{"id":878,"date":"2013-03-14T09:42:00","date_gmt":"2013-03-14T09:42:00","guid":{"rendered":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/?page_id=878"},"modified":"2013-06-10T17:01:31","modified_gmt":"2013-06-10T17:01:31","slug":"18-2","status":"publish","type":"page","link":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/?page_id=878","title":{"rendered":"18 Evidence-based medicine a hodnocen\u00ed kvality v chirurgii j\u00edcnu"},"content":{"rendered":"

V\u0161ichni l\u00e9ka\u0159i se p\u0159i diagnostice i l\u00e9\u010db\u011b sv\u00fdch nemocn\u00fdch \u0159\u00edd\u00ed znalostmi nabyt\u00fdmi v prei postgradu\u00e1ln\u00edm studiu a dle vlastn\u00edch zku\u0161enost\u00ed z\u00edskan\u00fdch b\u011bhem sv\u00e9 praxe. I na\u0161i z\u00e1konod\u00e1rci l\u00e9ka\u0159e zavazuj\u00ed k tomu, aby postupovali dle nejnov\u011bj\u0161\u00edch poznatk\u016f l\u00e9ka\u0159sk\u00e9 v\u011bdy, tj. lege artis.<\/p>\n

K napln\u011bn\u00ed tohoto po\u017eadavku jsou dnes l\u00e9ka\u0159\u016fm n\u00e1pomocn\u00e9 nov\u00e9 discipl\u00edny. Na prvn\u00edm m\u00edst\u011b je t\u0159eba se zm\u00ednit o klinick\u00e9 epidemiologii<\/i>. Tento pojem nelze zdaleka redukovat jen na oblast infek\u010dn\u00edch chorob, jak byla u n\u00e1s epidemiologie ch\u00e1p\u00e1na zvl\u00e1\u0161t\u011b p\u0159ed rokem 1990. Klinick\u00e1 epidemiologie, kter\u00e1 se ve sv\u011bt\u011b za\u010dala rozv\u00edjet od 60. let minul\u00e9ho stolet\u00ed, vyu\u017e\u00edv\u00e1 kvantitativn\u00edch v\u011bdeck\u00fdch metod pro studium p\u0159\u00ed\u010din a z\u00e1vislost\u00ed, kter\u00fdmi se \u0159\u00edd\u00ed v\u00fdskyt onemocn\u011bn\u00ed v lidsk\u00e9 populaci.<\/p>\n

\"Obr.<\/a>

Obr. 1
Medic\u00edna zalo\u017een\u00e1 na d\u016fkazu<\/p><\/div>\n

Zakladatel\u00e9 a hlavn\u00ed zast\u00e1nci t\u00e9to discipl\u00edny A. Feinstein a D. L. Sackett v USA a A. Cochrane v Evrop\u011b [1, 2] se stali hlavn\u00edmi nositeli t\u00e9to metody v klinick\u00e9 medic\u00edn\u011b, kter\u00e1 se soust\u0159edila na zp\u016fsoby, jak se v klinick\u00fdch discipl\u00edn\u00e1ch rozhoduje. Pojem EBM (evidence-based medicine) \u2013 medic\u00edna zalo\u017een\u00e1 na d\u016fkazech <\/i>\u2013 se za\u010dal u\u017e\u00edvat od po\u010d\u00e1tku 90. let minul\u00e9ho stolet\u00ed. Definuje se jako zp\u016fsob p\u00e9\u010de o pacienta zalo\u017een\u00fd na nejlep\u0161\u00edch v\u011bdeck\u00fdch d\u016fkazech poch\u00e1zej\u00edc\u00edch z v\u00fdzkumn\u00fdch v\u011bdeck\u00fdch klinick\u00fdch a epidemiologick\u00fdch publikac\u00ed. P\u0159i aplikaci EBM v praxi je kladen d\u016fraz na spojen\u00ed klinick\u00fdch zku\u0161enost\u00ed a um\u011bn\u00ed s nejlep\u0161\u00edmi v sou\u010dasnosti dostupn\u00fdmi klinick\u00fdmi d\u016fkazy. Je nutn\u00e9 br\u00e1t ohled na vyv\u00e1\u017eenost rizika a prosp\u011bchu, kter\u00e9 to pacientovi p\u0159in\u00e1\u0161\u00ed, a na osobn\u00ed zvl\u00e1\u0161tnosti, jako je komorbidita \u010di individu\u00e1ln\u00ed preference nemocn\u00e9ho.<\/p>\n

