A positive surgical margin (PSM) following cancer resection oftentimes necessitates adjuvant treatments and carries significant financial and prognostic implications. We sought to compare PSM rates ...for the ten most common solid cancers in the United States, and to assess trends over time. Over 10 million patients were identified in the National Cancer Data Base from 1998-2012, and 6.5 million had surgical margin data. PSM rates were compared between two time periods, 1998-2002 and 2008-2012. PSM was positively correlated with tumor category and grade. Ovarian and prostate cancers had the highest PSM prevalence in women and men, respectively. The highest PSM rates for cancers affecting both genders were seen for oral cavity tumors. PSM rates for breast cancer and lung and bronchus cancer in both men and women declined over the study period. PSM increases were seen for bladder, colon and rectum, and kidney and renal pelvis cancers. This large-scale analysis appraises the magnitude of PSM in the United States in order to focus future efforts on improving oncologic surgical care with the goal of optimizing value and improving patient outcomes.
Transoral robotic surgery (TORS) utilizing the da Vinci robotic system has opened a new era for minimally-invasive surgery (MIS) in Otolaryngology-Head and Neck Surgery. Awareness of the historical ...steps in developing robotic surgery (RS) and understanding its current application within our field can help open our imaginations to future of the surgical robotics. We compiled a historical perspective on the evolution of surgical robotics, the road to the da Vinci surgical system, and conducted a review of TORS regarding clinical applications and limitations, prospective clinical trials and current status in Japan. We also provided commentary on the future of surgical robotics within our field. Surgical robotics grew out of the pursuit of telerobotics and the advances in robotics for non-medical applications. Today in our field, cancers and diseases of oropharynx and supraglottis are the most common indications for RS. It has proved capable of preserving the laryngopharyngeal function without compromising oncologic outcomes, and reducing the intensity of adjuvant therapy. TORS has become a standard modality for MIS, and will continue to evolve in the future. As robotic surgical systems evolve with improved capabilities in visual augmentation, spatial navigation, miniaturization, force-feedback and cost-effectiveness, we will see further advances in the current indications, and an expansion of indications. By promoting borderless international collaborations that put 'patients first', the bright future of surgical robotics will synergistically expand to the limits of our imaginations.
Background
Round trip signal latency, or time delay, is an unavoidable constraint that currently stands as a major barrier to safe and efficient remote telesurgery. While there have been significant ...technological advancements aimed at reducing the time delay, studies evaluating methods of mitigating the negative effects of time delay are needed. Herein, we explored instrument motion scaling as a method to improve performance in time-delayed robotic surgery.
Methods
This was a robotic surgery user study using the da Vinci Research Kit system. A ring transfer task was performed under normal circumstances (no added time delay), and with 250 ms, 500 ms, and 750 ms delay. Robotic instrument motion scaling was modulated across a range of values (− 0.15, − 0.1, 0, + 0.1, + 0.15), with negative values indicating less instrument displacement for a given amount of operator movement. The primary outcomes were task completion time and total errors. Three-dimensional instrument movement was compared against different motion scales using dynamic time warping to demonstrate the effects of scaling.
Results
Performance declined with increasing time delay. Statistically significant increases in task time and number of errors were seen at 500 ms and 750 ms delay (
p
< 0.05). Total errors were positively correlated with task time on linear regression (
R
= 0.79,
p
< 0.001). Under 750 ms delay, negative instrument motion scaling improved error rates. Negative motion scaling trended toward improving task times toward those seen in non-delayed scenarios. Improvements in instrument path motion were seen with the implementation of negative motion scaling.
Conclusions
Under time-delayed conditions, negative robotic instrument motion scaling yielded fewer surgical errors with slight improvement in task time. Motion scaling is a promising method of improving the safety and efficiency of time-delayed robotic surgery and warrants further investigation.
Background
Since the conception of robotic surgery, remote telesurgery has been a dream upon which incredible technological advances haven been built. Despite the considerable enthusiasm for, there ...have been few published studies of remote telesurgery on humans.
Methods
We performed a systematic review of the English literature (PubMed, EMbase, Inspec & Compendex and Web of Science) to report studies of remote telesurgery in humans. Keywords included telesurgery, remote surgery, long-distance surgery, and telerobotics. Subjects had to be human (live patients or cadavers). The operating surgeon had to be remote from the patient, separated by more than one kilometer. The article had to explicitly report the use of a long-distance telerobotic technique. Articles that focused on telepresence or tele-mentoring were excluded.
