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Hello, everyone. I'd like to welcome you to the second edition of the Bassa Trainees Research Forum. We have five presentations lined up for this evening and I hope that you will enjoy your time spend with us. My name is Samuel Stefan. I work as a specialist doctor in, um, collective surgery in Portsmouth. And I'd like to invite my other colleagues from the, uh bustle trainees to briefly introduce themselves. Then I'm going to introduce the first speaker. Hi, everyone. My name is Mike. M, I'm a 50 a medical street at University of Liverpool and I'm currently Basso trainees research lead. I have a Chase Andrew and, uh, Harvoni. Hi, everyone. I'm Andrew. I'm the Basso trainees secretary. Great to have you with us tonight. Hi, everyone. I'm sure some of the communication lead for pastor trainees. I'm a course surgical training as well. We'll be doing a talk later. So I hope you guys enjoyed it. Nice to see you all. Hi, everyone. I'm Avni, I'm the medical student representative. I'm both your medical student, Bristol. Okay. Um, so I'd like to introduce for speaker in our, uh research forum. We have MS Shen thing. Uh, that is a plastic theme course, surgical trainee currently working at Royal Stock Hospital. I'd like to welcome uh Centene and uh ask uh in to introduce herself. Uh your, your mute. Okay. Sorry about that. Welcome. Thank you. I'm just going to share my slides. So, so we're going to have 78 minutes for the presentation and 23 minutes for a couple of questions. Hopefully. So, feel free to start when, when you're ready. Okay, thank you. Just a plating the slide. Can you see the smells? Okay. Uh This is the slides coming up for you guys. Yeah, they look good. Uh Happy for you to stop. Okay, great. Thank you. Yeah. So, hi, everyone. I'm presenting on our research on the development of a rapid PCR diagnostic test for oral cancer. This was developed in bars in a London School of Medicine dentistry. So first, I'd like to talk a bit about oral cancer and why there's a need for a rapid digital diagnostic test for it. So currently oral cancer is that tends most common cancer in the UK. Um And as you can see, uh there is uh the incidence of oral cancer has been on a steady increase for both men and women. And the trend has been observed for over three decades now, but the survival rate has not changed for the past three decades, depart despite the improvement in treatment including surgery and chemotherapy. Uh So this is a quite big problem. So, oral squamous outcast known weight, uh oh sec is responsible for 90% of all oral cancer. Uh It's associated with the consumption of alcohol, tobacco and HPV. However, actually majority of oral cancer HPV, negative. So when um or squamous cell carcinoma is diagnosed early, the five year survival rate is 85%. But this dropped down to 20% if it's uh diagnosed at an advanced stage. So, for example, involving the lymph loads. So this means that early diagnosis can increase the patient's chance of survival between 2 to 4 times. Um or a Miko's are kind of like the skin has easy access. So, despite this and the availability of diagnostic tool, um as high as two thirds of O S E C R confirmed during the late stage of the disease. So, what's the cause for this diagnostic delay? So, oral cancer is diagnosed through conventional or examination, biopsy and histopathology analysis. And histopathology is the only definitive method for um confirmation of local disease and for disease grading. So, um oral potentially malignant disorder or O P M D uh includes these pre cancer solutions such as leukoplakia and erythroplasia. And over 70% of O R C C are preceded by the potentially malignant disorders. Um and O P M D has 12% risk of malignant progression. So, currently, there is no quantitative method to assess the likelihood of um O P M D to become malignant. Um and most if not all of patient's uh with O P M D are either put on regular surveillance um or biopsied and put on variable periods of review before discharge. Which means for, for low risk patient is high cost of NHS and can cause anxiety for for high risk patient, early discharge from review can result in late presentation which increases mobility and mortality. So, um histopathology was there is quite a few ways that's currently limited in diagnosis of both O P M D and O S E C. So, firstly, histopathology is quite time consuming, especially currently, there's a very high workload everywhere. Pathologists are sometimes not in agreement with each other regarding the histopathology, grading especially of epithelial dysplasia because the grading can be very complex and the pathology is also susceptible to misdiagnosis, do the sampling error. So currently biopsy um needs to be taken for margin and course a biopsy are usually quite large between 5 to 15 millimeter taken. So therefore, only usually one biopsy is taken and O P M D can affect a large area of the mouth and can be very difficult to locate word to biopsy also. Or a squamous cell casts, normal can have a quite uh multi centric in its origin where molecular changes uh indicating malignancy do not necessary produce visible lesions that we can see. So it's not somehow possible to telework to biopsy. So, um this indicates that there is a need for a rapid reliable and quantitative molecular test to complement his histopathology to identify the high risk patient. So, um we developed a test for the diagnosis and risk stratification of the O P M D S. Uh and we called it quantitative malignancy index diagnostic system shortens accu mids. We validated this test in 535 patient's from UK, China and India and Cumin is a multiple gene expression QPCR test. So you may all be familiar with a PCR test for for COVID diagnosis. Um So, quantitative PCR and methods used for the detection and quantification of D N A R N A. Our cume it's has involved testing of 16 genes. Um And we selected these genes by analyzing genetics for O P M D and O S E C and we identify key oncogenic driver genes. Um And our teams, previous work has provided us with over for 24,000 gene expression data points. And we exploited this data point also to find to our gene panel selection. So you can see a list of genes in the right hand side here. Um Our humid test only need one millimeter square tissue sample. So like rice grain sides, we provide a malignancy index which is a score calculated in the uh algorithm you can see in the right bottom corner that indicating how likely the tissue is cancerous. Um So the entire Q mids test consists of four steps which can be carried out within 90 minutes, it's entirely possible to automate this process like many other PCR tests. So um we developed the first version of Q meds um using slightly different set of genetic marker back in 2013. So we compared the data from UK population between the two and