asit yearbook 2010, association of surgeons in training.pdf

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YEARBOOK 2009-2010Surgical Training.What Is The Right Attitude?

EWTD:The Surgical Community Fights Back

10Years of The Silver Scalpel Award

Updates On Clinical Management: Hernia, Breast Cancer and More

NewThis Year: Book Reviews And A Student Only Section

The Association ofSurgeons in Training

the pursuit of excellence in training

ASSOCIATION

OF

SURGEONS IN TRAINING

YEARBOOK

2009-2010

Published byTHE ROWAN GROUP

Boundary House, Boston Road, London W7 2QETel: 020 8434 3424

on behalf of

THE ASSOCIATION OF SURGEONS IN TRAININGat the Royal College of Surgeons

35/43 Lincoln’s Inn Fields, London WC2A 3PETel: 020 7973 0300

www.asit.org

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Contents

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All rights reserved. No part of this publication may be produced, stored in a retrieval system, or transmitted in any form or by any means without priorpermission from the Publisher. While every care is taken to ensure that the information published in this yearbook is accurate, the Publisher cannot acceptresponsibility for any errors, omissions or inaccuracies. The views and opinions expressed in this yearbook are not necessarily those of the Association.

AwardsNick Taffinder Travelling Fellowship Award 2009Ben Griffiths and Bruce Levy 73ASiT-Covidien Bariatric Fellowship Winner 2009Girish Bapat 75

Scientific PapersWhat’s New in Hernia SurgeryAndrew Kingsnorth 77Moving Paradigm Towards Scarless SurgeryJames Pollard and Irfan Ahmed 80Breast Cancer: Non-surgical TreatmentsGhazia Shaikh and Mohammed Rizwanullah 84Management of Gastrointestinal Carcinoid TumoursShridhar Dronamraju 90Aetiology and Pathogenesis of Colorectal CancerMuhammad Kabeer, Adam Widdison, Andrew Demaineand Joseph Mathew 95The Role of Combined Positron Emission Tomography andComputed Tomography (PET/CT) in Head andNeck Squamous Cell CarcinomaJonathan Hobson, Jonathan Hill and John P de Carpentier 102Fixation Techniques in Laparoscopic Groin Hernia RepairNehal Shah and Aali Sheen 107Fast Track Surgery (also called Enhanced RecoveryAfter Surgery [ERAS])Prit Anand Singh and Grant Haldane 110Acute Pain Management in Adult Surgical PatientsGrant Haldane 113Radiofrequency Ablation and Barrett’s OesophagusNatasha Henley and Simon Galloway 118Evaluating the Effectiveness of the Mini-CEX in theModern NHS - Trainee’s Perspective 122Ilyas Arshad, Loaie Maraqa, Karim Jamal andReg DennickNutrition: In the Surgical Patient andThe Role of Enteral Feeding in Patients withHead and Neck CancerJustice Reilly 126Management Strategies for Aortocaval FistulaRobert Brightwell and Tahir Hussain 130

Students’ SectionStudent Plenary Sessions: Anatomy DebateMatt White 133Finding the Silver Lining: Making the Most of theEWTD in Your Student YearsHugo Gemal 134Surgical Etiquette: a Guide to Time Spent inOperating TheatresJessica Johnston and Antonia Mortimer 135Becoming a Surgeon: a Personal Account of Finding YourFeet on the Surgical LadderJoy Singh 137The Role of Surgical Societies in Undergraduate EducationSabrina Akhtar and Justice Reilly 138

Book Reviews 140

Directory of Members 142

Editor’s ForewordIshtiaq Ahmed 3President’s ReportEdward Fitzgerald 5Honorary Secretary’s ReportConor Marron 7Vice-presidents’ ReportsRoddy O’Kane and Charles Gidding 8/9Director of Education ReportWill Hawkins 10Web Master’s ReportIshtiaq Ahmed 11ASiT Council 11Past ASiT Office Bearers 12Reports from the Regions and Subspecialty Groups 13

Political PortfolioEWTD for Surgical TraineesPress Release: Surgical Trainees Worried as TrainingDeteriorates Under European Working Time Regulations 20Position Statement: Optimising Working Hours toProvide Quality in Training and Patient Safely 30The ISCP Evaluation Report by Professor Michael Eraut 35Surgical Leadership Development 39The Checklist - From Theory to Action 41

Training and EducationThe New IMRCS ExamWill Hawkins 46Applied Basic Surgical Sciences for theIMRCS OSCE Course ReviewAbeyna Jones 47The Provision of Excellence in Training - ASSETSWill Hawkins 48Information Technology and Audit: Making WhatMatters MeasurableSarah Mills and Mike Bradburn 50IT in Training and BeyondChris Macklin 52A Guide to Less Than Full Time (THFT) TrainingMandy Chadwick 54My Most Brilliant DiagnosisHarold Ellis 56

Silver Scalpel AwardDavid O’Regan 57Silver Scalpel Award Winner 2009 - Surgical Training:What is the Right Attitude?David Khoo 58Silver Scalpel Award SymposiumBettina Lieske 61

AGMTrauma in the TropicsDavid Nott 62How to Write a Surgical CVGillian Tierney 66Providing a Global Service - The Trainee’s ContributionRobert Lane 67Damage Control ResuscitationMatthew Reeds and Adam Brooks 69

Contents

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Editor’s Foreword

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Having edited the ASiT yearbook last year together withBruce Levy, it was certainly a pleasure being given thechance to do this again. Sadly Bruce was unable to continuewith this role and I certainly found it a lot harder to managethe yearbook without his support.

Last year saw the full implementation of the EWTD. Thishas had significant impact on surgical training, and in thisyearbook there are several papers and position statementson this topical issue. Other topical issues that have beendescribed in the political section are surgical leadershipdevelopment and the surgical checklist.

The Silver Scalpel Award is now in its tenth year, and withthe introduction of the 48 hour week, the importance ofmaximising training opportunities is paramount. The award isgiven to clinicians who continue to deliver excellence intraining. In this edition Mr David OʼRegan, past ASiTpresident and creator of the award, describes the importanceof recognising training skills in trainers. This is followed byreflections from the 2009 Silver Scalpel Award winner, MrDavid Khoo, on surgical training and the right attitude totraining. A Silver Scalpel Award symposium was held recentlyto discuss educational and training issues and to define theattributes of an excellent trainer. This was attended bytrainers who had been short-listed for the award previouslytogether with surgical trainees and business psychologists. Abrief summary of the discussions in the symposium can befound in the educational section of the yearbook.

Information technology is integral to the way we learn,

Editor’s ForewordIshtiaq (Ish) Ahmed

communicate and in the delivery of healthcare. In this edition,there is an excellent paper by Mr Mike Bradburn and MsSarah Mills on the use of IT in healthcare management, andby Mr Chris Macklin on its use in training and beyond.

ASiT has seen a significant increase in medical studentmembership and to recognise this we have introduced aMedical Student section for the first time. I am very gratefulto Jessica Johnston, the ASiT student representative, for allher help in putting this section together. The other sectionthat is new to this yearbook is a Book Review section. Hereyou will find reviews on several books that will be of use tostudents as well as to junior and senior trainees.

In the scientific section there are some excellent reviewsthat summarise current concepts on topics of clinical interest:Professor Kingsnorthʼs paper on hernia surgery is anexcellent summary of current concepts in herniamanagement; there is a comprehensive review on non-surgical management of breast cancer; alongside whichthere are several other outstanding reviews on painmanagement, fast track surgery, radiofrequency ablation inBarrettʼs oesophagus… to name but a few.

I am very grateful to all the contributors to this yearbookand to Julie Cornish for her help in proofreading some of thecontents. I would particularly like to thank Anne Rowe of TheRowan Group, our publisher, for all her hard work in bringingthe yearbook together. Above all, I would like to thank her foraccommodating all the delays we have had in getting thisyearbook together.

