The IDEAL prospective development study format for reporting surgical innovations. An illustrative case study of robotic oesophagectomy

Examining the application of the IDEAL framework in the reporting and evaluation of innovative invasive procedures: secondary qualitative analysis of a systematic review

OBJECTIVES

The development of new surgical procedures is fundamental to advancing patient care. The Idea, Developments, Exploration, Assessment and Long-term (IDEAL) framework describes study designs for stages of innovation. It can be difficult to apply due to challenges in defining and identifying innovative procedures. This study examined how the IDEAL framework is operationalised in real-world settings; specifically, the types of innovations evaluated using the framework and how authors justify their choice of IDEAL study design.

DESIGN

Secondary qualitative analysis of a systematic review.

DATA SOURCES

Citation searches (Web of Science and Scopus) identified studies following the IDEAL framework and citing any of the ten key IDEAL/IDEAL_D papers.

ELIGIBILITY CRITERIA

Studies of invasive procedures/devices of any design citing any of the ten key IDEAL/IDEAL_D papers.

DATA EXTRACTION AND SYNTHESIS

All relevant text was extracted. Three frameworks were developed, namely: (1) type of innovation under evaluation; (2) terminology used to describe stage of innovation and (3) reported rationale for IDEAL stage.

RESULTS

48 articles were included. 19/48 described entirely new procedures, including those used for the first time in a different clinical context (n=15/48), reported as IDEAL stage 2a (n=8, 53%). Terminology describing stage of innovation was varied, inconsistent and ambiguous and was not defined. Authors justified their choice of IDEAL study design based on limitations in published evidence (n=36) and unknown feasibility and safety (n=32) outcomes.

CONCLUSION

Identifying stage of innovation is crucial to inform appropriate study design and governance decisions. Authors' rationale for choice of IDEAL stage related to the existing evidence base or lack of sufficient outcome data for procedures. Stage of innovation was poorly defined with inconsistent descriptions. Further work is needed to develop methods to identify innovation to inform practical application of the IDEAL framework. Defining the concept of innovation in terms of uncertainty, risk and degree of evidence may help to inform decision-making.

Prospective development study of the Versius Surgical System for use in transoral robotic surgery: an IDEAL stage 1/2a first in human and initial case series experience

PURPOSE

Transoral robotic surgery is well established in the treatment paradigm of oropharyngeal pathology. The Versius Surgical System (CMR Surgical) is a robotic platform in clinical use in multiple specialities but is currently untested in the head and neck. This study utilises the IDEAL framework of surgical innovation to prospectively evaluate and report a first in human clinical experience and single centre case series of transoral robotic surgery (TORS) with Versius.

METHODS

Following IDEAL framework stages 1 and 2a, the study evaluated Versius to perform first in human TORS before transitioning from benign to malignant cases. Iterative adjustments were made to system setup, instrumentation, and technique, recorded in accordance with IDEAL recommendations. Evaluation criteria included successful procedure completion, setup time, operative time, complications, and subjective impressions. Further evaluation of the system to perform four-arm surgery was conducted.

RESULTS

30 TORS procedures were successfully completed (15 benign, 15 malignant) without intraoperative complication or conversion to open surgery. Setup time significantly decreased over the study period. Instrumentation challenges were identified, urging the need for TORS-specific instruments. The study introduced four-arm surgery, showcasing Versius' unique capabilities, although limitations in distal access were observed.

CONCLUSIONS

TORS is feasible with the Versius Surgical System. The development of TORS-specific instruments would benefit performance and wider adoption of the system. 4-arm surgery is possible however further evaluation is required. Multicentre evaluation (IDEAL stage 2b) is recommended.

Robot-Assisted Minimally Invasive Esophagectomy versus Open Esophagectomy for Esophageal Cancer: A Systematic Review and Meta-Analysis

Simple Summary

Robot-assisted minimally invasive esophagectomy (RAMIE) constitutes a newly developed surgical technique for the treatment of resectable esophageal cancer, aiming to further improve the high morbidity and mortality associated with open esophagectomy. We performed a systematic review of the literature and compared the outcomes of RAMIE and open esophagectomy. RAMIE is a safe and feasible procedure, resulting in decreased cardiopulmonary morbidity, wound infections, blood loss, and hospital stays compared to open esophagectomy.

