Complex Surgical Oncology Research Articles

Virtual Reality for Preoperative Planning in Complex Surgical Oncology: A Single-Center Experience

IntroductionVirtual reality models (VRM) are three-dimensional (3D) simulations of two-dimensional (2D) images, creating a more accurate mental representation of patient-specific anatomy. MethodsPatients were retrospectively identified who underwent complex oncologic resections whose operations differed from preoperative plans between April 2018 and April 2019. Virtual reality modeling was performed based on preoperative 2D images to assess feasibility of use of this technology to create models. Preoperative plans made based upon 2D imaging versus VRM were compared to the final operations performed. Once the use of VRM to create preoperative plans was deemed feasible, individuals undergoing complex oncologic resections whose operative plans were difficult to define preoperatively were enrolled prospectively from July 2019 to December 2021. Preoperative plans made based upon 2D imaging and VRM by both the operating surgeon and a consulting surgeon were compared to the operation performed. Confidence in each operative plan was also measured. ResultsTwenty patients were identified, seven retrospective and 13 prospective, with tumors of the liver, pancreas, retroperitoneum, stomach, and soft tissue. Retrospectively, VRM were unable to be created in one patient due to a poor quality 2D image; the remainder (86%) were successfully able to be created and examined. Virtual reality modeling more clearly defined the extent of resection in 50% of successful cases. Prospectively, all VRM were successfully performed. The concordance of the operative plan with VRM was higher than with 2D imaging (92% versus 54% for the operating surgeon and 69% versus 23% for the consulting surgeon). Confidence in the operative plan after VRM compared to 2D imaging also increased for both surgeons (by 15% and 8% for the operating and consulting surgeons, respectively). ConclusionsVirtual reality modeling is feasible and may improve preoperative planning compared to 2D imaging. Further investigation is warranted.

Patterns of Unnecessary Insurer Prior Authorization Denials in a Complex Surgical Oncology Practice

IntroductionInsurance prior authorization (PA) is a determination of need, required by a health insurer for an ordered test/procedure. If the test/procedure is denied, a peer-to-peer (P2P) discussion between ordering provider and payer is used to appeal the decision. The objective of this study was to measure the number and patterns of unnecessary PA denials. MethodsThis was a retrospective review at a quaternary cancer center from October 2021 to March 2022. Included were all patients with outpatient imaging orders for surgical planning or surveillance of gastrointestinal, endocrine, or skin cancer. Primary outcome was unnecessary initial denial (UID) defined as an order that required preauthorization, was initially denied by the insurer, and subsequently overturned by P2P. ResultsNine hundred fifty seven orders were placed and 419 required PA (44%). Of tests requiring authorization, 55/419 (13.1%) were denied. Variability in the likelihood of initial denial was seen across insurers, ranging from 0% to 57%. Following P2P, 32/55 were overturned (58.2% UID). The insurers most likely to have a UID were Aetna (100%), Anthem (77.8%), and Cigna (50.0%). UID was most common for gastrointestinal (58.9%) and endocrine (58.3%) cancers. Average P2P was 33.5 min (interquartile range 28-40). ConclusionsThe majority of imaging studies initially denied were overturned after P2P. If all UIDs were eliminated, this would represent 108 less P2P discussions with an estimated time-savings of 60.3 h annually within a high-volume surgical oncology practice. Combined personnel costs to the health systems and stress on patients with cancer due to image-associated PAs and P2P appear hard to justify.