V EBM se za d\u016fkaz pova\u017euj\u00ed v\u0161echny informace a poznatky z\u00edskan\u00e9 na z\u00e1klad\u011b vlastn\u00edch zku\u0161enost\u00ed, empirick\u00fdch pozorov\u00e1n\u00ed a r\u016fzn\u00fdch typ\u016f v\u00fdzkumu. V\u0161echna tato data mus\u00ed b\u00fdt relevantn\u00ed ve vztahu ke zkouman\u00e9mu probl\u00e9mu a mus\u00ed m\u00edt podle posouzen\u00ed odborn\u00edk\u016f na danou tematiku v\u00fdznam pro klinick\u00e1 rozhodnut\u00ed, kter\u00e1 se t\u00fdkaj\u00ed dan\u00e9ho p\u0159\u00edpadu, co\u017e p\u0159edstavuje kvalitativn\u00ed posouzen\u00ed <\/i>p\u0159edkl\u00e1dan\u00e9ho d\u016fkazu. Podstata d\u016fkazu v EBM jako discipl\u00edny odvozen\u00e9 z klinick\u00e9 epidemiologie v\u0161ak mus\u00ed m\u00edt nutn\u011b i kvantitativn\u00ed aspekt. <\/i>Ka\u017ed\u00fd d\u016fkaz p\u0159edstavuje ur\u010ditou kvantitativn\u00ed pravd\u011bpodobnostn\u00ed slo\u017eku, kter\u00e1 ho v hierarchii d\u016fkaz\u016f \u0159ad\u00ed na ur\u010dit\u00e9 m\u00edsto. Validitou d\u016fkaz\u016f rozum\u00edme, \u017ee budeme-li se p\u0159edlo\u017een\u00fdm d\u016fkazem \u0159\u00eddit, dos\u00e1hneme po\u017eadovan\u00e9ho v\u00fdsledku. Kvalita a s\u00edla d\u016fkazu a z n\u011bho vypl\u00fdvaj\u00edc\u00ed doporu\u010den\u00ed ud\u00e1vaj\u00ed m\u00edru jistoty, \u017ee d\u016fkaz je spr\u00e1vn\u00fd a \u017ee jeho dodr\u017eov\u00e1n\u00edm sp\u00ed\u0161e pom\u016f\u017eeme ne\u017e ubl\u00ed\u017e\u00edme [3]. Obr. 1 ukazuje se\u0159azen\u00ed studi\u00ed podle kvality a s\u00edly doporu\u010den\u00ed. Pro stupe\u0148 kvality d\u016fkaz\u016f se pou\u017e\u00edv\u00e1 ozna\u010den\u00ed \u010d\u00edslicemi jedna a\u017e \u010dty\u0159i (v n\u011bkter\u00fdch klasifikac\u00edch a\u017e p\u011bt) a b\u00fdvaj\u00ed u\u017e\u00edv\u00e1ny i subkategorie a\u2013c, pro stupe\u0148 s\u00edly doporu\u010den\u00ed tomu odpov\u00eddaj\u00ed p\u00edsmena A\u2013D. Rozd\u00edly ve zp\u016fsobu klasifikace b\u00fdvaj\u00ed i dle toho, zda je hodnocena etiologie, l\u00e9\u010dba, diagn\u00f3za, progn\u00f3za atd. P\u0159\u00edklad hierarchie d\u016fkaz\u016f [4, 5] je uveden v tab. 1.<\/p>\n\n\n\n\n\n\n\n\n
Tab. 1<\/span>
\nHierarchie d\u016fkaz\u016f<\/span><\/td>\n<\/tr>\n
\u00darove\u0148 d\u016fkazu<\/strong><\/td>\nS\u00edla doporu\u010den\u00ed<\/strong><\/td>\nD\u016fkaz<\/strong><\/td>\n\u00da\u010dinek<\/strong><\/td>\n<\/tr>\n
I<\/td>\nA<\/td>\nSystematick\u00fd p\u0159ehled a metaanal\u00fdza KRS Dob\u0159e proveden\u00e9 KRS<\/td>\nDok\u00e1z\u00e1n
\n\u2013 benefit p\u0159eva\u017euje<\/em>
\n nad rizikem<\/em><\/td>\n<\/tr>\n
II<\/td>\nB<\/td>\nDobr\u00e1 kohortov\u00e1 studie nebo studie p\u0159\u00edpad\u016f
\na kontrol<\/td>\n		Mo\u017en\u00fd
\n\u2013 nen\u00ed jasn\u00e9, zda benefit<\/em>
\n p\u0159eva\u017euje nad rizikem<\/em><\/td>\n<\/tr>\n
III<\/td>\nC<\/td>\nPopisn\u00e9 studie, nekontrolovan\u00e9 studie, kazuistiky<\/td>\nNazna\u010den
\n \u2013 nen\u00ed jasn\u00e9, zda benefit<\/em>
\n p\u0159eva\u017euje nad rizikem<\/em><\/td>\n<\/tr>\n
IV<\/td>\nD<\/td>\nExpertn\u00ed v\u00fdroky<\/td>\nNejsou d\u016fkazy<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