Abstract

Robot-assisted minimally invasive esophagectomy (RAMIE) was introduced as a further development of the conventional minimally invasive esophagectomy, aiming to further improve the high morbidity and mortality associated with open esophagectomy. We aimed to compare the outcomes between RAMIE and open esophagectomy, which remains a popular approach for resectable esophageal cancer. Ten studies meeting our inclusion criteria were identified, including five retrospective cohort, four prospective cohort, and one randomized controlled trial. RAMIE was associated with significantly lower rates of overall pulmonary complications (odds ratio (OR): 0.38, 95% confidence interval (CI): [0.26, 0.56]), pneumonia (OR: 0.39, 95% CI: [0.26, 0.57]), atrial fibrillation (OR: 0.53, 95% CI: [0.29, 0.98]), and wound infections (OR: 0.20, 95% CI: [0.07, 0.57]) and resulted in less blood loss (weighted mean difference (WMD): −187.08 mL, 95% CI: [−283.81, −90.35]) and shorter hospital stays (WMD: −9.22 days, 95% CI: [−14.39, −4.06]) but longer operative times (WMD: 69.45 min, 95% CI: [34.39, 104.42]). No other statistically significant difference was observed regarding surgical and short-term oncological outcomes. Similar findings were observed when comparing totally robotic procedures only to OE. RAMIE is a safe and feasible procedure, resulting in decreased cardiopulmonary morbidity, wound infections, blood loss, and shorter hospital stays compared to open esophagectomy.

Outcome selection, measurement and reporting for new surgical procedures and devices: a systematic review of IDEAL/IDEAL-D studies to inform development of a core outcome set

BACKGROUND

Outcome selection, measurement and reporting for the evaluation of new surgical procedures and devices is inconsistent and lacks standardization. A core outcome set may promote the safe and transparent evaluation of surgical innovations. This systematic review examined outcome selection, measurement and reporting in studies conducted within the IDEAL (Idea, Development, Exploration, Assessment and Long-term monitoring) framework to examine current practice and inform the development of a core outcome set for early-phase studies of surgical procedures/devices.

METHODS

Web of Science and Scopus citation searches were performed to identify author-reported IDEAL/IDEAL-D studies for any surgical procedure/device. Outcomes were extracted verbatim, including contextual information regarding outcome selection and measurement. Outcomes were categorized to inform a conceptual framework of outcome domains relevant to evaluating innovation.

RESULTS

Some 48 studies were identified. Outcome selection, measurement and reporting varied widely across studies in different IDEAL stages. From 1737 outcomes extracted, 22 domains specific to evaluating innovation were conceptualized under seven broad categories: procedure completion success/failure; modifications; unanticipated events; surgeons' experiences; patients' experiences; resource use specific to the innovative procedure/device; and other innovation-specific outcomes. Most innovation-specific outcomes were measured and reported in only a small number of studies.

CONCLUSION

This review highlighted the need for guidance and standardization in outcome selection and reporting in the evaluation of new surgical procedures/devices. Novel outcome domains specific to innovation have been identified to establish a core outcome set for future evaluations of surgical innovations.

Intrathoracic side-to-side esophagogastrostomy with a linear stapler and barbed suture in robot-assisted Ivor Lewis esophagectomy

Background

The side‐to‐side anastomosis was considered a promising approach to create an intrathoracic esophagogastrostomy in the minimally invasive esophagectomy, with advantages over the side‐to‐end anastomosis with aspects of no need for additional mini‐thoracotomy and lower occurrence of stenosis. The hand‐sewing anterior aspect of the anastomosis is technically challenging in the thoracoscopic Ivor Lewis esophagectomy. Here we introduced our initial experience to facilitate this approach by using the surgical robot and barbed suture.

Methods

A retrospective study of all patients underwent robot‐assisted Ivor Lewis esophagectomy with side‐to‐side esophagogastrostomy from February 2016 to September 2018 was performed. The technical details are described in this paper.

Results

A total of 37 patients (35 male and 2 female, median age of 62.7 years) were successfully treated with completely robot‐assisted Ivor Lewis esophagectomy. The median total surgical time was 340 minutes including 65 minutes to perform the anastomosis. Median estimated blood loss was 120 mL and the length of hospital stay was 10 days. There was no 90‐day mortality. Three patients suffered anastomotic leakage (8.1%,3/37), who were successfully treated without reoperation.

Conclusion

Our initial results imply that it is technically feasible to perform intrathoracic gastroesophageal anastomosis by taking advantage of a robotic system and knotless suturing.

