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Rao E, Grady C, Wendler D. The Need for Institutional Policies for Innovative Therapy: Existing Approaches and Key Elements. Crit Care Med 2025; 53:e320-e327. [PMID: 39526839 DOI: 10.1097/ccm.0000000000006517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2024]
Abstract
OBJECTIVES Innovative therapy is common in many areas of medicine. Yet, it is unknown whether medical centers have policies to ensure innovative therapy is conducted appropriately. DESIGN We contacted three informants at leading U.S. medical centers to determine whether the center has a policy for innovative therapy and, if so, what requirements the policies include and whether the policies lack any important elements. SETTING Existing policies and published recommendations. PATIENTS None. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Our search found that 46 of 58 responding centers (79%) do not have a policy for innovative therapy. Of the ten policies available for review, half lack requirements to report patient outcomes, and half do not explicitly coordinate innovative therapy with research. CONCLUSIONS A majority of leading U.S. medical centers do not have a policy for innovative therapy. In addition, existing policies lack important elements, especially with respect to reporting patient outcomes and coordinating innovative therapy with research. Based on the existing policies and recommendations in the literature, we thus identify eight key elements that should be included in policies for innovative therapy. Future research should assess whether these elements can be feasibly implemented and whether, in practice, they offer patients appropriate protection.
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Affiliation(s)
- Emily Rao
- Department of Psychiatry, Keck School of Medicine, USC, Los Angeles, CA
| | | | - David Wendler
- Department of Bioethics, NIH Clinical Center, Bethesda, MD
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Pelizzo G, Destro F, Pierucci UM, Costanzo S, Camporesi A, Diotto V, Calcaterra V, Saxena AK. Minimal Access in Pediatric Surgery: An Overview on Progress towards Dedicated Instrument Developments and Anesthesiologic Advances to Enhance Safe Completion of Procedures. CHILDREN (BASEL, SWITZERLAND) 2024; 11:679. [PMID: 38929258 PMCID: PMC11201956 DOI: 10.3390/children11060679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Revised: 05/20/2024] [Accepted: 05/26/2024] [Indexed: 06/28/2024]
Abstract
Surgical techniques are evolving in Pediatric Surgery, especially in the area of minimal access surgery (MAS) where indications for applications are expanding. Miniaturization of instruments, using natural orifices, single incisions, or remotely controlled robot-assisted procedures, promises to increase the benefits of MAS procedures in pediatrics. Many pediatric pathologies are rare, and specialized surgical and anesthesiologic instruments are necessary to manage them, defined as "orphan devices", for which development and dissemination on the market are slowed down or sometimes hindered by regulatory standards and limiting financial conflicts of interest. In pediatric surgery, it is of utmost importance to work in a multidisciplinary way to offer a surgical path that is safe and supported by technological advances. For this reason, optimizing pediatric anesthesia is also a crucial factor where technological advances have made monitoring more precise, thereby enhancing safety in the operative room. The development of customized instruments and technologies should be supported by pediatric research and should be adapted to the individualities of the small patient. This overview outlines the importance of dedicated instruments developed for the safe completion of MAS procedures in pediatrics.
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Affiliation(s)
- Gloria Pelizzo
- Department of Biomedical and Clinical Science, University of Milan, 20157 Milan, Italy;
- Department of Pediatric Surgery, “V. Buzzi” Children’s Hospital, 20154 Milan, Italy; (U.M.P.); (S.C.)
| | - Francesca Destro
- Department of Pediatric Surgery, “V. Buzzi” Children’s Hospital, 20154 Milan, Italy; (U.M.P.); (S.C.)
| | - Ugo Maria Pierucci
- Department of Pediatric Surgery, “V. Buzzi” Children’s Hospital, 20154 Milan, Italy; (U.M.P.); (S.C.)
| | - Sara Costanzo
- Department of Pediatric Surgery, “V. Buzzi” Children’s Hospital, 20154 Milan, Italy; (U.M.P.); (S.C.)
