Strengths and opportunities for improvement in surgical education in Ukraine: A qualitative study.

BACKGROUND: The full-scale invasion of Ukraine by Russia in 2022 has significantly impacted the country's healthcare system including surgical education. To assess the current state and identify the strengths and opportunities for the improvement of Ukraine's surgical education system during the peri-war period, this study is one of the first to explore the state of surgical education across Ukraine in peri-war, providing essential insights for current and postwar healthcare reconstruction. METHODS: This qualitative study involved semi-structured interviews with 24 Ukrainian surgical residents, surgeons, and program leadership from various regions. The study focused on clinical training, didactics, mentorship, autonomy, resident evaluation, the impact of war, and gender disparities in surgical education. Data analysis was conducted using a rapid qualitative analysis technique. RESULTS: Interviews revealed strengths in surgical education such as adaptability to war conditions and international collaborations. However, opportunities for improvement were identified including a lack of structured clinical and didactic experiences, limited autonomy and access to simulators, gender discrimination, and war-time challenges. These issues highlight a need for more comprehensive training and support systems for surgical trainees in Ukraine. CONCLUSIONS: The study underscores the resilience and adaptability of Ukrainian surgical education in the face of war while also emphasizing the need for significant improvements. It calls for implementing structured training programs, enhanced mentorship, and attention to gender equality. These findings are crucial for improving surgical education in Ukraine and can be used as an example for other lower-middle-income countries, especially in conflict settings.

Colonoscopy Needs for Implementation of a Colorectal Cancer Screening Program in Ukraine.

BACKGROUND: In Ukraine, there is no established colorectal cancer screening program. We aimed to project the number of screening colonoscopies needed for implementation of various CRC screening strategies in Ukraine. METHODS: We modified a previously developed Markov microsimulation model to reflect the natural history of adenoma and CRC progression among average-risk 50-74-year-olds. We simulated colonoscopies needed for the following screening strategies: no screening, fecal occult blood test yearly, FOBT yearly with flexible sigmoidoscopy every 5 years, FS every 5 years, fecal immunohistochemistry test (FIT) yearly, or colonoscopy every 10 years. Assuming 80% screening adherence, we estimated colonoscopies required at 1 and 5 years depending on the implementation rate. In one-way sensitivity analyses, we varied implementation rate, screening adherence, sensitivity, and specificity. RESULTS: Assuming an 80% screening adherence and complete implementation (100%), besides a no screening strategy, the fewest screening colonoscopies are needed with an FOBT program, requiring on average 6,600 and 26,800 colonoscopies per 100,000 persons at 1 and 5 years post-implementation, respectively. The most screening colonoscopies are required with a colonoscopy program, requiring on average 76,600 and 101,000 colonoscopies per 100,000 persons at 1 and 5 years post-implementation, respectively. In sensitivity analyses, the biggest driver of number of colonoscopies needed was screening adherence. CONCLUSIONS: The number of colonoscopies needed and therefore the potential strain on the healthcare system vary substantially by screening test. These findings can provide valuable information for stakeholders on equipment needs when implementing a national screening program in Ukraine.

Barriers to Evidence-Based Colorectal Cancer Care in Ukraine.

BACKGROUND: The incidence of colorectal cancer (CRC) is increasing in many low- to middle-income countries, including Ukraine. Ukraine reports high mortality rates in CRC patients. To identify potential areas for targeted interventions to improve CRC care in Ukraine, we investigated Ukrainian clinician perspectives on evidence-based CRC treatment guidelines. METHODS: An explanatory sequential mixed-methods study design was used. A survey was administered to attendees of a regional surgical conference. Semi-structured interviews were subsequently performed with practicing clinicians in Ukraine. Interviews were coded to identify prominent themes. RESULTS: Quantitative: 105 clinicians completed the survey. 76% of respondents reported using guidelines in daily practice. Lack of English proficiency was cited by 28.6% of respondents as a barrier to guideline use. Improved knowledge and additional financial resources were reported as factors that would be helpful in providing evidence-based care. QUANTITATIVE: 15 clinicians were interviewed. Two major themes were identified: limitations in access to the medical literature resources (language barriers and financial barriers), and sense of clinician initiative and willingness to learn despite hardships. CONCLUSIONS: Clinicians in Ukraine have positive perspectives on utilization of evidence-based CRC treatment guidelines. However, they face major barriers in accessing resources needed to keep up-to-date on the current literature. Fortunately, there exists both willingness and initiative on the clinician level to pursue continuing education. Efforts should be made on the international society level to improve open-access and foreign language translation availability to support physicians in Ukraine and other low- to middle-income countries.