Minimally invasive and robotic surgery in the surgical treatment of esophagogastric junction cancer

Minimally invasive surgery provides for the treatment of esophagogastric junction tumors under safe conditions, reducing respiratory and abdominal wall complications. Recovery is improved, while maintaining the oncological principles of surgery to obtain an optimal long-term outcome. It is important to have a sufficient volume of activity to progress along the learning curve with close expert supervision in order to guarantee R0 resection and adequate lymphadenectomy. Minimal invasiveness ought not become an objective in itself. Should total gastrectomy be performed, the risk of a positive proximal margin makes intraoperative biopsy compulsory, without ruling out a primary open approach. Meanwhile, minimally invasive esophagectomy has been gaining ground. Its main difficulty, the intrathoracic anastomosis, can be safely carried out either with a mechanical side-to-side suture or a robot-assisted manual suture, thanks to the 3-D vision and versatility of the instruments.

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.

Mediastinal lymphadenectomy for esophageal cancer: Differences between two countries, Japan and the Netherlands

Extent of mediastinal lymphadenectomy during esophagectomy is clearly different between two representative countries of the Eastern and Western world, such as Japan and the Netherlands. In Japan, a clear policy is the standard complete two- or three-field type of lymphadenectomy whereas, in the Netherlands, a limited form is usually carried out. Reasons for these differences can be found in the different types of tumor, 80% of adenocarcinomas in the West and almost 95% of squamous cell cancer in Japan. Moreover, location of the tumors, distally located in the Netherlands whereas, in Japan, the majority are located in the middle and proximal thoracic esophagus. Also, type of neoadjuvant therapy, namely chemoradiotherapy in the Netherlands, and chemotherapy in Japan, are different. Arguments for more extended mediastinal lymphadenectomy are currently challenged in the West, first by the systematic use of chemoradiotherapy as neoadjuvant therapy and, second, the retrospective analysis of large data. According to two studies, the importance of extended lymphadenectomy is shown to be relative and less clear, especially in esophageal adenocarcinomas after neoadjuvant therapy. International efforts such as the TIGER study will help to standardize and find a relationship between the type and location of esophageal cancer, use of neoadjuvant therapy, extent of lymphadenectomy and survival.

Conceptualizing treatment of uncomplicated type B dissection using the IDEAL framework

OBJECTIVE

The objective of this study was to introduce a new framework, called IDEAL (idea, development, exploration, assessment, and long-term study), to guide physicians, investigators, and regulatory agencies through the life cycle of device development and procedural refinement.

METHODS

This review describes the IDEAL framework and illustrates its application for treatment of uncomplicated type B dissection (uTBD) as an example of this process.

RESULTS

Components of IDEAL are summarized and applied to devices used to treat uTBD. Treatment of uTBD is currently in the exploration phase, with concurrent assessment and long-term study being facilitated by detailed registries.

CONCLUSIONS

The application of IDEAL to the development and monitoring of technologies standardizes the nomenclature, facilitates evidence-based practice, and enhances the innovation process.

Prevalence of haptic feedback in robot-mediated surgery: a systematic review of literature

With the successful uptake and inclusion of robotic systems in minimally invasive surgery and with the increasing application of robotic surgery (RS) in numerous surgical specialities worldwide, there is now a need to develop and enhance the technology further. One such improvement is the implementation and amalgamation of haptic feedback technology into RS which will permit the operating surgeon on the console to receive haptic information on the type of tissue being operated on. The main advantage of using this is to allow the operating surgeon to feel and control the amount of force applied to different tissues during surgery thus minimising the risk of tissue damage due to both the direct and indirect effects of excessive tissue force or tension being applied during RS. We performed a two-rater systematic review to identify the latest developments and potential avenues of improving technology in the application and implementation of haptic feedback technology to the operating surgeon on the console during RS. This review provides a summary of technological enhancements in RS, considering different stages of work, from proof of concept to cadaver tissue testing, surgery in animals, and finally real implementation in surgical practice. We identify that at the time of this review, while there is a unanimous agreement regarding need for haptic and tactile feedback, there are no solutions or products available that address this need. There is a scope and need for new developments in haptic augmentation for robot-mediated surgery with the aim of improving patient care and robotic surgical technology further.