| | - Anna Camporesi
- Pediatric Anesthesiology and Intensive Care Unit, Department of Pediatric Surgery, “V. Buzzi” Children’s Hospital, 20154 Milan, Italy; (A.C.); (V.D.)
| | - Veronica Diotto
- Pediatric Anesthesiology and Intensive Care Unit, Department of Pediatric Surgery, “V. Buzzi” Children’s Hospital, 20154 Milan, Italy; (A.C.); (V.D.)
| | - Valeria Calcaterra
- Department of Pediatrics, “V. Buzzi” Children’s Hospital, 20154 Milan, Italy;
| | - Amulya K. Saxena
- Department of Pediatric Surgery, Chelsea Children’s Hospital, Chelsea and Westminster Hospital NHS Fdn Trust, Imperial College London, London SW10 9NH, UK;
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Hendriks S, Althaus J, Atkinson MA, Baschat AA, Berkman BE, Grady C, Wasserman D, Wendler D, Miller JL. Precarious hope: Ethical considerations for offering experimental fetal therapies outside of research after initial studies in humans. Prenat Diagn 2024; 44:180-186. [PMID: 38069681 PMCID: PMC10932810 DOI: 10.1002/pd.6474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 10/24/2023] [Accepted: 11/20/2023] [Indexed: 01/06/2024]
Abstract
OBJECTIVE Risks and benefits of experimental fetal therapies can remain uncertain after initial clinical studies, especially long-term effects. Nevertheless, pregnant individuals may request them, hoping to benefit their future child. Guidance about offering experimental fetal therapies outside research (as "innovative therapy") is limited, despite their ethical complexity. We propose points for clinicians and reviewers to consider when deciding whether and how to offer experimental fetal therapies as innovative therapies after initial clinical studies. METHOD We used conceptual analysis and a current case to develop points for consideration, grounded in broader debates on innovative therapy and the unique challenges associated with experimental fetal therapies. RESULTS Clinicians should evaluate whether offering experimental fetal therapies as innovative therapy is appropriate for a pregnant individual and their fetus. The anticipated risk-benefit ratio for the fetus should be favorable. For the pregnant individual, risks may outweigh benefits, within reasonable limits. Medical resources should be sufficient to ensure appropriate care. Clinicians should support pregnant individuals in making informed choices. Clinicians offering innovative therapies with more than minimal risk should collect and report data on outcomes. Independent review should take place. CONCLUSION Considering these points may advance the interests of fetuses, future children, and their families.
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Affiliation(s)
| | - Janyne Althaus
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland, Baltimore, MD
| | - Meredith A. Atkinson
- Department of Pediatrics, Division of Nephrology, Johns Hopkins University, Baltimore, MD
| | - Ahmet A. Baschat
- Center for Fetal Therapy, Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, MD
| | - Benjamin E. Berkman
- Department of Bioethics, NIH Clinical Center, Bethesda, MD
- National Human Genome Research Institute, Bethesda, MD
| | | | | | - David Wendler
- Department of Bioethics, NIH Clinical Center, Bethesda, MD
| | - Jena L Miller
- Center for Fetal Therapy, Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, MD
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4
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Wendler D, Anjum S, Williamson P. Innovative treatment as a precursor to clinical research. J Clin Invest 2021; 131:152573. [PMID: 34338225 PMCID: PMC8321566 DOI: 10.1172/jci152573] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
- David Wendler
- Department of Bioethics, NIH Clinical Center, Bethesda, Maryland, USA
| | - Seher Anjum
- Laboratory of Clinical Immunology & Microbiology, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland, USA
| | - Peter Williamson
- Laboratory of Clinical Immunology & Microbiology, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland, USA
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Xun H, Clarke S, Baker N, Shallal C, Lee E, Fadavi D, Wong A, Brandacher G, Kang SH, Sacks JM. Method, Material, and Machine: A Review for the Surgeon Using Three-Dimensional Printing for Accelerated Device Production. J Am Coll Surg 2021; 232:726-737.e19. [PMID: 33896478 DOI: 10.1016/j.jamcollsurg.2021.01.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 12/23/2020] [Accepted: 01/13/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Physicians are at the forefront of identifying innovative targets to address current medical needs. 