The Current Landscape of Staging and Treatment of Colorectal Cancer in a Region of Ukraine: a Mixed Methods Study.

BACKGROUND: In Ukraine, the 1-year mortality for colorectal cancer is much higher than that seen in high-income countries. We investigated practice patterns of colorectal cancer treatment in a region of Ukraine to account for high mortality rates. METHODS: An explanatory sequential mixed methods design was used. Data from patients who underwent surgery for colorectal cancer in Ivano-Frankivsk from 2011 to 2015 were collected via retrospective chart review, and descriptive statistics were calculated. Semi-structured interviews were performed with local practicing surgeons and oncologists until thematic saturation was reached. RESULTS: A total of 960 patients who underwent surgery were identified in the Ivano-Frankivsk region with colon (689) or rectal (271) cancer. 11.7% of patients underwent preoperative CT of the abdomen and pelvis, and only 1.7% underwent CT of the chest. 4.1% of patients underwent a complete preoperative colonoscopy, while 31.0% had incomplete colonoscopies. Postoperatively, 31.1% of patients with stage II colon cancer and 43.9% of patients with stage III colon cancer underwent adjuvant chemotherapy. For patients with stage II and III rectal cancers, 20.9% and 33.3% underwent chemotherapy, while 68.4% and 66.7% underwent radiation therapy, respectively. Fifteen physicians completed interviews. Two major themes emerged regarding physician perceptions on providing colorectal cancer care: lack of resources and systems level issues negatively impacting patient care. CONCLUSION: In this region in Ukraine, staging practices for colorectal malignancies are inconsistent and inadequate, and adjuvant treatments are varied. This is likely attributable to the lack of resources facing providers and the prohibitively high cost of care to patients.

Racial and Socioeconomic Disparities After Surgical Resection for Rectal Cancer.

BACKGROUND: There are various racial, socioeconomic, and tumor-specific factors that can impact rectal cancer outcomes. The current systematic review and meta-analysis evaluate the effect socioeconomic and racial variables on overall survival of rectal cancer patients after surgical resection. METHODS: A literature search was performed via electronic databases according to Systematic Reviews and Meta-Analyses and Meta-analysis Of Observational Studies in Epidemiology guidelines. All studies were evaluated by three authors and validated for data extraction. Predictive variables and survival profiles (1-, 5-, and 10-y survival and overall survival) reported by the studies were recorded for the systematic review. Hazard ratios, odds ratios, and 95% confidence intervals were extracted for meta-analysis. Forest plots were used to interpret the results. The primary outcome was the effect size of the predictive variables on overall survival after surgical resection. RESULTS: Of the 265 articles collected, 22 met inclusion criteria. Sixteen studies were used for the systematic review, and 17 studies were considered for meta-analysis. Overall, 662,053 subjects with rectal cancer were studied (439,766 with race reported), of which 344,193 (78.3%) were White and 60,283 (13.7%) were Black. The median survival was 56.8% for White patients and 47.9% for Black patients. Meta-analysis revealed that race, socioeconomic variables (education level, income level, and insurance status), and facility characteristics (type and volume) were significantly associated with overall survival in rectal cancer. CONCLUSIONS: Racial and socioeconomic disparities are present in outcomes for rectal cancer patients undergoing surgical resection. It is important to consider these disparities in the management of patients with rectal cancer to minimize any consequent disparities in surgical outcomes.

Cytoreductive Surgery and HIPEC in an Enhanced Recovery After Surgery Program: A Feasibility Study.

