Mixed Reality Annotation of Robotic-Assisted Surgery videos with real- time tracking and stereo matching

Robotic-Assisted Surgery (RAS) is beginning to unlock its potential. However, despite the latest advances in RAS, the steep learning curve of RAS devices remains a problem. A common teaching resource in surgery is the use of videos of previous procedures, which in RAS are almost always stereoscopic. It is important to be able to add virtual annotations onto these videos so that certain elements of the surgical process are tracked and highlighted during the teaching session. Including virtual annotations in stereoscopic videos turns them into Mixed Reality (MR) experiences, in which tissues, tools and procedures are better observed. However, an MR-based annotation of objects requires tracking and some kind of depth estimation. For this reason, this paper proposes a real-time hybrid tracking–matching method for performing virtual annotations on RAS videos. The proposed method is hybrid because it combines tracking and stereo matching, avoiding the need to calculate the real depth of the pixels. The method was tested with six different state-of-the-art trackers and assessed with videos of a sigmoidectomy of a sigma neoplasia, performed with a Da Vinci® X surgical system. Objective assessment metrics are proposed, presented and calculated for the different solutions. The results show that the method can successfully annotate RAS videos in real-time. Of all the trackers tested for the presented method, the CSRT (Channel and Spatial Reliability Tracking) tracker seems to be the most reliable and robust in terms of tracking capabilities. In addition, in the absence of an absolute ground truth, an assessment with a domain expert using a novel continuous-rating method with an Oculus Quest 2 Virtual Reality device was performed, showing that the depth perception of the virtual annotations is good, despite the fact that no absolute depth values are calculated

A prospective multicentre study evaluating the outcomes of the abdominal wall dehiscence repair using posterior component separation with transversus abdominis muscle release reinforced by a retro-muscular mesh: filling a step

Background This study aimed to evaluate the results of posterior component separation (CS) and transversus abdominis muscle release (TAR) with retro-muscular mesh reinforcement in patients with primary abdominal wall dehiscence (AWD). The secondary aims were to detect the incidence of postoperative surgical site occurrence and risk factors of incisional hernia (IH) development following AWD repair with posterior CS with TAR reinforced by retromuscular mesh. Methods Between June 2014 and April 2018, 202 patients with grade IA primary AWD (Björck’s first classification) following midline laparotomies were treated using posterior CS with TAR release reinforced by a retro-muscular mesh in a prospective multicenter cohort study. Results The mean age was 42 ± 10 years, with female predominance (59.9%). The mean time from index surgery (midline laparotomy) to primary AWD was 7 ± 3 days. The mean vertical length of primary AWD was 16 ± 2 cm. The median time from primary AWD occurrence to posterior CS + TAR surgery was 3 ± 1 days. The mean operative time of posterior CS + TAR was 95 ± 12 min. No recurrent AWD occurred. Surgical site infections (SSI), seroma, hematoma, IH, and infected mesh occurred in 7.9%, 12.4%, 2%, 8.9%, and 3%, respectively. Mortality was reported in 2.5%. Old age, male gender, smoking, albumin level < 3.5 gm%, time from AWD to posterior CS + TAR surgery, SSI, ileus, and infected mesh were significantly higher in IH. IH rate was 0.5% and 8.9% at two and three years, respectively. In multivariate logistic regression analyses, the predictors of IH were time from AWD till posterior CS + TAR surgical intervention, ileus, SSI, and infected mesh. Conclusion Posterior CS with TAR reinforced by retro-muscular mesh insertion resulted in no AWD recurrence, low IH rates, and low mortality of 2.5%. Trial registration Clinical trial: NCT05278117

Estándares de calidad en la cirugía de carcinomatosis peritoneal de origen colorectal mediante citorreducción y quimioterapia intraperitoneal hipertermia (HIPEC)

