Applications of natural language processing tools in the surgical journey.

Background: Natural language processing tools are becoming increasingly adopted in multiple industries worldwide. They have shown promising results however their use in the field of surgery is under-recognised. Many trials have assessed these benefits in small settings with promising results before large scale adoption can be considered in surgery. This study aims to review the current research and insights into the potential for implementation of natural language processing tools into surgery. Methods: A narrative review was conducted following a computer-assisted literature search on Medline, EMBASE and Google Scholar databases. Papers related to natural language processing tools and consideration into their use for surgery were considered. Results: Current applications of natural language processing tools within surgery are limited. From the literature, there is evidence of potential improvement in surgical capability and service delivery, such as through the use of these technologies to streamline processes including surgical triaging, data collection and auditing, surgical communication and documentation. Additionally, there is potential to extend these capabilities to surgical academia to improve processes in surgical research and allow innovation in the development of educational resources. Despite these outcomes, the evidence to support these findings are challenged by small sample sizes with limited applicability to broader settings. Conclusion: With the increasing adoption of natural language processing technology, such as in popular forms like ChatGPT, there has been increasing research in the use of these tools within surgery to improve surgical workflow and efficiency. This review highlights multifaceted applications of natural language processing within surgery, albeit with clear limitations due to the infancy of the infrastructure available to leverage these technologies. There remains room for more rigorous research into broader capability of natural language processing technology within the field of surgery and the need for cross-sectoral collaboration to understand the ways in which these algorithms can best be integrated.

A systematic review of minimally invasive cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in patients with peritoneal malignancy.

BACKGROUND: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is traditionally a maximally invasive operation with a large abdominal incision and multi-visceral resections. However, to minimize abdominal wall morbidity and improve functional recovery, some centres have adopted a minimally invasive (MI) approach in select cases. The primary aim of this systematic review and meta-analysis was to assess the evidence for safety and patient selection for minimally invasive approaches to CRS and HIPEC with curative intent. METHODS: A PRISMA-compliant systematic review was performed using three electronic databases: Ovid MEDLINE, EMBASE and Web of Science. Data regarding postoperative morbidity was meta-analysed. RESULTS: Thirteen studies met the inclusion criteria (N = 462 MI patients), all of which were retrospective in design. Six studies included an open comparison group. Pseudomyxoma peritonei, mesothelioma and ovarian carcinoma made up the majority of cases (>90%), with a PCI < 10 listed as a prerequisite to selection across all studies. On pooled analysis there was no difference in major morbidity between MI and open groups (OR 0.52 95% CI 0.18-1.46, P = 0.33). There was one perioperative death reported in the MI group. Length of stay appeared shorter in the MI group (median range MI: 4-11 v Open: 7-13 days). Short-term recurrence and overall survival between both groups also appeared no different. CONCLUSION: Minimally invasive CRS and HIPEC appears feasible and safe in appropriately selected patients. Clear histological stratification and longer term follow up is required to determine oncological safety, particularly in more aggressive tumours such as colorectal peritoneal metastases.

Emerging multi-port soft tissue robotic systems: a systematic review of clinical outcomes.

Multiple novel multi-port robotic surgical systems have been introduced into clinical practice. This systematic review aims to evaluate the clinical outcomes of these novel robotic systems to conventional laparoscopic technique and established da Vinci robotic surgical platforms. A literature search of Embase, Medline, Pubmed, Cochrane library, and Google Scholar was performed according to the PRISMA guidelines from 2012 to May 2023. Studies comparing clinical outcomes of novel multi-port robotic surgical systems with laparoscopic or the da Vinci platforms were included. Case series with no comparison groups were excluded. Descriptive statistics were used to report patient and outcome data. A systematic narrative review was provided for each outcome. Twelve studies comprised of 1142 patients were included. A total of 6 novel multi-port robotic systems: Micro Hand S, Senhance, Revo-i MSR-5000, KangDuo, Versius, and Hugo™ RAS were compared against the laparoscopic or the da Vinci robotic platforms. Clinical outcomes of these novel robotic platforms were comparable to the established da Vinci platforms. When compared against conventional laparoscopic approaches, the robotic platforms demonstrated lower volume of blood loss, shorter length of stay but longer operative time. This systematic review highlighted the safe implementation and efficacy of 6 new robotic systems. The clinical outcomes achieved by these new robotic systems are comparable to the established da Vinci robotic system in simple to moderate case complexities. There is emerging evidence that these new robotic systems provide a viable alternative to currently available robotic platforms.

Impact of neoadjuvant systemic chemotherapy followed by cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for appendiceal adenocarcinoma.