BACKGROUND: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have historically been associated with high morbidity given the physiologic insult of an extensive operation. Enhanced Recovery after Surgery (ERAS) pathways have been successful in improving postoperative outcomes for many procedures but have not been well studied in these cases. We examined the feasibility and effect of ERAS pathway implementation for patients undergoing CRS/HIPEC. MATERIALS AND METHODS: Patients with peritoneal carcinomatosis who underwent CRS/HIPEC between October 2015 to September 2018 were identified. Patient characteristics, disease pathology, and perioperative outcome data were obtained. Primary outcomes were hospital length of stay (LOS), 30-d readmissions, renal dysfunction, and complications. RESULTS: Of the 31 patients who were included, 11 (35.5%) patients underwent CRS/HIPEC prior to the implementation of the ERAS pathway, and 20 (64.5%) patients underwent CRS/HIPEC according to the ERAS guidelines. There were no significant differences in the baseline clinical or pathologic characteristics between groups. There was a significant decrease in LOS with ERAS pathway management from 9 d to 6 d (P = 0.002). No patients from either cohort experienced acute kidney injury. There was no significant difference in 30-d readmission rates or complications. CONCLUSIONS: In this feasibility study, ERAS pathway utilization significantly decreased postoperative LOS for patients undergoing CRS/HIPEC, without evidence of increased complications or readmissions. ERAS programs should be considered for integration into future CRS/HIPEC protocols.

The GAMMA concept (gastrointestinal activity manipulation to modulate appetite) preliminary proofs of the concept of local vibrational gastric mechanical stimulation.

BACKGROUND: Mechanical stimulation of the stretch receptors of the gastric wall can simulate the presence of indigested food leading to reduced food intake. We report the preliminary experimental results of an innovative concept of localized mechanical gastric stimulation. METHODS: In a first survival study, a biocompatible bulking agent was injected either in the greater curvature (n = 8) or in the cardia wall (n = 8) of Wistar rats. Six animals served as sham. Changes of bulking volume, leptin levels and weight gain were monitored for 3 months. In a second acute study, a micro-motor (n = 10; MM) or a size-paired inactive device (n = 10; ID) where applied on the cardia, while 10 additional rats served as sham. Serum ghrelin and leptin were measured at baseline and every hour (T0-T1-T2-T3), during 3 h. In a third study, 24 implants of various shapes and sizes were introduced into the gastric subserosa of 6 Yucatan pigs. Monthly CT scans and gastroscopies were done for 6 months. RESULTS: Weight gain in the CW group was significant lower after 2 weeks and 3 months when compared to the shame and GC (p = 0.01/p = 0.01 and p = 0.048/p = 0.038 respectively). Significant lower increase of leptin production occurred at 2 weeks (p = 0.01) and 3 months (p = 0.008) in CW vs. SG. In the MM group significant reduction of the serum ghrelin was seen after 3 h. Leptin was significantly increased in both MM and ID groups after 3 h, while it was significantly reduced in sham rats. The global device retention was 43.5%. Devices with lower profile and with a biocompatible coating remained more likely in place without complications. CONCLUSIONS: Gastric mechanical stimulation induced a reduced weight gain and hormonal changes. Low profile and coated devices inserted within the gastric wall are more likely to be integrated.

Anatomic Distribution of Colorectal Adenocarcinoma in Young Patients.

BACKGROUND: The incidence of colorectal cancer has increased in the younger population. Studies show an increased prevalence of left-sided tumors in younger patients; however, exact anatomic distribution is not known. OBJECTIVE: We sought to determine the anatomic distribution of colorectal cancer in young patients and to calculate the proportion of tumors that would be within reach of a flexible sigmoidoscopy. DESIGN: The National Cancer Database (2004-2015) was used to identify patients with colorectal cancer. SETTINGS: This was a multicenter study using national data. PATIENTS: The study included 117,686 patients under the age of 50 years diagnosed with colorectal cancer and 1,331,048 patients over the age of 50 years diagnosed with colorectal cancer. MAIN OUTCOME MEASURES: The primary outcome was the proportion of left-sided tumors in patients under the age of 50 years. RESULTS: A total of 74.4% of patients under age 50 years and 56.1% of patients over age 50 years had left-sided colorectal cancer. LIMITATIONS: The study is a retrospective review and does not exclude young patients who developed colorectal cancer with familial syndromes with a colorectal cancer disposition. CONCLUSIONS: A total of 74.4% of colorectal cancers diagnosed before age 50 years are left sided. In light of recent changes to screening recommendations, distribution of disease in young patients is important to both provider and patient education and decision-making. See Video Abstract at http://links.lww.com/DCR/A966.