El mayor conocimiento de la historia natural de la carcinomatosis peritoneal ha permitido su valoración como una progresión locorregional. Tras los trabajos publicados por Sugarbaker tanto a nivel quirúrgico, con la descripción de las técnicas de peritonectomía como a nivel farmacológico experimental para la aplicación de la quimioterapia intraperitoneal hipertérmica (HIPEC), se considera un tratamiento locorregional de la enfermedad confinada al abdomen. Así, una cirugía radical de citorreducción con extirpación de la enfermedad macroscópica y la aplicación posterior de HIPEC para control de la enfermedad microscópica residual, ha obtenido resultados muy superiores a la quimioterapia aislada. En todo tratamiento quirúrgico, y más en aquellos de mayor complejidad como la cirugía de citorreducción y HIPEC (CRS+HIPEC), se debe garantizar una atención sanitaria óptima que ofrezca una adecuada calidad en la asistencia y disminuya la variabilidad en los tratamientos y en los resultados. Esta gestión de la calidad viene determinada por una serie de indicadores y estándares, medibles, reproducibles y que garantizan los cambios y mejoras en la asistencia si fuera necesario. En los últimos años se han evaluado estándares de calidad en varios procesos asistenciales relacionados con el cáncer, sin embargo, Carecemos de estándares de ca en el ámbito del tratamiento multidisciplinar de la cirugía oncológica peritoneal. Hipótesis Mediante la aplicación de los métodos de análisis y la utilización de las gráficas de control de procesos, es posible determinar los estándares de calidad en los resultados de la cirugía de carcinomatosis peritoneal de origen colorrectal, a partir de datos objetivos y estadísticamente robustos publicados en la literatura. Objetivos 1. Determinar cuáles son los indicadores de calidad y su valor correspondiente, clínicamente relevantes 2. Establecer escalas o intervalos con los límites de variabilidad o límites de calidad aceptables para cada indicador, de fácil medición, que sirvan de herramienta a las unidades de cirugía oncológica peritoneal y permitan auditar los resultados de forma sencilla y objetiva Resultados y conclusiones 1. Se han determinado 20 indicadores de calidad: media de supervivencia global, media de supervivencia global a 1 año y a 5 años, media de supervivencia libre de enfermedad global, a 1 año y a 5 años, supervivencia libre de enfermedad global, a 1 año y a 5 años, tasa de resecciones completas, duración media de la cirugía, estancia media hospitalaria, tasa de mortalidad global, tasa de morbilidad global, tasa de morbilidad mayor, tasa de reintervenciones, tasa de hemorragias postoperatorias, tasa de fístulas intestinales, tasa de dehiscencia de anastomosis, tasa de infecciones de herida, tasa de complicaciones médicas, tasa de recurrencia global y tasa de fallo de rescate

La acreditación y dedicación en Coloproctología se asocian a buenos cuidados perioperatorios en un análisis evolutivo de agrupamiento

[EN] Complex data analysis methods require optimisation techniques such as evolutionary algorithms in order to generate reliable results. The objective of this study is to analyse the relationships of particular perioperative care in colorectal surgery (CRS) with surgeon epidemiological data, performing partition grouping to look for significant relationships. Methods: Data were used from a survey of members of Spanish coloproctology associations on perioperative care in colorectal surgery, and analysing the responses associated with mechanical bowel preparation (MBP), nasogastric intubation (NGI), drainages (D), and early feeding (EF), over the existing scientific evidence (SE) which shows that the first ones are unnecessary and the importance of the last one. We applied a variant of particle swarm optimization (PSO), to group data conglomerates, optimising variables with statistical grouping criteria. Results: A total of 130 surveys were analysed, finding 2 clear groups which included 21.5% and 78.5% of the sample, respectively. Sixty eight per cent of the surgeons in Group A belonged to the European Board in Coloproctology, compared to none in Group B, and the former performed 80% of the coloproctology activity, compared to 60% of the rest. A responded homogeneously to questions on MBP, NGI, D and EF, those of group A following the SE, while the others did it randomly and without following it. Age, work position or academic range were not significant in the grouping. Conclusions: The evolutionary algorithm was shown to be able to identify groups according to the use of perioperative care in CRS. Accreditation and dedication was associated with behaviour based on the SE. # 2010 AEC. Published by Elsevier España, S.L. All rights reserved.[ES] Los métodos complejos de análisis de datos precisan de técnicas de optimización tales como los algoritmos evolutivos para generar resultados fiables. El objetivo de este estudio es analizar las relaciones de determinados cuidados perioperatorios en cirugıía colorrectal (CCR) con datos epidemiológicos de cirujanos efectuando un agrupamiento particional para buscar asociaciones relevantes. Métodos: Se emplearon datos de una encuesta sobre cuidados perioperatorios en CCR a miembros de las asociaciones coloproctológicas españolas, analizando respuestas relacionadas con preparación cólica (PMC), sonda nasogástrica (SNG), drenajes (D) y alimentación precoz (AP), sobre las que existe evidencia científica (EC) que muestra innecesarias las primeras e importante la última. Aplicamos una variante de Particle Swarm Optimization (PSO), para agrupar conglomerados de datos optimizando variables con criterios de agrupación estadística. Resultados: Se analizaron 130 encuestas hallando 2 grupos claros que incluían respectivamente al 21,5 y 78,5% de la muestra. El 68% de cirujanos del grupo A eran European Board in Coloproctology, frente a ninguno del B y los del primero desarrollaban 80% de actividad coloproctológica frente al 60% del resto. A preguntas sobre PMC, SNG, D y AP respondieron homogéneamente siguiendo la EC los del grupo A, mientras los otros lo hicieron de modo disperso y sin seguirla. Edad, puesto de trabajo o rango académico no fueron relevantes en el agrupamiento. Conclusiones: El algoritmo evolutivo se ha mostrado capaz de identificar grupos según el empleo de cuidados perioperatorios en CCR. La acreditación y dedicación se han asociado a comportamientos basados en la EC. # 2010 AEC. Publicado por Elsevier España, S.L. Todos los derechos reservados.Este trabajo se ha realizado con el soporte del proyecto IDAWAS, DPI2009-11591 de la Dirección General de Investigación del Ministerio de Educación y Ciencia y de la beca MAEC-AECI 0000202066, obtenidas por el autor I.M. del Ministerio de Asuntos Exteriores y Cooperación españolRoig, JV.; García Armengol, J.; García Fadrique, A.; Herrera Fernández, AM.; Montalvo Arango, I.; Izquierdo Sebastián, J. (2011). La acreditación y dedicación en Coloproctología se asocian a buenos cuidados perioperatorios en un análisis evolutivo de agrupamiento. Cirugía Española. 89(2):94-100. https://doi.org/10.1016/j.ciresp.2010.11.003S9410089

