The development of a deep learning model for automated segmentation of the robotic pancreaticojejunostomy.

BACKGROUND: Minimally invasive surgery provides an unprecedented opportunity to review video for assessing surgical performance. Surgical video analysis is time-consuming and expensive. Deep learning provides an alternative for analysis. Robotic pancreaticoduodenectomy (RPD) is a complex and morbid operation. Surgeon technical performance of pancreaticojejunostomy (PJ) has been associated with postoperative pancreatic fistula. In this work, we aimed to utilize deep learning to automatically segment PJ RPD videos. METHODS: This was a retrospective review of prospectively collected videos from 2011 to 2022 that were in libraries at tertiary referral centers, including 111 PJ videos. Each frame of a robotic PJ video was categorized based on 6 tasks. A 3D convolutional neural network was trained for frame-level visual feature extraction and classification. All the videos were manually annotated for the start and end of each task. RESULTS: Of the 100 videos assessed, 60 videos were used for the training the model, 10 for hyperparameter optimization, and 30 for the testing of performance. All the frames were extracted (6 frames/second) and annotated. The accuracy and mean per-class F1 scores were 88.01% and 85.34% for tasks. CONCLUSION: The deep learning model performed well for automated segmentation of PJ videos. Future work will focus on skills assessment and outcome prediction.

Baseline performance in a robotic virtual reality platform predicts rate of skill acquisition in a proficiency-based curriculum: a cohort study of surgical trainees.

BACKGROUND: Residency programs must prepare to train the next generation of surgeons on the robotic platform. The purpose of this study was to determine if baseline skills of residents on a virtual reality (VR) robotic simulator before intern year predicted future performance in a proficiency-based curriculum. METHODS: Across two academic years, 21 general surgery PGY-1s underwent the robotic surgery boot camp at the University of Texas Southwestern. During boot camp, subjects completed five previously validated VR tasks, and their performance metrics (score, time, and economy of motion [EOM]) were extracted retrospectively from their Intuitive learning accounts. The same metrics were assessed during their residency until they reached previously validated proficiency benchmarks. Outcomes were defined as the score at proficiency, attempts to reach proficiency, and time to proficiency. Spearman's rho and Mann-Whitney U tests were used; median (IQR) was reported. Significance level was set at p < 0.05. RESULTS: Twenty-one residents completed at least three out of the five boot camp tasks and achieved proficiency in the former during residency. The median average score at boot camp was 12.3 (IQR: 5.14-18.5). The median average EOM at boot camp was 599.58 cm (IQR: 529.64-676.60). The average score at boot camp significantly correlated with lower time to achieve proficiency (p < 0.05). EOM at boot camp showed a significant correlation with attempts to proficiency and time to proficiency (p < 0.01). Residents with an average baseline EOM below the median showed a significant difference in attempts to proficiency (p < 0.05) and time to proficiency (p < 0.05) compared to those with EOMs above or equal to the median. CONCLUSION: Residents with an innate ability to perform tasks with better EOM may acquire robotic surgery skills faster. Future investigators could explore how these innate differences impact performance throughout residency.

Perioperative outcomes of robotic and laparoscopic surgery for colorectal cancer: a propensity score-matched analysis.

BACKGROUND: Robotic colorectal surgery is becoming the preferred surgical approach for colorectal cancer (CRC). It offers several technical advantages over conventional laparoscopy that could improve patient outcomes. In this retrospective cohort study, we compared robotic and laparoscopic surgery for CRC using a national cohort of patients. METHODS: Using the colectomy-targeted ACS-NSQIP database (2015-2020), colorectal procedures for malignant etiologies were identified by CPT codes for right colectomy (RC), left colectomy (LC), and low anterior resection (LAR). Optimal pair matching was performed. "Textbook outcome" was defined as the absence of 30-day complications, readmission, or mortality and a length of stay < 5 days. RESULTS: We included 53,209 out of 139,759 patients screened for eligibility. Laparoscopic-to-robotic matching of 2:1 was performed for RC and LC, and 1:1 for LAR. The largest standardized mean difference was 0.048 after matching. Robotic surgery was associated with an increased rate of textbook outcomes compared to laparoscopy in RC and LC, but not in LAR (71% vs. 64% in RC, 75% vs. 68% in LC; p < 0.001). Robotic LAR was associated with increased major morbidity (7.1% vs. 5.8%; p = 0.012). For all three procedures, the mean conversion rate of robotic surgery was lower than laparoscopy (4.3% vs. 9.2%; p < 0.001), while the mean operative time was higher for robotic (225 min vs. 177 min; p < 0.001). CONCLUSIONS: Robotic surgery for CRC offers an advantage over conventional laparoscopy by improving textbook outcomes in RC and LC. This advantage was not found in robotic LAR, which also showed an increased risk of serious complications. The associations highlighted in our study should be considered in the discussion of the surgical management of patients with colorectal cancer.