A propensity score matching analysis: Impact of senior resident versus fellow participation on outcomes of complex surgical oncology

BackgroundTeaching hospitals that train both general surgery residents and fellows in complex general surgical oncology have become more common. This study investigates whether participation of a senior resident versus a fellow has an impact on outcomes of patients undergoing complex cancer surgery. MethodsPatients who underwent esophagectomy, gastrectomy, hepatectomy, or pancreatectomy between 2007 and 2012 with assistance from a senior resident (post-graduate years 4–5) or a fellow (post-graduate years 6–8) were identified from the ACS NSQIP. Based on age, sex, body mass index, ASA classification, diagnosis of diabetes mellitus, and smoking status, propensity-scores were created for odds of undergoing the operation assisted by a fellow. Patients were matched 1:1 based on propensity score. Postoperative outcomes including risk of major complication were compared after matching. ResultsIn total, 6934 esophagectomies, 13,152 gastrectomies, 4927 hepatectomies, and 8040 pancreatectomies were performed with assistance of a senior resident or fellow. After matching, overall rates of major complications were equivalent across all four anatomic locations between cases performed with the participation of a senior resident versus a surgical fellow: esophagectomy (37.0%% vs 31.6%, p = 0.10), gastrectomy (22.6% vs 22.3%, p = 0.93), hepatectomy (15.8% v 16.0%, p = 0.91), and pancreatectomy (23.9% vs 25.2%, p = 0.48). Operative time was shorter for gastrectomy (212 vs. 232 min; p = 0.004) involving a resident compared to a fellow, but comparable for esophagectomy (330 vs. 336 min; p = 0.41), hepatectomy (217 vs. 219 min; p = 0.85), and pancreatectomy (320 vs. 330 min; p = 0.43). ConclusionsSenior resident participation in complex cancer operations does not appear to negatively impact operative time or postoperative outcomes. Future research is needed to further assess this domain of surgical practice and education, particularly with regard to case selection and operative complexity.

Feasibility of perioperative remote monitoring of patient-generated health data in complex surgical oncology.

The feasibility of remote perioperative telemonitoring of patient-generated physiologic health data and patient-reported outcomes in a high risk complex general and urologic oncology surgery population is evaluated. Complex general surgical/urologic oncology patients wore a pedometer, completed ePROs (electronic patient-reported outcome surveys) and record their vitals (weight, pulse, pulse oximetry, blood pressure, and temperature) via a telehealth app platform. Feasibility (% adherence) was assessed as the primary outcome measure. Twenty-one patients with a median age 58 (32-82) years were included. The readmission rate was 33% and the incidence of ≥Grade 3a morbidity was 24%. Adherence to vital sign and ePRO measurements was 95% before surgery, 91% at discharge, and 82%, 68%, and 64% at postdischarge d2, 7, 14, and 30, respectively. There was significant worsening of mobility, self-care and usual daily activity at postdischarge d2 compared to preoperative baseline (p < 0.05). Median daily preoperative steps taken by patients with <Grade 3a versus ≥Grade 3a postoperative morbidity was 6062 versus 4166 (p < 0.05). Of those interviewed, 87% (13/15) viewed vital sign devices as helpful in recovery. Telemonitoring is feasible in a general surgical and urologic oncology setting. Future studies will ascertain optimal patient selection, duration, and extent of perioperative monitoring.

Quality of superior mesenteric and hepatic artery dissection in robotic pancreatoduodenectomy for pancreatic cancer.

This video manuscript by Ikoma and colleagues demonstrates their approach to the superior mesenteric artery and hepatic artery periadventitial dissection. The quality of superior mesenteric artery and hepatic artery dissections should be maintained in robotic pancreatoduodenectomy when performed for pancreatic cancer, to provide the best possible oncological outcomes.

Virtual Reality for Preoperative Planning in Complex Surgical Oncology Increases Surgeon’s Confidence

Virtual Reality for Preoperative Planning in Complex Surgical Oncology Increases Surgeon’s Confidence

Systematic review of prospective studies focused on regionalization of care in surgical oncology.