* KRS \u2013 kontrolovan\u00e9 randomizovan\u00e9 studie<\/em><\/p>\n

<\/em>Podrobnosti o r\u016fzn\u00fdch typech studi\u00ed, vhodnosti pou\u017eit\u00ed pro ten \u010di onen p\u0159\u00edpad, jejich hodnocen\u00ed a vyu\u017eit\u00ed statistick\u00fdch metod p\u0159edstavuj\u00ed dnes ji\u017e ohromn\u00fd objem znalost\u00ed spadaj\u00edc\u00edch do samostatn\u00fdch v\u011bdn\u00edch obor\u016f [6, 7, 8, 9, 10, 11, 12] a v p\u0159\u00edslu\u0161n\u00e9 literatu\u0159e je mo\u017eno z\u00edskat bli\u017e\u0161\u00ed pou\u010den\u00ed. P\u0159i koncipov\u00e1n\u00ed a vyhodnocov\u00e1n\u00ed t\u00e9to pr\u00e1ce dnes mus\u00ed klinik spolupracovat s p\u0159\u00edslu\u0161n\u00fdmi odborn\u00edky. Dal\u0161\u00edm krokem od EBM je cesta k praktick\u00e9mu vyu\u017eit\u00ed t\u011bchto poznatk\u016f a vytv\u00e1\u0159en\u00ed klinick\u00fdch doporu\u010den\u00fdch postup\u016f (KDP)<\/i>. Lze je definovat jako systematicky vytv\u00e1\u0159en\u00e1 stanoviska, pom\u00e1haj\u00edc\u00ed l\u00e9ka\u0159\u016fm a pacient\u016fm ve specifick\u00fdch klinick\u00fdch p\u0159\u00edpadech rozhodovat o p\u0159im\u011b\u0159en\u00e9 zdravotn\u00ed p\u00e9\u010di [5]. KDP vytv\u00e1\u0159ej\u00ed odborn\u00e9 l\u00e9ka\u0159sk\u00e9 organizace a nejr\u016fzn\u011bj\u0161\u00ed vl\u00e1dn\u00ed a nevl\u00e1dn\u00ed organizace. Tato \u010dinnost prob\u00edh\u00e1 i v \u010cesk\u00e9 republice, ale v sou\u010dasnosti neexistuj\u00ed \u017e\u00e1dn\u00e9 ofici\u00e1ln\u00ed KDP, kter\u00e9 by se t\u00fdkaly problematiky chirurgie j\u00edcnu.<\/p>\n

