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Journal Club 28/2/2019 (Thread closed)

Discussion Edit

Journal Club
2

 

xenia sara
6:29 pm
Hello all, welcome to the second Journal Club of 2019!

 

Daniel Lewis
6:30 pm
Hi all

 

suhaibamin
6:30 pm
Hello everyone

 

Saad Salman
6:30 pm
Hey

 

xenia sara
6:30 pm
Before we begin may I ask everyone to put their full name and email for certificates of participation in Journal club

 

Saad Salman
6:31 pm
Muhammad Saad Salman

 

wkoubeh1
6:31 pm
Warren Koubeh. wkoubeh1@gmail.com

 

suhaibamin
6:31 pm
Mohammed Suhaib Aminsuhaib.amin@students.salegrammar.co.uk

 

Saad Salman
6:31 pm
saad.salman@students.salegrammar.co.uk

 

suhaibamin
6:31 pm
Mohammed Suhaib Amin - suhaib.amin@students.salegrammar.co.uk

 

EdwinKoubeh
6:32 pm
Edwin Koubeh

 

EdwinKoubeh
6:32 pm
edwin.koubeh@students.salegrammar.co.uk

 

sohail
6:33 pm
Sohail Nakhuda sohail95@gmail.com

 

sohail
6:34 pm
Gayathri Suresh gayathri.suresh@student.manchester.ac.uk

 

Won
6:34 pm
Won Young Yoon won.yoon@student.manchester.ac.uk

 

xenia sara
6:36 pm
Thank you, shall we start the discussion. If anyone enters the chat from here on please feel free to put your details down

 

Daniel Lewis
6:36 pm
What did everyone think of the paper?

 

wkoubeh1
6:37 pm
I thought that it seemed to be quite a reliable paper overall and came to a clear, logical conclusion

 

sohail
6:37 pm
difficult paper to read especially compared to the last neurosurgical paper. a lot of cost analysis done, which we arent so familiar with in the NHS

 

suhaibamin
6:38 pm
Very interesting. I am intrigued to find out the figures for the UK...Dictionar

 

Sacha Chiuta
6:40 pm
hello I am Sacha sacha.chiuta@student.manchester.ac.uk

 

Daniel Lewis
6:40 pm
Very good point that this study was looking at US heathcare rather than UK, what were then main study objectives?

 

Saad Salman
6:40 pm
The paper interested me because the idea was quite clever, seemed a well balanced argument although very expensive.

 

wkoubeh1
6:40 pm
To assess whether the recent increase in the use of robotics in keyhole surgery is warranted or helpful

 

Kartik Kumar
6:41 pm
Hi Kartik here! Kartik.kumar@student.manchester.ac.uk

 

suhaibamin
6:42 pm
The paper also looked at any increased financial costs and how many resources were used.

 

Daniel Lewis
6:43 pm
So i think their primary objective was just to establish trends in usage of robotic surgery, the secondary objectives were to look at complication rate, cost etc

 

sohail
6:43 pm
primary: assess trend in the use of robotic assisted surgery in radical nephrectomies; secondary: perioperative complications, resource use and hospital costs

 

Daniel Lewis
6:44 pm
Was their methodology valid?

 

EdwinKoubeh
6:44 pm
They had a very large sample size, increasing reliability

 

wkoubeh1
6:45 pm
It is quite a recent trend in the field, so I wonder how reliable the data is. Maybe it would have been productive to have some more long term data

 

Kartik Kumar
6:45 pm
Also a large sample size for the number of hospitals! And the study spanned a time period of 12 years to help analyse trends over time

 

suhaibamin
6:46 pm
It was looked at over a 12 year period which seems reasonable

 

Daniel Lewis
6:48 pm
Do we think that the sample studied is representative of the population of renal cancer patients as a whole?

 

Saad Salman
6:48 pm
The 12 year period suggests that data would have been somewhat reliable though since robotic surgery is relatively new as compared to most other treatments it’s not as reliable as it could be.

