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Article ; Online: Automatic generation of operation notes in endoscopic pituitary surgery videos using workflow recognition.

Das, Adrito / Khan, Danyal Z / Hanrahan, John G / Marcus, Hani J / Stoyanov, Danail

Intelligence-based medicine

2024 Volume 8, Page(s) 100107

Abstract: Operation notes are a crucial component of patient care. However, writing them manually is prone to human error, particularly in high pressured clinical environments. Automatic generation of operation notes from video recordings can alleviate some of the ...

Abstract	Operation notes are a crucial component of patient care. However, writing them manually is prone to human error, particularly in high pressured clinical environments. Automatic generation of operation notes from video recordings can alleviate some of the administrative burdens, improve accuracy, and provide additional information. To achieve this for endoscopic pituitary surgery, 27-steps were identified via expert consensus. Then, for the 97-videos recorded for this study, a timestamp of each step was annotated by an expert surgeon. To automatically determine whether a step is present in a video, a three-stage architecture was created. Firstly, for each step, a convolution neural network was used for binary image classification on each frame of a video. Secondly, for each step, the binary frame classifications were passed to a discriminator for binary video classification. Thirdly, for each video, the binary video classifications were passed to an accumulator for multi-label step classification. The architecture was trained on 77-videos, and tested on 20-videos, where a 0.80 weighted-
Language	English
Publishing date	2024-03-08
Publishing country	Netherlands
Document type	Journal Article
ISSN	2666-5212
ISSN (online)	2666-5212
DOI	10.1016/j.ibmed.2023.100107
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Article ; Online: Addressing the reporting chasm of artificial intelligence research: the DECIDE-AI reporting guidelines.

Hanrahan, John Gerrard / Khan, Danyal Zaman / Marcus, Hani J

BMJ surgery, interventions, & health technologies

2022 Volume 4, Issue 1, Page(s) e000154

Language	English
Publishing date	2022-07-29
Publishing country	England
Document type	Editorial
ISSN	2631-4940
ISSN (online)	2631-4940
DOI	10.1136/bmjsit-2022-000154
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Article: Process analysis of the patient pathway for automated data collection: an exemplar using pituitary surgery.

Hanrahan, John G / Carter, Alexander W / Khan, Danyal Z / Funnell, Jonathan P / Williams, Simon C / Dorward, Neil L / Baldeweg, Stephanie E / Marcus, Hani J

Frontiers in endocrinology

2024 Volume 14, Page(s) 1188870

Abstract: Introduction: Automation of routine clinical data shows promise in relieving health systems of the burden associated with manual data collection. Identifying consistent points of documentation in the electronic health record (EHR) provides salient ... ...

Abstract	Introduction: Automation of routine clinical data shows promise in relieving health systems of the burden associated with manual data collection. Identifying consistent points of documentation in the electronic health record (EHR) provides salient targets to improve data entry quality. Using our pituitary surgery service as an exemplar, we aimed to demonstrate how process mapping can be used to identify reliable areas of documentation in the patient pathway to target structured data entry interventions. Materials and methods: This mixed methods study was conducted in the largest pituitary centre in the UK. Purposive snowball sampling identified frontline stakeholders for process mapping to produce a patient pathway. The final patient pathway was subsequently validated against a real-world dataset of 50 patients who underwent surgery for pituitary adenoma. Events were categorized by frequency and mapped to the patient pathway to determine critical data points. Results: Eighteen stakeholders encompassing all members of the multidisciplinary team (MDT) were consulted for process mapping. The commonest events recorded were neurosurgical ward round entries (N = 212, 14.7%), pituitary clinical nurse specialist (CNS) ward round entries (N = 88, 6.12%) and pituitary MDT treatment decisions (N = 88, 6.12%) representing critical data points. Operation notes and neurosurgical ward round entries were present for every patient. 43/44 (97.7%) had a pre-operative pituitary MDT entry, pre-operative clinic letter, a post-operative clinic letter, an admission clerking entry, a discharge summary, and a post-operative histopathology pituitary multidisciplinary (MDT) team entries. Conclusion: This is the first study to produce a validated patient pathway of patients undergoing pituitary surgery, serving as a comparison to optimise this patient pathway. We have identified salient targets for structured data entry interventions, including mandatory datapoints seen in every admission and have also identified areas to improve documentation adherence, both of which support movement towards automation.
MeSH term(s)	Humans ; Pituitary Neoplasms/surgery ; Electronic Health Records ; Referral and Consultation
Language	English
Publishing date	2024-01-12
Publishing country	Switzerland
Document type	Journal Article ; Research Support, Non-U.S. Gov't
ZDB-ID	2592084-4
ISSN	1664-2392
ISSN	1664-2392
DOI	10.3389/fendo.2023.1188870
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Article ; Online: Distribution of case volumes in surgery: an analysis of the British Spine Registry.

