Multimodal Approaches to Patient Selection for Pancreas Cancer Surgery

With an overall 5-year survival rate of 12%, pancreas ductal adenocarcinoma (PDAC) is an aggressive cancer that claims more than 50,000 patient lives each year in the United States alone. Even those few patients who undergo curative-intent resection with favorable pathology reports are likely to experience recurrence within the first two years after surgery and ultimately die from their cancer. We hypothesize that risk factors for these early recurrences can be identified with thorough preoperative staging, thus enabling proper patient selection for surgical resection and avoiding unnecessary harm. Herein, we review evidence supporting multidisciplinary and multimodality staging, comprehensive neoadjuvant treatment strategies, and optimal patient selection for curative-intent surgical resections. We further review data generated from our standardized approach at the Mayo Clinic and extrapolate to inform potential future investigations.

Early Cholecystectomy in Patients with Sickle Cell Disease with Uncomplicated Cholelithiasis Is Associated with Better Outcomes

BACKGROUND

Up to 85% of patients with sickle cell disease (SCD) will develop gallstones by their third decade. Cholecystectomy is the most commonly performed procedure in these patients. Cholecystectomy is recommended for patients with SCD with symptomatic cholelithiasis and leads to lower morbidity. No contemporary large studies have evaluated this recommendation or associated clinical outcomes. This study evaluates clinical outcomes after cholecystectomy in patients with SCD and cholelithiasis with specific advanced clinical presentations.

STUDY DESIGN

The Nationwide Inpatient Sample was queried for patients with SCD and gallbladder disease between 2006 and 2015. Patients were divided into groups based on their disease presentation, including uncomplicated cholelithiasis, acute and chronic cholecystitis, and gallstone pancreatitis. Clinical outcomes associated with disease presentation were analyzed. Statistical analysis was performed using the Student's t -test, chi-square test, ANOVA, and logistic regression.

RESULTS

There were 6,662 patients with SCD who presented with cholelithiasis. Median age was 20 (interquartile range 16 to 34) years and 54% were female patients. Cholecystectomy was performed in 1,779 patients with SCD with the most common indication being chronic cholecystitis (44%), followed by uncomplicated cholelithiasis (27%), acute cholecystitis (21%), and choledocholithiasis or gallstone pancreatitis (8%). On multivariable regression, advanced clinical presentation was the strongest predictor of perioperative vaso-occlusive crisis, which was the most common complication. Patients undergoing cholecystectomy for uncomplicated cholelithiasis were at lower risk than those with acute cholecystitis (odds ratio [OR] 2.37; 95% CI 1.64 to 3.41), chronic cholecystitis (OR 1.74; 95% CI 1.26 to 2.4), and choledocholithiasis or gallstone pancreatitis (OR 2.24; 95% CI 1.41 to 3.57).

CONCLUSIONS

Seventy-three percent of patients with SCD have advanced clinical presentation at the time of their cholecystectomy. After cholecystectomy, perioperative vaso-occlusive events were significantly increased in patients with advanced clinical presentation. These data support screening abdominal ultrasounds and early cholecystectomy for cholelithiasis in patients with SCD.

Gender Differences in Autonomy Granted to Residents and Fellows During Procedural Training: A Systematic Review and Meta-Analysis

PURPOSE

Supervisors may be prone to implicit (unintentional) bias when granting procedural autonomy to trainees due to the subjectivity of autonomy decisions. The authors aimed to conduct a systematic review and meta-analysis to assess the differences in perceptions of procedural autonomy granted to physician trainees based on gender and/or race.

METHOD

MEDLINE, Embase, CENTRAL, Scopus, and Web of Science were searched (search date: January 5, 2022) for studies reporting quantitative gender- or race-based differences in perceptions of procedural autonomy of physician trainees. Reviewers worked in duplicate for article selection and data abstraction. Primary measures of interest were self-reported and observer-rated procedural autonomy. Meta-analysis pooled differences in perceptions of procedural autonomy based on trainee gender.

RESULTS

The search returned 2,714 articles, of which 16 were eligible for inclusion. These reported data for 6,109 trainees (median 90 per study) and 2,763 supervisors (median 54 per study). No studies investigated differences in perceptions of autonomy based on race. In meta-analysis of disparities between genders in autonomy ratings (positive number favoring female trainees), pooled standardized mean differences were -0.12 (95% confidence interval [CI] = -0.19, -0.04; P = .003; n = 10 studies) for trainee self-rated autonomy and -0.05 (95% CI = -0.11, 0.01; P = .07; n = 9 studies) for supervisor ratings of autonomy.

