlled clinical trials in orthopedics: difficulties and limitations
Rev Bras Ortop
(2011) - et al.
Challenges in evaluating surgical innovation
Lancet
(2009) - et al.
The SCARE statement: consensus-based surgical case report guidelines
Int J Surg
(2016) - et al.
Preferred reporting of case series in surgery; the PROCESS guidelines
Int J Surg
(2016) - et al.
Effect of statins on early and late clinical outcomes of carotid endarterectomy and the rate of post-carotid endarterectomy restenosis
J Am Coll Surg
(2015) - et al.
Esophageal perforation management using a multidisciplinary minimally invasive treatment algorithm
J Am Coll Surg
(2014) - et al.
Two thousand consecutive pancreaticoduodenectomies
J Am Coll Surg
(2015) - et al.
Applicability of an established management algorithm for destructive colon injuries after abbreviated laparotomy: a 17-year experience
J Am Coll Surg
(2014)