GECOP-MMC: phase IV randomized clinical trial to evaluate the efficacy of hyperthermic intraperitoneal chemotherapy (HIPEC) with mytomicin-C after complete surgical cytoreduction in patients with colon cancer peritoneal metastases.

The French PRODIGE 7 trial, published on January 2021, has raised doubts about the specific survival benefit provided by HIPEC with oxaliplatin 460 mg/m2 (30 minutes) for the treatment of peritoneal metastases from colorectal cancer. However, several methodological flaws have been identified in PRODIGE 7, specially the HIPEC protocol or the choice of overall survival as the main endpoint, so its results have not been assumed as definitive, emphasizing the need for further research on HIPEC. It seems that the HIPEC protocol with high-dose mytomicin-C (35 mg/m2) is the preferred regime to evaluate in future clinical studies. GECOP-MMC is a prospective, open-label, randomized, multicenter phase IV clinical trial that aims to evaluate the effectiveness of HIPEC with high-dose mytomicin-C in preventing the development of peritoneal recurrence in patients with limited peritoneal metastasis from colon cancer (not rectal), after complete surgical cytoreduction. This study will be performed in 31 Spanish HIPEC centres, starting in March 2022. Additional international recruiting centres are under consideration. Two hundred sixteen patients with PCI ≤ 20, in which complete cytoreduction (CCS 0) has been obtained, will be randomized intraoperatively to arm 1 (with HIPEC) or arm 2 (without HIPEC). We will stratified randomization by surgical PCI (1-10; 11-15; 16-20). Patients in both arms will be treated with personalized systemic chemotherapy. Primary endpoint is peritoneal recurrence-free survival at 3 years. An ancillary study will evaluate the correlation between surgical and pathological PCI, comparing their respective prognostic values. HIPEC with high-dose mytomicin-C, in patients with limited (PCI ≤ 20) and completely resected (CCS 0) peritoneal metastases, is assumed to reduce the expected risk of peritoneal recurrence from 50 to 30% at 3 years. EudraCT number: 2019-004679-37; Clinicaltrials.gov: NCT05250648 (registration date 02/22/2022, )

Predictors of complications and mortality following left colectomy with primary stapled anastomosis for cancer: results of a multicentric study with 1111 patients

Aim: Reports detailing the morbidity–mortality after left colectomy are sparse and do not allow definitive conclusions to be drawn. We aimed to identify risk factors for anastomotic leakage, perioperative mortality and complications following left colectomy for colonic malignancies. Method: We undertook a STROBE-compliant analysis of left colectomies included in a national prospective online database. Forty-two variables were analysed as potential independent risk factors for anastomotic leakage, postoperative morbidity and mortality. Variables were selected using the ‘least absolute shrinkage and selection operator’ (LASSO) method. Results: We analysed 1111 patients. Eight per cent of patients had a leakage and in 80% of them reoperation or surgical drainage was needed. A quarter of patients (24.9%) experienced at least one minor complication. Perioperative mortality was 2%, leakage being responsible for 47.6% of deaths. Obesity (OR 2.8, 95% CI 1.00–7.05, P = 0.04) and total parenteral nutrition (TPN) (OR 3.7, 95% CI 1.58–8.51, P = 0.002) were associated with increased risk of leakage, whereas female patients had a lower risk (OR 0.36, 95% CI 0.18–0.67, P = 0.002). Corticosteroids (P = 0.03) and oral anticoagulants (P = 0.01) doubled the risk of complications, which was lower with hyperlipidaemia (OR 0.3, P = 0.02). Patients on TPN had more complications (OR 4.02, 95% CI 2.03–8.07, P = 0.04) and higher mortality (OR 8.7, 95% CI 1.8–40.9, P = 0.006). Liver disease and advanced age impaired survival, corticosteroids being the strongest predictor of mortality (OR 21.5, P = 0.001). Conclusion: Requirement for TPN was associated with more leaks, complications and mortality. Leakage was presumably responsible for almost half of deaths. Hyperlipidaemia and female gender were associated with lower rates of complications. These findings warrant a better understanding of metabolic status on perioperative outcome after left colectomy

Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

Background Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks. Methods The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned. Results A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P < 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31). Conclusion Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov)