Challenges in evaluating surgical innovation

Review of 20 years of vascular surgery research in Australasia: Defining future directions

Objectives

High-quality research is fundamental to the advancement of surgical practice. Currently, there is no quantitative assessment of the research output of vascular surgeons in Australia and New Zealand. By conducting this bibliometric analysis, we aim to provide an objective representation of the trends in vascular surgery and guide future research.

Methods

A list of all current vascular surgeons in Australia and New Zealand was compiled from the Royal Australasian College of Surgeons 'Find a Surgeon' website tool and correlated with the Australia and New Zealand Society for Vascular Surgery database. A Scopus search of each surgeon's author profile over the last 20 years was conducted.

Results

In total, 2120 articles were published by 208 Australasian vascular surgeons between 1998 and July 2018, with an overall increase in publications over time. Audits or case series were the most published type of study and only 8% of the publications were of high-level evidence. The most popular topics were thoracoabdominal aortic pathologies (24%), followed by peripheral arterial disease (15%). Chronological analysis illustrates an increasing volume of peripheral arterial disease research over time and there is a clear trend towards more endovascular and hybrid surgery publications. The top 10 (5%) highest publishing authors by h-index account for 41% of all publications and 49% of all citations and are also responsible for producing significantly more high-level evidence research.

Conclusion

Australasian vascular surgeons have made a significant contribution to medical research. However, the majority of these articles are of low-level evidence. In this time, there has been an increasing number of publications on endovascular and hybrid surgery in keeping with the trend in clinical practice. These areas, as well as research regarding peripheral arterial disease, show potential for high-evidence research in the future.

Research waste in surgical randomized controlled trials

BACKGROUND

Research waste is a major challenge for evidence-based medicine. It implicates misused resources and increased risks for research participants. The aim of this study was to quantify constituent components of waste in surgical RCTs and explore targets for improvement.

METHODS

ClinicalTrials.gov was searched for RCTs registered between January 2011 and December 2012 using the keyword 'surgery'. The primary outcome was research waste, defined as non-publication, inadequate reporting or presence of an avoidable design limitation. Serial systematic searches of PubMed and Scopus databases were performed to determine publication status. Adequacy of reporting was assessed using the CONSORT checklist. Avoidable design limitations were evaluated according to the presence of bias and/or the absence of a cited systematic review of the literature.

RESULTS

Of 5617 registered RCTs, 304 met all eligibility criteria. Overall, 259 of 304 (85·2 per cent) demonstrated at least one feature of waste. Of these, 221 (72·7 per cent) were published in a peer-reviewed journal and 219 were accessible for full-text review. Only 73 of 131 (55·7 per cent) RCTs with a pharmacological intervention and 24 of 88 (27 per cent) with a non-pharmacological intervention were reported adequately, and 159 of 219 (72·6 per cent) demonstrated an avoidable design limitation. Multicentre (odds ratio 0·31, 95 per cent c.i. 0·11 to 0·88) and externally funded (OR 0·35, 0·15 to 0·82) RCTs were less associated with research waste.

CONCLUSION

This study identified a considerable burden of research waste in surgical RCTs. Future initiatives should target improvements in single-centre, poorly supported RCTs.

Ethical considerations in conducting surgical research in severe complicated intra-abdominal sepsis

Background

Severe complicated intra-abdominal sepsis (SCIAS) has high mortality, thought due in part to progressive bio-mediator generation, systemic inflammation, and multiple organ failure. Treatment includes early antibiotics and operative source control. At surgery, open abdomen management with negative-peritoneal-pressure therapy (NPPT) has been hypothesized to mitigate MOF and death, although clinical equipoise for this operative approach exists. The Closed or Open after Laparotomy (COOL) study (https://clinicaltrials.gov/ct2/show/NCT03163095) will prospectively randomize eligible patients intra-operatively to formal abdominal closure or OA with NPTT. We review the ethical basis for conducting research in SCIAS.

Main body

Research in critically ill incapacitated patients is important to advance care. Conducting research among SCIAS is complicated due to the severity of illness including delirium, need for emergent interventions, diagnostic criteria confirmed only at laparotomy, and obtundation from anaesthesia. In other circumstances involving critically ill patients, clinical experts have worked closely with ethicists to apply principles that balance the rights of patients whilst simultaneously permitting inclusion in research. In Canada, the Tri-Council Policy Statement-2 (TCPS-2) describes six criteria that permit study enrollment and randomization in such situations: (a) serious threat to the prospective participant requires immediate intervention; (b) either no standard efficacious care exists or the research offers realistic possibility of direct benefit; (c) risks are not greater than that involved in standard care or are clearly justified by prospect for direct benefits; (d) prospective participant is unconscious or lacks capacity to understand the complexities of the research; (e) third-party authorization cannot be secured in sufficient time; and (f) no relevant prior directives are known to exist that preclude participation. TCPS-2 criteria are in principle not dissimilar to other (inter)national criteria. The COOL study will use waiver of consent to initiate enrollment and randomization, followed by surrogate or proxy consent, and finally delayed informed consent in subjects that survive and regain capacity.

Conclusions

A delayed consent mechanism is a practical and ethical solution to challenges in research in SCIAS. The ultimate goal of consent is to balance respect for patient participants and to permit participation in new trials with a reasonable opportunity for improved outcome and minimal risk of harm.

Multi-institutional trial of non-operative management and surgery for uncomplicated appendicitis in children: Design and rationale

Traditionally, children presenting with appendicitis are referred for urgent appendectomy. Recent improvements in the quality and availability of diagnostic imaging allow for better pre-operative characterization of appendicitis, including severity of inflammation; size of the appendix; and presence of extra-luminal inflammation, phlegmon, or abscess. These imaging advances, in conjunction with the availability of broad spectrum oral antibiotics, allow for the identification of a subset of patients with uncomplicated appendicitis that can be successfully treated with antibiotics alone. Recent studies demonstrated that antibiotics alone are a safe and efficacious treatment alternative for patents with uncomplicated appendicitis. The objective of this study is to perform a multi-institutional trial to examine the effectiveness of non-operative management of uncomplicated pediatric appendicitis across a group of large children's hospitals. A prospective patient choice design was chosen to compare non-operative management to surgery in order to assess effectiveness in a broad population representative of clinical practice in which non-operative management is offered as an alternative to surgery. The risks and benefits of each treatment are very different and a "successful" treatment depends on which risks and benefits are most important to each patient and his/her family. The patient-choice design allows for alignment of preferences with treatment. Patients meeting eligibility criteria are offered a choice of non-operative management or appendectomy. Primary outcomes include determining the success rate of non-operative management and comparing differences in disability days, and secondarily, complication rates, quality of life, and healthcare satisfaction, between patients choosing non-operative management and those choosing appendectomy.

Evolution of transanal total mesorectal excision according to the IDEAL framework

Tremendous innovations have taken place in surgical procedures, but contrary to drug development, this process has been unregulated in the past. IDEAL promotes a structured framework for the safe implementation and assessment of a new surgical technique or intervention, by describing five stages for evaluating and reporting of innovations: Idea, Development, Exploration, Assessment and Long term. Transanal total mesorectal excision (TaTME) is a relatively new technique in rectal cancer surgery that has attracted huge interest and increasing adoption worldwide. This review article aims to provide an overview of the evolution of TaTME, according to the IDEAL framework, which guides us in the difficult yet exciting process of surgical innovation.

Prospective Blinded Evaluation of Patient-Physician Agreement Using the Summary Outcome Determination (SOD) Score

OBJECTIVE

To determine whether the Summary Outcome Determination (SOD) score demonstrates a high level of physician-patient agreement in a prospective setting with multiple raters.