3D printing technology has emerged as a state-of-the-art method of prototyping medical devices or producing patient-specific models that is more cost-efficient, with faster turnaround time, in comparison to traditional prototype manufacturing. However, initiating 3D printing projects can be daunting due to the engineering learning curve, including the number of methodologies, variables, and techniques for printing from which to choose. To help address these challenges, we sought to create a guide for physicians interested in venturing into 3D printing. STUDY DESIGN All commercially available, plug-and-play, material and stereolithography printers costing less than $15,000 were identified via web search. Companies were contacted to obtain quotes and information sheets for all printer models. The qualifying printers' manufacturer specification sheets were reviewed, and pertinent variables were extracted. RESULTS We reviewed 309 commercially available printers and materials and identified 118 printers appropriate for clinicians desiring plug-and-play models for accelerated device production. We synthesized this information into a decision-making tool to choose the appropriate parameters based on project goals. CONCLUSIONS There is a growing clinical need for medical devices to reduce costs of care and increase access to personalized treatments; however, the learning curve may be daunting for surgeons. In this review paper, we introduce the "3Ms of 3D printing" for medical professionals and provide tools and data sheets for selection of commercially available, affordable, plug-and-play 3D printers appropriate for surgeons interested in innovation.
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Affiliation(s)
- Helen Xun
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, MD
| | - Scott Clarke
- Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Nusaiba Baker
- Medical Scientist Training Program, Emory University School of Medicine, Atlanta, GA
| | - Christopher Shallal
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD
| | - Erica Lee
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, MD
| | - Darya Fadavi
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, MD
| | - Alison Wong
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, MD
| | - Gerald Brandacher
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, MD
| | - Sung Hoon Kang
- Department of Mechanical Engineering and Institute for NanoBioTechnology, Johns Hopkins University, Baltimore, MD
| | - Justin M Sacks
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, MD; Division of Plastic and Reconstructive Surgery, Washington University in St Louis School of Medicine, St Louis, MO.
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Romero RM. Management of Primary Obstructive Megaureter by Endoscopic High-Pressure Balloon Dilatation. IDEAL Framework Model as a New Tool for Systematic Review. Front Surg 2019; 6:20. [PMID: 31058164 PMCID: PMC6478015 DOI: 10.3389/fsurg.2019.00020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 03/21/2019] [Indexed: 11/13/2022] Open
Abstract
Introduction: Therapeutic management of primary obstructive megaureter (POM) requiring surgery has been under debate for the last 15 years especially regarding the outcomes of endoscopic techniques compared to most traditional approaches. This review aims to analyze endoscopic High-Pressure Balloon Dilatation (HPBD) using the IDEAL model, a five-stage framework that describes surgical innovations (Idea, Development, Exploration, Assessment, and Long-term Study) and provides recommendations for a rigorous stepwise surgical research pathway. This model has been developed and demonstrated its value in evaluating surgical innovations assessing data quality and providing relevant information for the optimal design and feasibility of research in surgery. Materials and Methods: A systematic review of the published series of endoscopic HPBD in patients with POM was done using the IDEAL model as a tool to assess evidence quality. Reported clinical outcomes are also analyzed and reviewed. Results: The analysis of the results of the systematic assessment of the reported cohort of patients treated with HPBD for POM that the technique up to date is in stage 2a and stage 2b, or development. Evidence quality among the reported cohorts of patients with POM treated with HPBD is adequate, although systematization and standardization should be improved. Clinical outcomes of HPBD in the management of POM consistently show a 87.7% success rate with a negligible operative complication rate once "learning curve" has been surpassed. Symptomatic vesicoureteral reflux (VUR) is the main reason for ureteric reimplantation, but asymptomatic VUR does not seem to influence clinical outcome. Conclusions: The IDEAL framework and recommendations have allowed a systematic analysis of the evidence quality of the reported experience in the management of children with POM with HPBD of the vesicoureteral junction. The available evidence demonstrates that HPBD is an effective treatment for patients with POM, with a long-term success rate of 87.7% with very low morbidity. Future research mandates a standardization of data reporting, "ideally" following IDEAL recommendations, that would be required for any intervention and facilitate comparative analysis.