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President's Report

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Surgeons are professionals, and must always be so. Assuch, much of what ASiT does as an organisation occursbehind closed doors. Members may not see themachinations, but we hope you see the results. Indeed, agreat deal of time and effort frequently goes into sayingnothing while others do our bidding for us. Such is the politicalworld we live in. Recognition that ‘news’ is placed and notreported is vital for ASiT to effectively influence our futuretraining and careers; the public are on our side. Hopefullymembers realise and appreciate our role in this, for withoutyour continued support ASiT could not exist.

Surgical trainees are not pawns for political (oftenunelected) masters to play with at will. We represent a highlytrained and skilled professional group. ASiT gives us acollective identity, a voice to negotiate with and anorganisation that can make a genuine change for the better;or at the very least a painful thorn in the side of those whochoose to ignore us. In the year to date we have served bothroles. By way of a brief summary:

ASiT EducationOur main focus remains the promotion of excellence insurgical education and training. In 2009 we appointed our firstDirector of Education to the Executive, Will Hawkins, who hascontinued to develop our range of courses and co-ordinatenumerous funding opportunities. From sponsoring fellow-ships, to overseas training courses, and numerous UK basedopportunities, ASiT continues to excel in providing training to

It seems like just a few years ago that I joined ASiT as amedical student, and yet here I find myself sat on a rainyDecember afternoon drafting the President’s report for ourYearbook. A lot has changed since those student days. Notonly has my hair receded and my liver regenerated, but thelandscape of surgical training has changed considerably.MTAS, MMC, ISCP, EWTD… who knows what acronym willcome along to blight our lives next?!

The demands of surgical training are different to otherbranches of medicine, even varying within the nine surgicalspecialties. ASiT remains the only pan-surgical voicerepresenting trainees from all these groups. As such, ourorganisation undertakes an increasingly important role inrepresenting surgical training as a whole to the wider medicalcommunity and beyond. It is to our credit that ASiTrepresentation is now sought on a myriad of committees andpanels, and it remains my ambition that on issues relating tosurgical training ASiT is regarded as the definitive voice.

On a personal level, I have learnt a great deal this year. I’mno fan of sitting in committee rooms, especially ones whereeveryone has the answer and no-one is actually listening.These crop up depressingly often in medico-politics, and situncomfortably with someone who has always seen actions asspeaking louder than words. Nonetheless, I’ve learnt that itserves us no benefit to wash our dirty scrubs in public, or topick fights we cannot win. Shouting makes us less likely to beheard, and evidence not anecdote is required to influencepolicy in this modern age.

President's ReportEd Fitzgerald

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President's Report

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our members. We hope to expand this further in 2010.Elsewhere, our input into the new surgical curriculum, revisionof the MRCS, and responses to the Eraut report have kepttraining at the top of the agenda.

ASiT PoliticsTrainees now find themselves stuck between a rock and ahard place. Although the framework that supports surgicaltraining has seen major development in the past decade, atthe coal-face there has been little change in how hospitalsfacilitate training on a day-to-day level within the NHS. Areduction in working hours against this backdrop isdisastrous. ASiT has worked hard to provide both evidenceand solutions to address both of these issues. Our work in thisarea is not yet done, and may never be, but there is progressand reason to be hopeful. It is likely that EWTD, the Erautreport, modular credentialing, workforce planning and sub-consultant grades will remains on the medico-political agendafor some time yet.

ASiT BusinessASiT membership has swelled by several hundred in the year-to-date, hopefully a sign that trainees are recognising ourwork and finding benefit from joining. Despite this, theeconomic environment has remained challenging for raisingsponsorship and we are keen to find new corporate patrons.This year we have devised a new prospectus, advertisingschedule, and conference sponsorship programme to helpsecure external funding. Elsewhere, we have increased effortsto communicate with members through bi-monthly emailsand development of our on-line presence via the ASiT websiteand Facebook group. A marketing strategy to potentialmembers has been rolled out, together with approaches toFoundation Schools and Schools of Surgery. Parallel with this,we have extensively revised the format of our regionalrepresentation. Elsewhere, our new affiliation with theInternational Journal of Surgery should prove mutuallybeneficial. More fundamentally, we are bringing our charitablestatus into the modern era with a move to an incorporatedcharity.

ASiT ConferenceTrust me, ASiT 2010 is going to be great! While there mayhave been a few raised eyebrows about choosing Hull (or ‘ull,as it is known to locals), those who know the city will know it’sa legendary night out. We are blessed with some splendidvenues with the grand City Hall, beautiful Ferens Art Galleryand historic Guildhall. Plus it’s all very affordable! With a rangeof new abstract prizes, and with our affiliation to theInternational Journal of Surgery seeing abstracts publishedfor the first time, we hope there will be a substantial rise in thenumber and quality of abstracts submitted. We haveexpanded the range of pre-conference courses and re-focused the weekend lectures on topics that will hopefully beuseful to trainees mapping out a surgical career. All of this,and we have reduced the cost of registration. We look forwardto seeing you there!

The ASiT TeamIn 1976 a bunch of angry young surgeons founded ASiT topromote excellence in surgical training. Some 33 years laterthere are more battles to be fought than ever before, butthroughout my year it has been a great support that one ofthose founders just happened to become President of theRCSEng. Mr Black, who openly confesses to still seeinghimself as President of ASiT, has been a great supporter ofsurgical trainees, and must be thanked for this.

ASiT as an organisation must be similarly grateful to thespecialty groups, particularly ASGBI, with whom we havebenefited greatly from a mature and productive workingrelationship. Our input into the JCST, the Royal Colleges andnumerous other working groups and committees has ensuredthat your trainee voice continues to be represented at thehighest level.

I am fortunate to have inherited a political monster fromBen Cresswell, Past-President, who helped push ASiT to thevery forefront of the debate surrounding EWTD. Continuingthis work and our other initiatives would not have beenpossible without the strong support of my Executive in theshape of Charlie Giddings, Roddy O’Kane, Conor Marron, WillHawkins and Tom Edwards. I owe them a debt of thanks.Suzy Mercer, our Secretariat, has been a never ending sourceof both black coffee and efficient administrative wizardry; Icannot imagine how ASiT ever existed without her. ASiTCouncil have proved a resourceful and enthusiastic groupwith their finger on the pulse of specialty and regional trainingissues. Thanks to them for their contribution and support.

ASiT’s Future?ASiT is stronger than ever before, and it is reassuring that assurgery continues to sub-specialise we still have a forumbringing together trainees from all nine specialties on areas ofmutual interest. It is vital for our future that this is strengthenedand promoted in a business-like, strategic fashion. Whingingtrainees do no-one any favours.

Yet no matter what ASiT does, you, sat out there readingthis now, represent the future of surgery in the UK. The serviceyou deliver, the leadership you provide, and the care withwhich you attend to both your patients and colleagues willdetermine the wider perception of our profession. When ourability to deliver this is threatened, ASiT will defend. When weare able to improve this, ASiT will lead the way. Yet it alldepends on having you there as an ASiT member, to supportus in our work. For my part, it has been an honour and aprivilege to undertake this on your behalf over the past year.

[email protected]

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Honorary Secretary’s Report

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The role of the Honorary Secretary has been revamped in 2009 with a greater focus onthe activities around conference organisation and coordination. The Conference inNottingham in March 2009 has continued the tradition of recent ASiT Conferences,getting larger, and offering more to our members, whilst continuing to explorecontroversial areas of education and training.

The economic downturn has, however, also taken its toll on the conferenceorganisation with many of our commercial partners finding the climate more difficult.This led to a net loss of 4 commercial sponsors for 2009 which has contributed tomaking the conference all the more difficult to budget, and the overall budget for ASiTand running your organisation even more difficult.