Systemic chemotherapy and survival in patients with metastatic low-grade appendiceal mucinous adenocarcinoma.

BACKGROUND: Appendiceal cancer is a rare malignancy that exhibits a wide range of histology and treatment response. Given the rarity and heterogeneous nature of the disease, it has been difficult to define optimal treatment strategies. Our goal is to examine the association between use of systemic chemotherapy and survival in patients with metastatic low-grade mucinous appendiceal adenocarcinoma. METHODS: The National Cancer Database (2004-2015) was queried, and patients with mucinous, grade 1, stage IV appendiceal adenocarcinoma were identified. The Kaplan-Meier method was used to calculate survival, and a Cox regression model was used to identify predictors of survival. RESULTS: Six hundred and thirty-nine patients were identified. Five-year overall survival (OS) for patients undergoing no chemotherapy vs chemotherapy was 52.9% and 61.3%, respectively. After adjusting with Cox proportional hazards model, chemotherapy was not associated with OS (HR:1.1, 95% CI:0.82-1.40, P = 0.61). Patients who underwent surgical resection (HR:0.40, 95% CI:0.28-0.57, P < .001) or were female (HR:0.61, 95% CI:0.5-0.8, P < .001) had improved survival in adjusted analysis. CONCLUSIONS: There is no association between undergoing chemotherapy and OS in this cohort of patients with stage IV low-grade mucinous appendiceal adenocarcinoma. Development of national treatment guidelines is urgently needed for more consistency in the management of patients with appendiceal cancers.

Comparative Study of the Initial Experience in Performing Robotic and Laparoscopic Right Hepatectomy with Technical Description of the Robotic Technique.

BACKGROUND: Despite potential benefits of robotic liver surgery, it is still considered a "development in progress" technique. METHODS: The outcomes of 14 patients undergoing robotic right hepatectomy were analyzed and compared with the results of 20 laparoscopic right hepatectomies consecutively performed by the same young surgeon. RESULTS: The overall mean operative time was less in robotic arm (425 ± 139 vs. 565.18 ± 183.73, p = 0.022) and the estimated blood loss was similar (335.15 ± 139.8 vs. 423.95 ± 205.15, p = 0.17); no blood transfusion was required. Two patients in robotic group and 5 in laparoscopic group (p = 0.454) underwent conversion to open surgery; the overall morbidity was 21.4 and 15% in studied arms, respectively (p = 0.634). Pathology reports showed a mean surgical margin of 26.02 ± 3.9 in robotic arm, 28.76 ± 4.6 for laparoscopic, (p = 0.079) and we achieved a R0 resection rate of 91.66 and 85%, respectively. Reoperation and 90-days mortality rate were both null in robotic arm. One patient in laparoscopic group was reoperated due to postoperative hemorrhage. One-year overall and disease free-survival rate were 92.3 and 84.6%, respectively in robotic arm and 90 and 85% in laparoscopic arm. CONCLUSIONS: Robotic right hepatectomy is a safe and feasible technique providing promising short-term outcomes and oncological results also in the initial phase of learning curve.

Robotic pancreatic surgery: old concerns, new perspectives.

BACKGROUND: Described for the first time in 2003, the robotic pancreatic surgery shows interesting results. The evaluation of post-operative outcomes is necessary once we describe an innovative surgical approach. METHODS: We have performed a retrospective analysis of a prospectively maintained database on robotic pancreatic surgery including malignant and benign indications for surgery. RESULTS: A total of 50 consecutive patients underwent robotic pancreatic surgery (26 pancreatico duodenectomy and 24 distal pancreatectomy) between January 2012 and July 2015 in a single centre. The overall operative time was 425 (390-620) min. In a subgroup of highly selected malignant tumours, we were able to achieve 88% of R0 resection with robotic approach. A number of lymphnodes rose significantly with growing experience (p = .025). The overall major complication rate (15%), as well as pancreatic fistula rate (16%) were acceptable. The two-year overall survival for the whole group was 65%. CONCLUSION: The robotic pancreatic surgery in a highly selected group of patients seems safe and feasible. The cost-effectiveness and long-term oncologic outcomes need further investigations.

