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المؤلفون: Philip H. Pucher, Maria S. Altieri, Angela Maria Rivera, Babak Namazi, Allison Navarrete-Welton, Daniel A. Hashimoto, Allan Okrainec, Ganesh Sankaranarayanan, L. Michael Brunt, Amin Madani, Adnan Alseidi
المصدر: Ann Surg
مصطلحات موضوعية: Surgeons, Visual perception, business.industry, Deep learning, MEDLINE, Gallbladder, Article, Semantics, 03 medical and health sciences, Dissection, 0302 clinical medicine, Surgical anatomy, Cholecystectomy, Laparoscopic, Artificial Intelligence, 030220 oncology & carcinogenesis, Medicine, Humans, 030211 gastroenterology & hepatology, Surgery, Segmentation, Artificial intelligence, business, F1 score, Laparoscopic cholecystectomy
الوصف: Objective To develop and evaluate the performance of artificial intelligence (AI) models that can identify safe and dangerous zones of dissection, and anatomical landmarks during laparoscopic cholecystectomy (LC). Summary background data Many adverse events during surgery occur due to errors in visual perception and judgment leading to misinterpretation of anatomy. Deep learning, a subfield of AI, can potentially be used to provide real-time guidance intraoperatively. Methods Deep learning models were developed and trained to identify safe (Go) and dangerous (No-Go) zones of dissection, liver, gallbladder, and hepatocystic triangle during LC. Annotations were performed by four high-volume surgeons. AI predictions were evaluated using 10-fold cross-validation against annotations by expert surgeons. Primary outcomes were intersection-over-union (IOU) and F1 score (validated spatial correlation indices), and secondary outcomes were pixel-wise accuracy, sensitivity, specificity, ± standard deviation. Results AI models were trained on 2627 random frames from 290 LC videos, procured from 37 countries, 136 institutions and 153 surgeons. Mean IOU, F1 score, accuracy, sensitivity, and specificity for the AI to identify Go zones were 0.53 (±0.24), 0.70 (±0.28), 0.94 (±0.05), 0.69 (±0.20) and 0.94 (±0.03) respectively. For No-Go zones, these metrics were 0.71 (±0.29), 0.83 (±0.31), 0.95 (±0.06), 0.80 (±0.21) and 0.98 (±0.05), respectively. Mean IOU for identification of the liver, gallbladder and hepatocystic triangle were: 0.86 (±0.12), 0.72 (±0.19) and 0.65 (±0.22), respectively. Conclusions AI can be used to identify anatomy within the surgical field. This technology may eventually be used to provide real-time guidance and minimize the risk of adverse events.
URL الوصول: https://explore.openaire.eu/search/publication?articleId=doi_dedup___::9c38de8afbfe2a23619f73999e682bdc
https://pubmed.ncbi.nlm.nih.gov/33196488 -
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المؤلفون: Alexander Bull, Philip H. Pucher, Jesper Lagergren, James A. Gossage
المصدر: Annals of Esophagus.
مصطلحات موضوعية: Gastroenterology, Surgery
URL الوصول: https://explore.openaire.eu/search/publication?articleId=doi_________::a275cf74a0e52762de811d1fd55d2d10
https://doi.org/10.21037/aoe-22-29 -
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المصدر: BJS Open. 6
مصطلحات موضوعية: Esophageal Neoplasms, Humans, Esophageal Squamous Cell Carcinoma, General Medicine
الوصف: Background The literature lacks robust evidence comparing definitive chemoradiotherapy (dCRT) with neoadjuvant chemoradiotherapy and surgery (nCRS) for oesophageal squamous cell carcinoma (ESCC). This study aimed to compare long-term survival of these approaches in patients with ESCC. Methods A systematic review performed according to PRISMA guidelines included studies identified from PubMed, Scopus, and Cochrane CENTRAL databases up to July 2021 comparing outcomes between dCRT and nCRS for ESCC. The main outcome measure was overall survival (OS), secondary outcome was disease-free survival (DFS). A meta-analysis was conducted using random-effects modelling to determine pooled adjusted multivariable hazard ratios (HRs). Results Ten studies including 14 092 patients were included, of which 30 per cent received nCRS. Three studies were randomized clinical trials (RCTs) and the remainder were retrospective cohort studies. dCRT and nCRS regimens were reported in six studies and surgical quality control was reported in two studies. Outcomes for OS and DFS were reported in eight and three studies respectively. Following meta-analysis, nCRS demonstrated significantly longer OS (HR 0.68, 95 per cent c.i. 0.54 to 0.87, P < 0.001) and DFS (HR 0.50, 95 per cent c.i. 0.36 to 0.70, P < 0.001) compared with dCRT. Conclusion Neoadjuvant chemoradiotherapy followed by oesophagectomy correlated with improved survival compared with definitive chemoradiation in the treatment of ESCC; however, there is a lack of literature on RCTs.