By the time you read this article, the ASiT conference 2010 will have taken place,and this will push the boundaries even further in terms of what we seek to offer ASiTmembers. An increased range of low cost courses, improved conference structure,better value for money, and improved social events will all enhance the ASiTConference experience. However, this all represents a challenge and finding ways ofreducing the cost of the conference in order that we can pass on the benefits ofreduced registration fees to our members.

The challenges posed with regards to the working time directive have beenexercising us all, and will continue to do so over the coming years, as it will take timeto gather the necessary evidence to improve surgical training.

I hope that ASiT, and the conference, will continue to grow and gather strength, andwe look forward to your continued support, as without it the organisation cannot exist.

Honorary Secretary’sReportConor Marron

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Vice-president’s Report

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The trainee-trainer relationship is the kernel of surgicaltraining. Without this, independent progressive responsibilityis lost. The balance between supervision and responsibility isthreatened. Trainees are in danger of becoming more of anobserver and less of a progressing responsible practitioner.

It would seem that over recent years everyone and theirdog have an opinion, veto and decision to make on surgicaltraining. The problem is not many of them are surgeons. It issad to see that we can be ignored by so many, including ournon-surgical colleagues within the medical profession. Ifsurgical training had a voice perhaps it would state whatAlexander (III) the Great (356BC-323BC) is quoted as sayingmany years ago: “I am dying with the help of too manyphysicians”

In an age where Evidence Based Medicine has become afashion if not a transfixion with some, I am reminded of theevidence categories. Our detractors are often heard to say“show me the evidence”. It is difficult, if not impossible, todemonstrate class 1 evidence in relation to deterioration intraining. But you as a trainee give class 4 evidence, yourprofessional and intelligent opinion. When over 1000 of theseexpert, class 4 opinions sing in chorus in our repeatedsurveys, it is only those who are decerebrate that choose toignore this as evidence. Time will hopefully allow them todevelop enough cortical mantle to eventually understand thesurgical profession’s voice.

I have spent some time this year examining ASiT’srepresentative structure, in particular the regional represen-tation. With the ever changing structures and trainingpathways, it is important that we continue to comprehensivelyrepresent our membership. We include members frommedical student’s right through to the end of training and wemust be effective in expressing the opinions and concerns ofall our members. The advent of the Schools of Surgery andregionalisation of surgical training has been a recognisablechange in the landscape. ASiT’s influence must not justremain central but should be present on the shop floor andwithin the schools of surgery. As a result, some fine tuning tothe representative structures will be proposed at this year’sAGM.

I would like to congratulate and thank Ed Fitzgerald for hishard work, commitment, dedication and leadership that hehas displayed as President. I have no doubt that without hiscontribution the many issues in surgical training would nothave been highlighted, debated and addressed maximally forthe benefit of surgical trainees.

The surgical training utopia has not yet been reached. It isunlikely to be reached overnight; it will remain the aspirationof ASiT to get there.

It is a pleasure to write a report as one of the Vice-presidentsof ASiT. I can already look back on this year with fondmemories. My first thoughts when sitting down to write thisreport was to look at the previous yearbooks, read what mypredecessors have written and think if I can say somethingfunnier or more intellectual. God knows if I had to rely on myvocabulary alone this report would not be printable!

In my 8 years as a member of ASiT, I must say that ASiTremains the one organisation that represents the opinions ofsurgical trainees most comprehensively and most accurately.Inclusivity for all surgical specialities is an obvious agenda thatruns through the organisation. Both Charlie (Vice-president)and myself are “non-general” surgeons and take great pride inrepresenting and developing this organisation.

Having looked through the previous yearbooks andconsidered my 10 years of post graduate training, it is obviousthat training is always under some form of threat. This year isno different. However the threat level in surgical training is atDefcon 1.

Our training has evolved over hundreds of years. Thenatural selection that has refined this process has been slow,calculated and methodical, most importantly it delivered theexcellence in training that we and our patients deserve.

Contemporary surgical training is being arbitrarilycompartmentalised to suit a paper exercise. This bureaucraticsimplification completely ignores the huge complexityinvolved in training a surgeon. Leaving aside the simplereduction in hours, working time legislation has forced manyinto a shift system. As a result, the intimate and highlycomplex learning relationship between trainer and trainee hasbeen broken.

Vice-president’sReportRoddy O’Kane

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Vice-president’s Report

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moving forward seems almost as important as making sure itis the right direction. We need to continue to representtrainees on committees such as these.

I have also been involved this year with The ConfidentialReporting System for Surgery (CORESS). This is a worthwhileproject that aims to inform and educate through lessonslearned. It is compulsive reading that I hope will make me lesslikely to make mistakes. Please submit your cases atwww.coress.org.uk, in the knowledge that no individual canbe identified, and someone else might just benefit from yourexperience.

Surgical trainees are caught between idealistic trainingreforms and delayed implementation of appropriate facilitiesand support. We are also now paying for much more of ourtraining and assessment than our predecessors – this may bea good thing as it elevates us to consumers. We need to bemore determined and vocal insisting on high quality trainingand value for money. It might appear to be a bad time toconsider a career in surgery especially with over-regulationand concerns about long-term recruitment. Surgery isnevertheless still the most competitive, fascinating andrewarding career. Would I do something else - of course not.

Thank you for persevering with all the surveys. Frustratingas they may seem when you’re in the middle of a busy week,they are essential to provide data to defend our position. Datais less easy to dismiss than opinion and allows us tochampion the surgical trainee cause.

Our Association thrives on the enthusiasm of its officersand over the last few years ASiT has been fortunate to haveindividuals who constantly strive to improve representation ofsurgeons in training. I appeal to you all to take a more activerole within ASiT. Come and get involved and offer support asthe load is small if shared between many.

It has been an interesting year as ASiT Vice-president and apleasure to represent the association. I also represent ENTtrainees and have been overjoyed to avoid work and dodgeclinics to attend meetings. I am a 5th year SpR in London andhave been lucky to avoid much of the disappointing imbrogliothat ‘modernising’ surgical training has brought - although itwas the stimulus that drove me to become more involved withASiT.

At the inception of the EWTD over a decade ago, I’m surea 48-hour week appeared attractive to most junior doctors.Many of you we know are working 48-hour rotas on paper, notgetting to theatre, taking home un-banded pay and still havingthe delight of weeks of nights. I never imagined that we wouldbe jealous of our American colleagues who now work “only”80 hours a week. The BMA unfortunately have failed tosupport us in our quest for increasing working hours to 65,arguing that quality of training should be improved. Sadly theNHS is currently unable to provide the quality of surgicaltraining we need within the allotted hours and much neededchanges will take years. ASiT will continue to press forimprovements in quality of training and provide guidanceon optimizing current training opportunities and theconsequences of opting out.

Surgical training is still in a constant state of reform.Changes are afoot, new boards and committees are springingup all the time. One of these is the committee on the MachineMarkable Test (MMT), which aims to evaluate trainees at theend of their foundation training. MMT aims not to assess thefoundation years themselves, but to inform selection into coretraining. The programme has an ambitious timetable and

Vice-president’sReportCharles Gidding

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Director of Education Report

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At ASiT’s 2009 AGM, a new role of Director of Education for ASiT was formed. This arose through increasingrequests for ASiT to be involved in training and examination committees but mainly because we could seeour educational portfolio growing fast. I was elected into this role and have set about creating an identityfor it.

The two main facets of this role are described in articles elsewhere in this yearbook, but it has been avery successful year. In partnership with our industry sponsors, notably Covidien, Ethicon and Karl Storz,we have developed a series of laparoscopic courses and fellowships that have benefited many of ourmembers over the last twelve months. The courses are moving away from being an optional extra at theconference and will continue to run regularly in regional centres. I hope that ASiT will continue to build onthese successes and ultimately be an integral part of surgical training in the United Kingdom.