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Affiliation(s)
- Rosa M Romero
- Pediatric Urology Unit, Hospital Universitario Virgen del Rocío, Seville, Spain
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Defining Innovation in Neurosurgery: Results from an International Survey. World Neurosurg 2018; 114:e1038-e1048. [PMID: 29604357 DOI: 10.1016/j.wneu.2018.03.142] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Revised: 03/20/2018] [Accepted: 03/20/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND Innovation is a part of the daily practice of neurosurgery. However, a clear definition of what constitutes innovation is lacking and opinions vary from continent to continent, from hospital to hospital, and from surgeon to surgeon. METHODS In this study, we distributed an online survey to neurosurgeons from multiple countries to investigate what neurosurgeons consider innovative, by gathering opinions on several hypothetical cases. The anonymous survey consisted of 52 questions and took approximately 10 minutes to complete. RESULTS A total of 355 neurosurgeons across all continents excluding Antarctica completed the survey. Neurosurgeons achieved consensus (>75%) in considering specific cases to be innovative, including laser resection of meningioma, focused ultrasonography for tumor, oncolytic virus, deep brain stimulation for addiction, and photodynamic therapy for tumor. Although the new dura substitute case was not considered innovative, there was consensus among neurosurgeons indicating that institutional review board approval was still necessary to maintain ethical standards. Furthermore, although 90% of neurosurgeons considered an oncolytic virus for glioblastoma multiforme to be innovative, only 78% believed that institutional review board approval was necessary before treatment. CONCLUSIONS Our results indicate that innovation is a heterogeneous concept among neurosurgeons that necessitates standardization to ensure appropriate patient safety without stifling progress. We discuss both the ethical drawbacks of not having a clear definition of innovation and the challenges in achieving a unified understanding of innovation in neurosurgery and offer suggestions for uniting the field.
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Bruny J, Ziegler M. Surgical innovation-enhanced quality and the processes that assure patient/provider safety: A surgical conundrum. Semin Pediatr Surg 2015; 24:323-6. [PMID: 26653169 DOI: 10.1053/j.sempedsurg.2015.08.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Innovation is a crucial part of surgical history that has led to enhancements in the quality of surgical care. This comprises both changes which are incremental and those which are frankly disruptive in nature. There are situations where innovation is absolutely required in order to achieve quality improvement or process improvement. Alternatively, there are innovations that do not necessarily arise from some need, but simply are a new idea that might be better. All change must assure a significant commitment to patient safety and beneficence. Innovation would ideally enhance patient care quality and disease outcomes, as well stimulate and facilitate further innovation. The tensions between innovative advancement and patient safety, risk and reward, and demonstrated effectiveness versus speculative added value have created a contemporary "surgical conundrum" that must be resolved by a delicate balance assuring optimal patient/provider outcomes. This article will explore this delicate balance and the rules that govern it. Recommendations are made to facilitate surgical innovation through clinical research. In addition, we propose options that investigators and institutions may use to address competing priorities.