PATIENTS AND METHODS

For this study, 100 patients who were being evaluated at various intervals following shoulder or elbow surgery were prospectively enrolled from May 30, 2017, through August 31, 2017. The patients' attending physicians and a member of their team (physician assistant, resident, fellow, medical student) assigned categorical and numerical SOD scores while blinded to the scores given by each other. All scores were analyzed among raters, assessing internal consistencies, agreement, and reliability.

RESULTS

The mean follow-up (interval between surgery and completion of the survey) was 31 months, with a range of 1 to 220 months. The intraclass correlation coefficient for patient and physician numerical scores was excellent at 0.82. The weighted κ value for categorical scores was 0.64. Bland-Altman analysis revealed low average discrepancy at 0.6 with a 95% CI of -3.3 to 4.5. The Cronbach α value was 0.94, indicating strong internal validity. The categorical physician-patient agreement occurred within one category 96% of the time.

CONCLUSION

This study found that the SOD score has strong agreement with excellent intraclass correlation coefficient and weighted κ values, indicating substantial agreement, reproducibility (shown by low average error), and strong internal validity. With promising results in the prospective setting, the SOD score was found to be an easy to use outcome measure with reliable agreement between patient and physician. This score has potential to be a metric revealing the "value" of a specific surgical intervention.

Value of surgical pilot and feasibility study protocols

BACKGROUND

RCTs in surgery are challenging owing to well established methodological issues. Well designed pilot and feasibility studies (PFS) may help overcome such issues to inform successful main trial design and conduct. This study aimed to analyse protocols of UK-funded studies to explore current use of PFS in surgery and identify areas for practice improvement.

METHODS

PFS of surgical interventions funded by UK National Institute for Health Research programmes from 2005 to 2015 were identified, and original study protocols and associated publications sourced. Data extracted included study design characteristics, reasons for performing the work including perceived uncertainties around conducting a definitive main trial, and whether the studies had been published.

RESULTS

Thirty-five surgical studies were identified, of which 29 were randomized, and over half (15 of 29) included additional methodological components (such as qualitative work examining recruitment, and participant surveys studying current interventions). Most studies focused on uncertainties around recruitment (32 of 35), with far fewer tackling uncertainties specific to surgery, such as intervention stability, implementation or delivery (10 of 35). Only half (19 of 35) had made their results available publicly, to date.

CONCLUSION

The full potential of pretrial work to inform and optimize definitive surgical studies is not being realized.

A Multicenter Study Evaluating Natural Orifice Specimen Extraction Surgery for Rectal Cancer

BACKGROUND

Low anterior resections are increasingly performed laparoscopically for rectal cancer. Recently, natural orifice specimen extraction surgery (NOSES) has been reported as an alternative approach without additional incisions or extensions. In this study, we aimed to evaluate the safety and feasibility of NOSES by comparing the short-term outcomes with those of conventional laparoscopic resection (CLR) in a multicenter retrospective study from China and Russia.

METHODS

The retrospective multicenter study was conducted at three centers between January 2015 and December 2017. Relevant collected data included patient demographics, operative parameters, and postoperative complications. All procedures were performed using either a NOSES or a CLR approach.

RESULTS

The data of a total of 768 consecutive patients with rectal cancer were retrospectively analyzed, including 412 CLR and 356 NOSES cases. The two groups were comparable for all demographics and characteristics except for the median tumor size (P = 0.038). No difference was found in the operative time and number of retrieved lymph nodes. Intraoperative complications and positive resection margins were nil in both groups. No difference was found in the time to first flatus (P = 0.150), time to first defecation (P = 0.084), length of postoperative hospital stay (P = 0.152), anastomotic leakage (P = 0.377), and intra-abdominal abscess (P = NA). The CLR group but not the NOSES group had incisional hernia or wound infection events, although the difference between groups was not significant (P = 0.253).

CONCLUSIONS

The NOSES procedure is a well-established strategy and may be considered as an alternative procedure to CLR for rectal cancer. However, the long-term benefits of this approach require further evaluation.

Research methodology and practical issues relating to the conduct of a medical device registry

BACKGROUND

The postmarket research goal is to assess "generalizability" or "external validity" to see if the early results of clinical trials with investigational devices are reproducible in everyday practice in the real world and the longer term. Registries have an important but ambivalent role in achieving this goal.

METHODS

Although registries are common, in practice they follow the regulatory processes that appear designed primarily for pharmaceutical clinical trials and confirmatory studies. We review the literature to assess different definitions and the role of registries in the hierarchy of scientific evidence. We analyze common characteristics affecting registry design, implementation, and governance as well as safety reporting and off-label use while describing the experience of setting up an international, prospective registry for an endovascular device used to treat abdominal aortic aneurysms.

RESULTS

Key areas in which to distinguish registries from trials are as follows: eligibility, setting (patients and institutions), device configurations and iterations, the use of design and quality "spaces," a focus on systematic quality checks (rather than source data monitoring), open-ended follow-up, flexibility in the definition of end points and sample sizes, data sharing, and publishing commitments.

CONCLUSION

Both clinical trials and registries are essential and complementary research methods and the strengths and weaknesses of each need to be recognized. The specific characteristics of registry research deserve to be acknowledged and safeguarded in the regulations governing clinical investigations with medical devices.

Funders improved the management of learning and clustering effects through design and analysis of randomized trials involving surgery

OBJECTIVE

The objective of this study was to provide insight into current practice in planning for, and acknowledging, the presence of learning and clustering effects, by treating center and surgeon, when developing randomized surgical trials.

STUDY DESIGN AND SETTING

Complexities associated with delivering surgical interventions, such as clustering effects, by center or surgeon, and surgical learning should be considered at trial design. Main trial publications, within the wider literature, under-report these considerations. Funded applications, within a 4-year period, from a leading UK funding body were searched. Data were extracted on considerations for learning and clustering effects and the driver, funder, or applicant, behind these.

RESULTS

Fifty trials were eligible. Managing learning through establishing predefined center and surgeon credentials was common. One planned exploratory analysis of learning within center, and two within surgeon. Clustering, by site and surgeon, was often managed through stratifying randomization, with 81% and 60%, respectively, also planning to subsequently adjust analysis. One-third of responses to referees contained funder led changes accounting for learning and/or clustering.

CONCLUSION

This review indicates that researchers do consider impact of learning and clustering, by center and surgeon, during trial development. Furthermore, the funder is identified as a potential driver of considerations.

Negative pressure wound therapy: A systematic review of randomized controlled trials from 2000 to 2017

BACKGROUND

Negative pressure wound therapy (NPWT) proposes to provide better wound healing than standard wound management. Evidence quality of randomized controlled trials (RCTs) varies.

METHODS

We included participants with any kind of wounds and commercial as well as the homemade NPWT system. Comparators were any other wound dressing including variant NPWTs. We included RCTs randomizing patients or wounds in parallel or crossover designs. We searched PubMed and Cochrane Library on January 03, 2018. We assessed the risk of bias according to Cochrane and appropriateness of clinical endpoints according to the Food and Drug Administration (FDA).

RESULTS

We included 93 RCTs originating in 30 countries, 70 studies on open wounds and 23 studies on closed wounds. With respect to random sequence generation, we judged an unclear or high risk of bias in 50% (47 of 93) studies. With respect to allocation concealment, we judged an unclear or high risk of bias in 90% (84 of 93). We identified 41% (38 of 93) studies that based their conclusion on not appropriate endpoints.

CONCLUSIONS

High risk of bias concerning random sequence generation and allocation concealment limited the credibility of the majority of 93 included RCTs on NPWT. A low risk of bias can and should be achieved with both items, and we recommend to align future RCTs to Cochrane. Many primary clinical endpoints were deemed not valid for making inferences on the efficacy of NPWT. We recommend using patient-centered endpoints as requested by the FDA and suggested in the present systematic review.

How does surgery compare to sham surgery or physiotherapy as a treatment for tendinopathy? A systematic review of randomised trials

Purpose

To assess the effectiveness of surgery on all tendinopathies by comparing it to no treatment, sham surgery and exercise-based therapies for both mid-term (12 months) and long-term (> 12 months) outcomes.

Methods

Our literature search included EMBASE, Medline, CINAHL and Scopus. A combined assessment of internal validity, external validity and precision of each eligible study yielded its overall study quality. Results were considered significant if they were based on strong (Level 1) or moderate (Level 2) evidence.

Results

12 studies were eligible. Participants had the following types of tendinopathy: shoulder in seven studies, lateral elbow in three, patellar in one and Achilles in one. Two studies were of good, four of moderate and six of poor overall quality. Surgery was superior to no treatment or placebo, for the outcomes of pain, function, range of movement (ROM) and treatment success in the short and midterm. Surgery had similar effects to sham surgery on pain, function and range of motion in the midterm. Physiotherapy was as effective as surgery both in the midterm and long term for pain, function, ROM and tendon force, and pain, treatment success and quality of life, respectively.

Conclusion

We recommend that healthcare professionals who treat tendinopathy encourage patients to comply with loading exercise treatment for at least 12 months before the option of surgery is seriously entertained.

Management of Primary Obstructive Megaureter by Endoscopic High-Pressure Balloon Dilatation. IDEAL Framework Model as a New Tool for Systematic Review

Introduction: Therapeutic management of primary obstructive megaureter (POM) requiring surgery has been under debate for the last 15 years especially regarding the outcomes of endoscopic techniques compared to most traditional approaches. This review aims to analyze endoscopic High-Pressure Balloon Dilatation (HPBD) using the IDEAL model, a five-stage framework that describes surgical innovations (Idea, Development, Exploration, Assessment, and Long-term Study) and provides recommendations for a rigorous stepwise surgical research pathway. This model has been developed and demonstrated its value in evaluating surgical innovations assessing data quality and providing relevant information for the optimal design and feasibility of research in surgery. Materials and Methods: A systematic review of the published series of endoscopic HPBD in patients with POM was done using the IDEAL model as a tool to assess evidence quality. Reported clinical outcomes are also analyzed and reviewed. Results: The analysis of the results of the systematic assessment of the reported cohort of patients treated with HPBD for POM that the technique up to date is in stage 2a and stage 2b, or development. Evidence quality among the reported cohorts of patients with POM treated with HPBD is adequate, although systematization and standardization should be improved. Clinical outcomes of HPBD in the management of POM consistently show a 87.7% success rate with a negligible operative complication rate once "learning curve" has been surpassed. Symptomatic vesicoureteral reflux (VUR) is the main reason for ureteric reimplantation, but asymptomatic VUR does not seem to influence clinical outcome. Conclusions: The IDEAL framework and recommendations have allowed a systematic analysis of the evidence quality of the reported experience in the management of children with POM with HPBD of the vesicoureteral junction. The available evidence demonstrates that HPBD is an effective treatment for patients with POM, with a long-term success rate of 87.7% with very low morbidity. Future research mandates a standardization of data reporting, "ideally" following IDEAL recommendations, that would be required for any intervention and facilitate comparative analysis.

Risk of bias judgements and strength of conclusions in meta-evidence from the Cochrane Colorectal Cancer Group

BACKGROUND

The Cochrane Collaboration records risk of bias (ROB) judgements on the original studies it analyses. The aim of this review is to perform an audit of all literature produced by the Cochrane Colorectal Cancer Group (CCCG), focusing on whether intervention type has any relationship with ROB and the ability of a review to inform clinical practice.

METHODS

The most recent version of every CCCG review from January 2000 to the end of July 2018 was included. Conclusions were categorized as informing clinical practice (I) or not (N). Both I and N categories were divided into firm (F) or tempered (T) based on the definitiveness of their language. ROB judgements were aggregated. Reviews were classed as Medical (M), Surgical (S), Medical & Surgical (MS) or Other (O) based on their intervention, with O reviews then excluded. Data were analyzed in SPSS.

RESULTS

Ninety-five reviews were included, covering 1892 studies. Sixty-two percent (n = 59/95) informed clinical practice (I). Thirty-eight percent (n = 36/95) did not inform clinical practice (N). Of the N group, 53% (n = 19/36) were completely equivocal (firm) while 47% (n = 17/36) were moderately so (tempered). In the I group, 46% (n = 27/59) gave a conclusion that was firm and 54% (n = 32/59) were tempered. Seven thousand five hundred sixty-four cases of bias were assessed. Risk of bias was low in 43%, high in 20% and unclear in 37%. A review that regarded a medical intervention alone was significantly more likely to be comprised of studies with a low risk of bias than a review that included a surgical intervention (p < 0.001).

CONCLUSION

The Cochrane Colorectal Cancer Group finds the risk of bias to be low in less than half of its judgements. A review that included a surgical intervention was less likely to display low risk of bias. Risk of bias was associated with whether a review informed clinical practice, but intervention type was not. Readers of colorectal literature should be cautious when considering original and meta-evidence in this field, particularly where a surgical intervention is assessed.

Bowel surgery as a fertility-enhancing procedure in patients with colorectal endometriosis: methodological, pathogenic and ethical issues

Bowel surgery for colorectal endometriosis is being promoted to infertile women without severe sub-occlusive symptoms, with the objective of improving the likelihood of conception. Contrary to rectal shaving, bowel surgery involving full-thickness disk excision and segmental resection entails opening of the intestinal lumen thus increasing the risk of postoperative infectious complications. About 1 in 10 patients undergoing colorectal resection for intestinal endometriosis will experience severe sequelae, including anastomotic dehiscence, rectovaginal fistula formation, and bladder and bowel denervation. Similar to other surgical procedures aiming at enhancing fertility in women with endometriosis, bowel surgery has been introduced into clinical practice without adequate evaluation through randomized controlled trials. According to systematic literature reviews based mainly on case series, the incremental gain of adding bowel procedures to standard surgery appears uncertain in terms of pregnancy rate after both natural attempts and IVF. Considering the methodological drawbacks and the high risk of bias in the available observational studies, it is not possible to exclude the suggestion that the benefit of colorectal surgery has been overestimated. Given the risk of harms to women's health and the important ethical implications, less emphasis should be put on strict statistical significance and more emphasis should be placed on the magnitude of the effect size. In this regard, the published data may not be generalizable, as the surgeons publishing their results may not be representative of all surgeons. Until the results of adequately designed and conducted RCTs are available, colorectal surgery with the sole intent of improving the reproductive performance of infertile patients with intestinal endometriosis should be performed exclusively within research settings and by highly experienced surgeons. Women should be informed about the uncertainties regarding the harms and benefits of bowel surgery in different clinical conditions, and preoperative counselling must be conducted impartially with the objective of achieving a truly shared medical decision.

Variation in neurosurgical management of traumatic brain injury: a survey in 68 centers participating in the CENTER-TBI study

BACKGROUND

Neurosurgical management of traumatic brain injury (TBI) is challenging, with only low-quality evidence. We aimed to explore differences in neurosurgical strategies for TBI across Europe.

METHODS

A survey was sent to 68 centers participating in the Collaborative European Neurotrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study. The questionnaire contained 21 questions, including the decision when to operate (or not) on traumatic acute subdural hematoma (ASDH) and intracerebral hematoma (ICH), and when to perform a decompressive craniectomy (DC) in raised intracranial pressure (ICP).

RESULTS

The survey was completed by 68 centers (100%). On average, 10 neurosurgeons work in each trauma center. In all centers, a neurosurgeon was available within 30 min. Forty percent of responders reported a thickness or volume threshold for evacuation of an ASDH. Most responders (78%) decide on a primary DC in evacuating an ASDH during the operation, when swelling is present. For ICH, 3% would perform an evacuation directly to prevent secondary deterioration and 66% only in case of clinical deterioration. Most respondents (91%) reported to consider a DC for refractory high ICP. The reported cut-off ICP for DC in refractory high ICP, however, differed: 60% uses 25 mmHg, 18% 30 mmHg, and 17% 20 mmHg. Treatment strategies varied substantially between regions, specifically for the threshold for ASDH surgery and DC for refractory raised ICP. Also within center variation was present: 31% reported variation within the hospital for inserting an ICP monitor and 43% for evacuating mass lesions.

CONCLUSION

Despite a homogeneous organization, considerable practice variation exists of neurosurgical strategies for TBI in Europe. These results provide an incentive for comparative effectiveness research to determine elements of effective neurosurgical care.

Use of the IDEAL framework in the urological literature: where are we in 2018?

OBJECTIVES

To assess uptake and application of the IDEAL principles in original surgical procedure- or device-related clinical research studies, as well as its reported relevance as characterized by secondary publications, editorials and reviews.

MATERIALS AND METHODS

IDEAL (Idea, Development, Exploration, Assessment, Long-term study) is a framework that provides stage-specific guidance for surgical innovation and represented a major advance towards raising evidential standards. We performed a comprehensive literature search of all urology-related publications citing one or more of seven key publications on IDEAL in The Lancet and BMJ using multiple databases up to 31 December 2017.

RESULTS

We identified a total of 150 urology-related manuscripts citing IDEAL, of which 83 (55.3%) were original research and 67 (44.7%) were secondary publications. Among the original research articles, 40 (48.2%) did not explicitly apply IDEAL principles or were not surgical innovation studies. The IDEAL phases of the 43 (51.8%) remaining original research studies were IDEAL, in nine (20.9%), 27 (62.8%), four (9.3%), 0 (0%), and three publications (7.0%), respectively. Across IDEAL stages, 30 (75.0%) studies were prospective, 29 (85.3%) reported ethical oversight, and 39 (90.7%) captured treatment-related harms. None of the studies collected information on physician experience.

CONCLUSIONS

The IDEAL framework has found widespread adoption in the urology literature as witnessed by a large number of original manuscripts and secondary publications citing IDEAL; however, its application is largely limited to the early stages of surgical innovation, frequently with inappropriate and incomplete implementation. Further efforts are needed to guide investigators in the optimal use of the IDEAL framework as it relates to surgical innovation in urology.

Analysis of National Presentations of Surgical Case Series Discussions: What Matters to Surgeons?

BACKGROUND

Although the surgical case series is a useful study design for surgical disciplines, elements of its presentation have not been standardized with a widely accepted reporting guideline. Hence, case series may not include all components necessary for surgeons to best interpret their results. We aimed to determine core elements of case series through qualitative analysis of discussions after presentations at national meetings.

METHODS

Case series with accompanying discussions in three high-impact journals from 2010 to 2015 were analyzed with conventional content analysis. All interrogative sentences were selected for analysis and were classified by a redundant iterative process into descriptive categories and subcategories.

RESULTS

Two hundred twenty-one case series were identified, 56 of which included discussion transcripts. Four hundred seventy six unique interrogatives were classified into 4 categories and 13 subcategories. The main categories identified were "Application of Results to Patient Care," "Clarification of Study Methodology," "Facilitation of Author Insight," and "Request for Additional Study-Specific Data." The most frequent subcategories of inquiry pertained to the changes to current standard of care, clarification of study variables, and subgroup data and outcomes.

CONCLUSIONS

We determined major themes of inquiry that reflected core elements surgeons use to evaluate case series for relevance and applicability to their own practice. Discussants frequently questioned how the study's results changed the author's standard of care. Specifically encouraging surgical case series authors to comment on changes they made to their practice as a result of their findings would allow the surgical audience to quickly assess potential clinical applicability.

Disseminating technology in global surgery

Background

Effective dissemination of technology in global surgery is vital to realize universal health coverage by 2030. Challenges include a lack of human resource, infrastructure and finance. Understanding these challenges, and exploring opportunities and solutions to overcome them, are essential to improve global surgical care.

Methods

This review focuses on technologies and medical devices aimed at improving surgical care and training in low- and middle-income countries. The key considerations in the development of new technologies are described, along with strategies for evaluation and wider dissemination. Notable examples of where the dissemination of a new surgical technology has achieved impact are included.

Results

Employing the principles of frugal and responsible innovation, and aligning evaluation and development to high scientific standards help overcome some of the challenges in disseminating technology in global surgery. Exemplars of effective dissemination include low-cost laparoscopes, gasless laparoscopic techniques and innovative training programmes for laparoscopic surgery; low-cost and versatile external fixation devices for fractures; the LifeBox pulse oximeter project; and the use of immersive technologies in simulation, training and surgical care delivery.

Conclusion

Core strategies to facilitate technology dissemination in global surgery include leveraging international funding, interdisciplinary collaboration involving all key stakeholders, and frugal scientific design, development and evaluation.

Ethics in musculoskeletal regenerative medicine; guidance in choosing the appropriate comparator in clinical trials

BACKGROUND

Regenerative Medicine (RM) techniques aimed at the musculoskeletal system are increasingly translated to clinical trials and patient care. This revolutionary era in science raises novel ethical challenges. One of these challenges concerns the appropriate choice of the comparator in (randomized controlled) trials, including the ethically contentious use of sham procedures. To date, only general guidelines regarding the choice of the comparator exist.

OBJECTIVE

To provide specific guidelines for clinical trial comparator choice in musculoskeletal RM.

METHODS

In this manuscript, we discuss the ethics of comparator selection in RM trials. First, we make a classification of RM interventions according to different health states from disease prevention, return to normal health, postponing RM treatment, supplementing RM treatment, substituting RM treatment, improving RM outcome, and slowing progression. Subsequently, per objective, the accompanying ethical points to consider are evaluated with support from the available literature.

RESULTS

a sham procedure is demonstrated to be an ethically acceptable comparator in RM trials with certain objectives, but less appropriate for musculoskeletal RM interventions that aim at preventing disease or substituting a surgical treatment. The latter may be compared to 'standard of care'.

CONCLUSION

From a scientific perspective, choosing the correct comparator based on ethical guidelines is a step forward in the success of musculoskeletal RM.

Has Publishing Surgeon-Specific Outcomes Had an Impact on Training in Cardiac Surgery?

BACKGROUND

Surgeon-specific outcome data are now published for most surgical specialties in the United Kingdom. There are concerns that this initiative has had a negative impact on training. The primary objective of this study was to assess whether training activity has changed since the publication of surgeon-specific outcomes in cardiac surgery.

METHODS

Prospectively collected data for cardiac surgical procedures performed at a single center from 2004 to 2016 were analyzed. The cohort was split into two halves according to operation date. Multivariable logistic regression was used to assess whether training activity had increased from the first to the second part of the study and to identify whether trainee first operator was associated with adverse outcomes.

RESULTS

A total of 14,054 cardiac surgical procedures were included, of which 1,777 (12.6%) had a trainee as first operator. Despite an increase in the risk profile of patients undergoing surgical procedures, the proportion of cases performed by trainees increased from 11.7% (786 of 6,708) in the first half of the study to 13.5% (991 of 7,346) in the second half of the study (p = 0.002). This effect remained after adjustment for confounding variables. Trainee first operator was not significantly associated with an increased risk of any adverse short-term outcome.

CONCLUSIONS

Since surgeon-specific outcome publication began in United Kingdom, cardiac surgical training activity has significantly increased at the study center despite an increase in the risk profile of patients. This study demonstrates that it is possible to maintain or even increase training activity with good outcomes in the era of surgeon-specific outcome publication.

Clinical trials

Clinical trials can be used to generate data on safety, efficacy, and/or effectiveness of treatments. They can be classified based on their purpose, phase, or design. Key components of clinical trial design include: identifying the study question and population; clearly defining the treatment and comparison groups; choosing the method of treatment group allocation; defining the primary and secondary outcomes; performing a power analysis; outlining an analytic plan; and reporting results. Critical issues to consider when either designing a trial or interpreting the results of a trial include evaluating the validity and generalizability of the results and assessing the appropriateness of the control group. Designing and implementing clinical trials in pediatric surgery is challenging, but well-constructed and executed trials are instrumental in improving clinical care.