Contemporary Surgical Management and Outcomes for Anal Melanoma: A National Cancer Database Analysis.

BACKGROUND: Anal melanoma is a rare disease with a poor prognosis. Limited data are available regarding oncologic outcomes during the last decade and surgical practice patterns. This study aimed to investigate survival and operative oncologic outcomes for patients with anal melanoma. METHODS: The National Cancer Database (2004-2013) was used to identify patients with nonmetastatic anal melanoma who underwent surgical treatment. The primary outcome was overall survival. RESULTS: The study enrolled 439 patients in the local excision group and 214 patients in the abdominoperineal resection (APR) group. The patients in the APR group were older (70 vs 65 years; p < 0.001) and had larger tumors (40 vs 25 mm; p < 0.001). After resection, the APR patients were more likely to have positive lymph nodes (65.7% vs 12.5%; p < 0.001) and less likely to have positive margins (10% vs 29.8%; p < 0.001). Overall survival did not differ significantly between the APR and local excision patients (hazard ratio [HR], 0.82; 95% confidence interval [CI], 0.67-1.01; p = 0.06). The patients undergoing local excision showed was a significant survival advantage for those with negative margins (HR, 0.70, 95% CI, 0.53-0.93; p = 0.009). Among the patients undergoing APR, a significant survival advantage was observed for those with negative nodes (HR, 0.50; 95% CI, 0.35-0.69; p = 0.002) and negative margins (HR, 0.34; 95% CI, 0.15-0.77; p < 0.001). CONCLUSIONS: The overall survival of anal melanoma patients is similar after local excision and APR. Patients with positive margins, positive lymph nodes, or both have a significantly decreased overall survival.

From Illusion to Reality: A Brief History of Robotic Surgery.

PURPOSE: Robotic surgery is currently employed for many surgical procedures, yielding interesting results. METHODS: We performed an historical review of robots and robotic surgery evaluating some critical phases of its evolution, analyzing its impact on our life and the steps completed that gave the robotics its current popularity. RESULTS: The origins of robotics can be traced back to Greek mythology. Different aspects of robotics have been explored by some of the greatest inventors like Leonardo da Vinci, Pierre Jaquet-Droz, and Wolfgang Von-Kempelen. Advances in many fields of science made possible the development of advanced surgical robots. Over 3000 da Vinci robotic platforms are installed worldwide, and more than 200 000 robotic procedures are performed every year. CONCLUSION: Despite some potential adverse events, robotic technology seems safe and feasible. It is strictly linked to our life, leading surgeons to a new concept of surgery and training.

Robust augmented reality registration method for localization of solid organs' tumors using CT-derived virtual biomechanical model and fluorescent fiducials.

BACKGROUND: Augmented reality (AR) is the fusion of computer-generated and real-time images. AR can be used in surgery as a navigation tool, by creating a patient-specific virtual model through 3D software manipulation of DICOM imaging (e.g., CT scan). The virtual model can be superimposed to real-time images enabling transparency visualization of internal anatomy and accurate localization of tumors. However, the 3D model is rigid and does not take into account inner structures' deformations. We present a concept of automated AR registration, while the organs undergo deformation during surgical manipulation, based on finite element modeling (FEM) coupled with optical imaging of fluorescent surface fiducials. METHODS: Two 10 × 1 mm wires (pseudo-tumors) and six 10 × 0.9 mm fluorescent fiducials were placed in ex vivo porcine kidneys (n = 10). Biomechanical FEM-based models were generated from CT scan. Kidneys were deformed and the shape changes were identified by tracking the fiducials, using a near-infrared optical system. The changes were registered automatically with the virtual model, which was deformed accordingly. Accuracy of prediction of pseudo-tumors' location was evaluated with a CT scan in the deformed status (ground truth). In vivo: fluorescent fiducials were inserted under ultrasound guidance in the kidney of one pig, followed by a CT scan. The FEM-based virtual model was superimposed on laparoscopic images by automatic registration of the fiducials. RESULTS: Biomechanical models were successfully generated and accurately superimposed on optical images. The mean measured distance between the estimated tumor by biomechanical propagation and the scanned tumor (ground truth) was 0.84 ± 0.42 mm. All fiducials were successfully placed in in vivo kidney and well visualized in near-infrared mode enabling accurate automatic registration of the virtual model on the laparoscopic images. CONCLUSIONS: Our preliminary experiments showed the potential of a biomechanical model with fluorescent fiducials to propagate the deformation of solid organs' surface to their inner structures including tumors with good accuracy and automatized robust tracking.