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Affiliation(s)
- Jennifer Bruny
- Department of Surgery, Children׳s Hospital Colorado, University of Colorado School of Medicine, 13123 E 16th Ave, Aurora, Colorado 80045.
| | - Moritz Ziegler
- Department of Surgery, Children׳s Hospital Colorado, University of Colorado School of Medicine, 13123 E 16th Ave, Aurora, Colorado 80045
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Fundoplication and gastrostomy versus percutaneous gastrojejunostomy for gastroesophageal reflux in children with neurologic impairment: A systematic review and meta-analysis. J Pediatr Surg 2015; 50:707-14. [PMID: 25783384 DOI: 10.1016/j.jpedsurg.2015.02.020] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2015] [Accepted: 02/13/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Children with neurologic impairment often fail medical management of gastroesophageal reflux and proceed to fundoplication and gastrostomy (FG) or percutaneous gastrojejunostomy (GJ). Current guidelines do not recommend one treatment over the other, and there is ongoing uncertainty regarding clinical management. METHODS We conducted a structured search of Medline, Embase, trial registries, and the gray literature. We included studies that compared outcomes for FG and GJ in children with neurologic impairment. RESULTS We identified 556 children from three retrospective studies who underwent FG (n=431) or GJ (n=125). There were no differences in rates of pneumonia (17% vs 19%, p=0.74) or mortality (13% vs 14%, p=0.76). Few deaths were due to procedural complications (1%) or reflux (2%). There was a trend towards more major complications with FG (29%) compared to GJ (12%) (risk ratio=1.70, 0.85-3.41, p=0.14). Minor complications were more common with GJ (70%) than FG (45%), but this difference was also not statistically significant (risk ratio=0.38, 0.05-3.07, p=0.36). No studies reported quality of life using validated measures. CONCLUSIONS The quality of the evidence for outcomes of FG versus GJ is very low. Large comparative studies are needed to determine which approach is associated with the best quality-of-life outcomes.
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Outcomes of pediatric laparoscopic fundoplication: a critical review of the literature. Can J Gastroenterol Hepatol 2014; 28:97-102. [PMID: 24288692 PMCID: PMC4071886 DOI: 10.1155/2014/738203] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND/OBJECTIVE Laparoscopic fundoplication for gastroesophageal reflux disease (GERD) is one of the most common procedures performed in children. A critical literature review was performed to evaluate the level and quality of evidence supporting the efficacy of this procedure. METHODS Systematic reviews of the EMBASE, PubMed and CENTRAL databases were conducted to retrieve all articles published over a 15-year period (1996 to 2010) reporting medium- to long-term outcomes (minimum six months follow-up) of laparoscopic fundoplication for the treatment of pediatric GERD. Articles were critically appraised using the Newcastle-Ottawa quality assessment scale and the Cochrane risk of bias assessment tool. Extracted outcomes included GERD recurrence, need for reoperation, postoperative morbidity and mortality. RESULTS A total of 5302 articles were retrieved. Thirty-six studies met inclusion and exclusion criteria, including five prospective (level 2b), four retrospective comparative (level 3b) and 27 case series (level 4). No studies compared laparoscopic fundoplication with medical treatment. Thirty-six per cent of studies did not describe the symptoms used to suspect GERD; 11% did not disclose the diagnostic modalities used; and 41% did not report the findings of diagnostic modalities. Only 17% of studies provided a definition of recurrence, and only 14% attempted to control for confounding variables. The follow-up intervals were inconsistently reported, ranging between two months and nine years. Significant heterogeneity among studies limited the ability to pool outcomes. Mean (± SD) recurrence rates varied between 0% and 48±19.6% of patients. Reoperation was required in 0.69±0.95% to 17.7±8.4% of patients. Mortality ranged between 0% and 24±16.7%. CONCLUSION The level and quality of the evidence supporting laparoscopic fundoplication are extremely poor. Higher-quality data are required before the procedure can be considered to be an effective intervention in the treatment of pediatric GERD.