 

EdwinKoubeh
6:48 pm
I agree that 12 years is very reasonable, however, there can occasionally be some side effects which take a long time to develop. whilst it may not apply to this specific study, secondary cancers as a result of radiotherapy can take longer

 

EdwinKoubeh
6:49 pm
Since the sample is from many different hospitals, I think this makes it represenative

 

sohail
6:49 pm
interesting method on identifying robotic v lap nephrectomies using the 'Charge Description Master', essentially the bill for the patient, as opposed to using hosp records

 

Daniel Lewis
6:52 pm
Whilst they looked at data from 416 hospitals, the hospitals were chosen based on whether they used the database or not which may have introduced bias

 

sohail
6:52 pm
probably not representative of only renal cancers as the ICD9 codes include beningn masses e.g. renal cysts, that are also indications for radical nephrectomies

 

Daniel Lewis
6:52 pm
Very good point

 

suhaibamin
6:52 pm
I agree - there may have been bias.

 

Daniel Lewis
6:53 pm
Were the patients in the two groups matched adequately for age, co-morbidities etc?

 

wkoubeh1
6:58 pm
I thought that the two groups would have similar age and other similar characteristics

 

Daniel Lewis
6:59 pm
So one of the problems with retrospective data as comapred to newly acquired propsective data is that you cant go back and match the primary data for age, gender, co-morbidities etc

 

sohail
7:00 pm
Dan Lewis, looking at table 1 (demographics), in the lap group, there are around 8300 pts of age 65+. anyone with age 60+ should have a charlson score of at least 2. but the charlson score of  2 or above is only in 4410 pts. why is this?

 

Daniel Lewis
7:01 pm
What you can do, and what they have done here is try to reduce the influence of confounding effects such as patient age etc through a sort of post hoc test called propensity matching

 

wkoubeh1
7:04 pm
I thought it was interesting that the paper raised the point that the recent increase in the use of robotics was driven by extensive marketing and competition amongst hospitals to offer the most advanced technology

 

wkoubeh1
7:04 pm
This might not be applicable to the NHS, since hospitals are not really competing with each other here

 

Kartik Kumar
7:04 pm
^probably as a result of the general healthcare system over there in the US. Patients are often seen as potential customers

 

suhaibamin
7:05 pm
It would be interesting to see the figures for the UK, especially with the current budget cuts to the NHS.

 

suhaibamin
7:06 pm
I would assume that robotics would be used substantially less frequently

 

Daniel Lewis
7:06 pm
Sohail, that is a very good point, I can only assume that they have not included age in their Charlson scoring so that they can separate the two confounding variables more easily

 

Daniel Lewis
7:07 pm
Is the increased use of robotics entirely due to marketing though do you think?

 

suhaibamin
7:07 pm
But this shouldn't be a problem as there was little difference in problems between the two

 

suhaibamin
7:08 pm
Probably also due to how technology has advanced and become more mainstream over the years

 

Daniel Lewis
7:09 pm
It may also reflect surgeons over their training becoming more comfortable with the technique and thereby using it more frequently

 

Saad Salman
7:09 pm
I think it’s not only just marketing other factors play into it, most advancements today are due to interest of people and doctors in technology

 

sohail
7:10 pm
various reasons including: public perception of "modern healthcare", younger trainees wanting a varied skillset

 

Daniel Lewis
7:11 pm
Are there any issues you think in pooling complication data/ operating time data from twelve years on a new technique?

 

sohail
7:12 pm
figure 1 i thought was v interesting to see the plateau in open surgeries. do you think this plateau is due to older consultants still prefering open approach that they trained with?

 

Daniel Lewis
7:13 pm
That is a good point, I suspect it miay be partly that but also may represent the cohort of renal tumours not amenable to laparoscopic or robotic resection

 

sohail
7:13 pm
that's a really good point Dan, was thinking of that. would be it better to pool data in a 3 or 5 year period

 

sohail
7:14 pm
risks of complications from surgery in 2004 is going to be massively different to risks in 2014

 

suhaibamin
7:14 pm
I would propose pooling the data in 5 year periods

 

Daniel Lewis
7:16 pm
One problem with pooling data from twelve years especially if it includes the same surgeon cohort is that the complication rate will go down, so it depends on the question being asked

 