Koh, Chan Hee / Muirhead, William / Khan, Danyal Zaman / Layard Horsfall, Hugo / Prezerakos, George / Sayal, Parag / Marcus, Hani J

BMJ surgery, interventions, & health technologies

2024 Volume 6, Issue 1, Page(s) e000202

Abstract: Objectives: To characterize the distribution of case volumes within a surgical field.: Design: An analysis of British Spine Registry.: Setting: 295 centers in England that conducted at least one spinal operation either within the NHS or private ... ...

Abstract	Objectives: To characterize the distribution of case volumes within a surgical field. Design: An analysis of British Spine Registry. Setting: 295 centers in England that conducted at least one spinal operation either within the NHS or private settings between 1 May 2016 and 27 February 2021. Participants: 644 surgeons. Main outcome measures: Mathematical descriptions of distributions of cases among surgeons and the extent of workforce-level case-volume concentration as a surrogate marker. Results: There were wide variations in monthly caseloads between surgeons, ranging from 0 to average monthly high of 81.8 cases. The curves showed that 37.7% of surgeons were required to perform 80% of all spinal operations, which is substantially less than in fields outside of healthcare.With the COVID-19 pandemic, the case volumes of surgeons with the highest volumes dropped dramatically, whereas those with the lowest case numbers remained nearly unchanged. This, along with the relatively low level of case-volume concentration within spinal surgery, may indicate an inevitability of at least some level of surgical care being provided by the relatively lower volume surgeons. Conclusions: While there is a reasonable degree of workforce-level case volume concentration within spinal surgery, with high volume spinal surgeons providing a large proportion of care, it is not clear whether a further concentration of case volumes into those few hands is possible or desirable.
Language	English
Publishing date	2024-03-22
Publishing country	England
Document type	Journal Article
ISSN	2631-4940
ISSN (online)	2631-4940
DOI	10.1136/bmjsit-2023-000202
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Article ; Online: Patient-specific automated cerebrospinal fluid pressure control to augment spinal wound closure: a case series using the LiquoGuard®.

Khan, Danyal Z / Tariq, Kanza / Lee, Keng Siang / Dyson, Edward W / Russo, Vittorio / Watkins, Laurence D / Russo, Antonino

British journal of neurosurgery

2024 , Page(s) 1–9

Abstract: Objective: Spinal cerebrospinal fluid (CSF) leaks are common, and their management is heterogeneous. For high-flow leaks, numerous studies advocate for primary dural repair and CSF diversion. The LiquoGuard7® allows automated and precise pressure and ... ...

