Validation and implementation of a mobile app decision support system for prostate cancer to improve quality of tumor boards

Certified Cancer Centers must present all patients in multidisciplinary tumor boards (MTB), including standard cases with well-established treatment strategies. Too many standard cases can absorb much of the available time, which can be unfavorable for the discussion of complex cases. In any case, this leads to a high quantity, but not necessarily a high quality of tumor boards. Our aim was to develop a partially algorithm-driven decision support system (DSS) for smart phones to provide evidence-based recommendations for first-line therapy of common urological cancers. To assure quality, we compared each single digital decision with recommendations of an experienced MTB and obtained the concordance.1873 prostate cancer patients presented in the MTB of the urological department of the University Hospital of Cologne from 2014 to 2018 have been evaluated. Patient characteristics included age, disease stage, Gleason Score, PSA and previous therapies. The questions addressed to MTB were again answered using DSS. All blinded pairs of answers were assessed for discrepancies by independent reviewers. Overall concordance rate was 99.1% (1856/1873). Stage specific concordance rates were 97.4% (stage I), 99.2% (stage II), 100% (stage III), and 99.2% (stage IV). Quality of concordance were independent of age and risk profile. The reliability of any DSS is the key feature before implementation in clinical routine. Although our system appears to provide this safety, we are now performing cross-validation with several clinics to further increase decision quality and avoid potential clinic bias.

[Management and treatment of liver injuries after blunt abdominal trauma]

The liver is involved in about 20% of cases of blunt abdominal trauma. The management of liver trauma has changed significantly in the past three decades towards conservative treatment. Up to 80% of all liver trauma patients can now be successfully treated by nonoperative management. Decisive for this is the adequate screening and assessment of the patient and the injury pattern as well as the provision of the appropriate infrastructure. Hemodynamically unstable patients require immediate exploratory surgery. In hemodynamically stable patients, a contrast-enhanced computed tomography (CT) should be performed. If active bleeding is detected angiographic imaging and embolization should be performed to stop the bleeding. Even after initially successful conservative management of liver trauma, subsequent complications can occur that make surgical inpatient treatment necessary.

Introduction of laparoscopic nephrectomy for autosomal dominant polycystic kidney disease as the standard procedure

PURPOSE

Autosomal dominant polycystic kidney disease (ADPKD) is a common hereditary disorder and accounts for 5-10% of all cases of kidney failure. 50% of ADPKD patients reach kidney failure by the age of 58 years requiring dialysis or transplantation. Nephrectomy is performed in up to 20% of patients due to compressive symptoms, renal-related complications or in preparation for kidney transplantation. However, due to the large kidney size in ADPKD, nephrectomy can come with a considerable burden. Here we evaluate our institution's experience of laparoscopic nephrectomy (LN) as an alternative to open nephrectomy (ON) for ADPKD patients.

MATERIALS AND METHODS

We report the results of the first 12 consecutive LN for ADPKD from August 2020 to August 2021 in our institution. These results were compared with the 12 most recent performed ON for ADPKD at the same institution (09/2017 to 07/2020). Intra- and postoperative parameters were collected and analyzed. Health related quality of life (HRQoL) was assessed using the SF36 questionnaire.

RESULTS

Age, sex, and median preoperative kidney volumes were not significantly different between the two analyzed groups. Intraoperative estimated blood loss was significantly less in the laparoscopic group (33 ml (0-200 ml)) in comparison to the open group (186 ml (0-800 ml)) and postoperative need for blood transfusion was significantly reduced in the laparoscopic group (p = 0.0462). Operative time was significantly longer if LN was performed (158 min (85-227 min)) compared to the open procedure (107 min (56-174 min)) (p = 0.0079). In both groups one postoperative complication Clavien Dindo ≥ 3 occurred with the need of revision surgery. SF36 HRQol questionnaire revealed excellent postoperative quality of life after LN.

CONCLUSION

LN in ADPKD patients is a safe and effective operative procedure independent of kidney size with excellent postoperative outcomes and benefits of minimally invasive surgery. Compared with the open procedure patients profit from significantly less need for transfusion with comparable postoperative complication rates. However significant longer operation times need to be taken in account.

Operating room time savings in Germany- and UK-based hospitals with 3D- VS. 2D-imaging technology in laparoscopic surgery: Meta analysis and budget impact model - Health economic evaluation

AIMS

Opportunity cost (OC) analysis is key when evaluating surgical techniques. Operating room (OR) time is one potential source of OC in laparoscopic surgery. This study quantifies differences in OR time between 3D- and 2D-imaging technology in laparoscopic surgery, translates these into OC and models the economic impact in real-world hospitals.

