An analysis of virtual reality in abdominal surgery-A scoping review.

BACKGROUND: The integration of virtual reality (VR) in surgery has gained prominence as VR applications have increased in popularity. METHODS: A scoping review was undertaken, gathering the most relevant sources, utilising a detailed literature search of medical and academic databases including EMBASE, PubMed, Cochrane, IEEE, Google Scholar, and the Google search engine. RESULTS: Of the 18 articles included, 7 focused on VR in colon surgery, 5 addressed VR in pancreas surgery, and the remaining 6 concentrated on VR in liver surgery. All the articles concluded that VR has a promising future in abdominal surgery by facilitating precision, visualisation, and surgeon training. CONCLUSIONS: Adopting VR technology in abdominal surgery has the potential to improve preoperative planning, decrease perioperative anxiety among patients, and facilitate the training of surgeons, residents, and medical students. Additional supporting studies are necessary before VR can be widely implemented in surgical care delivery.

Analysis of artificial intelligence in thyroid diagnostics and surgery: A scoping review.

BACKGROUND: Artificial Intelligence provides numerous applications in the healthcare sector. The main aim of this study is to evaluate the extent of the current application of artificial intelligence in thyroid diagnostics. METHODS: Our protocol was based on the Scoping Reviews extension of the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA-ScR). Information was gathered from PubMed, Cochrane, and EMBASE databases and Google Scholar. Eligible studies were published between 2017 and 2022. RESULTS: The search identified 133 records, after which 18 articles were included in the scoping review. All the publications were journal articles and discussed various ways that specialists in thyroid diagnostics and surgery have utilized artificial intelligence in their practice. CONCLUSIONS: The development and incorporation of Artificial Intelligence applications in thyroid diagnostics and surgery has been moderate yet promising. However, applications are currently inconsistent and further research is needed to delineate the true benefit and limitations in this field.

Development and validation of a predictive model of the hospital cost associated with bariatric surgery.

Hospitals are facing difficulties in predicting, evaluating, and managing cost-affecting parameters in patient treatments. Inaccurate cost prediction leads to a deficit in operational revenue. This study aims to determine the ability of Machine Learning (ML) algorithms to predict the cost of care in bariatric and metabolic surgery and develop a predictive tool for improved cost analysis. 602 patients who underwent bariatric and metabolic surgery at Wetzikon hospital from 2013 to 2019 were included in the study. Multiple variables including patient factors, surgical factors, and post-operative complications were tested using a number of predictive modeling strategies. The study was registered under Req 2022-00659 and approved by an institutional review board. The cost was defined as the sum of all costs incurred during the hospital stay, expressed in CHF (Swiss Francs). The data was preprocessed and split into a training set (80%) and a test set (20%) to build and validate models. The final model was selected based on the mean absolute percentage error (MAPE). The Random Forest model was found to be the most accurate in predicting the overall cost of bariatric surgery with a mean absolute percentage error of 12.7. The study provides evidence that the Random Forest model could be used by hospitals to help with financial calculations and cost-efficient operation. However, further research is needed to improve its accuracy. This study serves as a proof of principle for an efficient ML-based prediction tool to be tested on multi-center data in future phases of the study.

Neoadjuvant Chemotherapy, Excision, and Observation for Early Rectal Cancer: The Phase II NEO Trial (CCTG CO.28) Primary End Point Results.

PURPOSE: Organ-sparing therapy for early-stage I/IIA rectal cancer is intended to avoid functional disturbances or a permanent ostomy associated with total mesorectal excision (TME). The objective of this phase II trial was to determine the outcomes and organ-sparing rate of patients with early-stage rectal cancer treated with neoadjuvant chemotherapy followed by transanal excision surgery (TES). METHODS: This phase II trial included patients with clinical T1-T3abN0 low- or mid-rectal adenocarcinoma eligible for endoscopic resection who were treated with 3 months of chemotherapy (modified folinic acid-fluorouracil-oxaliplatin 6 or capecitabine-oxaliplatin). Those with evidence of response proceeded to transanal endoscopic surgery 2-6 weeks later. The primary end point was protocol-specified organ preservation rate, defined as the proportion of patients with tumor downstaging to ypT0/T1N0/X and who avoided radical surgery. RESULTS: Of 58 patients enrolled, all commenced chemotherapy and 56 proceeded to surgery. A total of 33/58 patients had tumor downstaging to ypT0/1N0/X on the surgery specimen, resulting in an intention-to-treat protocol-specified organ preservation rate of 57% (90% CI, 45 to 68). Of 23 remaining patients recommended for TME surgery on the basis of protocol requirements, 13 declined and elected to proceed directly to observation resulting in 79% (90% CI, 69 to 88) achieving organ preservation. The remaining 10/23 patients proceeded to recommended TME of whom seven had no histopathologic residual disease. The 1-year and 2-year locoregional relapse-free survival was, respectively, 98% (95% CI, 86 to 100) and 90% (95% CI, 58 to 98), and there were no distant recurrences or deaths. Minimal change in quality of life and rectal function scores was observed. CONCLUSION: Three months of induction chemotherapy may successfully downstage a significant proportion of patients with early-stage rectal cancer, allowing well-tolerated organ-preserving surgery.