The synkinetic mentalis muscle and its negative effect on the smile: pathomechanism and treatment with mentalis targeted selective neurectomies.

BACKGROUND: The treatment of post-paretic facial synkinesis is based on a combination of nonsurgical and surgical strategies. Even if improvements towards the restoration of a natural smile have been obtained with selective neurectomies (SN) and depressor anguli oris (DAO) myectomy, the lower lip frequently remains asymmetric and cranially displaced. The aim of this study was to evaluate the effect of the mentalis muscle on the position and symmetry of the lower lip in patients with synkinesis and to assess the added benefit of neurectomies of nerves innervating the mentalis muscle in improving the lower lip configuration and mandibular teeth show. METHODS: A retrospective cohort study on all patients affected by post-paretic synkinesis at our Institution was performed. A Non-mentalis Neurectomy Group including twelve patients treated with SN without targeting the branches to mentalis muscle was compared to a Mentalis Neurectomy Group, including sixteen patients who underwent additional specific mentalis branches neurectomies. All patients underwent DAO myectomy. Analyses of standardized images were performed with ImageJ software. RESULTS: Post-operative comparisons between the two groups showed superior and significant improvements in the Mentalis Neurectomy Group across all measures, including lower and upper border deviation (p=0.035 and p=.004, respectively), inclination of the lower lip (p=.019), and lower quadrant dental show (p=.004). CONCLUSIONS: The addition of targeted selective neurectomies to the branches innervating mentalis muscle significantly improved dental show and caudal position and symmetry of the lower lip during open mouth smile.

Basilar Impression: A Systematic Review and Meta-Analysis of Clinical Features, Operative Strategies and Outcomes.

OBJECTIVE: Basilar Impression (BI) is a rare yet debilitating abnormality of the craniovertebral junction (CVJ), known to cause life-threatening medullary brainstem compression. Our study analyzes surgical approaches for BI and related outcomes. METHODS: A systematic review was conducted using PubMed, Google Scholar, and Web of Science electronic databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to critically assess primary articles examining BI. RESULTS: We analyzed 87 patients from 65 articles, mostly female (55.17%) with a mean age of 46.31 ± 17.94 years, commonly presenting with motor (59.77%) and sensory deficits (55.17%). Commonly employed procedures included posterior occipitocervical fusion (24.14%), anterior decompression (20.69%), and combined anterior decompression with posterior fusion (21.84%). Patients who underwent anterior approaches were found to be older (55.38 ± 17.67 vs. 45.49 ± 18.78 years, p < 0.05) and had a longer duration from symptom onset to surgery (57.39 ± 64.33 vs. 26.02 ± 29.60 months, p < 0.05) compared to posterior approaches. Our analysis revealed a significant association between a longer duration from symptom onset to surgery and an increased likelihood of undergoing odontoidectomy and decompression (OR: 1.02, 95% CI: 1.00-1.03, p < 0.05). Furthermore, after adjusting for all other covariates, a history of rheumatoid arthritis and the use of a posterior approach were significantly associated with an elevated risk of postoperative complications (p < 0.05). CONCLUSIONS: The treatment approach to complex CVJ disease should be tailored to the surgeon's experience and the nature of the compressive pathology.

Adapting to a Robotic Era: The Transferability of Open and Laparoscopic Skills to Robotic Surgery.

BACKGROUND: The learning curve of robotic surgical skills is poorly understood. There is a lack of data on the transferability of skills from open and laparoscopic training to robotic surgery. In this retrospective cohort study, we investigated the impact of training acquired during intern year on the development of robotic skills in general surgery residents, prior to formal robotic training. METHODS: Between 2019 and 2021, novice general surgery residents underwent robotic skill assessment using 3 validated inanimate drills before starting intern year. After completing basic open and laparoscopic proficiency-based curricula, they completed an identical robotic skill assessment at the end of intern year. Pre and post intern year robotic performances were recorded and analyzed by 2 blinded graders. Video-based assessment included completion time, errors, and the modified Objective Structured Assessment of Technical Skills (mOSATS) score. RESULTS: The total time needed to complete all 3 robotic drills decreased from a mean of 26 to 17 minutes after intern year (p < 0.001). The number of errors decreased from a mean of 2.16 to 0.56 errors per subject (p < 0.001). The aggregated mOSATS score increased by an average of 41% (p < 0.001), with a greater increase in technical skill domains compared to the knowledge-based domain. The interrater intraclass correlation coefficient was 0.91. CONCLUSIONS: Baseline robotic surgical skills are limited without formal training. Our findings suggest that acquiring basic open and laparoscopic skills, such as knot tying, needle driving, and tissue handling results in improved performance on the robotic platform, prior to formal robotic training. Therefore, requiring trainees to complete fundamental open and laparoscopic training prior to robotic training may be an efficient and effective strategy within a surgical residency curriculum.