V jednotliv\u00fdch speci\u00e1ln\u00edch kapitol\u00e1ch jsou uvedeny publikace vztahuj\u00edc\u00ed se k prob\u00edran\u00e9 tematice. Jen v men\u0161\u00edm po\u010dtu spl\u0148uj\u00ed tyto publikace nejvy\u0161\u0161\u00ed stupe\u0148 kvality a s\u00edly d\u016fkaz\u016f podle z\u00e1sad EBM. D\u016fvodem, pro\u010d je tomu tak, je cel\u00e1 \u0159ada. Frekvence n\u011bkter\u00fdch j\u00edcnov\u00fdch onemocn\u011bn\u00ed nen\u00ed p\u0159\u00edli\u0161 velk\u00e1 a shrom\u00e1\u017edit v\u011bt\u0161\u00ed po\u010det pacient\u016f na jednom pracovi\u0161ti trv\u00e1 \u010dasto l\u00e9ta. Z t\u011bchto d\u016fvod\u016f m\u016f\u017ee b\u00fdt obt\u00ed\u017en\u00e9 nebo i nemo\u017en\u00e9 prov\u00e1d\u011bt randomizaci a m\u016f\u017ee to v ur\u010dit\u00fdch p\u0159\u00edpadech nar\u00e1\u017eet i na etick\u00e9 probl\u00e9my. Obt\u00ed\u017ee mohou b\u00fdt i s vytv\u00e1\u0159en\u00edm srovnateln\u00fdch homogenn\u00edch skupin vzhledem ke komorbidit\u00e1m, r\u016fzn\u00fdm stadi\u00edm a charakteristik\u00e1m u n\u00e1dorov\u00fdch onemocn\u011bn\u00ed atd. \u010casto spln\u011bn\u00ed po\u017eadavk\u016f z\u00e1sad EBM a pot\u0159eba pr\u016fkazn\u00e9ho statistick\u00e9ho vyhodnocen\u00ed vy\u017eaduj\u00ed multicentrickou studii, co\u017e neb\u00fdv\u00e1 v\u017edy organiza\u010dn\u011b jednoduch\u00e9. P\u0159i aplikaci z\u00e1sad EBM do na\u0161eho my\u0161len\u00ed a v\u00fdzkumu si mus\u00edme b\u00fdt v\u011bdomi, \u017ee v r\u016fzn\u00fdch situac\u00edch lze z\u00edskat jen ur\u010dit\u00fd typ d\u016fkaz\u016f a v chirurgii jsou kohortov\u00e9 studie a studie p\u0159\u00edpad\u016f a kontrol mnohdy jedin\u00fdm mo\u017en\u00fdm p\u0159\u00edstupem, jak ut\u0159\u00eddit na\u0161e informace. \u017de v\u0161ak i u j\u00edcnov\u00e9 problematiky doch\u00e1z\u00ed k obratu ve v\u011bt\u0161\u00ed aplikaci z\u00e1sad EBM do v\u00fdzkumu, je dokladov\u00e1no nap\u0159. v kapitole o karcinomu j\u00edcnu. Dal\u0161\u00edm p\u0159\u00edkladem, kde u n\u011bkter\u00fdch ot\u00e1zek doch\u00e1z\u00ed k pokroku a u jin\u00fdch budeme muset je\u0161t\u011b \u010dekat na pr\u016fkazn\u00e9 zodpov\u011bzen\u00ed, je zde uveden\u00e1 pr\u00e1ce o kontroverzn\u00edch probl\u00e9mech v l\u00e9\u010db\u011b paraezofage\u00e1ln\u00edch herni\u00ed [13]. C\u00edlem pr\u00e1ce bylo srovnat