URL الوصول: https://explore.openaire.eu/search/publication?articleId=doi_dedup___::9162fda182ee06448f462a8f36899d04
https://doi.org/10.1093/bjsopen/zrac125 -
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المؤلفون: Alexander R. Darbyshire, Ina Kostakis, Philip H. Pucher, David Prytherch, Stuart J. Mercer
المصدر: World Journal of Surgery. 46:552-560
مصطلحات موضوعية: Surgery
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المؤلفون: Oliver J Pickering, Gijs I van Boxel, Nick C Carter, Stuart J Mercer, Benjamin C Knight, Philip H Pucher
المصدر: Diseases of the esophagus : official journal of the International Society for Diseases of the Esophagus.
مصطلحات موضوعية: Gastroenterology, General Medicine
الوصف: Summary Background: Robot-assisted minimally invasive esophagectomy (RAMIE) is gaining increasing popularity as an operative approach. Learning curves to achieve surgical competency in robotic-assisted techniques have shown significant variation in learning curve lengths and outcomes. This study aimed to summarize the current literature on learning curves for RAMIE. Methods: A systematic review was conducted in line with PRISMA guidelines. Electronic databases PubMed, MEDLINE, and Cochrane Library were searched, and articles reporting on learning curves in RAMIE were identified and scrutinized. Studies were eligible if they reported changes in operative outcomes over time, or learning curves, for surgeons newly adopting RAMIE. Results: Fifteen studies reporting on 1767 patients were included. Nine studies reported on surgeons with prior experience of robot-assisted surgery prior to adopting RAMIE, with only four studies outlining a specified RAMIE adoption pathway. Learning curves were most commonly analyzed using cumulative sum control chart (CUSUM) and were typically reported for lymph node yields and operative times, with significant variation in learning curve lengths (18–73 cases and 20–80 cases, respectively). Most studies reported adoption without significant impact on clinical outcomes such as anastomotic leak; significant learning curves were more likely in studies, which did not report a formal learning or adoption pathway. Conclusion: Reported RAMIE adoption phases are variable, with some authors suggesting significant impact to patients. With robust training through formal programmes or proctorship, however, others report RAMIE adoption without impact on clinical outcomes. A formalized adoption curriculum appears critical to prevent adverse effects on operative efficiency and patient care.
URL الوصول: https://explore.openaire.eu/search/publication?articleId=doi_dedup___::f4c76d53b96272282c73b692d38c7971
https://pubmed.ncbi.nlm.nih.gov/36572404 -
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المؤلفون: Michael A. Glaysher, Peter May-Miller, Nicholas C. Carter, Gijs van Boxel, Philip H. Pucher, Benjamin C. Knight, Stuart J. Mercer
المصدر: Surgical endoscopy.
مصطلحات موضوعية: Surgery
الوصف: Despite overwhelming evidence of the clinical and financial benefit of urgent cholecystectomy, there is variable enthusiasm and uptake across the UK. In 2014, following the First National Emergency Laparotomy Audit Organisational Report, we implemented a specialist-led urgent surgery service, whereby all patients with gallstone-related pathologies were admitted under the direct care of specialist upper gastrointestinal surgeons. We have analysed 5 years of data to investigate the results of this service model.Computerised operating theatre records were interrogated to identify all patients within a 5-year period undergoing cholecystectomy. Patient demographics, admission details, length of stay, duration of surgery, and complications were analysed.Between 01/01/2016 and 31/12/2020, a total of 4870 cholecystectomies were performed; 1793 (36.8%) were urgent cases and 3077 (63.2%) were elective cases. All cases were started laparoscopically; 25 (0.5%) were converted to open surgery-14 of 1793 (0.78%) urgent cases and 11 of 3077 (0.36%) elective cases. Urgent cholecystectomy took 20 min longer than elective surgery (median 74 versus 52 min). No relevant difference in conversion rate was observed when urgent cholecystectomy was performed within 2 days, between 2 and 4 days, or greater than 4 days from admission (P = 0.197). Median total hospital stay was 4 days.Urgent laparoscopic cholecystectomy is safe and feasible in most patients with acute gall bladder disease. Surgery under the direct care of upper gastrointestinal specialist surgeons is associated with a low conversion rate, low complication rate, and short hospital stay. Timing of surgery has no effect on conversion rate or complication rate.
