Robotic Head and Neck Surgery

Open and endoscopic surgery improve survival for squamous and nonsquamous cell nasopharyngeal carcinomas: An NCDB cohort study

BACKGROUND

Nasopharyngeal tumors (NPTs) are primarily treated with nonsurgical therapy. Recent studies have demonstrated endoscopic salvage surgery for NPT recurrences may improve survival relative to reirradiation. However, there are very limited data on open compared with endoscopic approaches for NPTs. We investigated whether endoscopic and open surgical approaches to the nasopharynx improve overall survival for all histologic subtypes of NPTs.

METHODS

We performed a retrospective cohort study using the National Cancer Database (NCDB). All adult patients with NPTs from 2004 to 2016 without distant metastasis who underwent treatment with curative intent were included. We extracted clinical and treatment variables to assess our primary outcome of overall survival.

RESULTS

On univariate analysis, patients undergoing endoscopic surgery, but not open surgery, had significantly improved overall survival relative to those undergoing nonsurgical treatment. Post hoc analysis demonstrated significantly improved overall survival for surgery in patients with minor salivary gland histology, but not squamous cell carcinoma (SCC) histology or by T or N classification. A Cox proportional hazards model was used for multivariate regression. After adjusting for covariates, both endoscopic and open approaches were associated with improved overall survival relative to nonsurgical treatment for all tumor types. A multivariate regression of SCC found that open surgery, but not endoscopic surgery, was significantly associated with improved overall survival.

CONCLUSION

Both endoscopic and open surgical approaches are associated with improved overall survival of patients with NPT. These findings highlight important oncologic validity as endoscopic and robotic platforms to the nasopharynx become more widely adopted.

How molecular imaging will enable robotic precision surgery : The role of artificial intelligence, augmented reality, and navigation

Molecular imaging is one of the pillars of precision surgery. Its applications range from early diagnostics to therapy planning, execution, and the accurate assessment of outcomes. In particular, molecular imaging solutions are in high demand in minimally invasive surgical strategies, such as the substantially increasing field of robotic surgery. This review aims at connecting the molecular imaging and nuclear medicine community to the rapidly expanding armory of surgical medical devices. Such devices entail technologies ranging from artificial intelligence and computer-aided visualization technologies (software) to innovative molecular imaging modalities and surgical navigation (hardware). We discuss technologies based on their role at different steps of the surgical workflow, i.e., from surgical decision and planning, over to target localization and excision guidance, all the way to (back table) surgical verification. This provides a glimpse of how innovations from the technology fields can realize an exciting future for the molecular imaging and surgery communities.

Robotic surgery may improve overall survival for T1 and T2 tumors of the hypopharynx: An NCDB cohort study

BACKGROUND

Hypopharyngeal cancer is associated with poor survival. Robotic surgery is emerging as a treatment for hypopharyngeal tumors, but no rigorous data are available to assess its effect on survival.

METHODS

The National Cancer Database (NCDB) was used to identify patients with T1 and T2 hypopharyngeal tumors undergoing robotic surgery, laser surgery, and primary radiation with or without chemotherapy from 2010 to 2016. All adult patients with available staging and no distant metastasis were included.

RESULTS

We compared 57 patients undergoing robotic surgery, 236 undergoing laser surgery, and 5,742 undergoing primary radiation. Compared to laser surgery, patients undergoing robotic surgery were significantly more likely to have negative margins, neck dissection, lower incomes, and care at an academic center. Rates of robotic surgery also significantly increased from 2010 to 2015. After multivariate regression, robotic surgery was associated with significantly improved overall survival compared to laser surgery and primary radiation.

CONCLUSION

Robotic surgery improves overall survival for T1 and T2 hypopharyngeal tumors compared to laser surgery and primary radiation in this NCDB cohort. This effect may be mediated by decreased positive margin rates relative to laser surgery. Rates of hypopharyngeal robotic surgery are expected to increase with wider adoption of robotic platforms and may improve overall survival rates for hypopharyngeal cancer.

Interest in technology among medical students early in their clinical experience

BACKGROUND

The world is in the midst of the "digital" revolution characterized by the ascendency of computerization, information systems and artificial intelligence with an emphasis on innovation and creativity. This revolution has affected current medical practice and promises to significantly impact it in the future. This requires physician's understanding and participation in adopting such technology. This study aimed to explore the role technology plays in the future career plans of medical students.

METHODS

A questionnaire examining selection criteria for medical specialty choice, criteria for choosing a post-residency job and demographic data was completed by a convenience sample of 5th-year Israeli medical students.

