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16th June - Long-term oncologic outcomes of robotic low anterior resec ... (Thread closed)

Welcome to Scalpel's second journal club! This is a series of events that helps to educate students on how to critique an academic paper, under the careful supervision of a doctor. No experience of assessing papers or being part of a journal club is necessary, and dont worry if you missed our first one! Just come along and learn some skills that will be essential for PEP and your future career!

The paper we will dicuss on the 16th of June is comparing the use of robotics to laparascopy, and it can be accessed using the University's network / VPN. The link to the paper is below:

http://www.ncbi.nlm.nih.gov/pubmed/24662411

 

We are trying a new discussion room for our 2nd journal club.  Please let us know whether you preferred the discussion on the forum or you prefer our new discussion room.  Only registered users can access the discussion.  Login and then click the link above!

Hi everyone, thank you for attending our 2nd journal club, the discussion will begin in a few minutes, for now lets begin with some introductions; i'm Nick a 4th year for Salford

Hi everyone, Daniel here, the chair for the journal club

This is the first time trying this new discussion room as in the previous journal club people said that the lack of auto-refresh on the forum was frustrating. Sorry for any technical glitches but will try and resolve any that occur as soon as possible.

19:10dwang

Hi everyone, it's Derek here. 4th year from Salford.

Hi Dan and Derek and thanks Bradley, this new chat seems to be workking much better

19:1052637

James, 4th year, new chat format looks better

Hi I'm Sarah 3rd year from MRI

I agree the new forum seems to work much better. I guess we may as well start. What were people's thoughts on the paper?

I thought the paper was overall good, some limitations on the paper but aimed to address a gap in the knowledge available

19:14Judith

Hi Judith 3rd year Salford

19:15Judith

It was disappointing to see the conclusion reached.

Nick what do you think the limitations were ? I've never reviewed a paper before and am not quite sure what to look at specifically

19:1752637

I think this paper is a lot more thorough than the last one reviewed

19:18dwang

I thought they used a very good statistical methods of analysing this paper.

I can understand why it happened but I think it wasn't ideal that people that opted for the robotic surgery have to pay $6000 extra.. does this create a socio-economic bias?

That's a good point Nick, if you look at other surgical trials patients are often randomized on entry into the trial. As you say the determinant in this case was whether perople were willing to pay for the robotic treatment.

I thought the stats methods were good and the use of the clavien-dindo classification was good to classify the complications

Do people think the 5 yr follow up was adequate to comment on long term outcomes?

19:22dwang

Agree Nick. they also used ASA grade to classify co-morbidities prior to the surgery giving a good overview of the medical background for those participants.

Considering the similarity of the outcomes it would be nice to have some more long term survival data

i agree sarah, from the results the follow-up data was 4-80 months, why wasn't the 80 month data displayed?

and should the 4 month only follow-up have been excluded as this was a study to assess long term outcomes?

On your point Derek, it is good that they discussed ASA grades but they were not used to stratify the patients into different groups. This was donw on willingness to pay. Furthermore if you look in detail at the methods patients were told there may be increased benefit from having the robotic approach, something the study didnt support

Do people think the two procedures were fairly compared?

19:3052637

They note that there was no significant difference in ASA grades and stratifying on ASA grades might be too much of a reduction in patient groups

I thought it was controversial that the TNM stages varied so much

yea I agree nick comparing stages 1-3 is quite a stretch of severities

19:32dwang

Presumably the power of study is good enough, but it would be ideal to have similar number of patients in each group

19:3852637

This being a single centre study rules out a lot of the possible stratifications that could have been used

how do you mean?

It being single centre does limit their numbers. It is a pretty common procedure but a limiting factor is the availability of the robotic apparautus.

Which brings me on to asking do you think the results of this study would change anyone's management?

I don't think the results would change my management but I'm not sure if the results would change as robotic skills increase and new techniques are developed?

Yes I agree the results surprised me as I assumed robotic would be much better than laparoscopic

Looking at other papers in the literature there are reports that show better results with robotic surgery in terms of conversions to open surgery,. length of hospital stay and resectin margin

http://link.springer.com/article/10.1007/s00464-012-2731-4

19:4852637

If there are benefits of robotic surgery to the surgeon such as reduced risk of accidental injury etc. and advances are being made in robotic surgery then this paper could contribute towards the case for early robotics training

i agree, thanks for sharing that article dan

19:49dwang

thanks Dan

If you are a practicising surgeon with good experience of robotic techniques and a sense of improved operations and outcomes following robotic procedures I doubt this would change your management. The reeasons being, as you've said:

- Its single centre

-not randomized/ and they showed equivalence not worse outcomes

It would have been interesting to have the author's decision on this as to whether they were going to stop offering the robotic treatment to their patients as a safer more expensive option

it could be useful to offer the robotic approach in select cases

e.g. very narrow pelvic cavity

I suspect the answer would probably be no, and that is a huge weakness of this paper in that one treatment arm is financially incentivised.

That's a good point Nick, and one of the real advantages of robotic surgery is allowing a better view of the pelvic cavity leading to greater surgeon comfort with the anatomy. This is not really assessed by the outcomes in this paper

As we are approaching an hour, has anyone got any final points to make?

19:57dwang

Can you also judge whether a paper is good or not based on the number of times being cited?

Thanks to Dan and everyone for joining us tonight; If everyone leaves their emails i'll ensure you all receive a certificate

Thank you everyone. in answer to your question Derek, it can act as one judging factor. You also need to look at the Journal quality and its impact factor and whether it is being cited in a positive way. It may that its been mentioned in a review or a letter to the editor but the reviewer is actually saying their methods were flawed etc

20:01dwang

Thank you Dan.

20:02dwang

Here is my email address <email> and the name is Haoyu Wang. Thanks Nick.

20:0352637

Thank you Dan and Nick, interesting read. <email>