found a significant reduction in false positive and false negative rate. So we showed that the humid test, false positive rates 4.5% and the false negative rate is 12%. And um we wanted to see if it works in different populations. So we expanded our study to include samples from China and India. And overall, we have samples from 535 patient's. So in the Chinese cohort, we can see in table uh engraft A and B, we have oral squamous cell cancer sample as well as nasal pharyngeal, nasal pharyngeal squamous cell samples. Um In the Indian cohort, you can see the graph, see we have normal oral mucosa tissue dysplasia and O S E C samples. So overall, you can see kind of the circle on the right hand side, the humid test performance for O S S detection is highly comparable in terms of sensitivity specificity accuracy. And in the bottom right corner is that A U C is a measure of diagnostic performance. Um and it's similar across the three cohorts. So this indicates that the test is not influenced by ethnicity or geographical factors. We have also shown that Um The cumin test can be used to create a tumor molecular topology for and also for margin Alice iss because we only need rice green size samples. We can take multiple tissue samples. And here you can see um in this graph uh sorry in this picture uh that the Q mid score were converted into color scales to generate a topa logical heat map displaying areas of advanced moderate as was normal tumor margins of the tissue sample. Um So, um both Q meds and histopathology involved uh analyzing tissue biopsy samples. So they are invasive and prone to miss sampling. However, uh they're both more reliable compared to other non invasive methods like uh saliva or brush biopsy. We've shown that that our cume it's has um only required very tiny fragments of biopsy tissue. So the MS sampling problem can be overcome by performing multiple punch biopsies to sample high risk area and it can be used to analyze margins. We've shown that cume it's s a has the advantage of uh documents essay has the advantage of minimizing staffing costs and, and handling errors. Um And unlike histopathology, it doesn't need careful fixation of tissue biopsy or handling. Uh humans test is fast, is reproductive and uh you can um it's amendable to high throughput. Automation doesn't really need any skilled personal personnel. So uh minimize the staffing costs human error as well as bias. And since COVID QPCR technology has advanced so much, um that is more cost effective and makes testing a lot easier. So, future validation of tumors uh would require long term prospective follow up study of the same patient's to analyze its effectiveness and reliability. Um uh in kind of real patient's. Um And we think similar QPCR test can also be apply to diagnosis of many other cancers, including ovarian long cancer, breast cancer, and prostate cancer. So that's the end of my presentation. Thank you. Sent in a very interesting presentation. I didn't know much about the oral sec. To be fair. To be honest, I'd like to, to ask you this study was done on general population or selected patient's. Uh So it was done on so for the UK cohort, it was prospective. So it's patient's that was seen in um uh kind of uh max max or a kind of clinic for the Indian cohort in China cohort. It was done retrospectively. So it was samples from patients' was diagnosed um uh or a squamous cell carcinoma. We have quite big samples which means that we can uh analyze kind of the tissue core, the margin as well as normal tissue outside of it. Uh Thank you. Any other questions from my colleagues? I can't see any in the chat, but I've got one for you sensing. Thanks very much, really interesting talk. Um Going back to those 16 genes that you're looking at as part of your essay. Do you know what the sort of penetrates of those genes are um in people with, with the relevant genetic variations. Yeah. So, um the genes includes quite lots of different kind of, uh we covered quite a bit um aspects of gene signaling, especially in moral cancer. Um And actually we changed it quite a bit from when we first developed the test in 2013. Um and we changed it by around eight genes. Um And it's basically through kind of discovery of the new genes over the past um eight years, uh looking at literature study as well as analyzing the data that we've collected previously. Um Yeah, so it's quite complex kind of calculation that we like statistical analysis that the team uh used to kind of decide which genes. Um But I can't go too much into detail just because it's a really complex process. So uh I don't completely understand kind of the the statistical side of things, right? I see because obviously, as we know cancer is a complex disease with many contributing genes. And so be interesting to know more about the effect size of each of those 16 and whether there's any ability to distinguish between people's tumor type and and therefore prognosis based on which genes are being expressed out of those. And, and sort of, yeah, we didn't look at individual profiles instead we used. So if I show you here, we'll go back to the gene panel. So you can see that they are divided into a kind of different um type of uncle genes. And instead we use the uh logarithms to give us an index. Um So we use the cut off score off for so anything above four, we would say um uh is a positive for cancer and anything below four is not. So using our log uh log a rhythm that we developed will give you index about kind of how likelihood it is a cancer. Great. Thank you. So, we're going to uh we have a third question that we're going to discuss at the end of the presentations because we have a few minutes where we total eyes, the scores with some up the scores. Uh I would like to ask like um to introduce the next speaker please. For our next speakers, we have Mr uh but Mary and Mr Montessouri, they're both clinical fellows at the Barking, Hovering and Redbridge University Trust. Hello, everyone. Um First of all, I would like to say a big thank you um to offer us this great opportunity to um do a talk on short term outcomes of D three versus D two dissection in patient's undergo undergoing open laparoscopic and robotic colectomy for right colon cancer in our trust. Um The presentation will be present by myself and my senior colleague are more. Mansouri has been um supervised by our colorectal consultant, consultant Mr Cole. Uh um A would you like to begin? Uh Yes. So my name is uh Mansourian, one of the uh senior clinical fellows uh in Queens Hospital Romford. And our trust is Barking Havering Red Bridge to University Hospital Trust. Uh as suggested by the first uh the topic slide that we're presenting the short term outcomes of uh D three versus D two dissection for uh right sided colonic cancers. And we have looked at all three approaches being open laparoscopic and