Another key element of my role this year has been as the first ever trainee on the Committee for theIntercollegiate MRCS. This examination has received a lot of bad press since the OSCE was introduced. Soafter visiting the examinations whilst they were being run at the English College I submitted an in-depthreport to the Committee that can be viewed on our website. I am pleased to report that this was wellreceived and the Committee, lead by Chris Oliver, has been very receptive to the trainees’ view. A numberof changes will be seen in the format of the OSCE in 2010 partly in response to this document, but we willcontinue to keep a close eye on this progress.

I will be stepping down from the ASiT Executive at the conference in Hull, but intend to be involved withASiT courses for the foreseeable future. I have thoroughly enjoyed my four years on the Executive. It hasoffered me a lot of opportunities that I would otherwise never have had and I believe that I have been ableto help make a difference in the lives of surgical trainees. It has also been a time during which ASiT’s profileand membership has grown significantly and I am proud to have been part of this.

I have always thought that we should never accept that things are as good as they can be and that it isimportant for all trainees to take some ownership for the quality of their education. If we are not already,most of us will ultimately be trainers one day. So even if we do not manage to change things for ourselves,identifying deficiencies in our own training will make a difference when we are training the next generationof surgeons. I hope to see more trainees getting involved and giving their view in the future. I also hope tosee ASiT continue to grow and increase its influence on the surgical community in years to come.

Director of EducationReportWill Hawkins

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Webmaster’s Report/ASiT Council

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Specialty Representatives

Regional Representatives

AOT Archana Soni-JaiswalBarrett’s Club Natasha Henley/John HammondBMA Johann MalawanaPast JDC Chair Ram MoorthyBNTA VacantBOTA Ben CaesarCardiothoracic VacantCarrel Club Ewen HarrisonDuke’s Club Joy SinghISCP Steve HornbyMammary Fold Suzanne ElgammalMilitary Catherine DoranOMFS Spencer HodgesPaeds Charlie KeysPLASTA Kristian SørensenRouleaux Club Robert DaviesSARS Stephen McNally/Bijan ModaraiSURG Philip CharlesworthMedical Student Jessica JohnstonFoundation Year Rep Kumaran Shanmugarajah

Eastern Thet-Su WinLNR/East Midlands M Eyad IssaSouth VacantMersey Goldie KheraNorth East VacantNorth West Paul MaloneNorthern Ireland Ciara StevensonOxford Bettina LieskeScotland - E John ScollayScotland - NE James MilburnScotland - SE VacantScotland - W Simon GibsonSouth Yorkshire & Humber VacantThames - NE Cynthia BorgThames - NW Alex von Roon/Joseph Shalhoub/

Sarah MillsThames - SE Alexis Schizas/Chetan BhanTrent/East Midlands Lizzy ElseyNorth VacantWales VacantWessex David Cruttenden-WoodWest Midlands Sarah RastallYorkshire Sara Atkins

ASiT CouncilOffice Bearers

President Ed FitzgeraldVice-presidents Charles Giddings/Roddy O’KaneEducation Director Will HawkinsConference Organiser/ Conor MarronHon SecretaryTreasurer Tom EdwardsWebmaster Ishtiaq AhmedYearbook Editor Ishtiaq Ahmed

Webmaster’s ReportIshtiaq (Ish) Ahmed

The new website was launched recently which continues toprovide updated information to ASiT members. The site hasspecific sections for ‘news’, ‘events’ and ‘resources’, most ofwhich can be linked with RSS feeds.

There are several new sections in the ASiT website. We arevery grateful to Andy Pillai (past ASiT student representative) forall his efforts in developing themedical student pages which arenow being consolidated by the current student rep. There areefforts to put together a dedicated section for foundationdoctors which will have, apart from other resources, pagesdedicated to application for core surgical training. If you haveany suggestions or would like to be involved in developing thestudent or foundation doctors section, please get in touch withyour representatives, details of whom may be found on theASiT website.

ASiT now has its own facebook page, and we have had asignificant increase in membership over the past few months.We are very grateful to Jessica Johnston, the ASiT studentrepresentative, in promoting the facebook application withinmedical students. Join facebook from the facebook link at theASiT website.

Photographs taken during the conference by our partnerphotographic team have been linked to the website in theappropriate conference pages. Photographs from the 2010conference in Hull will similarly be linked to the conferencepages.

Over the next few months, there are several exciting areasthat we will be developing. One of the foremost is theintroduction of video uploads of educational content. Thisbegan with videos from the RSM-ACPGBI colorectal teachingday in Newcastle that were recorded in video format, and whichmay be uploaded by the time the yearbook is in print. Toexpand on from this, we will record and upload videopresentations from ASiT conferences. Videos in downloadablepodcasts are also in the plan.

Blogging is another area that is in the developmentalpipeline. Whilst we are sure no one would want to follow blogsfrom ASiT council members, we feel it may be very interestingto invite clinical leaders to write a blog post on frequentintervals. This may be followed by discussion threads withmembers feeding into the discussion.

We would be very keen to have suggestions to improve ourwebsite contents. If you have any suggestions, please do nothesitate to get in touch.

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Past ASiT Office Bearers

Past ASiT Office BearersPresident76-77 Anthony Giddings77-78 John Black78-79 John Smith79-80 John Logie80-81 Brian Rees81-82 Eric Taylor82-83 George Foster83-84 Terry Hall84-85 AR Hearn85-86 Greg McClatchie86-87 Tim Archer87-88 Keith Vellacot88-89 Linda de Cossart89-90 John Templeton90-91 Barry Taylor91-92 John Taylor92-93 Richard Cobb93-94 Malcolm Reed94-95 Jane McCue95-96 Tim Brown96-97 Mick Corlett97-98 Dermot O’Riordan98-99 Gareth Griffiths99-00 Ged Byrne*

David O’Regan*00-01 David O’Regan *

Bryony Lovett*01-02 Bryony Lovett*

Carrie Rodd*02-03 Carrie Rodd*

Simon Cole*03-04 Simon Cole04-05 Joe Huang05-06 Leith Williams06-07 Conor Marron07-08 Ewen Harrison08-09 Ben Cresswell09-10 Ed Fitzgerald

Vice-president03-04 Joe Huang04-05 Sasha Burn05-06 Conor Marron*

Simon Shaw*06-07 Sarah Mills07-08 Sarah Mills*

Ben Cresswell*08-09 Alex von Roon*

Ed Fitzgerald*09-10 Charles Giddings*

Roddy O’Kane*

Treasurer76-78 Tony Griffith78-79 John Fielding79-80 Karl Fortes-Mayer80-83 Roddy Nash83-85 Peter Moore85-87 Simon Ambrose87-89 Andrew Mclrvine89-90 Paul Sauven90-93 Peter Dawson93-95 Mark Hartley95-99 Grant Kane99-02 Joe Huang02-05 Mohamed Baguneid06-07 John Bolton07-09 Conor Marron09-10 Tom Edwards

Secretary77-78 Brian Shorey78-79 John Fielding79-80 Karl Fortes-Mayer80-83 Roddy Nash83-85 Peter Moore85-87 Simon Ambrose87-89 Andrew Mclrvine89-91 Barney Harrison91-93 Bob Baigrie93-95 Anne Stebbing95-97 Nick Shaper97-98 Ged Byrne98-00 Carrie Rodd00-01 Simon Cole01-02 Caroline Burt02-06 Dominic Slade06-07 Alex Kovalic07-09 Will Hawkins09-10 Conor Marron

