1

Call to order and role call

@Jim Case

This meeting is being recorded to ensure that important discussion points are not missed in the minutes.  The recording will be available to the SNOMED International community.  Joining the meeting by accepting the Zoom prompt declares that you have no objection to your comments being recorded

2

Conflicts of interest and agenda review

@Jim Case

None reported

3

Bypass graft and shunt modeling proposal update

@Victor Medina 

The remodeling work proposed at the face-to-face meeting related to bypass grafts is ready for review in the authoring platform.  It can be found here:

https://authoring.ihtsdotools.org/#/tasks/task/QICONST/QICONST-11/edit

The EAG has been asked to review the proposed changes in context and provide feedback.

A revised BN is available and is attached.

Previous decisions by the EAG (2024-10-21):

• the proposed definitions for bypass and shunt be updated based on input from the EAG 

• Proximal and distal anastomosis attributes would be used for bypass grafts

Specific questions:

• Is the direction of flow in bypass and shunt relevant?

• How do you model shunt to/shunt from?

• What is the alternative to using Procedure site - indirect for the destination site for shunts?  Two RGs?

Discussion:

Should bypass - action and shunt - action be a subtype of anastomosis? Previously agreed that these would be moved under construction.  The question is how to model the remaining semantics of the procedure.  The current model for shunt only represents the result of the procedure, not the actions that are being performed.  MVB: If shunt is the result, why is it an action at all?   The construction of a shunt is an anastomosis.  The direction of flow is not addressed.  VME: Previous agreement that we would not use and Introduction - action to represent the use of a device in cases where there is no anastomosis.  There were concerns about using Procedure site - indirect as a proxy for the direction of flow in a shunt.  

JSN: Should we not have proximal and distal analogs for shunt?  VME: If we do not have a device or an anastomosis in a shunt procedure, how would we address the flow direction?  

MCO: Using the proximal and distal anastomosis in bypass concepts still results in concepts classifying as anastomosis.  The language of bypass and shunt are often conflated.  Having shunt as a subtype of bypass is incorrect. In many cases the flow is implied, especially in shunts.  

JRO - Linguistically, "Shunt" I think originally implied a non-anatomical connection between specifically one higher and one lower pressure volume, such that retrograde flow UP the shunt is therefore essentially physically impossible. By contrast, anastomoses and bypasses are usually between volumes at essentially the same pressure, such that retrograde flow is at least a theoretical possibility. Anastomotic structures - the anastomosis itself - also doesn't usually have any meaningful tubular length, whereas bypasses and shunts both usually have a length.

FHE: Should we question the view of anastomosis as a method as opposed to a morphology (e.g. distal and proximal anastomosis)?  VME: We are currently using the bypass action and shunt actions incorrectly, but we have a need to represent the connections to/from.  If the flow is not important, then we just need to use anastomosis and the direction is implied.  

JCAM: Bypass and shunt are complex actions that may include anastomoses.  The model is complex but that is needed to represent these procedures.  There is an issue with the use of Procedure site - direct and Procedure site - indirect, why was that model chosen?  VME:  This was done to address concepts where only one aspect (i.e. shunt to or shunt from) to get them to classify correctly.  

JRO: The use of the actions is the root of the problem and maybe using morphologies would address the issue.  There are many other areas where we use a more general action and focus on the morphology and body structure.  WRT direction of flow, it can mostly be implied, but there are cases where it is needed.  

MVB: The concern is that there are two different ways to represent bypass and shunt.  Concern about the misuse of Procedure site - direct. 

Additional comments from MVB:

Open

Questions/comments from chat:

JSN:    Do Direct morphology and Indirect morphology have a range constraint that allows for selection of all the body structures involved? JTC: No, but they would not need to as all they describe is the "type" of structural change, not the location.

FHE:    41796003 |anastomosis (morphologic abnormality)| is in range for those attributes. We could explore: method = creation, direct morph = proximal anastomosis, direct site = [whatever source anatomy is plausible; and a second RG with direct morph = distal anastomosis.  JTC: This will be invesitgated.

Decision:

Need to rewrite the proposal to address the concerns.  

Need to review whether we keep bypass and shunt as actions as opposed to morphologies.  

4

Endoscopy and endoscopic procedures

@Victor Medina 

A summary document related to proposed changes to Endoscopy and endoscopic procedures is attached.  This document is a result of prior discussion with the EAG on an optimal model for representing both surgical and non-surgical endoscopic procedures.  It has been tested and is available for review in the Authoring platform.

Discussion:

Took the decisions made at the last meeting.  Keep Endoscopy and Endoscopic procedures.  This surfaced issues with surgical and non-surgical endoscopic procedures.  The broadening of the value for the GCI in Surgical procedure will allow for the removal of the incision RG from these procedures.  When the FSN specified the type of scope, it is added to ensure that it classifies correctly.   All of the suggested changes related to the USING DEVICE and USING ACCESS DEVICE.  Have also responded to additional comments that were provided.

FHE: agrees with removing the Incision RG, but need a review of the list of scopes that would belong under intercavitary endoscope.  

MVB: Are there scopes that can be used as either surgical or not.  Victor will review the list of scopes.

JRO: I struggle to think how you could use any "scope" type visualisation instrument except inside some kind of natural or (rarely) unnaturally inflated cavity.  JTC:  The distinction here is intracavitary vs. intraluminal.  

Decision:

EAG members will review the final endoscopy modeling in the TS browser under the SURGAPP project.  This does not reflect the removal of the incision RG.

Replacement procedures

@Victor Medina 

An analysis document "Review of the replacement procedure hierarchy" is attached for discussion.  The issues related to the use of a single concept "Replacement - action" to model replacement procedures are discussed an alternative modeling constructs proposed. Consistent use of the Procedure site attributes for Replacement procedures is also discussed. 

The content team reviewed the consistency of the use of the Procedure site attributes for Replacement procedures, specially those regarding the appropriate procedure site for prosthetic implantations.

A document with a proposal is available for review and discussion here.

Discussion:

Decision:

Container modeling

@Feikje Hielkema (Unlicensed) 

@Daniel Karlsson 

A revised briefing note for the model representation of container types has been provided and is attached for discussion.

Discussion:

The previous discussion resulted in questions around the value of this proposal in light of the small number of affected concepts.  Recent evaluation identified that there are at least 70 new concepts that need to be added.  Discussions in the EU indicated that it is not important to designate a container is evacuated or not.  Thus the concepts in the US extension would not be useful as they 

Decision:

Not enough time to discuss.  Will be continued to next call.

10

AOB

EAG

None

11

Next meeting

@Jim Case 

TBD