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المؤلفون: Deirdre Nally, Walid Mohamed, Christina Fleming, Helen Mohan, Joshua Michael Clements, G. Humm, Philip H. Pucher, Adam Peckham-Cooper
المصدر: International Journal of Surgery. 84:207-211
مصطلحات موضوعية: Male, Consensus, Delphi Technique, Trainer, education, Delphi method, Staffing, 03 medical and health sciences, 0302 clinical medicine, Surveys and Questionnaires, Nominal group technique, Humans, Medicine, Qualitative Research, Surgeons, Service (business), Medical education, business.industry, General Medicine, Mental health, Education, Medical, Graduate, 030220 oncology & carcinogenesis, Workforce, Female, 030211 gastroenterology & hepatology, Surgery, Clinical Competence, business, Delivery of Health Care, Qualitative research
الوصف: Background Ensuring the highest quality of surgical training remains a challenge as demands on health service provision rise. This study aimed to explore the differences and potential conflicts between service provision and dedicated training activity provided by surgical trainees, and recommend solutions. Methods Participants were drawn from the Association of Surgeons in Training (ASiT) national council. Nominal Group Technique (NGT) was employed by members of the ASiT executive addressing 3 key domains (1) defining differences between training and service tasks, (2) impact of service-provision on training and (3) ways to improve training. A two-round Delphi process was conducted via electronic survey to ASiT council. Consensus was considered achieved for any statement where 80% or more of respondents indicated agreement. Results 47 statements were generated through NGT which were put to the Delphi process. Consensus was reached on a total of 24/47 statements. Educational or training tasks were identified as being activities which progressed a trainee's skill set, could be tailored to a trainee's own ability, and involved acting as a trainer to more junior colleagues. The negative impact of excess service provision included training quality, trainee mental health, and surgical trainee recruitment. Potential measures to improve training included increasing hospital staffing and resources, protected training times, trainee-specific or competency-based learning and training or incentivising trainers. Conclusion This trainee-based study provides several consensus recommendations on the characteristics that define surgical training and how a balance between service provision and training can potentially be achieved. Policy makers and health systems may be guided by these to ensure high quality training and a satisfied workforce.
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المؤلفون: Saqib Rahman, Fergus Noble, B Grace, Andrew Jackson, Timothy J. Underwood, Andrew Bateman, Philip H. Pucher, Jamie Kelly, Timothy Iveson, Charlotte Rees, Robert C. Walker, James P. Byrne
المصدر: European Journal of Surgical Oncology. 46:2248-2256
مصطلحات موضوعية: Male, Esophageal Neoplasms, medicine.medical_treatment, Leucovorin, Docetaxel, 030230 surgery, Postoperative Complications, 0302 clinical medicine, Antineoplastic Combined Chemotherapy Protocols, Hospital Mortality, Chemoradiotherapy, General Medicine, Middle Aged, Esophageal cancer, Neoadjuvant Therapy, Oxaliplatin, Survival Rate, Treatment Outcome, medicine.anatomical_structure, Oncology, 030220 oncology & carcinogenesis, Adenocarcinoma, Female, Esophageal Squamous Cell Carcinoma, Esophagogastric Junction, Fluorouracil, Radiology, medicine.medical_specialty, Anastomosis, Disease-Free Survival, 03 medical and health sciences, medicine, Humans, Esophagus, Propensity Score, Capecitabine, Aged, Epirubicin, Neoplasm Staging, business.industry, Cancer, Length of Stay, medicine.disease, Esophagectomy, Radiation therapy, Propensity score matching, Lymph Node Excision, Surgery, business
الوصف: Background: esophageal cancer is increasingly common and carries a poor prognosis. The optimal treatment modality for locally advanced cancer is unknown, with current guidance recommending either neoadjuvant chemotherapy (CT) or chemoradiotherapy (CRT) followed by surgery. There is a lack of adequately powered trials comparing CT against CRT. We retrospectively compared CT versus CRT using a propensity score weighting approach.Methods: demographic, disease, treatment and outcome data were retrieved from a local database for patients who received neoadjuvant CT or CRT followed by surgery. Inverse probability of treatment weighting (IPTW) was used to balance groups using a propensity score-weighting approach. Groups were assessed for differences in postoperative outcomes and survival. Kaplan-Meier and non-parametric tests were used to compare survival and outcome data as appropriate.Results: data for 284 patients were retrieved. Following IPTW groups were well matched. No significant differences were seen for postoperative complications (CT 64.9% vs. CRT 63.3%, p=0.807), including major complications (24.0% vs. 23.6%, p=0.943) and anastomotic leak (7.8% vs. 5.6%, p=0.526). Significantly higher rates of clinical regression and complete pathological response were seen following CRT (p=0.002 for both). Rates of R0 resection were higher with CRT, CT 79.1% vs. CRT 93.1%, p=0.006. There was no difference between groups for overall or disease-free survival.Conclusion: this study suggests that the significant improvements in local tumour response seen after neoadjuvant CRT compared to CT may not translate to different survival outcomes. However, it must be stressed that adequately powered prospective trials are sti
وصف الملف: text
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المصدر: Annals of surgery.