Yearbook Editor85-91 Peter Cox90-92 Tom Holme91-93 Tom Holme93-94 Michael Rhodes94-95 Michael Bradburn95-96 Michael Bradburn*

lona Reid*96-97 lona Reid97-98 lona Reid*

Gareth Griffiths*98-99 Rowan Parks99-00 Rowan Parks*

Michael Lamparelli*Finlay Curran*

00-01 Finlay Curran01-02 Michael Lamparelli*

Mohamed Baguneid*02-03 Mohamed Baguneid*

Michael Lamparelli*Suhail Anwar*

03-04 Elizabeth Shah*Andrew Renwick*Mohamed Baguneid*

04-05 Lucy Wales*Paul Glen*

05-06 Jonathan Ghosh*Dimitri Raptis*

06-07 Jonathan Ghosh*Emma Cheasty*Jitesh Palmar*

07-08 Jonathan Ghosh08-09 Bruce Levy*

Ishtiaq Ahmed*09-10 Ishtiaq Ahmed

Membership Secretary89-90 John Templeton90-91 Tom Holme91-95 Michelle Lucarotti95-96 Julie Dunn96-10 ASGBI

Webmaster04-05 Jason Smith05-06 Chris Macklin06-09 Ewen Harrison09-10 Ishtiaq Ahmed

* Shared office

Past ASiT Office Bearers:ASiT Council 2008 11/5/10 13:36 Page 12

Reports from the Regions

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has been reduced to £300 or less. In the case of somehospitals, this sum is only available as £150 for each six monthperiod leaving the onus on trainees to meet the cost of coursesfrom their own pockets. This is a not inconsiderable cost at atime when themajority of SpR level courses cost between £500and £1500 pounds. This is inevitably contributing to the senseof loweredmorale amongst trainees, who are forced to work fullshift rotas that compromise their training, are significantly lesslifestyle-friendly and inevitably involve a down-banding ofsalary.

Sarah Mills

OxfordAugust this year saw the implementation of the 48 hour workingweek by law, the cohort of run-through specialty traineesemployed in 2007 to enter higher surgical training, and severalhospitals in the region short of Core trainees, after trainingposts had been left unfilled following the recruitment round inFebruary. This shortfall was aggravated by the need to fill EWTDcompliant rotas, leaving rota gaps which had to be filled withinternal locums, thus reducing valuable training time during thenormal working day in order to ensure cover of on call servicesand ultimately patient safety.

The shortfall became apparent after several traineesdeclined the posts they were offered after the interviews, andtrainees who had been placed on the waiting list had in themeantime accepted posts elsewhere. This situationmay remaina problem in further recruitment years, as trainees are allowedto hold offers before making a final decision, making workforceplanning difficult. The surgical subspecialties using nationalrecruitment either with or without run-through programmes arenot affected by this.

All trainees appointed to run-through training in 2007moved into higher surgical training posts this August, subject tosuccessfully passing their ARCPs. Some trainees who failed toreach the required competencies for higher surgical trainingwere placed into specifically designed transition posts,resembling very much the old style senior SHO posts, withmiddle grade on call commitments and access to theatre liststo acquire the necessary operative skills and experience. Allhospitals in the region have implemented 48 hour compliantrotas, with all core trainees and the majority of higher surgicaltrainees working full shift rotas. Few exceptions are trustsrunning a hospital at night team, allowing higher surgicaltrainees to be non-resident on call. Several Core traineeshowever are seen on their days off after a set of nights to attendoperating lists and specialist clinics to gain training andexperience, most of them quite happy with the arrangementsas it allows them to remain in theatre or clinic undisturbed byduties that would otherwise require them to answer theirbleeps. Higher surgical trainees operate on similar principles,especially when non-resident on call.

The Core trainee regional teaching programme, started lastyear, is now well established, appreciated by the trainees andattended by about half of the cohort each time. Having used ablueprint mapped on the ISCP for the last year, this year sees adeviation from concentrating on subspecialties alone, with a

Reports fromthe Regions andSubspecialty Groups

Regions

MerseySince our last conference Nottingham 2009 - we areunfortunately still in the clutches of EWTD. I know for a fact thatlocally surgical trainees of all grades have worked above andbeyond their 'hours' not only to maintain their logbooks andcutting experience, but also to directly stop patient suffering.This has got to be highly commended and a defactopaybanding cut in times of recession is never easy. The wholesituation is intolerable and unsustainable and we await Nationalevents to quickly unfold. We were recently honoured to receivea visit to our region from the President of the Royal College ofSurgeons of England Mr John Black who as a past ASiTpresident is whole heartedly and passionately on our side -grassroot grumblings have finally been heard at the very top!

Looking forward to seeing everyone at conferenceKingston-Upon-Hull 2010!

Goldie Khera

North West ThamesAs is the case around the country, the impact of the EuropeanWorking Time Directive (EWTD) has been felt in the North WestThames Deanery. A move to full shift rotas has had adetrimental effect on surgical logbooks and clinical experience.Those hospitals not operating full shift rotas in the deanery havedown-banded jobs on the basis of non-resident on calls, but itis debatable whether these rotas stand up to close scrutiny interms of EWTD compliance. Certainly, there is a pressure withinthe deanery for all hospitals to be operating a full shift rota forSurgical Registrars and this will create problems for smallerhospitals, with fewer SpRs, in terms of service provision duringdaylight hours, not to mention the detrimental effects ontraining.

On a more positive note, in an attempt to address theimpact of EWTD on training the London deanery is running apopular Clinical Skills training programme for trainees up to thelevel of ST6 on monthly basis. In addition, there is also a well-attended lecture based teaching morning each month. Theintention of replacing lost hours of hospital-based training withtargeted training in clinical skills and on specialist courses ishowever, hampered by the significant cuts to study budgetsavailable for courses. This is particularly a problem in non-teaching hospitals where the £800 deanery allocated budget

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Reports from the Regions

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Scotland

East of Scotland DeaneryThe East of Scotland deanery has never had an ASiTrepresentative before this year. I think it’s been overlooked byASiT previously as it is the smallest deanery in the UK. At theend of 2008 I emailed the then ASiT president to explain thatI was unable to complete an online ASiT survey as it wouldn’taccept details of my deanery. A couple of days later I wasasked to become the ASiT representative for the region andthe East of Scotland region has since appeared on the ASiTwebsite!

Surgical trainees within the region were genuinely sorrywhen Mr Gareth Griffiths (a former ASiT president) announcedhe was going to relinquish his role as training programmedirector. Mr Griffiths had been a popular programme directorfor many years and there was a superb turnout at his “thankyou” dinner. We are pleased to report that although he’s leftthe top job Mr Griffiths continues to be involved with surgicaltraining within the deanery.

The coming year looks like being an exciting year within thedeanery with many senior registrars set to finish their trainingand move on. On a personal note I look forward to being moreinvolved with ASiT council and publicising ASiT within theregion.

John Scollay

North of ScotlandThe North of Scotland this year has, as with all regions, seendramatic changes in the complexion of surgical training. Onthe positive side there has been a re-introduction of astructured teaching programme in the region which hasinvolved a well attended and well orchestrated series oftraining days in Aberdeen, Elgin and Inverness. The resourcesfrom these training days are now posted on-line and areavailable to trainees for review. In addition to this, the localtrainees group (the A96 club) has continued to arrangeengaging evening lectures and social events throughout theyear.

As with every year we congratulate colleagues completingtheir training and welcome new trainees however, this year wehave also found new colleagues in the form of fellows - a HPBfellow and a colorectal fellow have recently started inAberdeen. Moreover, this year marks the beginning of theRemote and Rural fellowships with two trainees already inpost training in specialities normally considered to be out withgeneral surgery.

Of course, the negative impact on training due to theEWTD has been apparent to all. With a reduction in electiveworkload exposure and a loss of the apprenticeship model oftraining we all still have some way to go to acclimatise to thisnew regime.

Alan Grant

move to incorporate sessions on patient safety, evidence basedpractice and mock OSCEs.

All in all surgical training goes on, trainees are still enthus-iastic, with a desire to make things work as best as they can.

Bettina Lieske

West Midlands2009 has been a period of change. Following the appointmentof Mr Mike Hallissey as the new programme director withinGeneral Surgery, the foundations to change training within theregion have been laid.