CONCLUSIONS

Limited evidence suggests that female trainees perceived that they received less procedural autonomy than did males. Further research exploring the degree of gender- and race-based differences in procedural autonomy, and factors that influence these differences, is warranted.

Promoting breast health awareness: Can a sensor-enabled training system for patient education help?

INTRODUCTION

According to a 2009 study published in the Journal of Clinical Oncology, 79% of women (N = 222) diagnosed with breast cancer reported that they identified their cancers through breast self-exam (BSE). However, the U.S. Preventative Services Task Force does not require clinicians to teach women how to perform BSE.

METHODS

To address this grave challenge, our team at the Technology Enabled Clinical Improvement (TECI) Center has developed a mobile, sensor-enabled haptic training system to teach women proper BSE technique. To validate the efficacy of the training system, our team deployed a data collection at the 2019 Breast Cancer and African Americans (BCAA) event where survey, sensor, and anecdotal data were collected from 61 participants. The custom-built breast model used in this study had a single, hard mass embedded in it.

RESULTS

Participants at the BCAA event were able to successfully identify the mass 65% of the time and used an average force of 7.2 N. When looking at participants' confidence in their abilities to perform BSE, only 10% of respondents answered "very confident" pre-training whereas post-training, the reporting for "very confident" jumped to 66% (p < 0.01).

CONCLUSION

By comparison, our previous work revealed that practitioners who use less than 10 N of force are 70% more likely to miss a lesion. The integration of sensors into the BSE haptic training system allowed for objective, evidence-based assessment of hands-on skill. In addition to teaching women proper BSE technique, this training empowered women to be informed advocates in their breast health journey. Future community-based training/feedback sessions will allow for continuous advancement of the training system.

A review of the American College of Surgeons accredited education institutes' assessment practices for learners, faculty, and continuous program improvement

Purpose

Simulation is an instructional modality that offers opportunities for assessment across many domains. The American College of Surgeons created the Accredited Education Institutes (AEIs) to build a community of high-quality simulation centers focused around improving surgical education and training. The goals of this project were to identify assessment methods used by AEIs, discuss how these methods align with established assessment frameworks, identify best practices, and provide guidance on best practice implementation.

Methods

The authors analyzed responses regarding learner assessment, faculty assessment, and continuous program improvement from AEI accreditations surveys using deductive qualitative analysis.

Results

Data from ninety-six centers were reviewed. Codes for each category were organized into formal and informal themes. For learner assessment, examinations and checklists identified as the most common types of formal assessment used and oral feedback as the most common type of informal assessment. For faculty assessment, written evaluations were the most common formal type and debriefs were the most common informal type. For continuous program improvement, written evaluations were the most common formal type and oral feedback was the most frequent informal type.

Discussion

The goal of assessment should be to encourage learning through feedback and to ensure the attainment of educational competencies. The data revealed a variety of assessment modalities used to accomplish this goal with AEIs frequently utilizing some of the most reliable forms of assessment. We discuss how these forms of assessment can be integrated with best practices to develop assessment portfolios for learners and faculty, performance improvement reports for faculty, and assessments of clinical impact.

Supplementary Information

The online version contains supplementary material available at 10.1007/s44186-023-00132-6.

AI-Based Video Segmentation: Procedural Steps or Basic Maneuvers?

INTRODUCTION

Video-based review of surgical procedures has proven to be useful in training by enabling efficiency in the qualitative assessment of surgical skill and intraoperative decision-making. Current video segmentation protocols focus largely on procedural steps. Although some operations are more complex than others, many of the steps in any given procedure involve an intricate choreography of basic maneuvers such as suturing, knot tying, and cutting. The use of these maneuvers at certain procedural steps can convey information that aids in the assessment of the complexity of the procedure, surgical preference, and skill. Our study aims to develop and evaluate an algorithm to identify these maneuvers.

METHODS

A standard deep learning architecture was used to differentiate between suture throws, knot ties, and suture cutting on a data set comprised of videos from practicing clinicians (N = 52) who participated in a simulated enterotomy repair. Perception of the added value to traditional artificial intelligence segmentation was explored by qualitatively examining the utility of identifying maneuvers in a subset of steps for an open colon resection.

RESULTS

An accuracy of 84% was reached in differentiating maneuvers. The precision in detecting the basic maneuvers was 87.9%, 60%, and 90.9% for suture throws, knot ties, and suture cutting, respectively. The qualitative concept mapping confirmed realistic scenarios that could benefit from basic maneuver identification.

CONCLUSIONS

Basic maneuvers can indicate error management activity or safety measures and allow for the assessment of skill. Our deep learning algorithm identified basic maneuvers with reasonable accuracy. Such models can aid in artificial intelligence-assisted video review by providing additional information that can complement traditional video segmentation protocols.

Surgical Training for Civilian Surgeons Interested in Humanitarian Surgery: A Scoping Review

INTRODUCTION

Humanitarian surgery is essential to surgical care in limited resource settings. The difficulties associated with resource constraints necessitate special training for civilian surgeons to provide care in these situations. Specific training or curricula for humanitarian surgeons are not well described in the literature. This scoping review summarizes the existing literature and identifies areas for potential improvement.

METHODS

A review of articles describing established courses for civilian surgeons interested in humanitarian surgery, as well as those describing training of civilian surgeons in conflict zones, was performed. A total of 4808 abstracts were screened by two independent reviewers, and 257 abstracts were selected for full-text review. Articles describing prehospital care and military experience were excluded from the full-text review.

RESULTS

Of the eight relevant full texts, 10 established courses for civilian surgeons were identified. Cadaver-based teaching combined with didactics were the most common course themes. Courses provided technical education focused on the management of trauma and burns as well as emergencies in orthopedics, neurosurgery, obstetrics, and gynecology. Other courses were in specialty surgery, mainly orthopedics. Two fellowship programs were identified, and these provide a different model for training humanitarian surgeons.

CONCLUSIONS

Humanitarian surgery is often practiced in austere environments, and civilian surgeons must be adequately trained to first do no harm. Current programs include cadaver-based courses focused on enhancing trauma surgery and surgical subspecialty skills, with adjunctive didactics covering resource allocation in austere environments. Fellowships programs may serve as an avenue to provide a more standardized education and a reliable pipeline of global surgeons.

Performance assessment using sensor technology

Over the past 30 years, there have been numerous, noteworthy successes in the development, validation, and implementation of clinical skills assessments. Despite this progress, the medical profession has barely scratched the surface towards developing assessments that capture the true complexity of hands-on skills in procedural medicine. This paper highlights the development implementation and new discoveries in performance metrics when using sensor technology to assess cognitive and technical aspects of hands-on skills.

Bispectral analysis measures sedation and memory effects of propofol, midazolam, isoflurane, and alfentanil in healthy volunteers

BACKGROUND

The bispectral index (BIS), a value derived from the electroencephalograph (EEG), has been proposed as a measure of anesthetic effect. To establish its utility for this purpose, it is important to determine the relation among BIS, measured drug concentration, and increasing levels of sedation. This study was designed to evaluate this relation for four commonly used anesthetic drugs: propofol, midazolam, isoflurane, and alfentanil.

METHODS

Seventy-two consenting volunteers were studied at four institutions. Volunteers were given either isoflurane, propofol, midazolam, or alfentanil. Each volunteer was administered a dose-ranging sequence of one of the study drugs to achieve predetermined target concentrations. A frontal montage was used for continuous recording of the EEG. At each pseudo-steady-state drug concentration, a BIS score was recorded, the participant was shown either a picture or given a word to recall, an arterial blood sample was obtained for subsequent analysis of drug concentration, and the participant was evaluated for level of sedation as determined by the responsiveness portion of the observer's assessment of the alertness/ sedation scale (OAAS). An OAAS score of 2 or less was considered unconscious. The BIS (version 2.5) score was recorded in real-time and the BIS (version 3.0) was subsequently derived off-line from the recorded raw EEG data. The relation among BIS, measured drug concentration, responsiveness score, and presence or absence of recall was determined by linear and logistic regression for both the individual drugs and, when appropriate, for the pooled results. The prediction probability was also calculated.

RESULTS

The BIS score (r = 0.883) correlated significantly better than the measured propofol concentration (r = -0.778; P < 0.05) with the responsiveness score. The BIS provided as effective correlation with responsiveness score of the OAAS as did the measured concentration for midazolam and isoflurane. None of the volunteers given alfentanil lost consciousness and thus were excluded from the pooled analysis. The pooled BIS values at which 50% and 95% of participants were unconscious were 67 and 50, respectively. The prediction probability values for BIS ranged from 0.885-0.976, indicating a very high predictive performance for correctly indicating probability of loss of consciousness.

CONCLUSIONS

The BIS both correlated well with the level of responsiveness and provided an excellent prediction of the loss of consciousness. These results imply that BIS may be a valuable monitor of the level of sedation and loss of consciousness for propofol, midazolam, and isoflurane.