METHODS

First a systematically performed literature review and meta-analysis were conducted. Then, methods to translate OR time savings into OC were theorised and a budget impact model was created. After that, the potential time savings of real-world hospital case mixes were extrapolated. Finally, the opportunity costs of not using 3D-imaging in laparoscopic surgery were evaluated.

RESULTS

Average OR time saving per laparoscopic procedure was -19.4 min (-24.3; -14.5) (-14%) in favour of 3D. The Budget Impact Model demonstrated an economic impact of using 3D-laparoscopy instead of 2D laparoscopy, ranging from £183,045-£866,316 in the British and 73,049€-437,829€ in German hospitals, modelling a mixture of cost savings and performing additional procedures (earning additional revenue).

CONCLUSION

The OC analysis revealed significant economic benefits of introducing 3D-imaging technology in laparoscopic surgery, on the basis that average procedure time is reduced. Utilising the saved OR time to perform additional procedures was the biggest driver of OC. Hospital case mix and procedure volume indicated the magnitude of the OC.

Navigated laparoscopic microwave ablation of tumour mimics in pig livers: a randomized ex-vivo experimental trial

BACKGROUND

In order to efficiently perform laparoscopic microwave ablation of liver tumours precise positioning of the ablation probe is mandatory. This study evaluates the precision and ablation accuracy using the innovative laparoscopic stereotactic navigation system CAS-One-SPOT in comparison to 2d ultrasound guided laparoscopic ablation procedures.

METHODS

In a pig liver ablation model four surgeons, experienced (n = 2) and inexperienced (n = 2) in laparoscopic ablation procedures, were randomized for 2d ultrasound guided laparoscopic or stereotactic navigated laparoscopic ablation procedures. Each surgeon performed a total of 20 ablations. Total attempts of needle placements, time from tumor localization till beginning of ablation and ablation accuracy were analyzed.

RESULTS

The use of the laparoscopic stereotactic navigation system led to a significant reduction in total attempts of needle placement. The experienced group of surgeons reduced the mean number of attempts from 2.75 ± 2.291 in the 2d ultrasound guided ablation group to 1.45 ± 1.191 (p = 0.0302) attempts in the stereotactic navigation group. Comparable results could be observed in the inexperienced group with a reduction of 2.5 ± 1.50 to 1.15 ± 0.489 (p = 0.0005). This was accompanied by a significant time saving from 101.3 ± 112.1 s to 48.75 ± 27.76 s (p = 0.0491) in the experienced and 165.5 ± 98.9 s to 66.75 ± 21.96 s (p < 0.0001) in the inexperienced surgeon group. The accuracy of the ablation process was hereby not impaired as postinterventional sectioning of the ablation zone revealed.

CONCLUSION

The use of a stereotactic navigation system for laparoscopic microwave ablation procedures of liver tumors significantly reduces the attempts and time of predicted correct needle placement for novices and experienced surgeons without impairing the accuracy of the ablation procedure.

[Online Teaching in Surgery]

For quite some time, the development and implementation of online teaching has been a controversial issue in surgical education for the degree in medicine. This has become more important with the progression of digitalisation and not least as a result of the current pandemic. It is becoming increasingly urgent to establish the opportunities and limits of online teaching, which has already proved successful under the current developmental pressure, and there are promising concepts. This article addresses the framework and the various online teaching formats in surgery, and illustrates the interplay between technical feasibility, practical experience, and didactic objectives.

Microwave ablation enhances tumor-specific immune response in patients with hepatocellular carcinoma

Thermal ablative therapies are standard treatments for localized hepatocellular carcinoma (HCC). In addition to local tumor destruction, ablation leads to abscopal effects in distant lesions most likely mediated by an anti-tumor immune response. Although microwave ablation (MWA) is increasingly substituting other ablative techniques, its systemic immunostimulatory effects are poorly studied. We analyzed tumor-specific immune responses in peripheral blood of HCC patients after thermal ablation with regard to T cell responses and disease outcome. While comprehensive flow cytometric analyses in sequential samples of a prospective patient cohort (n = 23) demonstrated only moderate effects of MWA on circulating immune cell subsets, fluorospot analyses of specific T cell responses against seven tumor-associated antigens (TTAs) revealed de-novo or enhanced tumor-specific immune responses in 30% of patients. This anti-tumor immune response was related to tumor control as Interferon-y and Interleukin-5 T cell responses against TAAs were more frequent in patients with a long-time remission (> 1 year) after MWA (7/16) compared to patients suffering from an early relapse (0/13 patients) and presence of tumor-specific T cell response (IFN-y and/or IL-5) was associated to longer progression-free survival (27.5 vs. 10.0 months). Digital image analysis of immunohistochemically stained archival HCC samples (n = 18) of patients receiving combined MWA and resection revealed a superior disease-free survival of patients with high T cell abundance at the time of thermal ablation (37.4 vs. 13.1 months). Our data demonstrates remarkable immune-related effects of MWA in HCC patients and provides additional evidence for a combination of local ablation and immunotherapy in this challenging disease.