Abstract	Objective: Spinal cerebrospinal fluid (CSF) leaks are common, and their management is heterogeneous. For high-flow leaks, numerous studies advocate for primary dural repair and CSF diversion. The LiquoGuard7® allows automated and precise pressure and volume control, and calculation of patient-specific CSF production rate (prCSF), which is hypothesized to be increased in the context of durotomies and CSF leaks. Methods: This single-centre illustrative case series included patients undergoing complex spinal surgery where: 1) a high flow intra-operative and/or post-operative CSF leak was expected and 2) lumbar CSF drainage was performed using a LiquoGuard7®. CSF diversion was tailored to prCSF for each patient, combined with layered spinal wound closure. Results: Three patients were included, with a variety of pathologies: T7/T8 disc prolapse, T8-T9 meningioma, and T4-T5 metastatic spinal cord compression. The first two patients underwent CSF diversion to prevent post-op CSF leak, whilst the third required this in response to post-op CSF leak. CSF hyperproduction was evident in all cases (mean >/=140ml/hr). With patient-specific CSF diversion regimes, no cases required further intervention for CSF fistulae repair (including for pleural CSF effusion), wound breakdown or infection. Conclusions: Patient-specific cerebrospinal fluid drainage may be a useful tool in the management of high-flow intra-operative and post-operative CSF leaks during complex spinal surgery. These systems may reduce post-operative CSF leakage from the wound or into adjacent body cavities. Further larger studies are needed to evaluate the comparative benefits and cost-effectiveness of this approach.
Language	English
Publishing date	2024-01-04
Publishing country	England
Document type	Journal Article
ZDB-ID	639029-8
ISSN	1360-046X ; 0268-8697
ISSN (online)	1360-046X
ISSN	0268-8697
DOI	10.1080/02688697.2023.2290101
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Zs.A 2210: Show issues

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Article: Spinal Research - A Field in Need of Standardization.

Khan, Danyal Z / Davies, Benjamin M / Kotter, Mark R N

The Journal of rheumatology

2020 Volume 47, Issue 4, Page(s) 633–634

MeSH term(s)	Humans ; Reference Standards ; Spine/diagnostic imaging
Language	English
Publishing date	2020-02-15
Publishing country	Canada
Document type	Letter ; Research Support, Non-U.S. Gov't
ZDB-ID	194928-7
ISSN	1499-2752 ; 0315-162X
ISSN (online)	1499-2752
ISSN	0315-162X
DOI	10.3899/jrheum.191225
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Zs.A 1168: Show issues			Location: Je nach Verfügbarkeit (siehe Angabe bei Bestand) bis Jg. 1994: Bestellungen von Artikeln über das Online-Bestellformular Jg. 1995 - 2021: Lesesall (1.OG) ab Jg. 2022: Lesesaal (EG)
Zs.MO 135: Show issues

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Article: Tool-tissue forces in surgery: A systematic review.

Golahmadi, Aida Kafai / Khan, Danyal Z / Mylonas, George P / Marcus, Hani J

Annals of medicine and surgery (2012)

2021 Volume 65, Page(s) 102268

Abstract: Background: Excessive tool-tissue interaction forces often result in tissue damage and intraoperative complications, while insufficient forces prevent the completion of the task. This review sought to explore the tool-tissue interaction forces exerted ... ...

Abstract	Background: Excessive tool-tissue interaction forces often result in tissue damage and intraoperative complications, while insufficient forces prevent the completion of the task. This review sought to explore the tool-tissue interaction forces exerted by instruments during surgery across different specialities, tissues, manoeuvres and experience levels. Materials & methods: A PRISMA-guided systematic review was carried out using Embase, Medline and Web of Science databases. Results: Of 462 articles screened, 45 studies discussing surgical tool-tissue forces were included. The studies were categorized into 9 different specialities with the mean of average forces lowest for ophthalmology (0.04N) and highest for orthopaedic surgery (210N). Nervous tissue required the least amount of force to manipulate (mean of average: 0.4N), whilst connective tissue (including bone) required the most (mean of average: 45.8). For manoeuvres, drilling recorded the highest forces (mean of average: 14N), whilst sharp dissection recorded the lowest (mean of average: 0.03N). When comparing differences in the mean of average forces between groups, novices exerted 22.7% more force than experts, and presence of a feedback mechanism (e.g. audio) reduced exerted forces by 47.9%. Conclusions: The measurement of tool-tissue forces is a novel but rapidly expanding field. The range of forces applied varies according to surgical speciality, tissue, manoeuvre, operator experience and feedback provided. Knowledge of the safe range of surgical forces will improve surgical safety whilst maintaining effectiveness. Measuring forces during surgery may provide an objective metric for training and assessment. Development of smart instruments, robotics and integrated feedback systems will facilitate this.
Language	English
Publishing date	2021-03-31
Publishing country	England
Document type	Journal Article ; Review
ZDB-ID	2745440-X
ISSN	2049-0801
ISSN	2049-0801
DOI	10.1016/j.amsu.2021.102268
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Article ; Online: Reducing prediction volatility in the surgical workflow recognition of endoscopic pituitary surgery.