RESULTS

Two-hundred forty-two students (51 % men) completed the questionnaire, an 84 % response rate. Only a third (35 %) rated the specialty selection criterion "provides mechanical/ technological challenges" as important, while only 7% considered as important that a specialty requires skills in computer science. Few students were interested in post-residency positions requiring much technological knowledge (25 %) and requiring much skill with computerized information systems (13 %). Male students were significantly more interested than females in such positions and these students more often reported that they were considering careers in surgery and its subspecialties. This surgical bent was confirmed by the 42 % of students interested in post-residency positions that include time in the operating room having more interest in positions requiring much technological knowledge than the students not interested in operating room time.

CONCLUSIONS

This preliminary study demonstrated that as a group the students' expressed relatively little interest in medical specialties and post-residency positions involving technological challenges and knowledge of information (computer) science. Yet, the sub-group interested in the surgical specialties had such interests. These findings were perplexing since the students belong to Generations Y and Z who are steeped in the use of smartphones and social media. Therefore, we failed to support our hypothesis that Generation Y and Z students would be attracted to specialties and positions that provide them with technological challenges. Furthermore, medical educators need to explore this apparent lack of interest in technology in order to insure that the future physician workforce is ready to face future "digital" challenges.

Is Transoral Robotic Surgery the Best Surgical Treatment for Lingual Thyroid?: A Case-Report and Literature Review

OBJECTIVES

To highlight the specific outcomes of the current surgical procedures for lingual thyroid excision, for benign and malignant lesions.

METHODS

We carried out a systematic review of surgical treatments of lingual thyroid, according to the PRISMA method. We conducted our literature search in PubMed and Ovid. Data was collected concerning patient demographics, tumor characteristics, types of surgery performed, and specific intra- and postoperative outcomes of each procedure. Surgical procedures were classified in 4 categories: transcervical approaches, "invasive" transoral approaches (transmandibular and/or tongue splitting), "non-invasive" transoral approaches, and transoral robotic surgery. We detailed the transoral robotic surgical technique through a case report, along with a surgical video.

RESULTS

Of 373 peer-reviewed articles found, 40 provided adequate information on surgical management and outcomes for patients with lingual thyroid. "Non-invasive" transoral approaches and transoral robotic surgeries required significantly fewer tracheostomies than "invasive" transoral and transcervical approaches (P < .001), while there was no statistical difference in the rate of surgical complications between each procedure.

CONCLUSIONS

Transoral robotic surgery appears to be a feasible, effective, and fast solution for lingual thyroid excision, with excellent short- and long-term surgical outcomes.

Transoral robotic surgery in Ireland: the beginning

BACKGROUND

Transoral robotic surgery (TORS) has shown promising results in the treatment of myriad head and neck pathologies but is now most commonly used in the investigation and management of oropharyngeal squamous cell carcinoma.

AIMS

The aim of this study was to report our cases of the newly introduced TORS, particularly its role in identifying primary of unknown origin and the potential implications for patients. A literature review and our early experience should begin to debunk some of the criticisms of TORS including setup times and cost.

METHODS

Prospective data was collected from all patients undergoing transoral robotic surgery including demographics, indication, histology results in primary of unknown origin and complications.

RESULTS

We have performed 36 TORS procedures in total ranging from intermediate to major complex. Our complication rate is low, and this has improved with the passage of time. Haemorrhage rates remain at 5.6% (n = 2), and the average length of stay is 1 day. Successful identification of a primary tumour in cancer of unknown primary was 80% (n = 8).

CONCLUSIONS

We anticipate the integration of TORS into routine practice in the investigation and management of a number of ENT pathologies following robust clinical trials.

How close are we to anterior robotic skull base surgery?

PURPOSE OF REVIEW

The application of robotic surgery to anterior skull base disease has yet to be defined despite the potential for improved tumour resection with less morbidity in this region. Complex anatomy and restricted access have limited the development of robotic anterior skull base surgery.

RECENT FINDINGS

A limited number of transoral robotic surgical anterior skull base procedures have been undertaken; however, there are significant limitations to the utilization of this technology in the anterior skull base. In this article, the advantages, disadvantages and limitations of robotic anterior skull base surgery are discussed. Currently, the major limitation is the size of the robotic endoscope and of the available instrumentation. Technological advancements that provide promise for the future development of robotic anterior skull base surgery are in development, such as single-port robots, flexible instrument systems and miniaturization and growth of minimally invasive platforms.