Systematic Review of Supraclavicular Artery Island Flap vs Free Flap in Head and Neck Reconstruction

OBJECTIVE

The aim of this systematic review is to compare the surgical outcomes of supraclavicular artery island flap (SCAIF) and free tissue transfer (FTT) in head and neck reconstruction.

DATA SOURCES

PubMed, Web of Science, and EMBASE databases.

REVIEW METHODS

Independent screening and data extraction were performed by 2 authors. Only studies that directly compared SCAIF and FTT were included. Data were pooled with random-effects meta-analysis to determine the standardized mean differences (SMDs), risk differences, and 95% confidence intervals (CIs). Heterogeneity was assessed using the I² statistics. The Methodological Index for Non-Randomized Studies tool was used to evaluate extent of bias in studies.

RESULTS

The initial query yielded 661 results, of which 4 comparative studies remained for final analysis. The pooled sample sizes for the SCAIF and FTT cohorts were 100 and 84, respectively. SCAIF was associated with reduction of operative time by a large effect size (SMD, 1.65; 95% confidence interval, 0.78-2.52). The harvested flap areas and perioperative complications, including rates of total flap loss, partial flap necrosis, and recipient/donor site dehiscences, were comparable between the 2 procedures with low to high heterogeneity among studies.

CONCLUSION

SCAIF requires less operative time and has comparable short-term perioperative results to FTT. The findings of this study support the viability of SCAIF as an alternative to FTT and provide evidence for its inclusion in the reconstructive armamentarium of major head and neck ablation and trauma.

Surgeons' and methodologists' perceptions of utilising an expertise-based randomised controlled trial design: a qualitative study

BACKGROUND

Randomised controlled trials (RCTs) are widely recognised to be the most rigorous way to test new and emerging clinical interventions. When the interventions under study are two different surgical procedures, however, surgeons are required to be trained and sufficiently proficient in the different surgical approaches to take part in such a trial. It is often the case that even where surgeons can perform both trial surgical procedures, they have a preference and/or have more expertise in one of the procedures. The expertise-based trial design, where participating surgeons only provide the procedure in which they have appropriate expertise, has been proposed to overcome this problem. When expertise-based designs should be best used remains unclear; such approaches may be more suited to addressing specific questions. The aim of this qualitative study was to improve understanding about the range of views that surgeons and methodologists have regarding the use of the expertise-based RCT design.

METHODS

Twelve individual interviews with surgeons and methodologists with experience of surgical trials were conducted. Interviews were semi-structured and conducted face-to-face or by telephone. Interviews were audio-recorded, transcribed and analysed systematically using an interpretive approach.

RESULTS

Both surgeons and methodologists saw potential advantages in the expertise-based design particularly in terms of surgeons' participation and in trials where the procedures being evaluated were significantly different. The main disadvantages identified were methodological (e.g. the potential for surgeons carrying out one of the trial procedure being systematically different) and operational (e.g. the need to 'transfer' patients between surgeons with potential consequences for the surgeon/patient relationship).

CONCLUSION

This study suggests that the expertise-based trial design has significant potential to increase surgeon participation in trials in some settings. In other settings the standard design was generally seen as the preferable design. Particularly suitable conditions for an expertise-based design include those where the surgical procedures under evaluation are substantially different, where they are routinely delivered by different health professionals/surgeons with clear proficiencies in each; and contexts in which a multiple-surgeon model is in use and trust between the patient and surgeons can be suitably protected. The standard design was seen by most participants as the default design. Several logistical and methodological concerns remain to be addressed before the expertise-based design is likely to be more widely adopted.

The current status of decompressive craniectomy in traumatic brain injury

PURPOSE

This review describes the evidence base that has helped define the role of decompressive craniectomy (DC) in the management of patients with traumatic brain injury (TBI).

RECENT FINDINGS

The publication of two randomized trials (DECRA and RESCUEicp) has strengthened the evidence base. The DECRA trial showed that neuroprotective bifrontal DC for moderate intracranial hypertension is not helpful, whereas the RESCUEicp trial found that last-tier DC for severe and refractory intracranial hypertension can significantly reduce the mortality rate but is associated with a higher rate of disability. These findings have reopened the debate about 1) the indications for DC in various TBI subtypes, 2) alternative techniques (e.g. hinge craniotomy), 3) optimal time and material for cranial reconstruction, and 4) the role of shared decision-making in TBI care. Additionally, the role of primary DC when evacuating an acute subdural hematoma is currently undergoing evaluation in the context of the RESCUE-ASDH randomized trial.

SUMMARY

This review provides an overview of the current evidence base, discusses its limitations and presents a global perspective on the role of DC, as there is growing recognition that attention should also focus on low- and middle-income countries due to their much greater TBI burden.

Maxillary distraction osteogenesis versus orthognathic surgery for cleft lip and palate patients

BACKGROUND

Cleft lip and palate is one of the most common birth defects and can cause difficulties with feeding, speech and hearing, as well as psychosocial problems. Treatment of orofacial clefts is prolonged; it typically commences after birth and lasts until the child reaches adulthood or even into adulthood. Residual deformities, functional disturbances, or both, are frequently seen in adults with a repaired cleft. Conventional orthognathic surgery, such as Le Fort I osteotomy, is often performed for the correction of maxillary hypoplasia. An alternative intervention is distraction osteogenesis, which achieves bone lengthening by gradual mechanical distraction. This review is an update of the original version that was published in 2016.

OBJECTIVES

To provide evidence regarding the effects and long-term results of maxillary distraction osteogenesis compared to orthognathic surgery for the treatment of hypoplastic maxilla in people with cleft lip and palate.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 15 May 2018), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2018, Issue 4), MEDLINE Ovid (1946 to 15 May 2018), Embase Ovid (1980 to 15 May 2018), and LILACS BIREME Virtual Health Library (Latin American and Caribbean Health Science Information database; from 1982 to 15 May 2018). The US National Institutes of Health Trials Registry (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing maxillary distraction osteogenesis to conventional Le Fort I osteotomy for the correction of cleft lip and palate maxillary hypoplasia in non-syndromic cleft patients aged 15 years or older.

DATA COLLECTION AND ANALYSIS

Two review authors assessed studies for eligibility. Two review authors independently extracted data and assessed the risk of bias in the included studies. We contacted trial authors for clarification or missing information whenever possible. All standard methodological procedures expected by Cochrane were used.

MAIN RESULTS

We found six publications involving a total of 47 participants requiring maxillary advancement of 4 mm to 10 mm. All of them related to a single trial performed between 2002 and 2008 at the University of Hong Kong, but not all of the publications reported outcomes from all 47 participants. The study compared maxillary distraction osteogenesis with orthognathic surgery, and included participants from 13 to 45 years of age.Results and conclusions should be interpreted with caution given the fact that this was a single trial at high risk of bias, with a small sample size.The main outcomes assessed were hard and soft tissue changes, skeletal relapse, effects on speech and velopharyngeal function, psychological status, and clinical morbidities.Both interventions produced notable hard and soft tissue improvements. Nevertheless, the distraction group demonstrated a greater maxillary advancement, evaluated as the advancement of Subspinale A-point: a mean difference of 4.40 mm (95% CI 0.24 to 8.56) was recorded two years postoperatively.Horizontal relapse of the maxilla was significantly less in the distraction osteogenesis group five years after surgery. A total forward movement of A-point of 2.27 mm was noted for the distraction group, whereas a backward movement of 2.53 mm was recorded for the osteotomy group (mean difference 4.8 mm, 95% CI 0.41 to 9.19).No statistically significant differences could be detected between the groups in speech outcomes, when evaluated through resonance (hypernasality) at 17 months postoperatively (RR 0.11, 95% CI 0.01 to 1.85) and nasal emissions at 17 months postoperatively (RR 3.00, 95% CI 0.14 to 66.53), or in velopharyngeal function at the same time point (RR 1.28, 95% CI 0.65 to 2.52).Maxillary distraction initially lowered social self-esteem at least until the distractors were removed, at three months postoperatively, compared to the osteotomy group, but this improved over time and the distraction group had higher satisfaction with life in the long term (two years after surgery) (MD 2.95, 95% CI 014 to 5.76).Adverse effects, in terms of clinical morbidities, included mainly occlusal relapse and mucosal infection, with the frequency being similar between groups (3/15 participants in the distraction osteogenesis group and 3/14 participants in the osteotomy group). There was no severe harm to any participant.

AUTHORS' CONCLUSIONS

This review found only one small randomised controlled trial concerning the effectiveness of distraction osteogenesis compared to conventional orthognathic surgery. The available evidence is of very low quality, which indicates that further research is likely to change the estimate of the effect. Based on measured outcomes, distraction osteogenesis may produce more satisfactory results; however, further prospective research comprising assessment of a larger sample size with participants with different facial characteristics is required to confirm possible true differences between interventions.

Innovation in Surgery: Qualitative Analysis of the Decision-Making Process and Ethical Concerns

BACKGROUND

Surgical innovation from surgeon's standpoint has never been scrutinized as it may lead to understand and improve surgical innovation, potentially to refine the IDEAL (Idea, Development, Exploration, Assessment, Long-term Follow-up) recommendations.

METHODS

A qualitative analysis was designed. A purposive expert sampling was then performed in organ transplant as it was chosen as the ideal model of surgical innovation. Interviews were designed, and main themes included the following: definition of surgical innovation, the decision-making process of surgical innovation, and ethical dilemmas. A semistructured design was designed to analyze the decision-making process, using the Forces Interaction Model. An in-depth design with open-ended questions was chosen to define surgical innovation and ethical dilemmas.

RESULTS

Interviews were performed in 2014. Participants were 7 professors of surgery: 3 in liver transplant, 2 in heart transplant, and 2 in face transplant. Saturation was reached. They demonstrated an intuitive understanding of surgical innovation. Using the Forces Interaction Model, decision leading to contemporary innovation results mainly from collegiality, when the surgeon was previously the main factor. The patient is seemingly lesser in the decision. A perfect innovative surgeon was described (with resiliency, legitimacy, and no technical restriction). Ethical conflicts were related to risk assessment and doubts regarding methodology when most participants (4/7) described ethical dilemma as being irrelevant.

CONCLUSIONS

Innovation in surgery is teamwork. Therefore, it should be performed in specific specialized centers. Those centers should include Ethics and Laws department in order to integrate these concepts to innovative process. This study enables to improve the IDEAL recommendations and is a major asset in surgery.

Strategies for New Skill Acquisition by Practicing Surgeons

OBJECTIVE

To understand how practicing surgeons utilize available training methods, which methods are perceived as effective, and important barriers to using more effective methods.

DESIGN

Online survey designed to characterize surgeon utilization and perception of available training methods.

SETTING

Two large Midwestern academic health centers.

PARTICIPANTS

150 faculty surgeons.

METHODS

Nominal values were compared using a McNemar's Test and Likert-like values were compared using a paired t-test (IBM SPSS Statistics v. 21.0; New York, NY).

RESULTS

Survey response rate was 81% (122/150). 98% of surgeons reported learning a new procedure or technology after formal training. Many surgeons reported scrubbing in expert cases (78%) and self-directed study (66%), while few surgeons (6%) completed a mini-fellowship. The modalities used most commonly were scrubbing in expert cases (34%) and self-directed study (27%). Few surgeons (7%) believed self-directed study would be most effective, whereas 31% and 16% believed operating under supervision and mini-fellowships would be most effective, respectively. Surgeons believed more effective methods "would require too much time" or they had "confidence in their ability to implement safely."

CONCLUSIONS

Practicing surgeons use a variety of training methods when learning new procedures and technologies, and there is disconnect between commonly used training methods and those deemed most effective. Confidence in surgeon's ability was cited as a reason for this discrepancy; and surgeons found time associated with more effective methods to be prohibitive.

Assessment of the Completeness of Lymph Node Dissection Using Near-infrared Imaging with Indocyanine Green in Laparoscopic Gastrectomy for Gastric Cancer

Purpose

This study assessed the feasibility of near-infrared (NIR) imaging with indocyanine green (ICG) in investigating the completeness of laparoscopic lymph node (LN) dissection for gastric cancer.

Materials and Methods

Patients scheduled for laparoscopic gastrectomy for treating gastric cancer were enrolled in the study. After intraoperative submucosal ICG injection (0.05 mg/mL), LN dissection was performed under conventional laparoscopic light. After dissection, the LN stations of interest were examined under the NIR mode to locate any extra ICG-stained (E) tissues, which were excised and sent for pathologic confirmation. This technique was tested in 2 steps: infra-pyloric LN dissection (step 1) and review of all stations after proper radical node dissection (step 2).

Results

In step 1, 15 patients who underwent laparoscopic pylorus-preserving gastrectomy (LPPG) and 15 patients who underwent laparoscopic distal gastrectomy (LDG) were examined. Seven and 2 E-tissues were obtained during LPPG and LDG, respectively. From the retrieved E-tissues, 1 and 0 tissue obtained during LPPG and LDG, respectively, was confirmed as LN. In step 2, 20 patients were enrolled (13 D1+ dissection and 7 D2 dissection). Six E-tissues were retrieved from 5 patients, and 1 tissue was confirmed as LN in the pathologic review. Overall, 15 E-tissues were detected and removed, and 2 tissues were confirmed as LNs in the pathologic review. Both nodes were from LN station #6, with 1 case each in the LDG and LPPG groups.

Conclusions

NIR imaging may provide additional node detection during laparoscopic LN dissection for gastric cancer, especially in the infra-pyloric area.

Exploring and adjusting for potential learning effects in ROLARR: a randomised controlled trial comparing robotic-assisted vs. standard laparoscopic surgery for rectal cancer resection

Background

Commonly in surgical randomised controlled trials (RCT) the experimental treatment is a relatively new technique which the surgeons may still be learning, while the control is a well-established standard. This can lead to biased comparisons between treatments. In this paper we discuss the implementation of approaches for addressing this issue in the ROLARR trial, and points of consideration for future surgical trials.

Methods

ROLARR was an international, randomised, parallel-group trial comparing robotic vs. laparoscopic surgery for the curative treatment of rectal cancer. The primary endpoint was conversion to open surgery (binary). A surgeon inclusion criterion mandating a minimum level of experience in each technique was incorporated. Additionally, surgeon self-reported data were collected periodically throughout the trial to capture the level of experience of every participating surgeon.

Multi-level logistic regression adjusting for operating surgeon as a random effect is used to estimate the odds ratio for conversion to open surgery between the treatment groups. We present and contrast the results from the primary analysis, which did not account for learning effects, and a sensitivity analysis which did.

Results

The primary analysis yields an estimated odds ratio (robotic/laparoscopic) of 0.614 (95% CI 0.311, 1.211; p = 0.16), providing insufficient evidence to conclude superiority of robotic surgery compared to laparoscopic in terms of the risk of conversion to open.

The sensitivity analysis reveals that while participating surgeons in ROLARR were expert at laparoscopic surgery, some, if not all, were still learning robotic surgery. The treatment-effect odds ratio decreases by a factor of 0.341 (95% CI 0.121, 0.960; p = 0.042) per unit increase in log-number of previous robotic operations performed by the operating surgeon. The odds ratio for a patient whose operating surgeon has the mean experience level in ROLARR – 152.46 previous laparoscopic, 67.93 previous robotic operations – is 0.40 (95% CI 0.168, 0.953; p = 0.039).