As in other specialties, notably Orthopaedics, our largegeographical region has been divided into three areas: ‘SouthBirmingham’ which incorporates Worcestershire andWarwickshire, a northern area covering Stoke, Staffordshireand Shropshire and a central area covering Birmingham, theBlack Country and (the less central) Hereford. Each area has aprogramme director overseeing the training of trainees ST3-ST6, with a separate programme director covering seniortrainees throughout the whole region for their final years withintheir sub-speciality. The aim is to minimise travelling within theregion for the first four years. As with any period of change,there have been teething problems but progress is being madeto establish tailored individual training for each trainee. We havebeen able to continue our working relationship with the HigherSurgical Training Committee for the region and have been a linkbetween the various programme directors and trainees duringthis period of change. They do appear to be listening to us andwe hope that 2010 sees things visibly improve for us all.

We are particularly interested in the plan to create regulartraining days to encompass the curriculum and hope toencourage trusts to improve training opportunities, especiallythose who have committed to a particular sub-speciality.Educational representatives from each area have now beenappointed by the deanery and next year a set programme oftraining days will start rotating around the whole region. Thisprocess does need involvement from us, so if you have aninterest in education and would like to help organise one of thetraining days please let John Lengyel know.

The West Midlands Research Collaborative continues to gofrom strength to strength due to their continued hard work.Presentations at the ASiT conference and other national forumshave led to a lot of interest nationally in what has beenachieved. As a result, the first national meeting was held inBirmingham in December. This is being written before the eventran, so we hope that this went well and thank them for theirongoing efforts.

We continue to be conscious that we primarily representthose specialising in General Surgery, so would encouragetrainees to get involved from the other specialities. We are alsolooking to the future and are both soon to complete our training,Sarah in the near future. We would therefore, encouragetrainees interested in becoming involved with ASiT and trainingwithin the region into the future to be in touch. The new regionaltraining committees will act as a good introduction to this sortof role.

Sarah Rastall and Will Hawkins

Page 13-19 Region Reports:Reports 12/5/10 10:49

Reports from the Regions/Subspecialty Groups

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West of ScotlandAs with the rest of the country, the move to full shift rotasappears to be detrimental to training opportunities. Theteaching programme in the region, however, is a success andfollowing concerns over a significant drop in study budget thishas subsequently been increased.

More junior trainees have been getting a lot out of theFoundation Skills in Surgery course run by ASIT at the RoyalCollege of Physicians and Surgeons of Glasgow and this hasallowed increased membership and links with undergraduateorganisations.

Simon Gibson

Northern IrelandThe Northern Ireland division of ASiT has held 2 regionalmeetings in 2009 with over 50 trainees attending eachmeeting. The first of these meetings was on the ever populartopic of experience of time spent in developing countries,whilst the second meeting focused on the organisation ofoverseas fellowships. A new NIASiT committee was electedwith the following office bearers:

President: Conor MarronTreasurer: Ben DoddSecretary: Ruth JohnstonCore Trainee Rep: Ciara Stevenson

The challenges of the Working Time Directive have beentaken up in Northern Ireland via MPs and the School ofSurgery has been actively canvassing evidence of the impactof the directive. Other challenges that have involved NIASiTinput at a regional level have included undergraduate surgicaleducation, and postgraduate surgical teaching, with thereinstitution of a regional teaching programme that has beenextremely well received.

We look forward to another productive year in 2010 withimproved trainee representation.

Conor Marron

Subspecialty Groups

Association of Otolaryngologistsin Training (AOT)ENT surgical training has been decoupled and now consists ofcore surgical training followed by higher surgical training.Following competitive entry, trainees do two years of coresurgical training, perhaps soon to be expanded to three years(CT1-3), giving them exposure to key affiliated specialties. Thisis followed by competitive entry into higher surgical training.

This year saw the successful pilot scheme for Nationalrecruitment into ENT higher surgical training. HST numbers inENT are few and heavily subscribed to. This situation is unlikelyto change in the future as only a few substantive consultantposts in the speciality were advertised this year. Consequently,workforce planning is on the minds of most trainees anddiscussed at length with Alan Johnson, president of ENT-UK atthe annual AOT conference, with ideas including expansion ofconsultant numbers, the un-popular sub-consultant grade anddecreasing overall HST training numbers.

The AOT conference this year was in Manchester at theMidland hotel and well attended. The theme of the conferencewas ‘how to optimise your higher surgical training years’. Thesocial side of the conference included clay pigeon shooting andthe annual black tie dinner.

The e-lefENT learning project saw its launch in September.It contains 750 different interactive training modules, coveringthe curriculum defined by the intercollegiate surgical curriculumproject and completion of modules will eventually form a part ofsuccessful progress at annual ARCP’s. The ENT section of theISCP website is still poor and faced with much criticism. NewPBA forms are being piloted at present.

No report this year would be complete without a mention ofthe stressful and in most parts unsuccessful transfer into the48hour European working time compliant week. Trainees reportregular internal locums to fill rota gaps and attending theatrelists on their rostered half days. Some trainees have alreadyopted out of EWTD on an individual basis. The AOT supportsASIT in its fight for extended surgical training hours

Archana Soni-Jaiswal

Barrett’s ClubThe Barrett’s Club represents Upper GI trainees (both OG andHPB). As President of the Barrett’s Club I am both the traineerepresentative on the AUGIS (Association of Upper GISurgeons) Council and the Barrett’s representative on the ASiTCouncil, a role I share with John Hammond. Our involvement inASiT only began at the beginning of 2009, but there is renewedinterest in building the club’s profile and we anticipate thisinvolvement will grow.

We held a very successful training day at the recent AUGISconference in Nottingham. The day combined both practical


Reports from the Subspecialty Groups

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sessions in upper GI and emergency surgery, with small grouptutorials from the AUGIS council and viva practice for the exitexamination. The day was rounded off by the Annual Barrett’sclub dinner which allowed the trainees to get together in arelaxed environment. We will run a similar event before theAUGIS conference at Oxford in 2010. There has even been talkof a new meeting for Upper GI trainees run separately from theconference and provided there is interest we aim to get this offthe ground next year.

As with our peers in the Duke’s Club, one of the mainconcerns of UK based UGI trainees is access to endoscopytraining. To build a more accurate picture of what is really goingon around the UK, we will be sending out a survey. It appearsthat JAG, the organisation that regulates endoscopy training inthe UK wants to engage with surgical trainees in order toimprove training and the quality of patient care. Hopefully thissurvey, which will be conducted in conjunction with the DukesClub, will highlight some important issues.

Finally, a plug for the Barrett’s Club website, it can beaccessed via the AUGIS website. At the time of writing this it isin advanced state of readiness. I hope it will provide a valuableresource.

Natasha Henley

British Neurosurgical TraineesAssociation (BNTA)The BNTA represents the Neurosurgical trainees in the UK andIreland. It was formerly open to members in higherNeurosurgical training. With the introduction of run-throughtraining we now include all ST trainees and FTSTA’s inNeurosurgery with career intentions for Neurosurgery. Our emaillist server has become more active particularly in relation toEWTD implementation.

The BNTA runs from strength to strength. Under thestewardship of our chairperson Ms. Katie Gilkes the BNTA is apowerful voice for Neurosurgical trainees. Wemeet twice a yearduring the Society of British Neurosurgeons conference. Thisyear we have had two successful meetings in Birmingham andDublin.

Of course our issues and contentions in relation to trainingare common to all the surgical specialities.

Implementation of EWTD has provoked much anger anddismay for neurosurgical trainees. We have categorically statedthat the EWTD legislation will be detrimental for:• Training• Patient care• Trainee work-life balance

This remains our experience and belief. Reconfiguration ofrotas and working patterns have not provided an appropriate“off set” to make up the deficits experienced in relation to theareas stated above.

Our middle grade manpower census revealed a 10%shortage of middle grades. This further adds to the fallacy thatEWTD is truly implementable. We are grateful to ASiT and JohnBlacks for their representations and are proud to be part of thepan-surgical alliance that stands in opposition to this legislation.