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The first decade of robotic surgery in children. J Pediatr Surg 2013; 48:858-65. [PMID: 23583146 DOI: 10.1016/j.jpedsurg.2013.01.031] [Citation(s) in RCA: 106] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2012] [Revised: 01/03/2013] [Accepted: 01/20/2013] [Indexed: 12/20/2022]
Abstract
BACKGROUND Robotic surgery offers technological solutions to current challenges of minimal access surgery, particularly for delicate and dexterous procedures within spatially constrained operative workspaces in children. The first robotic surgical procedure in a child was reported in April 2001. This review aims to examine the literature for global case volumes, trends, and quality of evidence for the first decade of robotic surgery in children. METHODS A systematic literature search was performed for all reported cases of robotic surgery in children during the period of April 2001 to March 2012. RESULTS Following identification of 220 relevant articles, 137 articles were included, reporting 2393 procedures in 1840 patients. The most prevalent gastrointestinal, genitourinary, and thoracic procedures were fundoplication, pyeloplasty, and lobectomy, respectively. There was a progressive trend of increasing number of publications and case volumes over time. The net overall reported conversion rate was 2.5%. The rate of reported robot malfunctions or failures was 0.5%. CONCLUSIONS Robotic surgery is an expanding and diffusing innovation in pediatric surgery. Future evolution and evaluation should occur simultaneously, such that wider clinical uptake may be led by higher quality and level of evidence literature.
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Biffl WL, Spain DA, Reitsma AM, Minter RM, Upperman J, Wilson M, Adams R, Goldman EB, Angelos P, Krummel T, Greenfield LJ. Responsible development and application of surgical innovations: a position statement of the Society of University Surgeons. J Am Coll Surg 2008; 206:1204-9. [PMID: 18501819 DOI: 10.1016/j.jamcollsurg.2008.02.011] [Citation(s) in RCA: 114] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2008] [Accepted: 02/08/2008] [Indexed: 10/22/2022]
Affiliation(s)
- Walter L Biffl
- Department of Surgery, Denver Health Medical Center/University of Colorado-Denver, Denver, CO, USA
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Abstract
Ethical issues in pediatric research have long been debated, and experimentation in pediatric surgery is under intense scrutiny. Extensive legislation and institutional systems that attempt to protect children while supporting necessary research are at times ineffective. Pediatric surgery has less funding and resources for innovation than fields with higher clinical volume. Not unlike pediatrics in general, innovation in pediatric surgery must be beyond criticism. And yet, for the sake of patients, innovation should not only be maintained, but must be encouraged.
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Affiliation(s)
- Daniel J Riskin
- Biodesign Surgical Innovation Program, Department of Surgery, Stanford University School of Medicine, Stanford, Califonia 94305-5148, USA
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Cuttler L, Whittaker JL, Kodish ED. The overweight adolescent: clinical and ethical issues in intensive treatments for pediatric obesity. J Pediatr 2005; 146:559-64. [PMID: 15812467 DOI: 10.1016/j.jpeds.2004.12.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Leona Cuttler
- Division of Pediatric Endocrinology and Metabolism, Rainbow Babies and Children's Hospital, 11100 Euclid Avenue, Cleveland, OH 44106, USA
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Reitsma AM, Moreno JD. Ethics of innovative surgery: US surgeons’ definitions, knowledge, and attitudes. J Am Coll Surg 2005; 200:103-10. [PMID: 15631926 DOI: 10.1016/j.jamcollsurg.2004.09.032] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2004] [Revised: 09/16/2004] [Accepted: 09/16/2004] [Indexed: 11/16/2022]
Abstract
BACKGROUND Innovative surgery is not clearly defined, nor is it formally regulated by governing bodies as is the development of drugs and medical devices. This unclear status and the subsequent questionable applicability of existing federal guidelines for human subject research pose an ethical concern. To clarify its position, we solicited US surgeons' definitions of, opinions toward, and attitudes about innovative surgery. Surgeons were also invited to self-report knowledge about current federal regulations guiding human subject research and rules for informed consent for and IRB review of clinical research. STUDY DESIGN A group of US surgeons received a 46-item questionnaire addressing the definition of innovative surgery versus those for research and practice, regulations for human subject research, need for specific informed consent, and IRB review of surgical innovations. RESULTS A total of 665 responses were used in the content analysis. Respondents expressed a fairly prudent stance when judging hypothetical innovative scenarios. Hallmarks for experimentation and clinical research as modes of innovation were defined more clearly for the surgical situation. CONCLUSIONS Defining criteria exist that prompt added scrutiny and previous review of surgical innovations. Some forms of innovation clearly fall under the current regulations for human subject research; others might not fully meet the definition but could still require some additional oversight.
