Use of a mobile tower-based robot--The initial Xi robot experience in surgical oncology.

BACKGROUND AND OBJECTIVES: The da Vinci Xi platform provides expanded movement of the arms relative to the base, theoretically allowing increased versatility in complex multi-field or multi-quadrant surgery. We describe the initial Xi experience in oncologic surgery at a tertiary cancer center. METHODS: One hundred thirty unique robot-assisted procedures were performed using the Xi between 2014 and 2015, 112 of which were oncology surgeries. For procedures involving multiple quadrants, the robot was re-targeted. Complications were assessed according to Martin criteria and the Clavien-Dindo classification up to 90 days after operation. RESULTS: Thirteen different operations were performed in five oncology subspecialties (urology, gynecology, thoracic, hepatobiliary, and gastrointestinal surgery). Median operative times ranged from 183 min for nephroureterectomy to 543 min for esophagogastrectomy. Median estimated blood loss did not exceed 200 ml for any of the categorized procedures . No patients were transfused intraoperatively and no positioning injuries occurred. Conversions to open operation occurred in three cases (2.7%), though not related to complications or technical considerations. Overall complication rate was 26% with major complication rate of 4%. Readmissions were necessary in 11 (10%) patients. CONCLUSIONS: The da Vinci Xi can be safely assimilated into a surgical oncology program. The Xi offers versatility to various oncologic procedures with satisfactory complication and readmission rates.

Machine Learning Algorithm to Perform the American Society of Anesthesiologists Physical Status Classification.

OBJECTIVE: The American Society of Anesthesiologists (ASA) Physical Status (PS) Classification System defines perioperative patient scores ranging from 1 to 6 (healthy to brain dead, respectively). The scoring is performed and used by physician anesthesiologists and providers to classify surgical patients based on co-morbidities and various clinical characteristics. There is potentially a variability in scoring stemming from individual biases. The biases impact the prediction of operating times, length of stay in the hospital, anesthetic management, and billing. This study's purpose was to develop an automated system to achieve reproducible scoring. METHODS: A machine learning (ML) model was trained on already assigned ASA PS scores of 12,064 patients. The ML algorithm was automatically selected by Wolfram Mathematica (Wolfram Research, Champaign, IL) and tested with retrospective records not used in training. Manual scoring was performed by the anesthesiologist as part of the standard preoperative evaluation. Intraclass correlation coefficient (ICC) in R (version 4.2.2; R Development Core Team, Vienna, Austria) was calculated to assess the consistency of scoring. RESULTS: An ML model was trained on the data corresponding to 12,064 patients. Logistic regression was chosen automatically, with an accuracy of 70.3±1.0% against the training dataset. The accuracy against 1,999 patients (the test dataset) was 69.6±1.0%. The ICC for the comparison between ML and the anesthesiologists' ASA PS scores was greater than 0.4 ("fair to good"). CONCLUSIONS: We have shown the feasibility of applying ML to assess the ASA PS score within an oncology patient population. Though our accuracy was not very good, we feel that, as more data are mined, a valid foundation for refinement to ML will emerge.

Inhibition of ß2-adrenergic receptor reduces triple-negative breast cancer brain metastases: The potential benefit of perioperative ß-blockade.

In response to recent studies, we investigated an association between perioperative ß-blockade and breast cancer metastases. First, a retrospective study examining perioperative ß-blocker use and cancer recurrence and metastases was conducted on 1,029 patients who underwent breast cancer surgery at the City of Hope Cancer Center between 2000 and 2010. We followed the clinical study and examined proliferation, migration, and invasion in vitro of primary and brain-metastatic breast cancer cells in response to ß2-activation and inhibition. We also investigated in vivo the metastatic potential of propranolol-treated metastatic cells. For stage II breast cancer patients, perioperative ß-blockade was associated with decreased cancer recurrence using Cox regression analysis (hazard's ratio =0.51; 95% CI: 0.23-0.97; p=0.041). Triple-negative (TN) brain-metastatic cells were found to have increased ß2-adrenergic receptor mRNA and protein expression relative to TN primary cells. In response to ß2-adrenergic receptor activation, TN brain-metastatic cells also exhibited increased cell proliferation and migration relative to the control. These effects were abrogated by propranolol. Propranolol decreased ß2-adrenergic receptor-activated invasion. In vivo, propranolol treatment of TN brain-metastatic cells decreased establishment of brain metastases. Our results suggest that stress and corresponding ß2-activation may promote the establishment of brain metastases of TN breast cancer cells. In addition, our data suggest a benefit to perioperative ß-blockade during surgery-induced stress with respect to breast cancer recurrence and metastases.