Pancreatic Cancer Metastasis to the Spine: A Systematic Review of Management Strategies and Outcomes with Case Illustration.

OBJECTIVE: We aim to provide a thorough review of the literature regarding patient characteristics, treatment options, and outcomes of pancreatic cancer metastasis to the spine. We also provide an illustrative case from our institution of a patients with pancreatic adenocarcinoma presenting initially as cervical radiculopathy with an isolated cervical spine lesion. METHODS: Using the PRISMA guidelines, the literature in PubMed, Google Scholar, and Web of Science databases was searched. We excluded systematic reviews and meta-analyses that did not provide novel cases, as well as reports of metastatic disease from other nonpancreatic primary cancers. RESULTS: Thirty-two patients across 21 studies met the inclusion criteria. The patients were predominantly male (58%), with a mean age of 59 years. Of patients, 64% presented with back pain, 39% with motor deficits, and 15% with bladder or bowel dysfunction. For treatment, chemotherapy was used in 55% of cases and radiotherapy in 42%. Surgical treatment was performed in 42% of cases, with complete tumor resection achieved in 24% of cases. The mean patient survival after treatment was 28 weeks (range, 1-83 weeks), with patients undergoing treatment involving surgery having increased survival (44 weeks) compared with noninvasive treatment alone (18 weeks). CONCLUSIONS: Spinal metastasis of pancreatic cancer is rare and typically portends a poor prognosis. It is vital to recognize the presence of spinal involvement early in the disease course and initiate treatment.

Transfusion Guidelines in Brain Tumor Surgery: A Systematic Review and Critical Summary of Currently Available Evidence.

OBJECTIVE: Red blood cell (RBC) transfusion is commonly indicated in brain tumor surgery due to risk of blood loss. Current transfusion guidelines are based on evidence derived from critically ill patients and may not be optimal for brain tumor surgeries. Our study is the first to synthesize available evidence to suggest RBC transfusion thresholds in brain tumor patients undergoing surgery. METHODS: A systematic review was conducted using PubMed, EMBASE, and Google Scholar databases in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines to critically assess RBC transfusion thresholds in adult patients with brain tumors and complications secondary to transfusion following blood loss in the operating room or perioperative period. RESULTS: Seven articles meeting our search criteria were reviewed. Brain tumor patients who received blood transfusions were older, had greater rates of American Society of Anesthesiologists class 3 or 4, and presented with increased number of comorbidities including diabetes, hypertension, and cardiovascular diseases. In addition, transfused patients had a prolonged surgical time. Transfusions were associated with multiple postoperative major and minor complications, including longer hospital length of stay, increased return to the operating room, and elevated 30-day mortality. Analysis of transfusion thresholds showed that a restrictive hemoglobin threshold of 8 g/dL is safe in patients, as evidenced by a reduction in length of stay, mortality, and complications (level C class IIa). CONCLUSIONS: A restrictive Hb threshold of 8 g/dL appears to be safe and minimizes potential complications of transfusion in brain tumor patients.

Postoperative Transfusion Guidelines in Aneurysmal Cerebral Subarachnoid Hemorrhage: A Systematic Review and Critical Summary of Available Evidence.

OBJECTIVE: Surgical management of aneurysmal subarachnoid hemorrhage (SAH) often involves red blood cell (RBC) transfusion, which increases the risk of postoperative complications. RBC transfusion guidelines report on chronically critically ill patients and may not apply to patients with SAH. Our study aims to synthesize the evidence to recommend RBC transfusion thresholds among adult patients with SAH undergoing surgery. METHODS: A systematic review was conducted using PubMed, Google Scholar, and Web of Science electronic databases according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to critically assess primary articles discussing RBC transfusion thresholds and describe complications secondary to RBC transfusion in adult patients with SAH in the perioperative period. RESULTS: Sixteen articles meeting our search strategy were reviewed. Patients with SAH who received blood transfusion were older, female, had World Federation of Neurosurgical Societies grade IV-V and modified Fisher grade 3-4 scores, and presented with more comorbidities such as hypertension, diabetes, and cardiovascular and pulmonary diseases. In addition, transfusion was associated with multiple postoperative complications, including higher rates of vasospasms, surgical site infections, cardiovascular and respiratory complications, increased postoperative length of stay, and 30-day mortality. Analysis of transfused patients showed that a higher hemoglobin (>10 g/dL) goal after SAH was safe and that patients may benefit from a higher whole hospital stay hemoglobin nadir, as shown by a reduction in risk of cerebral vasospasm and improvement in clinical outcomes (level B class II). CONCLUSIONS: Among patients with SAH, the benefits of reducing cerebral ischemia and anemia are shown to outweigh the risks of transfusion-related complications.