IDEAL framework in surgical innovation applied on laparoscopic niche repair

The research objective of the current systematic literature review is to classify the laparoscopic niche repair according to the IDEAL framework of 'innovation stages' and to recommend the required research setting to facilitate safe and properly timed implementation of the technique. In doing so, we are also able to evaluate the practical applicability of the IDEAL framework. A systematic search of the available literature on laparoscopic niche repair was performed in PubMed, Embase, and the Wiley/Cochrane library. Articles were classified according to the IDEAL framework and recommendations were given on additional required research before the technique can be safely implemented. Practical applicability of the IDEAL framework was also evaluated. Introduction of laparoscopic niche repair matches Idea (1) and Development (2a), according to the stages of IDEAL framework, although most studies are retrospective and complications have not been registered structurally in a considerable number of the articles. As feasibility and safety have been more or less established and surgery has been further developed we enter stage 2b (Exploration) and need prospective trials preferably comparing the effectiveness of laparoscopic niche repair to expectant management, the current standard care. Available studies were classified with the use of the IDEAL framework, achieving an overall IDEAL stage to be 2a Development. As clinical outcomes, though poorly registered, have been substantially improved, laparoscopic niche repair needs to be carried forward by more advanced study designs.

Laparoscopic pancreatoduodenectomy combined with a novel self-assessment system and feedback discussion: a phase 1 surgical trial following the IDEAL guidelines

PURPOSE

Pancreatoduodenectomy (PD) is the standard yet complicated procedure for periampullary tumors. To introduce a laparoscopic approach for PD (Lap-PD), a robust and objective assessment system to evaluate the quality of this approach is needed. We describe a phase 1 surgical trial of Lap-PD (Registration ID: UMIN000015328) as a triad of surgery, novel self-assessment system, and feedback discussion implementing the Idea, Development, Exploration, Assessment, Long-term study (IDEAL) guidelines.

METHODS

This was a surgical phase I trial (corresponding to IDEAL stage 1) approved by the Ethics Committee of our hospital. The resection sequence was divided into 10 parts that were assessed and classified into one of four grades of achievement. Evaluation of each part was then integrated, and the whole Lap-PD was categorized into three grades of achievement. We set discontinuance criteria based on historical surgical outcome of open PD. The previous case was discussed before each new case, and measures to overcome problems were implemented. Five patients underwent Lap-PD.

RESULTS

All Lap-PDs were completed laparoscopically and reconstructed via mini-laparotomy. One patient suffered recurrent ileus requiring re-laparotomy to resolve a severe adhesion. After 1 year, no patient suffered disease recurrence or complication. Based on the self-assessment system, four Lap-PDs were successful, whereas one was rated as feasible owing to bleeding requiring conversion of resection sequence.

CONCLUSIONS

Our triad system for evaluating Lap-PD could be a useful tool for the safe introduction and maintenance of Lap-PD.

Video-assisted thoracoscopic esophagectomy: keynote lecture

Minimally invasive esophagectomy (MIE) by thoracoscopy after neoadjuvant therapy results in significant short-term advantages such as a lower incidence of pulmonary infections and a better quality of life (QoL) with the same completeness of resection. After 1 year, a better QoL is still observed for MIE in comparison with the open approach, while having the same survival. Seven issues about implementation of MIE for cancer require discussion: (1) choice of the extension of esophageal resection and use of neoadjuvant therapy; (2) reasons to approach the esophageal cancer by MIE; (3) determining the best minimally invasive approach for gastro-esophageal junction cancers; (4) implementation of evidence-based MIE; (5) standardization of the surgical anatomy of the esophagus based on MIE; (6) future lines of research of MIE; and (7) learning process. In the time of imaging-integrated surgery it is clear that the MIE approach should be increasingly implemented in all centers worldwide having an adequate volume of patients and expertise.

Practical guide to the Idea, Development and Exploration stages of the IDEAL Framework and Recommendations

BACKGROUND

Evaluation of new surgical procedures is a complex process challenged by evolution of technique, operator learning curves, the possibility of variable procedural quality, and strong treatment preferences among patients and clinicians. Preliminary studies that address these issues are needed to prepare for a successful randomized trial. The IDEAL (Idea, Development, Exploration, Assessment and Long-term follow-up) Framework and Recommendations provide an integrated step-by-step evaluation pathway that can help investigators achieve this.

METHODS

A practical guide was developed for investigators evaluating new surgical interventions in the earlier phases before a randomized trial (corresponding to stages 1, 2a and 2b of the IDEAL Framework). The examples and practical tips included were chosen and agreed upon by consensus among authors with experience either in designing and conducting IDEAL format studies, or in helping others to design such studies. They address the most common challenges encountered by authors attempting to follow the IDEAL Recommendations.

RESULTS

A decision aid has been created to help identify the IDEAL stage of an innovation from literature reports, with advice on how to design and report the IDEAL study formats discussed, along with the ethical and scientific rationale for specific recommendations.

CONCLUSION

The guide helps readers and researchers to understand and implement the IDEAL Framework and Recommendations to improve the quality of evidence supporting surgical innovation.