r\u016fzn\u00e9 aspekty v l\u00e9\u010db\u011b paraezofage\u00e1ln\u00edch herni\u00ed p\u0159i klasick\u00e9 operaci s laparoskopick\u00fdm p\u0159\u00edstupem. V datab\u00e1zi Medline auto\u0159i vyhledali za obdob\u00ed 10 let (1993\u20132004) 32 publikac\u00ed s touto tematikou. Po\u010dty pacient\u016f v jednotliv\u00fdch studi\u00edch kol\u00edsaly mezi\u00a010\u2013240, medi\u00e1n sledov\u00e1n\u00ed byl 21 m\u011bs\u00edc\u016f (6\u201394), del\u0161\u00ed byl u klasicky operovan\u00fdch (45 versus 17,5 m\u011bs\u00edc\u016f po operaci). V\u0161echny pr\u00e1ce byly posouzeny z hlediska EBM. Ani v jednom p\u0159\u00edpad\u011b se nejednalo o randomizovanou kontrolovanou studii. U 13 prac\u00ed byla \u00farove\u0148 kvality d\u016fkaz\u016f hodnocena IIc, u zbyl\u00fdch 19 jako IV (d\u016fkaz pr\u016fkaznosti nen\u00ed). Doba hospitalizace byla v pr\u016fm\u011bru 3 dny u laparoskopicky operovan\u00fdch a 10 dn\u016f u otev\u0159en\u00fdch operac\u00ed, kde byl tak\u00e9 v\u011bt\u0161\u00ed v\u00fdskyt poopera\u010dn\u00edch komplikac\u00ed. Recidiva hernie se vyskytla v 9,1% u konven\u010dn\u011b operovan\u00fdch proti 7,1 % u laparoskopie. Nebyla shled\u00e1na jasn\u00e1 krit\u00e9ria pro u\u017eit\u00ed s\u00ed\u0165ky ke zpevn\u011bn\u00ed hi\u00e1tu a pro p\u0159ipojen\u00ed antirefluxn\u00ed fundoplikace. Stejn\u011b tak nebylo mo\u017en\u00e9 u\u010dinit z\u00e1v\u011br k ot\u00e1zce p\u0159\u00edpadn\u00e9ho u\u017eit\u00ed Collisovy gastroplastiky u zkr\u00e1cen\u00ed j\u00edcnu. K vyjasn\u011bn\u00ed t\u011bchto ot\u00e1zek navrhli auto\u0159i dob\u0159e napl\u00e1novan\u00e9 kontrolovan\u00e9, nejl\u00e9pe multicentrick\u00e9 studie. V dob\u011b zve\u0159ejn\u011bn\u00ed citovan\u00e9 publikace (2005) byla zn\u00e1ma jen jedna kontrolovan\u00e1 studie poukazuj\u00edc\u00ed na v\u00fdhody zpevn\u011bn\u00ed hi\u00e1tu vst\u0159ebatelnou s\u00ed\u0165kou [14]. Od t\u00e9 doby p\u0159ibyly dal\u0161\u00ed randomizovan\u00e9 studie [15, 16, 17] podporuj\u00edc\u00ed zpevn\u011bn\u00ed hi\u00e1tu vst\u0159ebatelnou s\u00ed\u0165kou p\u0159i operaci paraezofage\u00e1ln\u00ed hernie. Ot\u00e1zka p\u0159ipojen\u00ed fundoplikace, postoj ke kr\u00e1tk\u00e9mu j\u00edcnu a u\u017eit\u00ed Collisovy gastroplastiky z\u016fst\u00e1vaj\u00ed nad\u00e1le nedo\u0159e\u0161eny (viz kap. 8).<\/p>\n