Das, Adrito / Bano, Sophia / Vasconcelos, Francisco / Khan, Danyal Z / Marcus, Hani J / Stoyanov, Danail

International journal of computer assisted radiology and surgery

2022 Volume 17, Issue 8, Page(s) 1445–1452

Abstract: Purpose: Workflow recognition can aid surgeons before an operation when used as a training tool, during an operation by increasing operating room efficiency, and after an operation in the completion of operation notes. Although several methods have been ...

Abstract	Purpose: Workflow recognition can aid surgeons before an operation when used as a training tool, during an operation by increasing operating room efficiency, and after an operation in the completion of operation notes. Although several methods have been applied to this task, they have been tested on few surgical datasets. Therefore, their generalisability is not well tested, particularly for surgical approaches utilising smaller working spaces which are susceptible to occlusion and necessitate frequent withdrawal of the endoscope. This leads to rapidly changing predictions, which reduces the clinical confidence of the methods, and hence limits their suitability for clinical translation. Methods: Firstly, the optimal neural network is found using established methods, using endoscopic pituitary surgery as an exemplar. Then, prediction volatility is formally defined as a new evaluation metric as a proxy for uncertainty, and two temporal smoothing functions are created. The first (modal, [Formula: see text]) mode-averages over the previous n predictions, and the second (threshold, [Formula: see text]) ensures a class is only changed after being continuously predicted for n predictions. Both functions are independently applied to the predictions of the optimal network. Results: The methods are evaluated on a 50-video dataset using fivefold cross-validation, and the optimised evaluation metric is weighted-[Formula: see text] score. The optimal model is ResNet-50+LSTM achieving 0.84 in 3-phase classification and 0.74 in 7-step classification. Applying threshold smoothing further improves these results, achieving 0.86 in 3-phase classification, and 0.75 in 7-step classification, while also drastically reducing the prediction volatility. Conclusion: The results confirm the established methods generalise to endoscopic pituitary surgery, and show simple temporal smoothing not only reduces prediction volatility, but actively improves performance.
MeSH term(s)	Endoscopy ; Humans ; Neural Networks, Computer ; Workflow
Language	English
Publishing date	2022-04-01
Publishing country	Germany
Document type	Journal Article
ZDB-ID	2365628-1
ISSN	1861-6429 ; 1861-6410
ISSN (online)	1861-6429
ISSN	1861-6410
DOI	10.1007/s11548-022-02599-y
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Zs.A 6615: Show issues

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Article: Image-guidance in endoscopic pituitary surgery: an in-silico study of errors involved in tracker-based techniques.

Enkaoua, Aure / Islam, Mobarakol / Ramalhinho, João / Dowrick, Thomas / Booker, James / Khan, Danyal Z / Marcus, Hani J / Clarkson, Matthew J

Frontiers in surgery

2023 Volume 10, Page(s) 1222859

Abstract: Background: Endoscopic endonasal surgery is an established minimally invasive technique for resecting pituitary adenomas. However, understanding orientation and identifying critical neurovascular structures in this anatomically dense region can be ... ...