robotic colectomies. Uh So, historically and still, currently, there has been a lot of debate about D two versus D three lymphadenectomy for colonic cancers. Uh In essence, if we see uh for what we call the complete metabolic excision, uh and the three lymphadenectomy, it essentially refers to mezza colic excision within uh intact fascia. And essentially, we are relying on the embryo embryonic planes. Uh uh When we take the uh ligation high, uh we aim to remove all the lymph nodes along the arterial tree. The idea what was generated was that, as we understand the total mesorectum excision TME is currently the considered a standard for rectal cancer surgery. And the TME essentially uh utilises or focuses on usage of the embryonic embryonic planes to get the intact package of the tumor. And also it's a main lymphatic drainage. So, utilizing this concept, uh that's what the concept for the CME for right sided colonic cancer or colon cancers as well. Uh if you move to the next side, please. So in 2009 W ho hamburger. Uh They published their data for the colonic sections and the data suggested uh that cmi in colonic cancers uh lead to maximize lymph node harvest. And it this essentially translated to lower local recurrence rates and overall survival. Uh And then there's another study which was conducted by one of the pathologists uh and suggested that improving the planes of dissection. Uh And when we have a good lymph node harvest, uh it leads to improved survival especially in patients with space three disease. Uh Next slide, please. So this essentially we're presenting half center short term outcomes for D three lymphadenectomy for pride, colon cancer. And we have compared it to the conventional D to approach uh for open laparoscopic and robotic uh colectomies. Uh This is we collected the data retrospectively. So, retrospective study where we examined the patient's uh undergoing right sided colon cancer treatment between January 2019 to November 2020 2022. Uh in our trust, uh If you look at the picture that we have uh just demonstrated, uh This is uh one of the pictures which is used by the Japanese Society for Cancer of colon and rectum. And they have defined the extent of lymphadenectomy for correctly cancers accordingly. Uh So it's extent for D three lymphadenectomy on the right hemicolectomy for the right colon cancer includes nodes of the root of the Isla colic that's station 203. In this picture, uh the right colic uh notes that station 213 and the medical card teres, that's 2 23 station 2 23. So that's their definition. And they've also uh explained the extent of the B three lymphadenectomy for sigmoidectomy uh for sigmoid colon cancers. And for that, they have advised uh nodes for, if you take the notes at the root of the I M A, that's, they have a demonstrated in station 2 53 in this picture, that sort of extended lymphadenectomy that's called D three for left, sorry, tumor's. Uh So I'll just pass on to uh Mr but Nori to uh further uh explain the results from our center. So our retrospective cohort, we've screened um 733 patient's which underwent colorectal redactions performed in the mentioned period of time. Uh from that 733 patient's 341 underwent uh right hemicolectomy. We excluded from our studied patient's who underwent palliative rejections or um underwent resections in uh emergency settings as a perforated tumor's which represented 27. And uh we also excluded um hemicolectomies done by uh surgeons who are not performing d free dissections. So, uh in our study, we included uh 41 patient's that are underwent um complete metabolic excision with the free lymphadenectomy. Um and 170 for patient's that underwent conventional d to um procedure. All patient's were operated by um four experienced colorectal surgeons who um possess um all free techniques as open lap and robotic. Um So, um um this uh 215 patient's uh included in the study. They, the variables are represented in this table. Um There were no statistical, as you see, there is no statistical difference in the duration of the procedure, estimated blood loss, uh post operative day one hemoglobin and requirement of blood transfusion. Also, there's no statistical difference in TMM staging of the uh both groups in terms of the post operative morbidity. Um Overall Cleveland indo grade three and four was 9.7% in D two groups and 4.87%. Indeed free group and positive status was more common. Of course, in D free group, which represented 48.78% versus 31.6% in D to the medial lymph node yield was 19 and 20 foreign D two and D three procedures respectably and there were no difference between are not resections. Um In conclusion, um I would like to say that our data demonstrates that different lymphadenectomy, it's a safe and feasible procedure in a specialized nursery centers with good patient selection, nodal harvest is increased with comparable margin of clearance. Um To study more in depth this thing, this question um we passed, our center thinks that long term randomized control trials are necessary in order to justify the implementation of this technique. Um I would like to point this out a very promising trial which is represented here in the picture is called called trial is being run by a Russian group in Moscow and um San Peters book where they published recently. Um the primary results um the short term outcomes of um the multi center randomize controlled trials comparing D two versus D free lymph node dissection for right and left open and laparoscopic. So they're short term outcome conclusion says that the free lymph node dissection is uh visible procedure and I hope the long term outcomes and surveillance will confirm um their conclusion as well. Um We would like to show to demonstrate you our standardized approach for um for complete metabolic excision and I'm sorry to interrupt you. I think we're running out of time. But, well, this is looks like a separate presentation and we're happy to include it in one of the future research forums. I'm sorry to cut you short, but we are out of time. That's okay. That's okay. Um All I want to say that um um we believe that with adequate training and supervision. Um complete music colic excision with D Freeland for adenectomy. It's visible in um tertiary centers. Thank you very much. Thank you very much for that um presentation. Uh We open up the floor for any questions from the audience. We have a question from Andrew. What was the selection criteria for patient's to have a D two or D three reception? Also? Um Basically the two dissection is being done routinely in our trust. But um the choice of CME with D free lymphadenectomy was the description of the operating surgeon. Um especially this procedure was done uh in a patient with uh nodal positive status. Uh uh And also we did consider in terms of the comorbidities. For example, if uh for the elderly frail or uh more