To perform a systematic review of studies prospectively analyzing the impact of regionalization of complex surgical oncology care on patient outcomes. High volume care of complex surgical oncology patients has been repeatedly associated with improved outcomes. Most studies, however, are retrospective and have not prospectively accounted for confounders such as financial ability and social support. Four electronic databases (Ovid MEDLINE®, Ovid EMBASE, Cochrane Library (Wiley), and EBSCHOHost) were searched from inception until August 25, 2018. Two authors independently reviewed 5887 references, with a third independent reviewer acting as arbitrator when needed. Data extracted from 11 articles that met inclusion criteria. Risk of bias assessments conducted using MINORS criteria for the non-randomized, observational studies, and the Cochrane tool for the randomized-controlled trial. Of the 11 studies selected, we found 7 historically-controlled trials, two retrospective cohort studies with prospective data collection, one prospective study, and one randomized-controlled trial. 73% of studies were from Northern Europe, 18% from Ontario, Canada, and 9% from England. Pancreatic surgery accounted for 36% of studies, followed by gynecologic oncology (27%), thoracic surgery (18%), and dermatologic surgery (9%). The studies reported varying outcome parameters, but all showed improvement post-regionalization. Included studies featured poor-to-fair risk of bias. 11 studies indicated improved outcomes following regionalization of surgical oncology, but most exhibit poor methodological rigor. Prospective evidence for the regionalization of surgical oncology is lacking. More research addressing patient access to care and specialist availability is needed to understand the shortcomings of centralization.

National Institutes of Health Research Funding to Academic Surgical Oncologists: Who Are We and Where Do We Stand?

The National Institutes of Health (NIH) is the primary public funding source for surgical research in the United States. Surgical oncology is a highly academic career, but NIH funding for surgical oncologists (SOs) is not well characterized. The NIH RePORTER (Research Portfolio Online Reporting Tools Expenditures and Results) was queried to identify R01-and-equivalents grants awarded to departments of surgery (DoS) between 2008 and 2018. Surgical oncologists were considered to be those who completed a Society of Surgical Oncology (SSO)-accredited fellowship (breast or complex surgical oncology). Of 1101 projects, 510 (46.3%) were led by practicing surgeons. Among these, general surgeons accounted for most grants (31%), followed by SOs (20.8%). Women represented 211 (24.1%) of the grantees. However, SOs had a higher proportion of female investigators than other surgeons (30.0% vs. 16.1%; P = 0.001). The SO grantees had fewer years of experience (YoE) (12years; interquartile range [IQR], 8.75 vs. 13years; IQR, 13years; P = 0.003), lower senior status (≥ 24 YoE), fewer investigators (4.0% vs. 18.9%; P < 0.001), and fewer PhD holders (30.8% vs. 65.5%; P < 0.001) than the overall cohort. Projects led by SOs accounted for 1121 publications (14.1%), with a higher proportion of high-impact articles (26.3% vs. 9.7%; P < 0.001), and were more likely to hold a registered patent (odds ratio [OR], 3.30; 95% confidence interval [CI], 1.24-8.74; P = 0.016). Among surgical subspecialties, SSO-accredited surgeons accounted for the largest share of the NIH grants. The SO grantees were younger in their career and had higher-impact scholarly productivity. A smaller proportion of female SOs received NIH grants than males, but this gender disparity was less significant among SOs than among other surgical specialties. Fellowship programs should continue to stimulate groundbreaking research by integrating grant-writing training and mentorship.

Virtual Reality for Preoperative Planning in Complex Surgical Oncology: The Initial Experience

Virtual Reality for Preoperative Planning in Complex Surgical Oncology: The Initial Experience

Health-Care Workers’ Perception of Reimbursement for Complex Surgical Oncology Procedures