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Affiliation(s)
- Angelique M Reitsma
- Center for Biomedical Ethics, University of Virginia, PO Box 800758, Charlottesville, VA 22908-0758, USA
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Bernstein M, Bampoe J. Surgical innovation or surgical evolution: an ethical and practical guide to handling novel neurosurgical procedures. J Neurosurg 2004; 100:2-7. [PMID: 14743905 DOI: 10.3171/jns.2004.100.1.0002] [Citation(s) in RCA: 92] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Object. Surgical innovation is an important driver of improvements in technique and technology, which ultimately translates into improvements in patients' outcomes. Nevertheless, patients may face new risks of morbidity and mortality when surgical innovation is used, and well-intentioned surgical “experimentation” on patients must be regulated and monitored. In this paper the authors examine the challenges of defining surgical innovation and briefly review the literature on this challenging subject.
Methods. Using examples from the field of neurosurgery and in part from the personal experience of the senior author, the authors develop a model of levels of experimental acuity of surgical procedures and offer recommendations on how these procedures would best be regulated.
Conclusions. The authors propose guidelines for determining the need for regulation of innovation. The potential role of institutional review boards in this process is highlighted.
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Affiliation(s)
- Mark Bernstein
- Division of Neurosurgery, Toronto Western Hospital, Ontario, Canada.
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Brower V. The ethics of innovation. Should innovative surgery be exempt from clinical trials and regulations? EMBO Rep 2003; 4:338-40. [PMID: 12671674 PMCID: PMC1319170 DOI: 10.1038/sj.embor.embor815] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Should innovative surgery be exempt from clinical trials and regulations?
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Evans WJ, Britt DW. The genomic revolution and the obstetrician/gynaecologist: from societal trends to patient sessions. Best Pract Res Clin Obstet Gynaecol 2002; 16:729-44. [PMID: 12475551 DOI: 10.1053/beog.2002.0312] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
A major aspect of reaping the benefits of the genome revolution in women's health relates to questions of how we are going to handle this scientific manna of information and potential treatment options while minimizing social exclusion along the lines of race, class and gender. Four society-level scenarios or patterns of diffusion of genomic access are discussed, each with its own set of assumptions and outcomes in terms of equity. Like it or not, the front-line obstetrician/gynaecologist will play a critical role in whether such new information helps either to reduce or to exacerbate discrepancies in health-care status along the lines of race and socio-economic status. Patients must not be denied access to knowledge and information within the genetic counselling session, or to the opportunity to make an informed autonomous decision because of the use of unfamiliar language and conventions of conversation that support power differentials and discourage rapport and empathy. Aspects of communication that are critical to the outcome of the genetic counselling session, such as the level of directness of counselling, physician interruptions of the patient and the power implications of the rhetorical question, are explored. In addition, the special challenges to counsellor neutrality and patient autonomy offered by the longitudinal primary obstetrician/gynaecologist relationship are discussed. Strategies encouraging more effective collaboration and communication between generalist and patient in the counselling session are offered.
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Affiliation(s)
- Wendy J Evans
- Department of Obstetrics and Gynecology, MCP Hahnemann University, 245 North 15th Street, Mail Stop 495, Philadelphia, PA 19102, USA
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