than 75 they weren't, they were not selected for D three or extensive lymphadenectomy as well. Um Yes, of course, this may buy us the results. So that's why we consider that randomized control trial, maybe even in our center um may show different results and further studies needs to be um done um to study this question. Thank you. You have mentioned that there was no difference, no major concern in um the rate of post operative complications. Uh We have noticed in Portsmouth uh major improvements in uh robotic cases for both D two ND three compared to laparoscopic in terms of postal complications, the functioning, I'll ostomy for, for left side resections um and uh post operative length of stay. So my suggestion for continuation of your studies to segregate the results in three categories, open lap and robotic. And in this way, you'll find uh significant differences in the, in the rates of the post operative complications or outcomes. Um We will uh we basically published recently an abstract and we've got accepted for open present, open uh sorry, oral presentation in association of um uh proctology surgeons from UK. So we'll, we'll definitely publish our results uh as per your recommendation. Thank you for your presentation. I'd like to introduce our next speaker. Um uh Mr Chase. Uh ink is a urology themed course, Surgical 20 Northwest London and going to talk about virtual Relative in surgical oncology. So I'd like to invite Chase to start his presentation. Yeah, sorry. Could you see the slides? Perfect. Can you see the side? Just tracking? Yes. Yes. Yeah, perfect. So, good evening everyone. Thank you for having me here for a couple of minutes. Um Great presentations to start with from diagnostic to treatment. So I thought I might humor you guys with a bit more sort of step back. Looking at surgical oncology as a as a whole career capacities and training and how we can move forward uh in our generation and the generation forward, not only in developed countries but also in low and middle income countries. My name is Chase and more of their clinical research fellow. I work with the Global Oncology Group in King's College, London. Uh and I'm a fellow in the City of Cancer Policy. Um full time boys. I'm a cultural training uh urology training in Chelsea and Westminster Hospital. So to get us started on something maybe slightly more exciting. Uh let's have a look at this uterine vessels, okay. And, and um as I mentioned, you mentioned before, you sometimes have a little bit difficulty with with this uh step. Why is this step a little bit difficult? Uh clamps position is very important, clamping two times to create a space where you will cut and the tips of the clamp to be touching the two clients need to be touching the tips. Mhm Perfect. So you may wonder why we are talking about virtual reality and surgical oncology and maybe the link in between. And that short video is to show you how virtuality when implemented well can actually be used for surgical training and the ice growing evidence behind the use of this uh eventually build surgical capacities. So this is what this talk to be about and how we look over the over arching analysis of how this trend has been going on for the past 10 years. So as you can see here every year, we have got about 15 million people to diagnose with cancer, all kind of cancer. And all of these 80% would require at least one cancer surgery for curative or palliative purposes. Uh But as you can see, the access to safe timely and affordable surgery is highly uh limited, especially in low middle income countries, which can be as low as 5%. If you look at virtuality, it has sort of emerged itself as a epiphenomenon of its recent advancement becoming a generalized consumer product. And as a result, we become more accessible. And it makes you wonder with the high realism of environment would it actually be uh to that we can use to actually train no visa uh to pick up uh surgical dexterity, ease and skills that will eventually hopefully shorten the time in training and improve their surgical proficiency in theater. The features of virtuality has come to a stage where it has high fidelity, which means the simulation would reflect the realism of the environment that you see in real life situation. Uh That is new happy feedback where you can essentially feel, transmit the resistance through hand gear as you're wearing the Google to be immersed fully into the experience. And obviously, one of the pros when it comes to medical surgical view is that it is risk free. And so the learning itself doesn't come at the cause of harm to patient. And lastly, the improvement in technology also means that VR nausea is one thing of ancient and most of the people find it quite visible and tolerable. Now to use VR for training, obviously, the limitation with the eye is that being a very new to in the market. Uh there's still a lack of clinical evidence. And secondly, most of them are still quite costly and the access as a result is very limited. So essentially what we do here is to want to know how we are actually has been applied in the team in the theme of surgical oncology in the past 10 year, globally, across surgical specialties and modalities meaning open, minimally invasive and robotic surgeries. We want to identify the gaps through these overarching analysis, what they are and how we can close it. And that is the aim of the study as you can see here, what we did was a systematic review on the web of science. Looking at all the papers including articles and reviews that has been published between January 2011 and January 2021. We then apply the to stab you of metric filter first identifying all articles that's related to cancer with more than 100 and three key title's identifying different kinds of cancers. Uh and then further filter it through VR uh in the in the sense of virtuality and all minded uh intelligence. And as you can see that we have a good precision level with the recall rate of 9.98, which in a way slightly overestimated to have an overarching view of of, of the theme. So this is a, a flow shot of our prisma guidance. As you can see, we identify 95 studies to start with, we reviewed all of them and excluded 18 because they either are not related to oncology of er or therapy, the laboratory research we were not interested in in clinical settings, we then make sure that the eligible ones exclude the case report, literature, review, systematic review and descriptive articles with then do a full data extraction and analysis on 53 of those studies. So we break down the results into four different parts. As you can see here to start with with the cancer care pathway, we then follow onto web VIAS adopted across the across the world. We then look into sort of uh scrutinizing how VR is applied cream mortality. And lastly the characteristics of the yard that's