Does Personality Matter? Perceptions and Experiences of Introverts and Extraverts as General Surgeons.

PHENOMENON: Medical educators increasingly recognize both the challenges introverts, compared to extraverts, may face in medical training and the unique strengths they bring to practice. However, few researchers have examined in-depth how introverts and extraverts truly experience training and practice, particularly in specialties like surgery that tend to value qualities (e.g., dominance and assertiveness) typically associated with extraverts. This study aimed to explore the perceptions and experiences of individuals with both personalities within the field of general surgery. APPROACH: Using a constructivist grounded theory approach, six general surgeons and 10 general surgery residents who identified as introverted, extraverted, or ambiverted were recruited from two Canadian tertiary care hospitals to participate in semi-structured interviews. Data collection and analysis occurred iteratively, and data were analyzed using open, selective, and thematic coding. Constant comparison allowed us to make sense of the similar and dissimilar views that emerged from each interview. FINDINGS: Irrespective of their personalities, participants voiced two general patterns of responses. Some participants believed that "personality doesn't matter": that both introverted and extraverted practice styles were equally viable and neither introverts nor extraverts would find surgical training more challenging than the other (culture of equality). However, others believed that "personality matters," emphasizing that surgeons should be dominant and aggressive leaders. Only those who believed "personality matters" felt that introverts sometimes needed to act more extraverted in order to succeed in surgical training (culture of hierarchy). Similar numbers of introverts and extraverts adhered to each viewpoint. INSIGHTS: Our qualitative approach allowed us to draw meaning from the complex subjective experiences of our research participants. Our findings suggest that two competing cultures (equality and hierarchy) co-exist within the field of surgery and that trainees, depending on which culture they adhere most to, will or will not "adapt" their personalities to the workplace. These findings deepen our understanding of the nuances of surgical culture and have important implications for how we select candidates based on personality.

Cost Analysis of Laparoscopic Low Anterior Resection vs. Transanal Endoscopic Microsurgery for Rectal Neoplasms.

Despite the increasing application of transanal endoscopic microsurgery (TEM) for rectal lesions, the cost of the equipment may play a role in a hospital's hesitancy to invest in the platform. This study compares the cost of TEM to laparoscopic low anterior resection (LAR). Patients who underwent laparoscopic LAR (n = 24) for rectal neoplasm between 2006 and 2014 were case-matched based on sex, age, comorbidities, lesion size and location to patients who underwent TEM at a busy secondary care urban hospital. Procedure-related costs and costs associated with readmissions for complications and related subsequent surgeries in the first 3 years were calculated. There were 42 hospital admissions for 24 LAR patients, totalling 326 hospital days. For 24 TEM patients, there were 25 hospital admissions, totalling 56 hospital days. Subsequent operations for LAR patients included 2 washout and diverting ileostomies (8%), 2 adhesionolysis (8%), 4 ventral hernia repairs (16%) and 11 ileostomy reversals (46%). In the TEM group, there was one operation for recurrence (4%). The mean cost of LAR, including all related hospital costs in the subsequent 3 years, was CAD 14,851 (95% CI: CAD 10,124-19,579). The mean cost of TEM was CAD 2449 (95% CI: CAD 2133-2767; p < 0.0001), with a savings of CAD 12,402 per patient. TEM for rectal neoplasm is associated with significantly lower hospital costs, which far outweigh the costs of acquiring and maintaining the technology.

Timing of recurrences of TEM resected rectal neoplasms is variable as per the surveillance practices of one tertiary care institution.

Transanal endoscopic microsurgery (TEM) is widely used for the excision of rectal adenomas and early rectal adenocarcinoma. Few recommendations currently exist for surveillance of lesions excised by TEM. The purpose of this study was to review the surveillance practices and the patterns of recurrence among TEM resected lesions at a tertiary care hospital. A retrospective chart review was performed on all patients who underwent TEM for rectal adenoma or adenocarcinoma before June 2017. In our study population of 114 patients, the final pathology included 78 (68%) adenomas and 36 (32%) adenocarcinomas. Of the adenocarcinomas 23, 9, and 4 were T1, T2, T3 lesions, respectively. Of those, 25 patients opted for surveillance instead of further treatment. The most commonly recommended endoscopic surveillance strategy by our group for both adenomas and adenocarcinomas excised by TEM was flexible sigmoidoscopy every 6 months for 2 years. Recurrences occurred in 4/78 (5.1%) adenoma patients, all found within 16.9 months of surgery, and in 4/25 (16%) adenocarcinoma patients, found between 7.4 and 38.5 months post-surgery. Our data highlights the fact that the timing of recurrences post TEM surgery is variable. Further studies looking at recurrence patterns are needed in order to create comprehensive guidelines for surveillance of these patients.