AIM: Peritoneal dissemination of infiltrative appendiceal tumors is a rare and poorly understood phenomenon. Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is a well-recognized treatment option for selected patients. Neoadjuvant systemic chemotherapy (NAC) has been shown to be associated with improved overall survival (OS) in colorectal peritoneal metastases but little is known of the impact of this from an appendiceal adenocarcinoma perspective. METHOD: A prospective database of 294 patients with advanced appendiceal primary tumors undergoing CRS ± HIPEC between June 2009 and December 2020 was reviewed. Baseline characteristics and long-term outcomes were compared between patients with adenocarcinoma who received neoadjuvant chemotherapy or upfront surgery. RESULTS: Eighty-six (29%) patients were histologically diagnosed with an appendiceal cancer. These included intestinal-type adenocarcinoma (11.6%), mucinous adenocarcinoma (43%), and goblet cell adenocarcinoma (GCA) or signet ring cell adenocarcinoma (SRCA) (45.4%). Twenty-five (29%) of these underwent NAC, of which eight (32%) exhibited some degree of radiological response. There was no statistical difference in OS at 3 years between the NAC and upfront surgery groups (47.3% vs. 75.8%, p = 0.372). Appendiceal histology subtypes, particularly GCA and SRCA (p = 0.039) and peritoneal carcinomatosis index >10 (p = 0.009), were factors independently associated with worse OS. CONCLUSION: Administration of NAC did not appear to prolong OS in the operative management of disseminated appendiceal adenocarcinomas. GCA and SRCA subtypes display a more aggressive biological phenotype.

Robotic versus laparoscopic gastric bypass in bariatric surgery: a systematic review and meta-analysis on perioperative outcomes.

BACKGROUND: Robotic-assisted surgery has emerged as a compelling approach to bariatric surgery. However, current literature has not consistently demonstrated superior outcomes to laparoscopic bariatric surgery to justify its higher cost. With its mechanical advantages, the potential gains from the robotic surgical platform are likely to be apparent in more complex cases such as gastric bypass, especially revisional cases. OBJECTIVE: This systematic review and meta-analysis aimed to summarize the literature and evaluate the peri-operative outcomes of patients with obesity undergoing robotic gastric bypass versus laparoscopic gastric bypass surgery. SETTING: Systematic review. METHODS: A literature search of Embase, Medline, Pubmed, Cochrane library, and Google Scholar was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies comparing outcomes of robotic and laparoscopic gastric bypass for obesity were included. RESULTS: Twenty-eight eligible studies comprised a total of 82,155 patients; 9051 robotic bypass surgery (RBS) versus 73,104 laparoscopic bypass surgery (LBS) were included. All included studies compared Roux-en-Y gastric bypass. RBS was noted to have higher reoperation rate within 30 days (4.4% versus 3.4%; odds ratio 1.31 [95% CI, 1.04-1.66]; P = .027; I2 = 43.5%) than LBS. All other endpoints measured (complication rate, anastomotic leak, anastomotic stricture, surgical site infections, hospital readmission, length of stay, operative time, conversion rate and mortality) did not show any difference between RBS and LBS. CONCLUSION: This systematic review and meta-analysis showed that there was no significant difference in key outcome measures in robotic versus laparoscopic gastric bypass. RBS was associated with a slightly higher reoperation rate and there was no reduction in overall complication rate with the use of robotic platform.

Use of patient-derived explants as a preclinical model for precision medicine in colorectal cancer: A scoping review.

PURPOSE: Whilst the treatment paradigm for colorectal cancer has evolved significantly over time, there is still a lack of reliable biomarkers of treatment response. Treatment decisions are based on high-risk features such as advanced TNM stage and histology. The role of the tumour microenvironment, which can influence tumour progression and treatment response, has generated considerable interest. Patient-derived explant cultures allow preservation of native tissue architecture and tumour microenvironment. The aim of the scoping review is to evaluate the utility of patient-derived explant cultures as a preclinical model in colorectal cancer. METHODS: A search was conducted using Ovid MEDLINE, EMBASE, Web of Science, and Cochrane databases from start of database records to September 1, 2022. We included all peer-reviewed human studies in English language which used patient-derived explants as a preclinical model in primary colorectal cancer. Eligible studies were grouped into the following categories: assessing model feasibility; exploring tumour microenvironment; assessing ex vivo drug responses; discovering and validating biomarkers. RESULTS: A total of 60 studies were eligible. Fourteen studies demonstrated feasibility of using patient-derived explants as a preclinical model. Ten studies explored the tumour microenvironment. Thirty-eight studies assessed ex vivo drug responses of chemotherapy agents and targeted therapies. Twenty-four studies identified potential biomarkers of treatment response. CONCLUSIONS: Given the preservation of tumour microenvironment and tumour heterogeneity, patient-derived explants has the potential to identify reliable biomarkers, treatment resistance mechanisms, and novel therapeutic agents. Further validation studies are required to characterise, refine and standardise this preclinical model before it can become a part of precision medicine in colorectal cancer.