currently in the market and what validation is behind such fee ours. So to start with the cancer care pathway, you can see here a swim lane diagram and on the uh uh columns, you will see the pathways that is following the mcmillan's pathway, which would describe most of the patient's journey through the cancer treatment and in the growth on the life, you can see the purpose of the are being applied. The highlights idea would be that most of the VRS are used in cancer treatment. And most of them focusing on surgery. If you follow that through the clinical training, you would then find that most of the ers are actually using clinical training as we expected. But there are also other applications of V R as you can see in radiotherapy educations, chemotherapy, uh applications as well as rehabilitations and pre habilitating for cancer patient's in terms of adoption of VR not surprisingly, again, North America as a continent is leading, especially with Candida and the states covering most if not all of the studies uh in that continent, followed by surprisingly maybe Asia where China actually is one of the leading uh VR players or publishes across the uh across the world and then does sort of tightly followed by uh the, the Europe as a continent. And as you can see here, low middle income countries in such continents are left behind in terms of the adoption and rate of er, in terms of surgical specialties and modality. Again, you can see here a widespread of your adoption across open and the Scorpion robotic surgeries. But I would like to draw your attention really to do things. One being that the open surgeries are mostly done by the neurosurgeons. And that is focusing on high risk uh complex surgeries that often are senior let uh in theaters setting, which many simulations, very appealing alternative to on the ground training. And if you look at under scoping and robotic surgeries, uh they are of course, technically more complex as a modality as often surgeons like human intuition to learn such device as, as a tool for to, to, to help them operate on patient. So this tell us how VR has been adopted mostly in high race operations and complex operations. Lastly, this is a rather complex slight and I'm going to go through them one after another. But before I do that, I'm gonna share the definition of most of these words uh in the chat box as you can see here, but walking through them one after another. So fidelity is essentially the level of realism of VR. In comparison to the surgery itself, high fidelity is generally explained by a VR that allows you to go through the key steps of the entire operation. While low fidelity focuses on basic psychomotor task. As you can see here, more than half or just about half of the VRS have achieved high fidelity uh level hefty feedback as I explained earlier is transmitted resistance that help you have a sense or develop a sense of hectic memory or muscle memory onto the surgery itself. And is currently in about two thirds of the VR that we have found in the past 10 years. Face validity is essentially the realism of your fully immersive environment to realize situation. And as you can see now, most of the three hours that uh you have in view simulators shows face validity very well content validity allows you to essentially be able to uh to to measure the domain that you are measuring, which basically means that the VR skills is actually that to help develop maybe economic of movements, they can test that accurately instead of testing you or maybe anatomy or the knowledge of the key steps of the surgery, perhaps construct validity is something more advanced and less VR as you can see here has achieved them. It basically in real term means that the simulations are able for you to essentially um discriminate level of expertise among surgeons. Oh So how they basically could determine or establish validity in construct validity is to get very experienced surgeons to use the V R followed by the novice surgeons to compare if their score will be different, given that they are both new to the simulations. And lastly most importantly is predictive validity where the VR simulations are able to actually show that the surgeons that are trained through the simulations has improved surgical or operative outcomes that has been proved in terms of patient outcome following the surgery in real life. In terms of how VR has been used to be validated or assess trainees, there are four main things that they do, but most popularly, you will be the objective uh structure of assessment uh of task which is commonly tested in in surgery. As you all probably know through traditional detective surgical training to VR training here and they are most uh likely to be replicable in a reliable manner as well. Psychomotor task is easier to be achieved by the same time, reliable as you can see here. What we're missing is test retest reliability, which means that the surgeons proficiency after the simulation can be test um to see if they still retain the surgical skills afterwards, which is very important to realize training as you would expect. And lastly that the assessment can be tested more by more than one individual assessor to make sure that that is crosschecked to develop external validity to the level of training. So moving from these results. It brings us into thinking about what this review is trying to tell us and how we can learn from the way or the direction of travel that the V I is taking. And the actual global cancer surgery demand that we need. Moving forward. As a generation, we divide them into four gaps. On the top left application gap is what we talked about before where VR is mostly focusing on complex as high risk operations naturally because there are more complex procedures that surgeons lack human intuitive for as such become bonafide early adopter of. Er and secondly, because of higher patient expectations and the duty we have against patient to do harm, which will naturally made us more inclined to use race free environment to learn. Secondly, we've got accessibility gap which through the hospitals, I've tried to show you that is currently adopted mostly in high income countries, mainly because of the cost and the technical advancement and the other sort of carry paraphernalia that you require to develop a VR technology uh that is currently sorely lacking in lower middle income country. Thirdly, we've got evaluation gap, meaning VRS at the moment really is quite a while. Well west where you get them in simulations without rigorously testing or clinical validation trial to develop the predictive validity that actually show that the training translates into better patient outcomes and operative outcomes. And lastly, we have got meta validation gap which looks at having a gold standard to develop uh that should be developed to guide or the assessment