Quality indicator selection for the Canadian Partnership against Cancer rectal cancer project: A modified Delphi study.

AIM: It is well established that (i) magnetic resonance imaging, (ii) multidisciplinary cancer conference (MCCs), (iii) preoperative radiotherapy, (iv) total mesorectal excision surgery and (v) pathological assessment as described by Quirke are key processes necessary for high quality, rectal cancer care. The objective was to select a set of multidisciplinary quality indicators to measure the uptake of these clinical processes in clinical practice. METHOD: A multidisciplinary panel was convened and a modified two-phase Delphi method was used to select a set of quality indicators. Phase 1 included a literature review with written feedback from the panel. Phase 2 included an in-person workshop with anonymous voting. The selection criteria for the indicators were strength of evidence, ease of capture and usability. Indicators for which ≥90% of the panel members voted 'to keep' were selected as the final set of indicators. RESULTS: During phase 1, 68 potential indicators were generated from the literature and an additional four indicators were recommended by the panel. During phase 2, these 72 indicators were discussed; 48 indicators met the 90% inclusion threshold and included eight pathology, five radiology, 11 surgical, six radiation oncology and 18 MCC indicators. CONCLUSION: A modified Delphi method was used to select 48 multidisciplinary quality indicators to specifically measure the uptake of key processes necessary for high quality care of patients with rectal cancer. These quality indicators will be used in future work to identify and address gaps in care in the uptake of these clinical processes.

The Canadian Partnership Against Cancer Rectal Cancer Project: Protocol for a Pan-Canadian, Multidisciplinary Quality Improvement Initiative to Optimize the Quality of Rectal Cancer Care.

BACKGROUND: Over the last 2 decades, the use of multimodal strategies, including total mesorectal excision (TME) surgery, preoperative chemotherapy, multidisciplinary case conference, pelvic magnetic resonance imaging, and pathologic assessment using Quirke method, has led to significant improvements in oncologic outcomes for patients with rectal cancer. Although the literature supports claims on the effectiveness of these multimodal strategies, the uptake of these multimodal strategies varies considerably among centers, suggesting that the best evidence is not always implemented into clinical practice. OBJECTIVE: This study aims to perform a quality improvement initiative to (1) identify existing gaps in care for these multimodal strategies and (2) implement knowledge translation (KT) interventions to close these gaps to optimize quality of care for patients with rectal cancer across high-volume centers in Canada. METHODS: Process indicators for the selected multimodal strategies to optimize rectal cancer care will be selected and prospectively collected for all patients with stages 1 to 3 rectal cancer undergoing TME surgery. KT interventions, including audit and feedback, opinion leaders, and community of practice, will be implemented to increase the uptake of these clinical strategies. RESULTS: The uptake of the process indicators over time and the effect of the uptake of the process indicators on short- and long-term oncologic outcomes will be evaluated for each multimodal strategy. CONCLUSIONS: This quality improvement initiative will identify existing gaps in care for the selected multimodal strategies and implement KT interventions to close these gaps. The results of this study will inform further efforts to optimize rectal cancer care. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/15535.

Safety and Feasibility of Using Magnetic Resonance Imaging Criteria to Identify Patients With "Good Prognosis" Rectal Cancer Eligible for Primary Surgery: The Phase 2 Nonrandomized QuickSilver Clinical Trial.