Abstract	Background: Endoscopic endonasal surgery is an established minimally invasive technique for resecting pituitary adenomas. However, understanding orientation and identifying critical neurovascular structures in this anatomically dense region can be challenging. In clinical practice, commercial navigation systems use a tracked pointer for guidance. Augmented Reality (AR) is an emerging technology used for surgical guidance. It can be tracker based or vision based, but neither is widely used in pituitary surgery. Methods: This pre-clinical study aims to assess the accuracy of tracker-based navigation systems, including those that allow for AR. Two setups were used to conduct simulations: (1) the standard pointer setup, tracked by an infrared camera; and (2) the endoscope setup that allows for AR, using reflective markers on the end of the endoscope, tracked by infrared cameras. The error sources were estimated by calculating the Euclidean distance between a point's true location and the point's location after passing it through the noisy system. A phantom study was then conducted to verify the in-silico simulation results and show a working example of image-based navigation errors in current methodologies. Results: The errors of the tracked pointer and tracked endoscope simulations were 1.7 and 2.5 mm respectively. The phantom study showed errors of 2.14 and 3.21 mm for the tracked pointer and tracked endoscope setups respectively. Discussion: In pituitary surgery, precise neighboring structure identification is crucial for success. However, our simulations reveal that the errors of tracked approaches were too large to meet the fine error margins required for pituitary surgery. In order to achieve the required accuracy, we would need much more accurate tracking, better calibration and improved registration techniques.
Language	English
Publishing date	2023-09-15
Publishing country	Switzerland
Document type	Journal Article
ZDB-ID	2773823-1
ISSN	2296-875X
ISSN	2296-875X
DOI	10.3389/fsurg.2023.1222859
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Article ; Online: Current and Future Advances in Surgical Therapy for Pituitary Adenoma.

Khan, Danyal Z / Hanrahan, John G / Baldeweg, Stephanie E / Dorward, Neil L / Stoyanov, Danail / Marcus, Hani J

Endocrine reviews

2023 Volume 44, Issue 5, Page(s) 947–959

Abstract: The vital physiological role of the pituitary gland, alongside its proximity to critical neurovascular structures, means that pituitary adenomas can cause significant morbidity or mortality. While enormous advancements have been made in the surgical care ...

Abstract	The vital physiological role of the pituitary gland, alongside its proximity to critical neurovascular structures, means that pituitary adenomas can cause significant morbidity or mortality. While enormous advancements have been made in the surgical care of pituitary adenomas, numerous challenges remain, such as treatment failure and recurrence. To meet these clinical challenges, there has been an enormous expansion of novel medical technologies (eg, endoscopy, advanced imaging, artificial intelligence). These innovations have the potential to benefit each step of the patient's journey, and ultimately, drive improved outcomes. Earlier and more accurate diagnosis addresses this in part. Analysis of novel patient data sets, such as automated facial analysis or natural language processing of medical records holds potential in achieving an earlier diagnosis. After diagnosis, treatment decision-making and planning will benefit from radiomics and multimodal machine learning models. Surgical safety and effectiveness will be transformed by smart simulation methods for trainees. Next-generation imaging techniques and augmented reality will enhance surgical planning and intraoperative navigation. Similarly, surgical abilities will be augmented by the future operative armamentarium, including advanced optical devices, smart instruments, and surgical robotics. Intraoperative support to surgical team members will benefit from a data science approach, utilizing machine learning analysis of operative videos to improve patient safety and orientate team members to a common workflow. Postoperatively, neural networks leveraging multimodal datasets will allow early detection of individuals at risk of complications and assist in the prediction of treatment failure, thus supporting patient-specific discharge and monitoring protocols. While these advancements in pituitary surgery hold promise to enhance the quality of care, clinicians must be the gatekeepers of the translation of such technologies, ensuring systematic assessment of risk and benefit prior to clinical implementation. In doing so, the synergy between these innovations can be leveraged to drive improved outcomes for patients of the future.
MeSH term(s)	Humans ; Pituitary Neoplasms/diagnostic imaging ; Pituitary Neoplasms/surgery ; Artificial Intelligence ; Adenoma/surgery ; Endoscopy/methods
Language	English
Publishing date	2023-05-17
Publishing country	United States
Document type	Journal Article ; Research Support, Non-U.S. Gov't
ZDB-ID	603096-8
ISSN	1945-7189 ; 0163-769X
ISSN (online)	1945-7189
ISSN	0163-769X
DOI	10.1210/endrev/bnad014
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