behind VR so that we can have a standardized matter moving forward to build a generation of surgeons that can learn through these novel twos that's coming our way. I would like to share from this review. A very interesting and impressive study that was done in Zambia actually where they use VR to do total abdominal hysterectomy for early stage cervical cancer. They did a pilot authority interrupt taste. Can we go to conclusions? Of course. Yeah, sorry, we just want that behind. So as you can see here, I would like to conclude basically that VR adoption and cancer surgery demand at the moment our head in different ways and that's why is synchrony and as a result, we are is not effectively efficiently and equitably applied to realize it's surgical capacity building potential. Uh We recommend that in the future to develop affordable, we are in high demand, open surgeries in common cancer sites like breast lung or corrective surgeries. I'd like to take a moment just to thank or acknowledge the ground that's supported by welcome trust and the publication we have recently with the cancer to promote the work. Uh Any questions? Thank you for listening. Thank you. Thank you Chase. Um I just had a question about whether there's any particular fields of cancer surgery which are particularly, which would particularly benefit from VR technology in low and middle income countries. Yes. So I personally have more, uh, specialty in, uh, sort of, uh, middle eastern, north eastern and subservient Africa's where the low middle income countries have suffered high disease burden from cervical cancer and breast surgery. And as such, you explain why they did or rather the trial A VR training into, uh, total abdominal hysterectomy, which is the prime, uh, surgery for early stage cervical cancer. Uh, the next step really would be looking into learning mastectomy and white a lesion taxation in those countries do, um, cure this early stage disease before they cause disastrous uh, morbidity and mortality. Thanks. Uh Thank you back to the camp. Everyone. Our fourth presentation is from Mishari HSA Bharadwaj. She's a third year medical student at University of Manchester who has a strong interest in surgery and research. Hi. Yah. Thank you. I'm just trying to, to upload my PPT. So it's not working. Would you be able to just send that link again and just tell me how I can upload it once more. I'm really sorry for this. Hi. Can you, can you, can you see my screen? Yes. Right. Ok. So, uh good, good evening everyone. My name is Harry HSA. I'm one of the third year medical student at the University of Manchester. And today I'd like to present my, a systematic review that I did. Um, while it was a neurosurgical placement, um called a job call is a meningioma dilemma, which is basically looking at comparing two different surgical procedures for the resection of tuberculum sellae, meningioma. So the two ones I'll be looking at is the traditional one which is the microscopic transcranial approaches. And uh the traditional craniotomy is versus the the the newer and the more advanced endoscopic Indonesia surgical treatment. So, um starting off with a brief introduction about tuberculum sellae, meningiomas, um stupid columns and a meningioma is obviously our tumor's that develop within the tuberculum sellae. Now, um these tumor's um they actually tend to, to grow. Um and, and, and in the tuberculum sellae, which is actually a high key in any of the high key risk. Because if you think of it, there's lots of different structures that actually tend to pass over here. We have the optic high as um we have the, the optic nerves that are very close by. So when meningioma center go over here, um the surgical reception can actually tend to be very, very difficult. So I've just uh I've just got a uh some small picture. So you can see that the typical um sentiment injury was growing the typical um study, which is the space that is present between the the anterior clinoid processes of the, of the, of the sphenoid bone. So essentially for the surgical reception of the tuberculum sellae meningiomas, there are the traditional craniotomy procedures and there are the newly advanced um endoscopic Indonesia procedures. So I'm just going to start in in this doc, I'm just going to uh to present the findings in my systematic review and also review the nuances of each of these approaches to see which one is better and which one can, which one as neurosurgeons can actually adopt going forward. So um this was our uh method. So we did a search strategy obviously um was done on MEDLINE and end base. Um And the following key terms we used, we used typical um Salamoni dioramas. An endoscopic endonasal approach is um our, our inclusion criteria was our CTS and quasi randomized control trials and also retrospective studies uh looking at the extended resection, looking at visual improvement chance of our factory loss CSF leakage and other relevant parameters. Um And um we also did exclude certain studies, we did excuse case reports, Casey music cetera. And um we started off with 211 papers which came up uh through our searching. And this is because this is a very, very nuanced topic and um to the best of our knowledge, um This is one of the first uh systematic reviews looking at this in a bit more detail. So just a basic idea of some of the tumor is that we obtained from our initial search results. So um just, just some starts. So majority of the tumor's were in, in males. Um But the the distribution was roughly even the main age of presentation was around 54.2 years Um and, and, and I'll talk a little bit about the outcomes in a bit. So just before we continue, I'm just going to talk a little bit about the endoscopic Indonesia approaches uh in a bit more detail. Um So the endoscopic endonasal approach is um are, are, are these newly device set of approaches for the surgical recessions meningiomas. Now, they're not being developed specifically for typical um CT meningiomas. They've been, they've been developed, developed meningiomas in general. However, the study wants to look at their effectiveness um specifically for two pills that have meningiomas. So if you look at the anatomy, obviously, we said that the we we we the typical insulin meningioma is actually present within a very new on specific area. So we tend to have the frontal sinuses anteriorly. We have the medial orbits and the plan um sphenoidale and the typical um sell it posteriorly. And so this actually gives us lots of different areas to actually um approach the tumor. So traditionally, these are mainly uh these are respected by a craniotomy is essentially you remove part of the scar and then you take deeper into the brain to reach the tumor. However, here we can actually access the tumor through uh different areas. So through the nose and through the different sinus, and I'm going to