IMPORTANCE: Chemoradiotherapy (CRT), followed by surgery, is the recommended approach for stage II and III rectal cancer. While CRT decreases the risk of local recurrence, it does not improve survival and leads to poorer functional outcomes than surgery alone. Therefore, new approaches to better select patients for CRT are important. OBJECTIVE: To conduct a phase 2 study to evaluate the safety and feasibility of using magnetic resonance imaging (MRI) criteria to select patients with "good prognosis" rectal tumors for primary surgery. DESIGN, SETTING, AND PARTICIPANTS: Prospective nonrandomized phase 2 study at 12 high-volume colorectal surgery centers across Canada. From September 30, 2014, to October 21, 2016, a total of 82 patients were recruited for the study. Participants were patients newly diagnosed as having rectal cancer with MRI-predicted good prognosis rectal cancer. The MRI criteria for good prognosis tumors included distance to the mesorectal fascia greater than 1 mm; definite T2, T2/early T3, or definite T3 with less than 5 mm of extramural depth of invasion; and absent or equivocal extramural venous invasion. INTERVENTIONS: Patients with rectal cancer with MRI-predicted good prognosis tumors underwent primary surgery. MAIN OUTCOMES AND MEASURES: The primary outcome was the proportion of patients with a positive circumferential resection margin (CRM) rate. Assuming a 10% baseline probability of a positive CRM, a sample size of 75 was estimated to yield a 95% CI of ±6.7%. RESULTS: Eighty-two patients (74% male) participated in the study. The median age at the time of surgery was 66 years (range, 37-89 years). Based on MRI, most tumors were midrectal (65% [n = 53]), T2/early T3 (60% [n = 49]), with no suspicious lymph nodes (63% [n = 52]). On final pathology, 91% (n = 75) of tumors were T2 or greater, 29% (n = 24) were node positive, and 59% (n = 48) were stage II or III. The positive CRM rate was 4 of 82 (4.9%; 95% CI, 0.2%-9.6%). CONCLUSIONS AND RELEVANCE: The use of MRI criteria to select patients with good prognosis rectal cancer for primary surgery results in a low rate of positive CRM and suggests that CRT may not be necessary for all patients with stage II and III rectal cancer. TRIAL REGISTRATION: ISRCTN.com identifier: ISRCTN05107772.

Is obesity associated with advanced stage or grade of colon cancer?

Population-based studies from Europe have suggested that obesity is associated with more advanced stage colorectal cancer on presentation. Obesity is an even more prevalent issue in North America, but comparable data on associations with cancer are lacking. We reviewed the cases of 672 patients with colon cancer diagnosed between 2004 and 2008 in the province of Manitoba who underwent surgical resection at a Winnipeg Regional Health Authority­affiliated hospital. We tested if obesity was associated with more advanced cancer stage or grade. On multivariate analysis, after adjusting for age, sex,tumour location and socioeconomic status, we were unable to show any significant associations between body mass index of 30 or more and advanced stage or grade cancer on presentation. The reasons for the lack of association are likely multifactorial, including the pathophysiology of the disease and process factors, such as screening habits and colonoscopic diagnostic success rates in obese patients.

Drosophila dihydrofolate reductase mutations confer antifolate resistance to mammalian cells.

Antifolates, such as methotrexate, are used to inhibit dihydrofolate reductase (DHFR), an enzyme essential for the biosynthesis of thymidylate, purines, and several amino acids. DHFR sequences corresponding to mutations found in a methotrexate resistant Drosophila S3 cell line (L30Q), a methotrexate resistant fly population (K31P, Q134K), as well as predicted in silico (L22R) were expressed in Chinese Hamster Ovary (CHO) cells. The L30Q and L22R DHFRs both conferred resistance to methotrexate. L22R DHFR provided approximately 200-fold resistance to methotrexate when compared to wild-type Drosophila DHFR allowing CHO(L22R) cells to divide in 10 microM methotrexate, a level of resistance not previously observed in any mammalian system. Constructs using this substitution in combination with other Drosophila DHFR specific residues would make excellent candidates for gene therapy and genetic markers in the treatment of certain human disorders.

The effects of methotrexate on Drosophila development, female fecundity, and gene expression.

Methotrexate (MTX), a synthetic folate analog, is a tight-binding inhibitor of dihydrofolate reductase (DHFR), a key enzyme for the biosynthesis of purines, thymidylate, and several amino acids. As a consequence, MTX decreases titres of reduced folates, interferes with DNA synthesis, and results in the arrest of rapidly proliferating cells, making it a drug of choice for the treatment of a variety of cancers and auto-immune disorders. MTX is also a known teratogen in all higher animals tested, but there is little information about the effects of this drug on invertebrates. Here we show that MTX has little effect on the survival of Drosophila melanogaster adult flies, but severely diminishes female fecundity. Reduced oviposition, coupled with aberrant egg morphologies, resulted in near sterility of MTX-treated females. Rare surviving progeny showed developmental abnormalities including larval tumors, and bristle, wing, eye, and leg defects. To determine if these phenotypes could be attributed solely to DHFR inhibition, microarray analysis was undertaken and included MTX-treated females, ovaries, and cell line samples. Genes encoding transcripts that were perturbed by the drug were verified using quantitative real-time RT-PCR. Many of these genes were involved in cell cycle regulation, signal transduction, transport, defense response, transcription, or various aspects of metabolism. These studies show that MTX treatment has multiple targets and, in addition, provides a new invertebrate model for the study of teratogenesis.