SUMMARY

Although transnasal access to the skull base is not possible with the currently available robotic systems, promising technology does exist and is in development. Robotic anterior skull base surgery promises to provide greater access to skull base disease, improve oncologic results, reduce morbidity and to reduce the ergonomic burden on the surgeon.

Head and neck robotic surgery combined with sentinel lymph node biopsy. Fascinating, but feasible?

Robotic approaches and sentinel lymph node (SLN) biopsy are both strategies that evolved driven by the need to reduce impact of head and neck oncological surgery in terms of operative timing, morbidity, hospitalization time, and aesthetic results. A comprehensive review of the scientific literature was performed on PubMed, Embase, ResearchGate, Cochrane, and CENTRAL electronic databases with the aim to discuss the role that these two approaches can play together in the management of head and neck cancers (HNCs) of various sites. Dedicated publications on the combined robotics and SLN biopsy approaches resulted, up to now very limited, while their separated application in non-shared fields is gaining strength. However, the possibility to implement and combine technologies to minimize sequelae of head and neck surgery is an interesting and evolving topic.

Postoperative management in the Intensive Care Unit of head and neck surgery patients

Patient care after major head and neck surgery has changed in recent years. Tumors are the most common reasons for this type of surgery, though it is also used to treat benign conditions. Recent advances in equipment and surgical techniques have improved the postoperative course in this field, allowing early recovery, less pain and infection, a shorter hospital stay, and even better aesthetic results. This is due to the use of minimally invasive techniques, which are gaining relevance. Such techniques allow complex procedures in the head and neck region, through natural orifices or small incisions, with minimal damage and sequelae for the patients. Despite these advances, however, the complexity of the treatment intervention requires multidisciplinary patient management, mostly in the Intensive Care Unit, in order to monitor the possible occurrence of complications. Potential risk factors include previous comorbidity, the type of surgery involved (e.g., bilateral cervical lymphadenectomy), multiple transfusions, and the appearance of early complications requiring repeat surgery. Despite the existence of several studies, there are no standardized protocols for the postoperative period in surgeries of this kind. This causes many specialists to resort to accelerated recovery protocols (ERAS: "Enhanced Recovery After Surgery") that have already been established in other surgical specialties.

TORS excision of lingual thyroid carcinoma: Technique and systematic review

OBJECTIVE

Clinically significant lingual thyroid tissue has a prevalence of 1/3000-10,000, and in 70% of these individuals, the lingual thyroid is their only thyroid tissue. Malignant transformation is exceedingly rare. Herein, we present a case of lingual thyroid carcinoma with a systematic literature review and description of our treatment technique.

DATA SOURCES

PubMed, Ovid.

REVIEW METHOD

The primary author performed a search of the literature for reports of lingual thyroid carcinoma or ectopic thyroid carcinoma associated with the tongue. Articles that did not present novel data, presented cases of ectopic thyroid carcinoma outside the tongue, non-malignant cases, non-thyroid carcinomas, or were non-English articles were excluded. Studies were limited to those published in the last 60 years.

RESULTS

There are 39 cases reported in the literature. 23 cases occurred in females. Age at diagnosis ranged from 12 to 86; cases were more commonly diagnosed in the second decade of life, then in the 5th and 6th decades of life. Dysphagia, globus sensation, episodes of bleeding, voice changes, and presence of a neck mass were common symptoms at initial presentation. Nearly all patients underwent some form of pre-operative imaging, but practices varied as to the type of imaging. Treatment included surgical excision of the tumor in all but one case that was successfully treated with radioactive iodine therapy alone.

CONCLUSIONS

Surgeons should be aware of lingual thyroid, its presentation, workup, and carcinoma treatment. Tumors are amenable to surgical excision, possibly followed by radioactive iodine therapy. Advances in robotic and endoscopic surgery over the past decade now allow for less morbid excisions of lingual thyroid tumors.

Artificial intelligence, regenerative surgery, robotics? What is realistic for the future of surgery?

The potential of surgery lies in the technological advances that would complement it. The landscape of the field will differ depending on the time period being looked at and would no doubt include conjecture. Initial breakthroughs will need to pave the way for future medical technology and apply to the surgical sciences. Within the next 10 years we would expect to see the emergence of big data analysis, cuttingedge image processing techniques for surgical planning and better implementation of virtual and augmented reality in operating theatres for both patient care and teaching purposes. Over the next 50 to 100 years, the use of quantum computing should lead to increased automation in our healthcare systems. The inception of novel biomaterial invention and advanced genetic engineering will usher in the new age of regenerative medicine in the clinical setting. The future of surgery includes many predictions and promises, but it is apparent that the development will lead to bettering outcome and focus on patient care.