Trends in Solid Tumor Incidence in Ukraine 30 Years After Chernobyl.

PURPOSE: There is limited knowledge of the long-term health effects of the Chernobyl nuclear power plant accident that occurred more than 30 years ago in Ukraine. This study describes trends in the incidence of solid organ malignancy in Ukraine and the five regions most affected by the radioactive fallout. METHODS: The National Cancer Registry of Ukraine was queried for age-standardized incidence rates (ASIRs) of solid organ malignancy in Ukraine and the regions of Kyiv, Chernihiv, Zhytomyr, Rivne, and Volyn covering the period of 1999 to 2016. Joinpoint analysis was used to calculate the average annual percentage of change. RESULTS: The highest burdens of cancer incidence in Ukraine were seen in the lung, stomach, breast, and prostate. We observed significant increases in the ASIRs of colon (average annual percentage of change, 1.5 [95% CI, 1.3 to 1.7]), rectal (0.9 [95% CI, 0.6 to 1.2]), kidney (2.3 [95% CI, 1.8 to 2.9]), thyroid (4.2 [95% CI, 3.1 to 5.3]), breast (1 [95% CI, 0.6 to 1.4]), cervical (0.7 [95% CI, 0.3 to 1.2]), and prostate (3.9 [95% CI, 3.6 to 4.2]) cancers, with decreases in stomach (-2.4 [95% CI, -2.5 to -2.3]) and lung (-1.8 [95% CI, -2.1 to -1.5]) cancers. ASIRs in the affected regions were similar to nationwide rates, with the exception of those for Kyiv. CONCLUSION: The incidence rates of many solid organ malignancies in Ukraine are rising. However, the rates of solid organ malignancy in the five regions most affected by fallout did not substantially differ from national patterns, with the exception of those for Kyiv. Ongoing monitoring of cancer incidence in Ukraine is necessary to understand how best to decrease disease burden nationwide and to elucidate the causes of regional variations in ASIRs, such as access to diagnostics and environmental exposures.

Colorectal Cancer in Ukraine: Regional Disparities and National Trends in Incidence, Management, and Mortality.

Purpose: The incidence of colorectal cancer (CRC) is increasing worldwide, and the greatest increase is in low- to middle-income countries, such as Ukraine. Better knowledge of epidemiology of CRC in Ukraine is needed to understand how best to decrease the burden of disease. Methods: The National Cancer Registry of Ukraine (NCRU) was queried for CRC incidence, mortality, stage, and treatment in Ukraine and assessed for regional variation from 1999 to 2015. Joinpoint analysis was used to analyze the trends. Results: The incidence of colon cancer increased from 10.6 to 13.3 occurrences per 100,000, which provided an average annual percent change (AAPC) of 1.48 (95% CI, 1.3 to 1.7; P < .05). The incidence of rectal and anal cancers also increased from 9.9 to 11.5 occurrences per 100,000, which provided an AAPC of 1.0 (95% CI, 0.8 to 1.3; P < .05). Mortality remained the same (AAPC, 0.1; 95% CI, -0.3 to 0.2; P = .4). The proportion of patients who received cancer-specific treatment increased from 54.6% to 68.5% for colon cancer and from 61% to 74.4% for rectal and anal cancers. Overall, 34.5% of patients with colon cancer and 27.5% of patients with rectal cancer died within a year of diagnosis in 2015. Great regional variations in 1-year mortality and treatment received were identified. Conclusion: The incidence of CRC in Ukraine is increasing. Despite stable mortality rates, many do not receive cancer-specific treatment, and a large proportion of patients die within a year of diagnosis. These findings illustrate the need to promote establishment of a screening program and to improve access to cancer-specific therapy in Ukraine.