We continue with run through training and national selection, sofar there have been no major concerns but as always time willtell the true successes and weaknesses of such systems. Aswith training, academic neurosurgery is curtailed and inhibitedby the relentless pressures placed on consultants to provideservice. We must continue to drive up the quality and quantityof research in Neurosurgery.

It has been a pleasure to see how Neurosurgery stands withall the surgical specialities to pursue excellence in training. Thepolitical impact of the pan-surgical alliance has been immenseand most importantly has been recognised and supported bythe patients.

The battles that are being fought to improve our training arenot won overnight. We must remain steadfast in our beliefs. Wewill ultimately succeed!

Roddy O’Kane

Duke’s ClubTo those who know little of the Dukes Club, we are surgicaltrainees interested in colorectal surgery. We are primarily a web-based group and any surgical trainee can join (for free!) atwww.thedukesclub.org. I personally became aware of theDuke’s Club midway through my SpR training, but it’s a greatsource of information especially for courses, fellowship andfunding opportunities, colorectal training issues and also forEXIT examination questions help and advice (for all surgicalspecialties).

Our AGM is at the ACPGBI annual meeting in June andeveryone is welcome.

We run an annual weekend meeting (heavily sponsored)that allows like-minded trainees to meet, discuss and socaliseas well as being educated by guest speakers on topical issues.In Spring 2009, our venue moved to the Marriott Hotel, Forestof Arden. Our eminent speakers included Mr Robin Kennedywho kicked off proceedings with an interesting discussion onLaparoscopic training. He discussed the need to move up thelearning curve and the use of task specific training using a safe,consistent, structured method. Mr Nick Carr (the then currentPresident of the ACPGBI) gave a fascinating talk on the prosand cons of ileoanal pouch surgery. His series over twentyyears rivals results from studies from the big States sideinstitutions… a real legend. Professor John Northover spokeabout pelvic clearance surgery and its pitfalls with someexcellent advice on controlling difficult operative situations andcoping strategies for them. Finally, Mr Graham Williamsentertained us with a talk on the current employment situationfor Consultant posts and discussed ways in which we couldmake ourselves a more saleable commodity. This included adiscussion afterwards on the controversial sub-consultantgrade that is unsupported by both ASiT and the Duke’s Club.

This year our meeting promises to be equally as topical andinformative. Once again current issues such as EWTD, JAGaccreditation, Colorectal Fellowships and much more will bediscussed. I look forward to seeing you.

Joy Singh



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The Mammary FoldThe Mammary Fold is a group that aims to represent all UKbased junior doctors who have decided to specialize in thetreatment of breast disease.

Over the last year, the expanded interim committee hasworked hard to both raise the profile of the group and todevelop a new more functional website that better serves theneeds of its members. The new web portal will provideimproved educational resources and exam advice as well asessential information on upcoming courses, trainingopportunities and jobs. It will also have a dedicated series offora where junior and honorary members (Mammary Foldalumni who are now consultants) will be able to exchange ideasand potentially gain valuable career advice.

In keeping with this renewed emphasis on training relatedissues, the MF held a session at the ABS at BASO meeting inYork in May 2009 focusing on breast screening and anoncoplastic approach to breast conserving surgery.

The newly elected committee, which took over theadministration of the MF in autumn 2009, have been keen toboth build on the work of the interim committee and torepresent the views of the members. The first priority has beento secure funding for the new website and current plans are forit to go live early in the New Year. For medical students thinkingabout a career in Breast Surgery, MF members will bementoring 8 students sponsored by ABS at the next springmeeting in 2010.

The future promises to be a period of considerable changenot least with the unresolved debate on the future of BreastSurgery in the UK. Decreasing numbers of Breast surgeons arebeing appointed to posts with general on-call commitments.However, a survey conducted by the previous MF ASITrepresentative, Jasper Gill, revealed that approximately half ofour respondents wished to continue with a general surgicalcommitment as consultants and 66% anticipated involvementin general surgical-on call. Furthermore, 44% wished tomaintain a specialisation in another branch of surgery inaddition to breast or oncoplastic surgery. Interestingly, 52%wished breast surgery to remain under the general surgeryumbrella with 35% suggesting it should be separate. The fullsurvey results will be available on the ABS at BASO websitesoon.

The Oncoplastic Fellowships continue to be successful andhave led to a significant increase in the number of highly trainedOncoplastic Breast Surgeons in the UK. More recently, theproposed MS degree in Oncoplastic Breast Surgery has beenapproved and is currently being developed for a roll out inSeptember 2010. This will be a web-based distance learningcourse provided by the University of East Anglia and issupported by ABS and BAPRAS. MF will be surveyingmembers to assess their views on the course shortly. I wouldencourage as many as possible to take part to help shape thefuture of training.

Suzanne Elgammal (ASIT rep) & Jennifer Hu (MF Chairman)

Oral and Maxillofacial Surgery(OMFS)Do we need Oral and Maxillofacial Surgery (OMFS)? Oral andMaxillofacial surgery is one of the nine surgical specialties.Consultants in OMFS have a degree in medicine and dentistry,have undergone basic surgical training, and have an FRCS aswell as a fellowship in dental surgery from one of the royalcolleges. We undertake the whole spectrum of surgicalprocedures in dentistry as well as operations involving themouth, face, jaws and neck. Why do I tell you this? Surelyeverything we do could be undertaken by other specialties inmedicine and dentistry? These questions were considered inthe document ‘PMETB report on training in OMFS’. Thespecialty had favourable feedback from all involved and arecurring response was that OMFS held an important positionin patient care as it spans both medicine and dentistry, enablingthose trained in OMFS to bridge the divide between these twoimportant pillars of healthcare. This report, which concludedlast year, made six recommendations:1. The statutory need for dual medical and dental

qualifications should remain.2. The training for OMFS should be streamlined.3. Specialty training should begin at the start of the second

degree course.4. Those on the specialist register in OMFS should only need

to be registered with the GMC.5. There should be a separate review of the specialty of Oral

Surgery.6. Dually qualified individuals who can demonstrate com-

petencies should have the option of moving into specialtytraining programmes without completing the F2 year.The penultimate point is very interesting to Oral and

Maxillofacial surgeons. I would like to take the time to let youknow why. Over the last few years, a dental specialty called‘Oral Surgery’ has sprung up. This has nothing to do withOMFS and so consultants in Oral Surgery have not undergonesurgical training and have not had an appropriate surgicaldiploma awarded. At the present time, an Oral Surgery reviewcommittee is convening to ascertain what surgical proceduresOral Surgeons should be allowed to undertake. I think theconcern by many (which will be aired to the committee in duecourse) is that this dental specialty will not be content with justtaking on minor surgical procedures in the mouth, but will belooking to undertake more complex operations that the publicwould expect to be performed by a surgeon with an FRCS.

We have had a productive year with regards to training. Thetrainees’ web site is now part of the British Association of Oraland Maxillofacial Surgeons (BAOMS) website, which contains alarge amount of information and is well worth a look. Thetrainees’ noticeboard has moved from quick-topic to Yahoogroups and the enhanced utility is being used to great effect.We have had some excellent web lectures this year thanks toSatheesh Prabhu who has worked very hard to get this projectup and running.

We had an enjoyable trainees' conference in Swansea thisyear. Leeds are to host the 2010 and Oxford the 2011conferences. OMFS trainees have been awarded fellowships in



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craniofacial surgery at Great Ormond Street Hospital andBirmingham Children’s Hospital, and several OMFS traineeshave been granted interface reconstructive cosmeticfellowships.

Spencer Hodges

Plastic SurgeryI have been the PLASTA representative on ASiT council sincelate 2008 after being elected onto the PLASTA committee thesame year. We act as the voice for plastic surgery trainees in theUK and endeavour to put forward concerns to the relevantcommittees.We have a large group of registered trainees on thePLASTA website (www.plasta.org.uk) and also have inter-national members. We will have relaunched the website in late2009, which is part of a major drive to improve our memberexperience.