Cesta k rozhodnut\u00ed n\u011bkter\u00fdch sporn\u00fdch ot\u00e1zek v chirurgii j\u00edcnu na z\u00e1klad\u011b vy\u0161\u0161\u00edho stupn\u011b kvality a s\u00edly d\u016fkaz\u016f podle z\u00e1sad EBM bude nepochybn\u011b dlouh\u00e1 a vzhledem ke st\u00e1le se objevuj\u00edc\u00edm novink\u00e1m v diagnostice a l\u00e9\u010db\u011b jde o kontinu\u00e1ln\u00ed nekon\u010d\u00edc\u00ed\u00a0proces. D\u016fvody, pro\u010d je tomu tak, byly zm\u00edn\u011bny. D\u016fle\u017eit\u00e9 v\u0161ak je, aby se na\u0161e postupy v diagnostice i l\u00e9\u010db\u011b st\u00e1le v\u00edce op\u00edraly o doporu\u010den\u00e9 postupy zalo\u017een\u00e9 na d\u016fkazech vy\u0161\u0161\u00ed kvality, ne\u017e jsou jen pouh\u00e1 expertn\u00ed \u010di konsenzu\u00e1ln\u00ed doporu\u010den\u00ed.<\/p>\n

Hodnocen\u00ed kvality opera\u010dn\u00ed l\u00e9\u010dby<\/strong> nen\u00ed nic nov\u00e9ho a chirurgov\u00e9 si sami v pr\u016f<\/span>b\u011bhu stalet\u00ed vyvinuli krit\u00e9ria hodnot\u00edc\u00ed jejich vlastn\u00ed pr\u00e1ci. Pat\u0159\u00ed mezi n\u011b hodnocen\u00ed opera\u010dn\u00edch a poopera\u010dn\u00edch komplikac\u00ed, \u00famrtnosti, po\u010det reoperac\u00ed, hodnocen\u00ed spokojenosti nemocn\u00fdch s provedenou l\u00e9\u010dbou, d\u00e9lka p\u0159e\u017e\u00edv\u00e1n\u00ed u onkologick\u00fdch nemocn\u00fdch, po\u010det recidiv a \u0159ada dal\u0161\u00edch krit\u00e9ri\u00ed. Nejv\u00edce pozornosti je t\u00e9to problematice v\u011bnov\u00e1no v onkochirurgii, ale obecn\u011b to plat\u00ed pro ve\u0161kerou chirurgickou p\u00e9\u010di.<\/p>\n