Saad Salman
7:16 pm
Pooling in 5 year periods would be more beneficial as the longer it is the better

 

Daniel Lewis
7:17 pm
It may be in this case that the complication rate/operating time from robotic surgery is overestimated through including early years 'training' cases

 

wkoubeh1
7:18 pm
But wouldn't this be the same for both the surgery with and without robotics? In theory, would the two not balance each other out

 

sohail
7:19 pm
no because surgery without robotics has been practised for many years prior to robotics being introduced

 

Saad Salman
7:20 pm
I agree with sohail, doctors have more experience with surgeries that have been practised on renal procedures

 

sohail
7:20 pm
has a similar study been done in the UK? taking the above into account?

 

suhaibamin
7:20 pm
But robotics have a less likely chance of making an accidental mistake.

 

Daniel Lewis
7:21 pm
I may have missed it but I'm not sure this paper discussed the number of training years of the operating surgeons between the two groups

 

suhaibamin
7:21 pm
I agree with warren

 

Saad Salman
7:22 pm
You can’t use robotics for a multitude of tasks tho @suhaib

 

sohail
7:22 pm
the robot is still controlled by the surgeon, surgeons need extra training to operate a da vinci for e.g.

 

suhaibamin
7:22 pm
Good point

 

Saad Salman
7:23 pm
Robots are only good at performing some tasks, yes they can help in these renal procedures though we shouldn’t rely on them comeplelely

 

Daniel Lewis
7:25 pm
A valid point, asnd as the authors acknowledge one of the resons for the high robotic radical nephrectomy rate may be numerous failed attempts at partial nephrectomy

 

Daniel Lewis
7:25 pm
which as they say is a more challenging operation

 

xenia sara
7:26 pm
In the final 5 minutes of this session are there any closing comments that anyone would like to make

 

Daniel Lewis
7:26 pm
Would this paper change anyone's opinion on the use of robotic surgery?

 

wkoubeh1
7:28 pm
Yes, I thought the use of robotics would have more widespread, extensive advantages over traditional methods. Having read this paper, I would say in the case of this procedure healthcare systems would be better investing their money elsewhere

 

Saad Salman
7:28 pm
I really think that the advancements robotic surgery has is impressive though I think there are clear issues which would prevent them being used around the world not just the UK. We also have to consider ethical arguemneys when using robots and consent form patients will have to sign if they were used to help doctors with procedures. Overall, they would be helpful in healthcare systems yes though others may not think so.

 

suhaibamin
7:29 pm
I feel like this is a very good and recent journal. I like how the secondary objectives included other important factors also. I would probably opt for robotic surgery due to their advantages, even if there are little differences in chance of complications. It is inevitable for robotics to have an impact within the surgical environment, it is probably better for the long run that surgeons are trained to use them more now.

 

EdwinKoubeh
7:29 pm
Whilst this paper shows that robotics might not necessarily be better than conventional treatment methods, I think that it is still worth investing in as I beliive that it still has the potential to be devlopped further

 

suhaibamin
7:29 pm
It would be interesting to see a similar journal based in the UK

 

sohail
7:29 pm
this paper may make a difference to smaller hospitals in a private setting as they could interpret it as robotics not providing financial benefit in the long run

 

xenia sara
7:31 pm
Thank you Dan for hosting this week's Journal club and thank you to all that have participated. Some interesting thoughts to close on and eloquently put too!

 

sohail
7:31 pm
given that the paper mentioned that for a robot to be cost effective, around 1 robotic nephrectomy has to be done every 3 days, which may be hard to achieve in a smaller hospital

 

Daniel Lewis
7:32 pm
Very good point, thank you all for your comments.

 

xenia sara
7:32 pm
Ok see you all in the next week weeks at the next Journal Club!

 

Saad Salman
7:33 pm
Thankyou Dr Lewis for today and Xenia.

 

EdwinKoubeh
7:33 pm
Thank you Dr Lewis

 

suhaibamin
7:34 pm
Thank you Dr Lewis

 

suhaibamin
7:34 pm
See everyone in the coming weeks

 

Saad Salman
7:34 pm
Good comments today sohail