Transfusion Guidelines in Traumatic Brain Injury: A Systematic Review and Meta-Analysis of the Currently Available Evidence.

Our study aims to provide a synthesis of the best available evidence on the hemoglobin (hgb) red blood cell (RBC) transfusion thresholds in adult traumatic brain injury (TBI) patients, as well as describing the risk factors and outcomes associated with RBC transfusion in this population. A systematic review and meta-analysis was conducted using PubMed, Google Scholar, and Web of Science electronic databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to assess articles discussing RBC transfusion thresholds and describe complications secondary to transfusion in adult TBI patients in the perioperative period. Fifteen articles met search criteria and were reviewed for analysis. Compared to non-transfused, TBI patients who received transfusion tended to be primarily male patients with worse Injury Severity Score (ISS) and Glasgow Coma Scale. Further, the meta-analysis corroborated that transfused TBI patients are older (p = 0.04), have worse ISS scores (p = 0.001), receive more units of RBCs (p = 0.02), and have both higher mortality (p < 0.001) and complication rates (p < 0.0001). There were no differences identified in rates of hypertension, diabetes mellitus, and Abbreviated Injury Scale scores. Additionally, whereas many studies support restrictive (hgb <7 g/dL) transfusion thresholds over liberal (hgb <10 g/dL), our meta-analysis revealed no significant difference in mortality between those thresholds (p = 0.79). Current Class B/C level III evidence predominantly recommends against a liberal transfusion threshold of 10 g/dL for TBI patients (Class B/C level III), but our meta-analysis found no difference in survival between groups. There is evidence suggesting that an intermediate threshold between 7 and 9 g/dL, reflecting the physiological oxygen needs of cerebral tissue, may be worth exploring.

Aggressively recurring cervical intramedullary anaplastic astrocytoma in a pregnant patient.

BACKGROUND: Many patients with spinal juvenile pilocytic astrocytoma can experience prolonged remission after resection. However, some reports suggest that pregnancy may be associated with progression. CASE DESCRIPTION: The authors provide an image report highlighting a case of rapid and aggressive transformation of an intramedullary astrocytoma of the cervical spine in a pregnant patient. Over the course of 1 year, the lesion progressed from a juvenile pilocytic astrocytoma to an anaplastic astrocytoma. Genetic testing revealed mutations associated with aggressive behavior. CONCLUSION: The case and associated imaging demonstrate the importance of close neurologic monitoring and counseling regarding risk of progression in pregnant patients with spinal gliomas.

The Clinical Use of Serum Biomarkers in Traumatic Brain Injury: A Systematic Review Stratified by Injury Severity.

BACKGROUND: Serum biomarkers have gained significant popularity as an adjunctive measure in the evaluation and prognostication of traumatic brain injury (TBI). However, a concise and clinically oriented report of the major markers in function of TBI severity is lacking. This systematic review aims to report current data on the diagnostic and prognostic utility of blood-based biomarkers across the spectrum of TBI. METHODS: A literature search of the PubMed/Medline electronic database was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. We excluded systematic reviews and meta-analyses that did not provide novel data. The American College of Cardiology/American Heart Association criteria were used to assess levels of evidence. RESULTS: An initial 1463 studies were identified. In total, 115 full-text articles reporting on 94 distinct biomarkers met the inclusion criteria. Glasgow Coma Scale scores, computed tomography/magnetic resonance imaging abnormalities, and injury severity scores were the most used clinical diagnostic variables. Glasgow Outcome Scores and 1-, 3-, and 6-month mortality were the most used clinical prognostic variables. Several biomarkers significantly correlated with these variables and had statistically significant different levels in TBI subjects when compared with healthy, orthopedic, and polytrauma controls. The biomarkers also displayed significant variability across mild, moderate, and severe TBI categories, as well as in concussion cases. CONCLUSIONS: This review summarizes existing high-quality evidence that supports the use of severity-specific biomarkers in the diagnostic and prognostic evaluation of TBI. These data can be used as a launching platform for the validation of upcoming clinical studies.