talk about the different approaches in, in just a bit. Um So before we talk a little bit more about the sort of advantages and disadvantages of these um procedures. And before I sort of present my findings from the systematic, but I just like to tell you a little bit more about these approaches. So endoscopic Indonesia approaches, like I said, it's a sort of an umbrella term, it includes what lots of different approaches within them. Some of the more notable ones are the microscopic transsphenoidal approach, the unilateral sub frontal approach, the unilateral um tero nial approach and the orbital frontal transcranial approaches. And as you can see, essentially in all of these different um surgical approaches are actually accessing the tumor from different sinuses. Um Why this systematically looked at these approaches collectively rather than looking at each of these. Um an exclusion is because of the availability of literature. Um So obviously, the the endoscopic and unusual approaches compared to the microscopic transfer, criminal ones actually do have certain advantages. So it act provides better access to centrally placed tumor's which T SMS tend to be, they provide better illuminated view of relevant anatomy. Um And it is, and one of the major major benefits of these is the cosmetic result that it sort of presents, it requires minimal or no brain attraction. And um and I think that uh and and also you don't require surgeries to the skull as well. So essentially this the cosmetic result is is one of the major benefits. We also tend to have some surgical benefits as well. So um it allows for easier um the compression of the media, medial optic nerve. And it also allows for an early and easier devascularization of the tumor by dealing with the blood supply during the extra general approach. And essentially, it allows for better exposure, better visualization and eventually better removal of tumor extensions. Now, despite um mentioning these advantages, there are certain disadvantages of endoscopic Indonesia approaches. The first thing is just the logistics of it. This is a technically challenging procedure with a steep learning curve. And if introduced and and as a medical student, I'm not very familiar with how training really works. But if introduced into the curriculum at this point of time, it will take a um assuming quite a lot, lot of time for it to become mainstream clinical practice. And like I, like I mentioned, there's not a lot of information out there about these approaches that they tend to be quite novel. So therefore, um further research and further implementation, further studies would have to be conducted before the guidelines change or before these tend to be incorporated within daily chemicals. Sorry about that. Um Also there is a difficulty approving, achieving the total removal of larger humans um with, with the sort of natural extensions especially into the optic nerve in carotid artery. Um So this is the results that we got um from our, from our systematic review. Um We know that visual improvement was noted in 81% of the patient's Um Sorry, sorry. Um And CSF leakage was actually noted in 13.2% of patients. So, um if you sort of compare this to the microscopic to the traditional trainee ostomies, the CSF leakage is it's very, very high in these approaches as compared to the traditional craniotomy. So this is something and that, that, that, that, that, that needs to be kept in mind when it comes to other outcomes. However, such as visual improvement, deteriorate, uh low levels of visual deterioration um and, and and developments of vascular injuries and endocrine disorders, these tend to far, they tend to far supersede and be better than the traditional craniotomy approaches. So, just summarizing my study, um we've actually found out that endoscopic Indonesia excision of tsmc's a feasible, safe, effective a surgical option tends to have lower rates of complications, lower rates and morbidities and mortalities. And this has developed, this has evolved and developed over the, over the over the last 10 years. However, um given the limited availability of studies, given the the the logistical difficulty of getting this introduced into mainstream neurosurgical practice and given the high amount of skill and time required to learn this study. Um Further details. Further studies would have to be conducted from a epidemiological and statistical perspective to get a better idea of whether these can be introduced into mainstream clinical practice. And obviously, the study does have limitations. We we did not, although I made a brief mention of it. We did not actually um formally compare the outcomes between endoscopic and unusual approaches. And the traditional craniotomy is and um the other thing is the nuances of endoscopic and a nasal approaches. Like I mentioned, it's an umbrella term that actually includes um wide right of different approaches. We weren't able to look at these individually because of the lack of literature available. Thank you. Thank you so much. Thank you very much for your cost base with them. Um Because of time, you can only take one question from the audience. Would any panel members like to ask questions in the interest of time? Uh I would like to introduce the last speaker. I'd like to invite uh sorry to talk about lowering syndrome. Do a screen for it. Uh Can I please ask you to uh present maybe no more than six minutes and then I might have one minute for questions. Yeah. Sure. Sure. Let me just share my screen. Uh Where is the press? Yeah. Okay, everyone see that. Okay. Just gonna start my time. So uh Lynch Syndrome question is, do we screen for it? So I'm one of the trainees at Norfolk Knowledge Hospital. Uh So am of this is an audit study and we wanted to see if we are compliant with the current nice guidelines that does screening for Lynch syndrome. And do we screen for it appropriately? And then the aim is to then raise awareness regarding this to the more wider community clinical community. So just some key facts about Lynch syndrome, too familiar with colorectal cancer has an also dominant strain and usually is due to a germline mutation of the Mmr gene. Uh usually manage surveillance prevention, surgical and archaeological management's uh depending on what they have. Uh how do we pick it up? We pick it up either clinically or with genetic analysis. Uh So clinically, we use the possessed or the Amsterdam Criteria Protocol. Genetic analysis usually involves checking for the Mmr gene as we mentioned earlier or doing uh you know, history, chemistry testing usually combined. Um Over years, these, there's controversy between what's the best way to do it. In 2015, the American American Gastroenterological Association decided that we should be testing all uh newly diagnosed coc colorectal cancers with an M S I or IHC testing. So MSI