Immune mediated colitis: a surgical perspective.

BACKGROUND: This study aims to review and summarize the current up to date literature that explore the current treatment approaches to immune mediated colitis and the role of surgical specialties in the landscape of management. METHODS: A narrative review of papers was performed following a literature search through Medline, EMBASE and Cochrane Central databases pertaining to immune mediated colitis as an adverse event of cancer immunotherapy. RESULTS: Current guidelines for the diagnosis and treatment of immune mediated colitis mirror the approach to the workup of inflammatory bowel disease and guided by treating oncology and gastroenterology specialties. Immune mediated colitis however relies on surgical specific skills as a consequence of obtaining a diagnosis as well as in the management of complications that may arise. CONCLUSION: Immune mediate colitis management has largely been under the purview of medical specialties. This review explores the current landscape of managing immune mediated colitis from a surgical perspective and highlights key areas in which surgeons can engage in the multidisciplinary care of this condition. To facilitate prompt diagnosis and management of immune-mediated colitis, there is an increasing necessity for surgeons to become familiar with the latest multidisciplinary approaches and recommendations.

The management of clinically suspicious para-aortic lymph node metastasis in colorectal cancer: A systematic review.

Approximately 1%-2% of patients with colorectal cancer (CRC) develop para-aortic lymph node (PALN) metastases, which are typically considered markers of systemic disease, and are associated with a poor prognosis. The utility of PALN dissection (PALND) in patients with CRC is of ongoing debate and only small-scale retrospective studies have been published on this topic to date. This systematic review aimed to determine the utility of resecting PALN metastases with the primary outcome measure being the difference in survival outcomes following either surgical resection or non-resection of these metastases. A comprehensive systematic search was undertaken to identify all English-language papers on PALND in the PubMed, Medline, and Google Scholar databases. The search results identified a total of 12 eligible studies for analysis. All studies were either retrospective cohort studies or case series. In this systematic review, PALND was found to be associated with a survival benefit when compared to non-resection. Metachronous PALND was found to be associated with better overall survival as compared to synchronous PALND, and the number of PALN metastases (2 or fewer) and a pre-operative carcinoembryonic antigen level of <5 was found to be associated with a better prognosis. No PALND-specific complications were identified in this review. A large-scale prospective study needs to be conducted to definitively determine the utility of PALND. For the present, PALND should be considered within a multidisciplinary approach for patients with CRC, in conjunction with already established treatment regimens.

Robotic pelvic side-wall lymph node dissection for rectal cancer: a systematic review of videos and application of the IDEAL 2A framework.

Lateral pelvic lymph node dissection (LPLND) in rectal cancer has gained increasing traction worldwide. Robotic LPLND is an emerging technique. Utilising the IDEAL (idea, development, exploration, assessment and long-term follow-up) framework for surgical innovation, robotic LPLND is currently at the IDEAL 2A stage (development) mainly limited to case reports, case series and videos. A systematic literature review was performed for videographic robotic LPLND. Pubmed, Ovid and Web of Science were searched with a predefined search strategy. The LapVEGAS score for peer review of video surgery was adapted for the robotic approach (RoVEGAS) and applied to measure video quality. Two reviewers independently reviewed videos and consensus reached on technical steps and learning points. Data are presented as a narrative synthesis of results. The IDEAL 2A framework was applied to videos to assess their content at the present stage of innovation. A total of 83 abstracts were identified. In accordance with the PRISMA statement, nine videos were analysed. Adherence to the complete IDEAL 2a framework was low. All videos demonstrated LPLND; however, reporting of clinical outcomes was heterogeneous and completed in six of nine videos. Histopathology was reported in six videos, with other outcomes variably reported. No videos presented patient-reported outcome measures. Two videos reported presence or absence of recurrence on follow-up. Video articles provide a valuable educational resource in dissemination and adoption of robotic techniques. Standardisation of reporting objectives are needed. Complete reporting of pathology and oncologic outcomes is required in videographic procedural-based publications to meet the IDEAL 2A framework criteria.

Robotic colon surgery in obese patients: a systematic review and meta-analysis.

BACKGROUND: Colon cancer resection can be technically difficult in the obese (OB) population. Robotic surgery is a promising technique but its benefits remain uncertain in OB patients. The aim of this study is to compare OB versus non-obese (NOB) patients undergoing robotic colon surgery, as well as OB patients undergoing robotic versus open or laparoscopic colonic surgery. METHODS: A systematic review and meta-analysis was performed. Primary outcome measures included length of stay (LOS), surgical site infection (SSI) rate, complications, anastomotic leak and oncological outcomes. RESULTS: A total of eight studies were included, with five comparing OB and NOB patients undergoing robotic colon surgery included in meta-analysis. A total of 263 OB patients and 400 NOB patients formed the sample for meta-analysis. There was no significant difference between the two groups in operative time, conversion to open, LOS, lymph node yield, anastomotic leak and postoperative ileus. There was a trend towards a significant increase in overall complications and SSI in the OB group (32.3% OB versus 26.8% NOB for complications, 14.2% OB versus 9.9% NOB for SSI). The three included studies comparing surgical techniques were too heterogeneous to undergo meta-analysis. CONCLUSION: Robotic colon surgery is safe in obese patients, but high-quality prospective evidence is lacking. Future studies should report on oncological safety and the cost-effectiveness of adopting the robotic technique in these challenging patients.

Operative and oncological outcomes after robotic rectal resection compared with laparoscopy: a systematic review and meta-analysis.

BACKGROUND: Most studies comparing robotic and laparoscopic surgery, show little difference in clinical outcomes to justify the expense. We systematically reviewed and pooled evidence from studies comparing robotic and laparoscopic rectal resection. METHOD: Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica (EMBASE), and Cochrane databases were searched for studies between 1996 and 2021 comparing clinical outcomes between laparoscopic and robotic rectal surgeries involving total mesorectal excision. Outcome measures included operative times, conversions to open, complications, recurrence and survival rates. RESULTS: Fifty eligible studies compared outcomes between robotic and laparoscopic rectal resections; three were randomized trials. Pooled results showed significantly longer operating times for robotic surgery but lower conversion and complications rates, shorter lengths of stay in hospital, better rates of complete mesorectal resection and better three-year overall survival. However, the low number of randomized studies makes most data subject to bias. CONCLUSION: Available evidence supports the safety and ongoing use of robotic rectal cancer surgery, while further high-quality evidence is sought to justify the expense.

Metabolic and magnetic resonance imaging: complementary modalities for the preoperative assessment of lateral pelvic lymph nodes in rectal cancer.

BACKGROUND: The management of lateral pelvic lymph nodes for rectal cancer is a topical and controversial issue. The aim of this study was to assess the relationship between lateral pelvic lymph node features on magnetic resonance imaging (MRI) and positron emission tomography-computed tomography (PET-CT) with oncological outcomes in patients with rectal cancer. METHODS: A retrospective analysis of 284 patients with primary locally advanced rectal cancer treated with neoadjuvant therapy and surgical resection with curative intent between January 2003 and Dec 2018 was undertaken. From this study population, a select cohort of 77 patients with abnormal lateral pelvic lymph nodes on preoperative imaging had imaging re-analysed by radiologists blinded to clinical outcomes. Pre and post neoadjuvant therapy MRI and PET-CT lateral pelvic lymph node features were correlated with oncological outcomes. RESULTS: A lateral pelvic lymph node short axis size ≥5 mm on post neoadjuvant therapy MRI was a significant predictor of worse 3-year local recurrence free survival (HR 8.35, P = 0.001). Lateral pelvic lymph node avidity on post neoadjuvant therapy PET-CT was a significant predictor of worse 3-year distant recurrence free survival (HR 5.62, P = 0.001). No correlation of oncological outcomes with overall survival was identified. CONCLUSION: Lateral pelvic lymph node imaging features on post-neoadjuvant therapy MRI and PET-CT predicted those at risk of rectal cancer recurrence. Further studies are required to confirm these findings that suggest restaging MRI and PET-CT are complementary modalities for the preoperative assessment of lateral pelvic lymph nodes in rectal cancer.

Retrospective audit: Utility of PET scan in routine preoperative rectal cancer staging.

BACKGROUND: Accurate staging for rectal cancer is pertinent with recent introduction of rectum-sparing approaches for patients showing complete clinical response on restaging. Positron emission tomography(PET) is used in detection of recurrence or metastasis, but its value in routine preoperative rectal cancer staging remains unclear. Studies report that preoperative PET altered the stage in 39% and changed the management in 17-27% of patients. Our study aims to look at the utility of PET in routine preoperative staging of rectal cancer within 2 two colorectal units, and to determine if PET did result in a change in management. METHODS: Patients in Nepean Hospital (NSW) and Peter MacCallum Cancer Centre (VIC) who were diagnosed with rectal cancer between 1 January 2017 and 31 December 2021 were included in this retrospective study. All patients who did not have a PET scan were excluded. PET scan results were then compared with MRI and CT results. RESULTS: Three hundred and fifty-seven patients were included in the study. 30.3% of the patients had Stage 3 rectal cancer. 71.7% received neoadjuvant therapy. PET scan provided additional information in 55.5% of patients when compared with CT and MRI alone; 18.2% of the PET findings resulted in an altered management for the patient. CONCLUSION: PET scan can be a valuable tool in accurate staging, especially for ambiguous or equivocal lesions on CT. Our study demonstrated that additional information from PET scan resulted in an altered management plan in 18.2% of the patients. PET/MRI as a newer modality may be more accurate with reduced radiation exposure.