3D vs. 4K Display System - Influence of "State-of-the-art"-Display Technique On Surgical Performance (IDOSP-Study) in minimally invasive surgery: protocol for a randomized cross-over trial

Background

Three-dimensional (3D) stereoscopic vision is crucial to perform any kind of manual task. The reduction from real life 3D to virtual two-dimensional (2D) sight is a major challenge in minimally invasive surgery (MIS). A 3D display technique has been shown to reduce operation time and mistakes and to improve the learning curve. Therefore, the use of a3D display technique seems to optimize surgical performance for novice and experienced surgeons. Inspired by consumer electronics, a 4K display technique was recently introduced to MIS. Due to its high resolution and zoom effect, surgeons should benefit from it. The aim of this study is to evaluate if “state-of-the-art” 3D- vs. 4K-display techniques could influence surgical performance.

Methods

A randomized, cross-over, single-institution, single-blinded trial is designed. It compares the primary outcome parameter “surgical performance”, represented by “performance time ”and “number of mistakes”, using a passive polarizing 3D and a 4K display system (two arms) to perform different tasks in a minimally invasive/laparoscopic training parkour. Secondary outcome parameters are the mental stress load (National Aeronautics and Space Administration (NASA) Task Load Index) and the learning curve. Unexperienced novices (medical students), non-board-certified, and board-certified abdominal surgeons participate in the trial (i.e., level of experience, 3 strata). The parkour consists of seven tasks (for novices, five tasks), which will be repeated three times. The 1st run of the parkour will be performed with the randomized display system, the 2nd run with the other one. After each run, the mental stress load is measured. After completion of the parkour, all participants are evaluated by an ophthalmologist for visual acuity and stereoscopic vision with five tests. Assuming a correlation of 0.5 between measurements per subject, a sample size of 36 per stratum is required to detect a standardized effect of 0.5 (including an additional 5% for a non-parametric approach) with a power of 80% at a two-sided type I error of 5%. Thus, altogether 108 subjects need to be enrolled.

Discussion

Complex surgical procedures are performed in a minimally invasive/laparoscopic technique. This study should provide some evidence to decide which display technique a surgeon could choose to optimize his performance.

Trial registration

ClinicalTrials.gov, NCT03445429. Registered on 7 February 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3330-7) contains supplementary material, which is available to authorized users.

Serious Games in Surgical Medical Education: A Virtual Emergency Department as a Tool for Teaching Clinical Reasoning to Medical Students

Background

Serious games enable the simulation of daily working practices and constitute a potential tool for teaching both declarative and procedural knowledge. The availability of educational serious games offering a high-fidelity, three-dimensional environment in combination with profound medical background is limited, and most published studies have assessed student satisfaction rather than learning outcome as a function of game use.

Objective

This study aimed to test the effect of a serious game simulating an emergency department (“EMERGE”) on students’ declarative and procedural knowledge, as well as their satisfaction with the serious game.

Methods

This nonrandomized trial was performed at the Department of General, Visceral and Cancer Surgery at University Hospital Cologne, Germany. A total of 140 medical students in the clinical part of their training (5th to 12th semester) self-selected to participate in this experimental study. Declarative knowledge (measured with 20 multiple choice questions) and procedural knowledge (measured with written questions derived from an Objective Structured Clinical Examination station) were assessed before and after working with EMERGE. Students’ impression of the effectiveness and applicability of EMERGE were measured on a 6-point Likert scale.

Results

A pretest-posttest comparison yielded a significant increase in declarative knowledge. The percentage of correct answers to multiple choice questions increased from before (mean 60.4, SD 16.6) to after (mean 76.0, SD 11.6) playing EMERGE (P<.001). The effect on declarative knowledge was larger in students in lower semesters than in students in higher semesters (P<.001). Additionally, students’ overall impression of EMERGE was positive.

Conclusions

Students self-selecting to use a serious game in addition to formal teaching gain declarative and procedural knowledge.