Conclusions

In this paper we have demonstrated the implementation of approaches for accounting for learning in a practical example of a surgery RCT analysis. The results demonstrate the value of implementing such approaches, since we have shown that without them the ROLARR analysis would indeed have been confounded by the learning effects.

Trial registration

International Standard Randomised Controlled Trial Number (ISRCTN) registry, ID: ISRCTN80500123. Registered on 27 May 2010.

Anterior colporrhaphy: a standard operation? Systematic review of the technical aspects of a common procedure in randomized controlled trials

INTRODUCTION

Anterior colporrhaphy (AC) is considered a standard procedure and is performed all over the world. However, not a single step of the procedure has ever been truly standardized and the rates of failure show a wide range in the literature from 0% up to 92%. The aim of this systematic review was to evaluate the differences in technique and procedure worldwide.

METHODS

We performed a systematic literature search up to March 2016 using the MeSH terms "(anterior AND (colporrhaph* or colporhaph* or repair* or cystocel*)" using Preferred Reporting Items for Sytematic Reviews and Meta-Analyses (PRISMA). Only randomized controlled trials (RCT) were included in the systematic review. A 14-point checklist was used to assess the quality of surgery undertaken in each RCT.

RESULTS

Forty RCTs from all over the world were included in the review. The indication for AC was urinary incontinence and/or pelvic organ prolapse. A detailed description of colporrhaphy was not provided even in the well-conducted RCTs. The review showed differences in each step of the procedure, in perioperative care, in anesthesia and in surgeon' experience.

CONCLUSION

Our results highlight the problems concerning AC with the great range in postoperative outcomes. There is diversity in the anatomical structures used in the repair, in perioperative care and in the procedure itself.

Minimally invasive vertical versus conventional tooth extraction: An interrupted time series study

BACKGROUND

Minimally invasive vertical tooth extraction techniques have evolved in light of the limitations of conventional tooth extraction techniques and flap surgery in preserving the alveolar bone. The authors conducted a study to obtain data on the performance of a vertical extraction system. This included comparing the need for flap surgery using the vertical extraction system versus conventional tooth extraction techniques for the extraction of anterior teeth and premolars not suitable for forceps extraction.

METHODS

The authors conducted a prospective observational clinical study of the vertical extraction system versus conventional tooth extraction techniques using an interrupted time series in line with the Idea, Development, Exploration, Assessment, Long-term Follow-up collaboration framework for surgical innovation.

RESULTS

Overall, 276 of 323 teeth (85.4%) in 240 patients were successfully extracted using the vertical extraction system. Of the 47 failures in the vertical tooth extraction cohort, 18 required flap surgery, resulting in an overall incidence of flap surgery of 5.6% (95% confidence interval [CI], 3.2% to 8.7%). During the routine care period, of the 94 anterior teeth and premolars in 78 patients, 21 teeth could not be extracted using conventional techniques and required flap surgery, leading to an incidence of flap surgery of 22% (95% CI, 14% to 32%).

CONCLUSIONS

The results suggest that the vertical extraction system may be used with a high success rate for extraction of severely destroyed teeth, and its use may lead to a marked reduction in the need for flap surgery. Randomized clinical trials are needed to confirm the findings.

PRACTICAL IMPLICATIONS

The use of a vertical extraction system may lower the incidence of flap surgery.

Orthopaedic regenerative tissue engineering en route to the holy grail: disequilibrium between the demand and the supply in the operating room

Orthopaedic disorders are very frequent, globally found and often partially unresolved despite the substantial advances in science and medicine. Their surgical intervention is multifarious and the most favourable treatment is chosen by the orthopaedic surgeon on a case-by-case basis depending on a number of factors related with the patient and the lesion. Numerous regenerative tissue engineering strategies have been developed and studied extensively in laboratory through in vitro experiments and preclinical in vivo trials with various established animal models, while a small proportion of them reached the operating room. However, based on the available literature, the current strategies have not yet achieved to fully solve the clinical problems. Thus, the gold standards, if existing, remain unchanged in the clinics, notwithstanding the known limitations and drawbacks. Herein, the involvement of regenerative tissue engineering in the clinical orthopaedics is reviewed. The current challenges are indicated and discussed in order to describe the current disequilibrium between the needs and solutions made available in the operating room. Regenerative tissue engineering is a very dynamic field that has a high growth rate and a great openness and ability to incorporate new technologies with passion to edge towards the Holy Grail that is functional tissue regeneration. Thus, the future of clinical solutions making use of regenerative tissue engineering principles for the management of orthopaedic disorders is firmly supported by the clinical need.

Effect of public reporting of surgeons' outcomes on patient selection, "gaming," and mortality in colorectal cancer surgery in England: population based cohort study

OBJECTIVE

To determine the effect of surgeon specific outcome reporting in colorectal cancer surgery on risk averse clinical practice, "gaming" of clinical data, and 90 day postoperative mortality.

DESIGN

National cohort study.

SETTING

English National Health Service hospital trusts.

POPULATION

111 431 patients diagnosed as having colorectal cancer from 1 April 2011 to 31 March 2015 included in the National Bowel Cancer Audit.

INTERVENTION

Public reporting of surgeon specific 90 day mortality in elective colorectal cancer surgery in England introduced in June 2013.

MAIN OUTCOME MEASURES

Proportion of patients with colorectal cancer who had an elective major resection, predicted 90 day mortality based on characteristics of patients and tumours, and observed 90 day mortality adjusted for differences in characteristics of patients and tumours, comparing patients who had surgery between April 2011 and June 2013 and between July 2013 and March 2015.

RESULTS

The proportion of patients with colorectal cancer undergoing major resection did not change after the introduction of surgeon specific public outcome reporting (39 792/62 854 (63.3%) before versus 30 706/48 577 (63.2%) after; P=0.8). The proportion of these major resections categorised as elective or scheduled also did not change (33 638/39 792 (84.5%) before versus 25 905/30 706 (84.4%) after; P=0.5). The predicted 90 day mortality remained the same (2.7% v 2.7%; P=0.3), but the observed 90 day mortality fell (952/33 638 (2.8%) v 552/25 905 (2.1%)). Change point analysis showed that this reduction was over and above the existing downward trend in mortality before the introduction of public outcome reporting (P=0.03).

CONCLUSIONS

This study did not find evidence that the introduction of public reporting of surgeon specific 90 day postoperative mortality in elective colorectal cancer surgery has led to risk averse clinical practice behaviour or "gaming" of data. However, its introduction coincided with a significant reduction in 90 day mortality.

Failed Randomized Clinical Trials in Radiation Oncology: What Can We Learn?

PURPOSE

Randomized clinical trials (RCTs) are essential to evidence-based medicine, yet a significant proportion fail to be completed. In radiation oncology, factors contributing to trial failure are not well understood. We sought to compare completed and incomplete clinical trials involving radiation therapy (RT) to identify predictors of trial failure.

METHODS AND MATERIALS

We undertook a review of ClinicalTrials.gov to identify RCTs involving RT. Eligible trials mandated external beam RT in ≥1 arm of the study and were registered between September 27, 2007, and December 31, 2010. Univariate and multivariate logistic regression analyses were performed to determine factors predictive of trial failure.

RESULTS

We included 134 eligible studies, of which 94 (70.1%) were successful and 40 (29.9%) failed. The reasons for trial failure were categorized as follows: lack of accrual (57.5%), inadequate funding (15.0%), drug unavailability (7.5%), interim data-monitoring report recommendations (7.5%), and other (12.5%). Over time, significantly more trials were failing to be completed (P = .010), with rates increasing from 11.8% (before 2007) to 34.0% (2007-2008) to 39.5% (2009-2012). On univariate analysis, predictors of failure were trials with a surgical comparator (odds ratio [OR], 8.12; P = .013), government sponsorship (vs non-government; OR, 3.67; P = .025), inclusion of a safety endpoint (OR, 2.85; P = .022), and studies starting after 2006 (P = .033). On multivariate analysis, surgical trials were strongly predictive of failure (OR, 12.30; P = .025) while behavioral trials were associated with success (OR, 0.11; P = .045).