Perception of physician reimbursement for surgical procedures is not well studied. The few existing studies illustrate that patients believe compensation to be higher than in reality. These studies focus on patient perceptions and have not assessed health-care workers' views. Our study examined health-care workers' perception of reimbursement for complex surgical oncology procedures. An anonymous online survey was distributed to employees at our cancer center with descriptions and illustrations of three oncology procedures-hepatectomy, gastrectomy, and pancreaticoduodenectomy. Participants estimated the Medicare fee and gave their perceived value of each procedure. Participants recorded their perception of surgeon compensation overall, both before and after revealing the Medicare fee schedule. Most of the 113 participants were physicians (33.6%) and nurses (28.3%). When blinded to the Medicare fee schedules, most felt that reimbursements were too low for all procedures (60-64%) and that surgeons were overall undercompensated (57%). Value predictions for each procedure were discordant from actual Medicare fee schedules, with overestimates up to 374 per cent. After revealing the Medicare fee schedules, 55 per cent of respondents felt that surgeons were undercompensated. Even among health-care workers, a large discrepancy exists between perceived and actual reimbursement. Revealing actual reimbursements did not alter perception on overall surgeon compensation.

Using Low-Cost Virtual Reality Simulation to Build Surgical Capacity for Cervical Cancer Treatment.

PURPOSEWorldwide, more than 80% of people diagnosed with cancer will require surgery during their disease course, but only 5% to 20% of low- and middle-income countries have access to safe, affordable, and timely surgery. Developing surgical oncology skills requires significant time and mentoring. Virtual reality (VR) simulators can reduce the time required to master surgical procedures but are prohibitively expensive. We sought to determine whether a VR simulator using low-cost computer gaming equipment could train novice surgeons in Africa to perform a virtual radical abdominal (open) hysterectomy (RAH).METHODSOur RAH VR simulator used the Oculus Rift (Oculus VR, Menlo Park, CA), a VR headset with hand controllers that costs less than $1,500. Surgical novices learned to perform five key steps of a virtual RAH. We measured and identified predictors of movement and time efficiency for the simulation.RESULTSTen novice surgeons in Lusaka, Zambia, enrolled in the study. Movement and time efficiency greatly improved over time. Independent predictors of movement efficiency were number of simulations, surgical experience, and time since college graduation. Independent predictors of time efficiency were number of simulations, surgical experience, days between simulation sessions, age, sex, and an interaction between number of simulations and surgical experience.CONCLUSIONLow-cost VR may be an effective tool to help surgical novices learn complex surgical oncology procedures. If learning to perform VR surgical procedures with low-cost hardware leads to faster mastery of surgical procedures in the operating room, low-cost VR may represent one of the solutions to increasing access to surgical cancer care globally.

ASO Author Reflections: Novel Robotic Training Curriculum Used in Complex Surgical Oncology.

ASO Author Reflections: Novel Robotic Training Curriculum Used in Complex Surgical Oncology.

Centralization of radical cystectomy for bladder cancer in a universal healthcare system: Early results from a Canadian academic center.

516 Background: Radical cystectomy for bladder cancer is a complex surgical oncology procedure. Centralization of this procedure to high volume, fellowship-trained surgeons may improve clinical outcomes. Our objective was to compare outcomes of radical cystectomy before and after centralization of care. Methods: A retrospective analysis of data from the University of Alberta Radical Cystectomy Database was performed. Eligible subjects were those with histologically proven urothelial carcinoma of the bladder (cTanyN1-3M0) undergoing curative intent surgery. Patients were classified into pre-centralization era (1994-2007; N = 523) and post-centralization era (2013-present; N = 134) cohorts for analyses. Pre-centralization era patients were treated by 1 of 11 urologic surgeons at 2 academic teaching hospitals. Post-centralization era patients were treated by 1 of 2 fellowship-trained urologic oncologists at 1 academic teaching hospital. Outcomes were overall survival, 90-day mortality rate, positive surgical margin (R1) resection rate, total number of lymph nodes evaluated, and 90-day blood product transfusion rate. The Kaplan-Meier method and multivariable regression analyses were used to analyze survival outcomes. Statistical tests were two-sided (p≤0.05). Results: The median follow-up duration in the pre- and post-centralization era was 33 months and 16 months, respectively. The predicted 2-year overall survival rate was 62% in the pre-centralization era and 84% in the post-centralization era (Log rank P = 0.0007; multivariable HR 0.40, 95% CI 0.24 to 0.68, P &lt; 0.0001). Treatment in the post-centralization era was associated with lower 90-day mortality (6.3% versus 1.5%, multivariable OR 0.23, 95% CI 0.06 to 0.99, P = 0.049), R1 resection (13.0% versus 1.5%; multivariable OR 0.07, 95% CI 0.01 to 0.51, P = 0.009), and 90-day blood product transfusion (59% versus 6%, P &lt; 0.0001) as well as higher total number of lymph nodes evaluated (7 versus 30 lymph nodes, P &lt; 0.0001). Conclusions: Surgical treatment in the post-centralization era was associated with superior survival, cancer control, and perioperative outcomes.

Between-surgeon variation in 90-day mortality after radical cystectomy for bladder cancer.

512 Background: Radical cystectomy for bladder cancer is a complex surgical oncology procedure. Given the high degree of skill required to perform radical cystectomy, it is plausible that outcomes may vary among surgeons. We determined whether between-surgeon variation, known as heterogeneity, exists for urologic surgeons practicing at a Canadian academic center. Methods: A retrospective analysis of data from the University of Alberta (UA) Radical Cystectomy Database was performed. Between September 1994 and August 2017, 1031 consecutive patients underwent curative-intent radical cystectomy for histologically proven urothelial carcinoma of the bladder (cTanyN1-3M0) by 1 of 11 urologic surgeons. The main outcome measure was 90-day mortality rate. Multivariable models were used to evaluate heterogeneity in 90-day mortality rate after adjustment for case mix. Statistical tests were two-sided (p≤0.05). Results: Data were evaluable for 1031 patients. There was between-surgeon variation in the 90-day mortality rate (unadjusted range, 0.9% to 13.1%). 3 surgeons had 90-day mortality rates ≤ 3% whereas 5 surgeons had 90-day mortality rates ≥ 5%. Conclusions: A patient’s likelihood of achieving an optimal perioperative outcome differs depending on which urologic surgeon performs his/her radical cystectomy. Research examining the mechanism (s) underlying surgical heterogeneity in perioperative outcome after radical cystectomy is needed.

The Efficacy of Dextran-40 as a Venous Thromboembolism Prophylaxis Strategy in Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

The incidence of venous thromboembolism (VTE) in peritoneal malignancies can approach 30 to 50 per cent without prophylaxis. Prophylaxis in cytoreductive surgeries (CRS) presents a challenge to preoperative heparin-based therapy because of an increased risk of coagulopathy and potential for bleeding. Herein, we report the large series of CRS and hyperthermic intraperitoneal chemotherapy receiving dextran-40 prophylaxis. Retrospective chart review of peritoneal malignancies patients undergoing CRS at University of Nebraska Medical Center identified 69 individuals who received dextran-40 between 2010 and 2013. The incidences of VTEs, perioperative bleeding, complications, morbidity, and mortality were determined in-hospital and at 90 days. Of the 69 patients treated, the 30-day VTE rate was 8.7 per cent, and no pulmonary embolisms, bleeding, anaphylactoid reaction, or mortality were observed with dextran usage. The specific VTE events included three upper extremity and three lower extremity VTEs. No additional VTE events were identified between 30 and 90 days. In conclusion, dextran-40 prophylaxis was not associated with any perioperative bleeding events, and the observed incidence of VTE was comparable to reported heparin-based prophylaxis in CRS/hyperthermic intraperitoneal chemotherapy patients. This data supports further exploration of dextran-40 as a VTE prophylactic agent in complex surgical oncology cases.

Safety in Numbers: Progressive Implementation of a Robotics Program in an Academic Surgical Oncology Practice.

Background Robotic-assisted surgery has potential benefits over laparoscopy yet little has been published on the integration of this platform into complex surgical oncology. We describe the outcomes associated with integration of robotics into a large surgical oncology program, focusing on metrics of safety and efficiency. Methods A retrospective review of a prospectively maintained database of robotic procedures from July 2009 to October 2014 identifying trends in volume, operative time, complications, conversion to open, and 90-day mortality. Results Fourteen surgeons performed 1236 cases during the study period: thyroid (246), pancreas/duodenum (458), liver (157), stomach (56), colorectal (129), adrenal (38), cholecystectomy (102), and other (48). There were 38 conversions to open (3.1%), 230 complications (18.6%), and 13 mortalities (1.1%). From 2009 to 2014, operative volume increased (7 cases/month vs 24 cases/month; P < .001) and procedure time decreased (471 ± 166 vs 211 ± 140 minutes; P < .001) with statistically significant decreases for all years except 2014 when volume and time plateaued. Conversion to open decreased (12.1% vs 1.7%; P = .009) and complications decreased (48.5% vs 12.3%; P < .001) despite increasing complexity of cases performed. There were 13 deaths within 90 days (5/13 30-day mortality) and 2 (15.4%) were from palliative surgeries. Conclusions Implementation of a diverse robotic surgical oncology program utilizing multiple surgeons is safe and feasible. As operative volume increased, operative time, complications, and conversions to open decreased and plateaued at approximately 3 years. No unanticipated adverse events attributable to the introduction of this platform were observed.

Attitudes and Perceptions of Surgical Oncology Fellows on ACGME Accreditation and the Complex General Surgical Oncology Certification.

With the first qualifying examination administered September 15, 2014, complex general surgical oncology (CGSO) is now a board-certified specialty. We aimed to assess the attitudes and perceptions of current and future surgical oncology fellows regarding the recently instituted Accreditation Council for Graduate Medical Education (ACGME) accreditation. A 29-question anonymous survey was distributed to fellows in surgical oncology fellowship programs and applicants interviewing at our fellowship program. There were 110 responses (79 fellows and 31 candidates). The response rate for the first- and second-year fellows was 66%. Ninety-percent of the respondents were aware that completing an ACGME-accredited fellowship leads to board eligibility in CGSO. However, the majority (80%) of the respondents stated that their decision to specialize in surgical oncology was not influenced by the ACGME accreditation. The fellows in training were concerned about the cost of the exam (90%) and expressed anxiety in preparing for another board exam (83%). However, the majority of the respondents believed that CGSO board certification will be helpful (79%) in obtaining their future career goals. Interestingly, candidate fellows appeared more focused on a career in general complex surgical oncology (p=0.004), highlighting the impact that fellowship training may have on organ-specific subspecialization. The majority of the surveyed surgical oncology fellows and candidates believe that obtaining board certification in CGSO is important and will help them pursue their career goals. However, the decision to specialize in surgical oncology does not appear to be motivated by ACGME accreditation or the new board certification.

Establishing a complex surgical oncology program with low morbidity and mortality at a community hospital

BackgroundWe report our experience with a large volume of complex oncologic resections and describe the framework necessary to develop a program with low morbidity and mortality in a community hospital. MethodsFrom August 2010 to May 2014, 224 consecutive patients underwent abdominal oncological resection, at a community hospital by a single surgeon (R.N.B.). Cases included pancreatic, gastric, hepatobiliary, colorectal, hyperthermic intraperitoneal chemotherapy with cytoreduction, splenic, and sarcoma resections. We retrospectively reviewed our prospectively maintained database and evaluated postoperative complications. ResultsThere was no 0, 30-, 60-, or 90-day mortality. The complication rate was 44%, including 5% grade I, 28% grade II, 9% grade III, and 1% grade IV complications. The median length of stay was 8 days. Mean follow-up for the entire group was 643 days. ConclusionOur study demonstrates that complex oncologic resections can be safely performed in the community setting if a well-organized, surgeon-led multidisciplinary team is assembled.

Predicting Adverse Outcomes After Complex Cancer Surgery

Predicting Adverse Outcomes After Complex Cancer Surgery