standing for microsatellite instability. So it basically means that we should be doing genetic testing for these patient's with patient's who've got a colorectal cancer. It's just a nice picture of uh microsatellite instability. I'm not going to probably going into too much detail about this. Uh So the nice guidelines then here in the UK, they decided to come out and say that we should be following the same thing. So in 2017, they said they recommended that anyone who has a code erectile cancer uh needs to be tested for using immunohistochemical tree to be tested for a mismatch repair or microsatellite instability. Okay. And if this repairs shows instability, they need further testing and genetic referral. So what we decided to is to test this guideline to see if our trust hospital actually does follow it. We did two loops. Uh It's a retrospective data collection. We we the first loop looked at before we implemented the testing. So by 2019, even though the guidelines were released in 2017, by 2019, our trust still had not um uh had had, had released this guideline. Whereas by early 2020 we did release guidelines and mandated that all patient's should have an M S I have had colorectal cancer. So as obviously, so in our first cycle, we looked at 361 colorectal cancer specimens. And of those only 5.8% of patient's were actually tested properly using immunohistochemical tree. So basically, we were just not doing it properly in the, in between 2019 in during the year of 2019. Um This is just the table which demonstrates the number of specimens we had during the 2019 during our first cycle. This is again before microsatellite instability testing was rolled out or immunohistochemical tree was rolled out. Um So by the second cycle, the new guidelines were rolled down, it was mandated that all patient's should be tested that that have been diagnosed with colorectal cancer, either on endoscopy or in reception have have gone to test, be tested for microsatellite instability. Uh And also on top of that, they will also check for breast mutations as well. Essentially, we looked at 268 specimens during the year of 2022. Of those. As you can see here of those MSI that was not tested. 63 patient's were not tested properly sew something was we still not hitting the mark of 100% of all patient's. But we found out uh 205 patient's web tested appropriately for the MSI. So that means 76% of patient's. So in comparison, we only did 5% of patient's. Now we managed in that 11 year to test 77 patient's that had a colorectal cancer for microsatellite instability and immunohistochemical tree. So, achieving the guidelines properly there and this is just a bar chart which demonstrates that. Okay, good. Uh So after we did the MSI testing, essentially those who did have a microsatellite instability, it was necessary for them to have an appropriate genetics referral. And as you can see here, those who were mismatch repair deficient. Basically, that meant that they needed a genetics referral. And of those of the mismatch, we had 45 patients who had a MSI instability, okay. And that means that if the 45 of them should have been referred, but only 10 of them were referred properly to the genetics assessment. So genetics referral again, this is just a bar chart which shows that. So you can see here, mismatch repair deficient bars, all of this should be blue, not green, there should be no green here. And so therefore, we're still not meeting that guidelines of 100% of patient's who now who have an MSI deficiency or an mmr deficiency, they're not having, they're not being appropriately referred to the genetics team. And this is just another bar chart which demonstrates whether we check for BRAF mutation or not. So, in conclusion, the estimated incidence of Lynch syndrome is 225%. This means that out of the 300 patient that only come to our hospital with colorectal cancer, 60 56 to 15 of them should be should essentially may, may have Lynch Syndrome and we need to pick up those 6 to 15 as a trust, we were able to screen 77% of those patient's in our second cycle from 5.8. However, we still did not meet the 100% mark for eyes for that testing and 13% of patient's with the actual deficiency. And that's so we've managed to pick up 13 patient's that may have potentially have Lynch Syndrome. We're not appropriately screened for for further for Lynch syndrome. In conclusion, we recommend promoting referral pathways and clinics run by colorectal specialist to ensure all patient's with abnormal immunohistochemical. Three are being tested properly and referred for further genetics analysis. Thank you. Thank you so much for your presentation and uh we'll have time for one questions. I don't know if Mohammed is online. No, he isn't. Okay. Do we have a question? Sure. I have a question. Um, so I just wanted to ask you, do you know what the reasons were for what any, the most common reasons were for testing, not being done in the patient's uh tested. I think just lack of, uh, there's no uh no, no, there's no reason why it shouldn't be done. This was 100% correct mark criteria that we, we rolled out these new guidelines and they should have been met. So essentially, we need to investigate this and we need to find out this could be due to some admin error. Potentially, it could be due to just lack of awareness in between the geneticists SRE and from, from the people in the lab. Um especially the more importantly, the the genetics referral, what I notice is the consultants not actually picking up on patient's who had uh and mmr deficiency uh and not referring them to the to the geneticist to check to see if other family members. So that was also so I think, I think overall it's just, it's just raising awareness between the consultants between the micro uh the histo pathologists and the geneticists and the cancer specialist nurses, etcetera. So that all of them are tested properly and referred properly. Great. Thank you. Uh Thank you. Can. Sorry. Uh I'd like to uh thank everyone for the participation of the second edition of our research forum. I'd like to thank my colleagues moderators to the speakers that have sent in the abstracts and presented and to all the participants and uh in the interest of time. We're going to do the score ing and announcement of the winner via email after at the end of this session, um I would like to invite you to take part of the next bus, it trainees research forum which will take place on the eighth of June in the evening from 7 to 8 PM. And uh if you'd like to present your research or some work that you've done some scientific work, feel free to email your one page abstract to uh um thank you everyone. Any comments from my colleagues. Thanks for joining us, everyone. Great to have you and hopefully see you all soon. Thank you. Have a nice evening. Goodbye, everyone. Bye. Good bye everyone. Okay.