مصطلحات موضوعية: Surgery
الوصف: We utilised a population dataset to compare outcomes for patients where surgery was independently performed by trainees to cases led by a consultant.Emergency laparotomy is a common, high-risk, procedure. While trainee involvement to improve future surgeons' experience and ability in the management of such cases is crucial, some studies have suggested this is to the detriment of patient outcomes. In the UK, appropriately skilled trainees may be entrusted to perform emergency laparotomy without supervision of a consultant (attending).Patients who underwent emergency laparotomy between 2013 and 2018 were identified from the National Emergency Laparotomy Audit (NELA) of England and Wales. To reduce selection and confounding bias, the inverse probability of treatment weighting (IPTW) approach was used, allowing robust comparison of trainee-led and consultant-led laparotomy cases accounting for eighteen variables, including details of patient, treatment, pathology, and preoperative mortality risk. Groups were compared for mortality and length of stay.A total of 111,583 patients were included in the study. The operating surgeon was a consultant in 103,462 cases (92.7%) and a trainee in 8,121 cases (7.3%). Mortality at discharge was 11.6%. Trainees were less likely to operate on high-risk and colorectal cases. After weighting, mortality (12.2% vs 11.6%, p = 0.338) was equivalent between trainee- and consultant-led cases. Median length of stay was 11 (IQR 7,19) vs. 11 (7,20) days (p = 0.004), respectively. Trainee-led operations reported fewer cases of blood loss500 ml (9.1% vs 11.1%, p0.001).Major laparotomy maybe safely entrusted to appropriately skilled trainees without impacting patient outcomes.
URL الوصول: https://explore.openaire.eu/search/publication?articleId=doi_dedup___::eb28882b6e960ac3616874dcc5166c47
https://pubmed.ncbi.nlm.nih.gov/35595566 -
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المؤلفون: Alexander R, Darbyshire, Ina, Kostakis, Philip H, Pucher, David, Prytherch, Stuart J, Mercer
المصدر: World journal of surgery. 46(3)
مصطلحات موضوعية: Laparotomy, Humans, Laparoscopy, Risk Assessment, Severity of Illness Index, United Kingdom, Retrospective Studies
الوصف: Risk stratification has become a key part of the care processes for patients having emergency bowel surgery. This study aimed to determine if operative approach influences risk-model performance, and risk-adjusted mortality rates in the United Kingdom.A prospectively planned analysis was conducted using National Emergency Laparotomy Audit (NELA) data from December 2013 to November 2018. The risk-models investigated were P-POSSUM and the NELA Score, with model performance assessed in terms of discrimination and calibration. Risk-adjusted mortality was assessed using Standardised Mortality Ratios (SMR). Analysis was performed for the total cohort, and cases performed open, laparoscopically and converted to open. Sub-analysis was performed for cases with ≤ 20% predicted mortality.Data were available for 116 396 patients with P-POSSUM predicted mortality, and 46 935 patients with the NELA score. Both models displayed excellent discrimination with little variation between operative approaches (c-statistic: P-POSSUM 0.801-0.836; NELA Score 0.811-0.862). The NELA score was well calibrated across all deciles of risk, but P-POSSUM over-predicted risk beyond 20% mortality. Calibration plots for operative approach demonstrated that both models increasingly over-predicted mortality for laparoscopy, relative to open and converted to open surgery. SMRs calculated using both models consistently demonstrated that risk-adjusted mortality with laparoscopy was a third lower than open surgery.Risk-adjusted mortality for emergency bowel surgery is lower for laparoscopy than open surgery, with P-POSSUM and NELA score both over-predicting mortality for laparoscopy. Operative approach should be considered in the development of future risk-models that rely on operative data.
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