V\u0161echny tyto \u00fadaje m\u016f\u017eeme nal\u00e9zt v publikac\u00edch star\u00fdch t\u0159eba i v\u00edce jak sto let a chirurgov\u00e9 je trvale sleduj\u00ed. Nikdy d\u0159\u00edve v\u0161ak nebyl tlak ve\u0159ejnosti po\u017eaduj\u00edc\u00ed zlep\u0161en\u00ed kvality poskytovan\u00e9 p\u00e9\u010de tak velk\u00fd. V tomto ohledu vystupuj\u00ed do pop\u0159ed\u00ed n\u011bkter\u00e9 nov\u00e9 faktory, jako jsou n\u00e1klady l\u00e9\u010dby, nutnost komunikace s ve\u0159ejnost\u00ed a tiskem, stoupaj\u00edc\u00ed v\u00fdznam nov\u00fdch technologi\u00ed, ale rozhoduj\u00edc\u00edm faktorem z\u016fst\u00e1v\u00e1 vlastn\u00ed profesion\u00e1ln\u00ed snaha po zlep\u0161ov\u00e1n\u00ed v\u00fdsledku pr\u00e1ce chirurga. Hledaj\u00ed se krit\u00e9ria pro hodnocen\u00ed kvality, kter\u00e1 by odr\u00e1\u017eela nov\u011b se vyv\u00edjej\u00edc\u00ed koncepci hodnocen\u00ed kvality v chirurgii, je\u017e vych\u00e1z\u00ed z p\u0159edpokladu, \u017ee se zvy\u0161uj\u00edc\u00edm se po\u010dtem v\u00fdkon\u016f (operac\u00ed) stoup\u00e1 i kvalita dosa\u017een\u00fdch v\u00fdsledk\u016f. Pod pojmem \u201eHigh Volume Hospital\u201c se rozum\u00ed centra, kde se prov\u00e1d\u011bj\u00ed vysok\u00e9 po\u010dty ur\u010dit\u00fdch operac\u00ed (\u201eSurgeon Volume\u201c).\u00a0Rozd\u00edly v poopera\u010dn\u00ed \u00famrtnosti a komplikac\u00edch jsou v\u00fdrazn\u011bj\u0161\u00ed u tzv. v\u011bt\u0161\u00edch operac\u00ed, jako jsou resekce jater, pankreatu a j\u00edcnu, proti jin\u00fdm resekc\u00edm, nap\u0159. pro kolorekt\u00e1ln\u00ed karcinom [18, 19]. Podrobn\u011b je o tom pojedn\u00e1no v kapitole 13 N\u00e1dory j\u00edcnu.\u00a0I kdy\u017e existuje \u0159ada doklad\u016f podporuj\u00edc\u00edch tuto koncepci, p\u0159i bli\u017e\u0161\u00edm rozboru se m\u016f\u017ee uk\u00e1zat, \u017ee po\u010dty v\u00fdkon\u016f nemus\u00ed b\u00fdt rozhoduj\u00edc\u00edm faktorem a p\u0159inejmen\u0161\u00edm stejn\u00fd v\u00fdznam m\u016f\u017ee m\u00edt individu\u00e1ln\u00ed erudice chirurga, kter\u00fd p\u0159edstavuje v\u00fdznamn\u00fd prognostick\u00fd faktor jak ve vztahu ke komplikac\u00edm, tak v\u00fdsledk\u016fm [20, 21]. Rozd\u00edly v p\u011btilet\u00e9m p\u0159e\u017e\u00edv\u00e1n\u00ed u vybran\u00fdch zhoubn\u00fdch n\u00e1dor\u016f na r\u016fzn\u00fdch pracovi\u0161t\u00edch v \u010cesk\u00e9 republice byly zji\u0161t\u011bny z anal\u00fdz z N\u00e1rodn\u00edho onkologick\u00e9ho registru v \u010cR [22, 23] a v\u00fdznamn\u011b koreluj\u00ed s po\u010dty operac\u00ed proveden\u00fdch na jednotliv\u00fdch pracovi\u0161t\u00edch.\u00a0Podobn\u00e9 rozd\u00edly srovnateln\u00e9 se situac\u00ed u n\u00e1s byly zji\u0161t\u011bny i ve Spolkov\u00e9 republice N\u011bmecko [24]. Vedle po\u010dtu prov\u00e1d\u011bn\u00fdch operac\u00ed, co\u017e by podporovalo koncepci \u201eHigh Volume\u201c, by vliv na tyto v\u00fdsledky mohlo m\u00edt \u0161patn\u00e9 za\u0159azov\u00e1n\u00ed do klinick\u00fdch stadi\u00ed, u\u017e\u00edvan\u00e1 opera\u010dn\u00ed taktika a technika a rozd\u00edln\u00e9 vyu\u017e\u00edv\u00e1n\u00ed kombinovan\u00e9 l\u00e9\u010dby.<\/p>\n