Results
The study included eight articles published from 2001 to 2020. One manuscript (1 subject) described remote surgery on a cadaver model, and the other seven were on live humans (72 subjects). Procedure types included percutaneous, endovascular, laparoscopic, and transoral. Communication methods varied, with the first report using a telephone line and the most recent studies using a 5G network. Six of the studies reported signal latency as a single value and it ranged from 28 ms to 280 ms.
Conclusions
Few studies have described remote telesurgery in humans, and there is considerable variability in robotic and communication methods. Future efforts should work to improve reporting of signal latency and follow careful research methodology.
Background
To investigate the feasibility of transoral robotic surgery (TORS) supraglottic laryngectomy (SGL) using a next‐generation flexible surgical robot.
Methods
Preclinical human cadaver ...anatomic study of TORS SGL via en bloc resection.
Results
A single‐port robotic surgical system (da Vinci Sp, Intuitive Surgical, Inc., Sunnyvale, California) provided sufficient access, reach, and visualization to perform TORS SGL. Access and exposure were achieved with a standard laryngo‐pharyngoscope retractor. The remote center of the robotic system was located 10 cm from the maxillary alveolus. Three surgical instruments and one flexible camera could be deployed with minimal collision or restriction of arm movement.
Conclusions
Routine resection supraglottic cancers through TORS have been hindered by challenging exposure and visualization and limited instrument maneuverability deep within the laryngopharyngeal complex. This preclinical feasibility study demonstrates the technical feasibility for TORS SGL using a next‐generation flexible surgical robot.
Shortening the time from surgery to the start of radiation (TS-RT) is a consideration for physicians and patients. Although the National Comprehensive Cancer Network recommends radiation to start ...within 6 weeks, a survival benefit with this metric remains controversial.
To determine the association of delayed TS-RT with overall survival (OS) using a large cancer registry.
In this observational cohort study, 25 216 patients with nonmetastatic stages III to IV head and neck cancer were identified from the National Cancer Database (NCDB).
Patients received definitive surgery followed by adjuvant radiation therapy, with an interval duration defined as TS-RT.
Overall survival as a function of TS-RT and the effect of clinicopathologic risk factors and accelerated fractionation.
We identified 25 216 patients with nonmetastatic squamous cell carcinoma of the head and neck. There were 18 968 (75%) men and 6248 (25%) women and the mean (SD) age of the cohort was 59 (10.9) years. Of the 25 216 patients, 9765 (39%) had a 42-days or less TS-RT and 4735 (19%) had a 43- to 49-day TS-RT. Median OS was 10.5 years (95% CI, 10.0-11.1 years) for patients with a 42-days or less TS-RT, 8.2 years (95% CI, 7.4-8.6 years; absolute difference, -2.4 years, 95% CI, -1.5 to -3.2 years) for patients with a 43- to 49-day TS-RT, and 6.5 years (95% CI, 6.1-6.8 years; absolute difference, -4.1 years, 95% CI, -3.4 to -4.7 years) for those with a 50-days or more TS-RT. Multivariable analysis found that compared with a 42-days or less TS-RT, there was not a significant increase in mortality with a 43- to 49-day TS-RT (HR, 0.98; 95% CI, 0.93-1.04), although there was for a TS-RT of 50 days or more (HR, 1.07; 95% CI, 1.02-1.12). A significant interaction was identified between TS-RT and disease site. Subgroup effect modeling found that a delayed TS-RT of 7 days resulted in significantly worse OS for patients with tonsil tumors (HR, 1.22; 95% CI, 1.05-1.43) though not other tumor subtypes. Accelerated fractionation of 5.2 fractions or more per week was associated with improved survival (HR, 0.93; 95% CI, 0.87-0.99) compared with standard fractionation.
Delayed TS-RT of 50 days or more was associated with worse overall survival. The multidisciplinary care team should focus on shortening TS-RT to improve survival. Unavoidable delays may be an indication for accelerated fractionation or other dose intensification strategies.
Background
Telehealth postoperative visits are an attractive strategy to minimize exposure, especially during the SARS‐CoV‐2 (COVID‐19) pandemic. The use of a surgical drain often prevents this ...minimal‐exposure approach in that patients return to the outpatient clinic for drain removal.
Methods and Results
Following unilateral neck dissection, the customary closed‐suction drain was replaced with a self‐removing, passive drain dressing to facilitate same‐day discharge and telehealth postoperative follow‐up. The patient removed the dressing and drain at home during a telehealth visit on postoperative day 4 and she healed favorably without any signs of infection or seroma.
Conclusions
When thoughtfully applied in the appropriate clinical context, small practice adaptations like this can facilitate telehealth solutions that diminish unnecessary exposure for patients, their caregivers, and health care staff.