CONCLUSIONS

RT RCTs involving ≥1 surgical arms are at a very high risk of failure, with 75% failing to be completed. In contrast, behavioral studies are associated with study completion, with 94% of studies being successful. Future RT trials involving surgical interventions should consider novel methods to reduce the risk of trial failure.

Oncologic Equivalence of Minimally Invasive Lobectomy: The Scientific and Practical Arguments

BACKGROUND

Despite the slow adoption of minimally invasive lobectomy (MIL), it is now a preferred approach for early lung cancer. Nevertheless, ongoing concerns about MIL oncologic effectiveness has led to calls for prospective, randomized trials.

METHODS

Retrospective analysis of on-line databases, collected readings, and other scholarly experiences of the experienced authors were used to construct this review. All available reports that contained long-term survival comparisons for open versus MIL were tabulated.

RESULTS

The preponderance of limited randomized and numerous large propensity-matched database analyses indicate equivalent or improved long-term MIL survival for early-stage disease. MIL lymph node dissection quality has been challenged; however, this was attributed to MIL avoidance of central tumors in early reports. Although technical inadequacies for MIL should be amplified for advanced cancer resections, early reports show no such concern. In fact, for special populations such as older, frail patients, evidence is much stronger that MIL confers a survival advantage.

CONCLUSIONS

MIL is an oncologically equivalent operation with substantially less morbidity, especially in frail populations. It is reasonable to suggest that MIL should be the technique of choice, even a quality indicator, for lobectomy.

Adoption of a novel surgical innovation into clinical practice: protocol for a qualitative systematic review examining surgeon views

INTRODUCTION

Efficient adoption of clinically effective novel surgical innovations has great potential benefits for patients. Factors affecting the adoption of surgical innovation are not well understood and proposed models of adoption do not accurately correlate with historical evidence. This protocol is for a systematic review that aims to identify the qualitative evidence relating to surgeon views regarding the adoption of novel surgical innovation into clinical practice.

METHODS AND ANALYSIS

A systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance will be performed. Two independent reviewers will search the following databases: MEDLINE, Embase, Science Direct, Scopus, Web of Science and the Cochrane Library of Systematic Reviews. Inclusion criteria are studies which report on the views of surgeons who adopt a novel surgical innovation into clinical practice. Each article will be screened for inclusion and assessed according to a Critical Appraisal Skills Programme tool. Data will be synthesised and analysed according to thematic analysis. Given the anticipated yield of a small heterogeneous body of evidence meeting the eligibility criteria for the review, a narrative-based summary is planned.

ETHICS AND DISSEMINATION

This review does not require formal ethical approval as it does not involve direct patient contact or patient-identifiable data. The results of this review will be published in a peer-reviewed journal and presented at relevant conferences. The results will also inform an empirical qualitative study exploring surgeon and other stakeholder views regarding the introduction of novel surgical technology and procedures into clinical practice.

PROSPERO REGISTRATION NUMBER

CRD42017076715.

Defining Innovation in Neurosurgery: Results from an International Survey

BACKGROUND

Innovation is a part of the daily practice of neurosurgery. However, a clear definition of what constitutes innovation is lacking and opinions vary from continent to continent, from hospital to hospital, and from surgeon to surgeon.

METHODS

In this study, we distributed an online survey to neurosurgeons from multiple countries to investigate what neurosurgeons consider innovative, by gathering opinions on several hypothetical cases. The anonymous survey consisted of 52 questions and took approximately 10 minutes to complete.

RESULTS

A total of 355 neurosurgeons across all continents excluding Antarctica completed the survey. Neurosurgeons achieved consensus (>75%) in considering specific cases to be innovative, including laser resection of meningioma, focused ultrasonography for tumor, oncolytic virus, deep brain stimulation for addiction, and photodynamic therapy for tumor. Although the new dura substitute case was not considered innovative, there was consensus among neurosurgeons indicating that institutional review board approval was still necessary to maintain ethical standards. Furthermore, although 90% of neurosurgeons considered an oncolytic virus for glioblastoma multiforme to be innovative, only 78% believed that institutional review board approval was necessary before treatment.

CONCLUSIONS

Our results indicate that innovation is a heterogeneous concept among neurosurgeons that necessitates standardization to ensure appropriate patient safety without stifling progress. We discuss both the ethical drawbacks of not having a clear definition of innovation and the challenges in achieving a unified understanding of innovation in neurosurgery and offer suggestions for uniting the field.

UK FASHIoN: feasibility study of a randomised controlled trial of arthroscopic surgery for hip impingement compared with best conservative care

BACKGROUND

Femoroacetabular impingement (FAI) is a syndrome of hip or groin pain associated with shape abnormalities of the hip joint. Treatments include arthroscopic surgery and conservative care. This study explored the feasibility of a randomised controlled trial to compare these treatments.

OBJECTIVES

The objectives of this study were to estimate the number of patients available for a full randomised controlled trial (RCT); to explore clinician and patient willingness to participate in such a RCT; to develop consensus on eligibility criteria, surgical and best conservative care protocols; to examine possible outcome measures and estimate the sample size for a full RCT; and to develop trial procedures and estimate recruitment and follow-up rates.

METHODS

Pre-pilot work: we surveyed all UK NHS hospital trusts (n = 197) to identify all FAI surgeons and to estimate how much arthroscopic FAI surgery they performed. We interviewed a purposive sample of 18 patients, 36 physiotherapists, 18 surgeons and two sports physicians to explore attitudes towards a RCT and used consensus-building methods among them to develop treatment protocols and patient information. Pilot RCT: we performed a pilot RCT in 10 hospital trusts. Patients were randomised to receive either hip arthroscopy or best conservative care and then followed up at 3, 6 and 12 months using patient-reported questionnaires for hip pain and function, activity level, quality of life, and a resource-use questionnaire. Qualitative recruitment intervention: we performed semistructured interviews with all researchers and clinicians involved in the pilot RCT in eight hospital trusts and recorded and analysed diagnostic and recruitment consultations with eligible patients.

RESULTS

We identified 120 surgeons who reported treating at least 1908 patients with FAI by hip arthroscopy in the NHS in the financial year 2011/12. There were 34 hospital trusts that performed ≥ 20 arthroscopic FAI operations in the year. We found that clinicians were positive about a RCT: only half reported equipoise, but most said that they would be prepared to randomise patients. Patients strongly supported a RCT, but expressed concerns about its design; these were used to develop patient information for the pilot RCT. We developed a surgical protocol and showed that this could be used in a RCT. We developed a physiotherapy-led exercise-based package of best conservative care called 'personalised hip therapy' and showed that this was practicable. In the pilot RCT, we recruited 42 out of 60 eligible patients (70%) across nine sites. The mean duration and recruitment rate across all sites were 4.5 months and one patient per site per month, respectively. The lead site recruited for the longest period (9.3 months) and accrued the largest number of patients (2.1 patients per month). We recorded and analysed 84 diagnostic and recruitment consultations in 60 patients and used these to develop a model for an optimal recruitment consultation. We identified the International Hip Outcome Tool at 12 months as an appropriate outcome measure and estimated the sample size for a full trial as 344 participants: a number that could be recruited in 25 centres over 18 months.

CONCLUSION

We have demonstrated that it is feasible to perform a RCT to establish the clinical effectiveness of hip arthroscopy compared with best conservative care for FAI. We have designed a full trial and developed and tested procedures for it, including an innovative approach to recruitment. We propose that a full trial be implemented.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.