Kvalitu chirurgick\u00e9 p\u00e9\u010de hodnot\u00edme jednak z pohledu kvality prov\u00e1d\u011bn\u00e9 l\u00e9\u010dby a d\u00e1le pod aspektem kvality \u017eivota nemocn\u00e9ho b\u011bhem \u010di po ukon\u010den\u00ed terapie. Hodnocen\u00ed kvality \u017eivota operovan\u00e9ho zahrnuje posouzen\u00ed fyzick\u00e9ho i psychick\u00e9ho stavu pacienta a dal\u0161\u00edch psychosoci\u00e1ln\u00edch faktor\u016f, jako je rodina, zam\u011bstn\u00e1n\u00ed, spole\u010densk\u00e9 vztahy, ekonomick\u00e1 situace a dal\u0161\u00ed pro nemocn\u00e9ho d\u016fle\u017eit\u00e9 oblasti \u017eivota. Definovat kvalitu \u017eivota je velmi obt\u00ed\u017en\u00e9 a toto hodnocen\u00ed podl\u00e9h\u00e1 velk\u00fdm individu\u00e1ln\u00edm rozd\u00edl\u016fm. Existuje cel\u00e1 \u0159ada n\u00e1vod\u016f, vizu\u00e1ln\u00edch \u0161k\u00e1l a dotazn\u00edk\u016f pro objektivn\u00ed vyhodnocen\u00ed kvality \u017eivota, u\u017e\u00edvan\u00fdch pro praktick\u00e9 i v\u00fdzkumn\u00e9 \u00fa\u010dely. V minulosti se pozornost soust\u0159e\u010fovala v\u00edce na fyzick\u00e9 aspekty, jak tomu bylo nap\u0159. u Karnovsk\u00e9ho indexu. V sou\u010dasnosti se d\u00e1v\u00e1 p\u0159ednost multidimenzion\u00e1ln\u00edmu posouzen\u00ed stavu nemocn\u00e9ho. \u010casto u\u017e\u00edvan\u00fd dotazn\u00edk pro posouzen\u00ed kvality \u017eivota navrhla spole\u010dnost EORTC (European Organization for Research and Treatment of Cancer) [25].<\/p>\n

Hodnocen\u00ed kvality chirurgick\u00e9 p\u00e9\u010de je dnes v pop\u0159ed\u00ed z\u00e1jmu ka\u017ed\u00e9ho chirurga, odborn\u00fdch spole\u010dnost\u00ed, nemocnic a nejr\u016fzn\u011bj\u0161\u00edch st\u00e1tn\u00edch instituc\u00ed. Chirurgov\u00e9 se nemohou zbavit povinnosti zve\u0159ej\u0148ovat v\u00fdsledky sv\u00e9 pr\u00e1ce, je jen ot\u00e1zkou, jakou formou a v jak\u00e9m rozsahu je to vhodn\u00e9. Jedn\u00edm z legitimn\u00edch a osv\u011bd\u010den\u00fdch zp\u016fsob\u016f je publikov\u00e1n\u00ed v odborn\u00e9 literatu\u0159e.<\/p>\n

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    .<\/span><\/p>\n","protected":false},"excerpt":{"rendered":"

    V\u0161ichni l\u00e9ka\u0159i se p\u0159i diagnostice i l\u00e9\u010db\u011b sv\u00fdch nemocn\u00fdch \u0159\u00edd\u00ed znalostmi nabyt\u00fdmi v prei postgradu\u00e1ln\u00edm studiu a dle vlastn\u00edch zku\u0161enost\u00ed z\u00edskan\u00fdch b\u011bhem sv\u00e9 praxe. I na\u0161i z\u00e1konod\u00e1rci l\u00e9ka\u0159e zavazuj\u00ed k tomu, aby postupovali dle nejnov\u011bj\u0161\u00edch poznatk\u016f l\u00e9ka\u0159sk\u00e9 v\u011bdy, tj. lege artis. K napln\u011bn\u00ed tohoto po\u017eadavku jsou dnes l\u00e9ka\u0159\u016fm n\u00e1pomocn\u00e9 nov\u00e9 discipl\u00edny. Na prvn\u00edm m\u00edst\u011b je […]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":65,"menu_order":90,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":"","_links_to":"","_links_to_target":""},"class_list":["post-878","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/878","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=878"}],"version-history":[{"count":19,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/878\/revisions"}],"predecessor-version":[{"id":3832,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/878\/revisions\/3832"}],"up":[{"embeddable":true,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/65"}],"wp:attachment":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=878"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}