Objectives
Most transoral robotic surgery (TORS) literature for HPV‐positive oropharyngeal squamous cell carcinoma (HPV‐OPC) derives from high‐volume tertiary‐care centers. This study aims to ...describe long‐term recurrence and survival outcomes among Veterans Health Administration patients.
Materials and Methods
Using the US Veterans Affairs database, we identified patients with HPV‐OPC treated with TORS between January 2010 and December 2016. Patients were stratified in risk categories: low (0–1 metastatic nodes, negative margins), intermediate (close margins, 2–4 metastatic nodes, lymphovascular or perineural invasion, pT3‐pT4 tumor), or high (positive margins, extranodal extension (ENE), and/or ≥5 metastatic nodes). Primary outcomes included overall survival (OS), disease‐specific survival (DSS), and recurrence‐free survival (RFS).
Results
The cohort included 161 patients of which 29 (18%) were low‐risk, 45 (28%) intermediate‐risk, and 87 (54%) high‐risk. ENE was present in 41% of node‐positive cases and 24% had positive margins. Median follow‐up was 5.6 years (95% CI, 3.0–9.3). The 5‐year DSS for low, intermediate, and high‐risk groups were: 100%, 90.0% (95% CI, 75.4–96.1%), and 88.7% (95% CI, 78.3–94.2%). Pathologic features associated with poor DSS on univariable analysis included pT3‐T4 tumors (HR 3.81, 95% CI, 1.31–11; p = 0.01), ≥5 metastatic nodes (HR 3.41, 95% CI, 1.20–11; p = 0.02), and ENE (HR 3.53, 95% CI, 1.06–12; p = 0.04). Higher 5‐year cumulative incidences of recurrence were observed in more advanced tumors (pT3‐T4, 33% 95% CI, 14–54% versus pT1‐T2, 13% 95% CI, 8–19%; p = 0.01).
Conclusions
In this nationwide study, patients with HPV‐OPC treated with TORS followed by adjuvant therapy at Veterans Affairs Medical Centers demonstrated favorable survival outcomes comparable to those reported in high‐volume academic centers and clinical trials.
Level of Evidence
4 Laryngoscope, 134:207–214, 2024
Using the US Veterans Affairs database, we identified 161 patients with HPV‐positive oropharyngeal carcinoma treated with TORS of which 29 (18%) were low‐risk, 45 (28%) intermediate‐risk, and 87 (54%) high‐risk. TORS followed by adjuvant treatment revealed 5‐year DSS of 100%, 90%, and 89% for low, intermediate, and high‐risk patients. ENE, pT3/T4 tumor, and >5 pathologic lymph nodes were associated with poor DSS. Cumulative incidence of first recurrence was 17%, 18%, and 13% and of distant metastasis was 0%, 12%, and 8%.
Age at diagnosis is incorporated into all relevant staging systems for differentiated thyroid carcinoma (DTC). There is growing evidence that a specific age cutoff may not be ideal for accurate risk ...stratification. We sought to evaluate the interplay between age and oncologic variables in patients with DTC using the largest cohort to date.
The Surveillance, Epidemiology, and End RESULTS (SEER) database was queried to identify patients with DTC as their only malignancy for the period 1973 to 2009. Multivariate analyses using a range of age cutoffs and age subgroupings were utilized in order to search for an optimal age that would provide the most significant risk stratification between young and old patients. The primary outcome was disease-specific survival (DSS) and covariates included: age, race, sex, tumor/nodal/metastasis (TNM) stage, decade of diagnosis, and radioactive iodine therapy.
A total of 85,740 patients were identified. Seventy-six percent of patients were American Joint Committee on Cancer (AJCC) stage I, 8% were stage II, 7% were stage III, and 8% were stage IV. Age over 45 years (hazard ratio HR 19.2, p<0.001) and metastatic disease (HR 13.1, p<0.001) were the strongest predictors of DSS. Other factors that significantly predicted DSS included: not receiving radioactive iodine (RAI; HR 1.3, p=0.002), T3 (HR 2.6, p<0.001), and T4 disease (HR 3.3, p<0.001), and nodal spread (HR 2.6 to 3.3, p<0.001). Female sex showed a significant protective effect (HR 0.7, p=0.001). Adjusting the age-group cutoff from 25 to 55 years showed consistently high HRs for advanced age, without a distinct change at any point. Comparing HRs for T, N, and M stage between young and old patient subgroups showed that advanced disease increased the risk for DSS regardless of age, and was oftentimes a worse prognosticator in young patient groups.
The contribution of age at diagnosis to a patient's DSS is considerable, but there is no age cutoff that affords any unique risk-stratification in patients with DTC.
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