The last year has been eventful, with decoupled nationalselection to HST becoming established. The selection criteriaare still difficult and there is significant competition for“numbers”, with members of the “lost tribe” still trying to get anational training number. In order to assist with workforceplanning, PLASTA undertook a survey to map out the numberof consultants and higher surgical trainees and the predictedCCT dates for the latter group. This shows a bulge due to finishin 2011-2013, however there is still a need for consultantexpansion. We will continually lobby to achieve the desirednumber of consultants as stipulated by BAPRAS (BritishAssociation of Plastic, Reconstructive and Aesthetic Surgeons).In light of the economic downturn and predicted NHS fundingcuts or static growth, expansion may be difficult to achieve.

In addition, the views of ISCP from plastic surgery traineeswere collected and presented. This generally consisted ofcriticism of the website and its use of forms. These werepresented at a national level and were noted by JCST and ISCP.A recurrent theme was the lack of time that consultants had toteach trainees, due to an inexorable rise in service demand forconsultants. It became clear at a meeting hosted by JCST atRCSE, that this concern was shared by all surgical specialties.This meeting allowed the trainees and specialties to voicesignificant concerns and hopefully this will lead to improve-ments in the website and tools for recording learning.

Another important development is the interface fellowships,which are becoming more common. These are now advertisedon a regular basis, which include head and neck, cleft,aesthetic, breast and hand fellowships. With regulation ofaesthetic medicine lookingmore likely, it’s important for traineesto demonstrate experience of this in addition to their “normal”clinical workload. To that effect BAPRAS have organisedaesthetic training days, which will hopefully tie in with a new e-learning project being developed with Department of Healthfunding.

PLASTA is looking to establish good links within thespecialty and also with other surgical specialties. 2009 hasbeen a good start with the promise of more to come next year.

Kristian Sørensen

Rouleaux ClubIt has been a pleasure representing the Rouleaux Club sincebeing voted into this position at the 2008 AGM in Bournemouth.There have been changes within the Rouleaux Club in the lastyear as well as Vascular Surgery in its broader form.

During Rob Hinchliffe’s presidency, Simon Hobbs(Treasurer) has been able to reconfigure the constitution of theClub in order that we were able to successfully apply forcharitable status. This has afforded us significant advantages interms of taxation and making the most of our industrialsponsorship.

Our Summer AGM was held at Walton Hall and for thesecond year was jointly attended by the Junior Section of theBritish Society of Interventional Radiology - a step thatdemonstrates our intention to complement, rather thancompete with, our radiological colleagues. We heard about theevidence base for vascular interventions from Prof Janet Powell– huge holes in our knowledge were all-to-easily opened! Wewent on to hear a compelling case from Professor Karim Brohithat the trauma surgeons of the future should perhaps berecruited from vascular surgeons in training now. He felt we willhave the ability to enter most body compartments and have thenecessary skills to ‘turn off the tap’ – whether this is using openor endovascular haemorrhage-control techniques. Keith Joneswrapped up the educational component demonstrating sometruly impressive limb salvage rates he has achieved in thediabetic population served by St George’s Vascular Institute.The evening was rounded off with a fantastic dinner and somenot-so fantastic dancing.

With regards to separate speciality status, the moratoriumon new specialities imposed by PMETB has been lifted. TheVascular Society now believes that separation of vascularsurgery from general surgery could take place very quickly.Indeed, it is believed that ratification of this plan could occurbefore February 2010.

The 2009 AGM was held during the VSGBI meeting inLiverpool on 19th November. The positions of Vice-President,Secretary, and ASiT representative (I am stepping down in orderto complete a Fellowship year in Australia) were available forelection. James Scurr narrowly defeated Nick Matharu and waselected Vice-President. Femi Oshin was re-elected as Secretaryafter defeating Said Abisi and Rob Davies was victorious in hisquest to become the new ASiT representative despite a valianteffort from Dean Godferry.

I wish Rob well and hope he gains as much from his timeon ASiT Council as I did.

Rob Brightwell



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Military SurgeryIt is with great pleasure that I can introduce the subspecialtygroup of Military Surgery having recently been invited to sit onthe ASIT council as the military trainee representative with theaim to raise the profile of a growing and enthusiastic group ofsurgical trainees. Having a voice on the council will allow us toput forward our point of view on issues that all Defence MedicalService (DMS) trainees face today whilst working within boththe military sphere and the NHS. To that end, I will beencouraging all trainees within the DMS to join ASIT and givetheir support, and will look forward to hearing from any traineescurrently in the Reserve Forces.

The current tempo of deployments has brought MilitarySurgery to the fore, and has highlighted the need for ourtrainees to obtain a broader base to our training to help prepareus for future deployments in our consultant roles. This is beingaided by co-operation and increased input with thepostgraduate deaneries in order to ensure core trainees areplaced in posts relevant to DMS requirements. At ST entry level,competition is high for places in the specialities oforthopaedics, plastic surgery and neurosurgery; however agreater number of places are available within general surgery. AtConsultant level, Joint Medical Command (JMC) has statedthat placement will be sought initially with RCDM Birminghamand theMDHUs. If the person cannot be accommodated withintheir specialities at these centres, then application for a stand-alone post can be sought.

The Academic Department of Military Surgery and Trauma -ADMST continues to grow from strength to strength under thecontrol of Surgeon Captain Mark Midwinter, Defence Professorof Surgery. This has been recently enhanced with Lt Col JohnClasper being appointed as the Defence Professor ofOrthopaedics. Exciting new developments this year haveincluded the introduction of Military Operational SurgicalTraining (MOST) Course which is being run at the Royal Collegeof Surgeons of England. It has been deemed as mandatorytraining prior to deployment and is an excellent basis to ensurethat our surgical teams of surgeons, anaesthetists, theatrenurses and ODPs are fully prepared for the wide range of caseswe encounter. The MSc in Trauma Surgery (Military) is nowbeing provided through Swansea University and all trainees areadvised to look into this. Information for this can be obtainedthrough the Defence Professor of Surgery at ADMST in RCDM.

The coming year is very encouraging with the developmentof trauma and military sections at both the ASIT conference inHull and ASGBI in Liverpool. Lastly and most importantly is toremind you all of the Military Surgical Conference(www.militarysurgery.org.uk) in March. I look forward to seeingyou then.

If you require any information within the DMS or if you are asurgical trainee within the reserve forces, I will be happy to hearfrom you.

Surgeon Lieutenant Commander Catherine [email protected]

Medical Student ReportSince taking on the position of ASITs Medical StudentRepresentative, I’ve worked closely with many members of theCouncil to continue to improve ASiTs work for MedicalStudents. My primary aims have been to raise ASiTsundergraduate profile and improve our student membershipincentives. Andy Pillai did a fantastic job last year and the bulkof my work so far has been to solidify and publicise hisachievements. This year, I’m delighted that there is a studentsection of the yearbook and hope that it provides a usefulresource for our members.

By January, ASiT will have selected two student membersas our first winners of the ASiT/Elsevier Surgical Elective Prize.As many will remember Electives are often the highlight ofundergraduate studies. I’m therefore thrilled that we’ve beenable to contribute to members’ experiences and eagerly lookforward to reading their reports.

This summer I successfully gained Council approval toselect individuals from each Medical School in the UK torepresent ASiT within their Universities. Establishing this grouphas allowed more direct access between ASiT and the studentpopulation. Now that involvement with UndergraduateSocieties has been included in the roles and responsibilities ofASiTs regional representatives, I hope we’ll decrease thenumber of junior doctors who are unaware of ASiTs vital role.

I recently attended the Medical Student Liaison Committeeof RCSEng, where I was able to present details on ASiTsmembership and latest achievements to the presidents of thecountries undergraduate surgical societies. The meeting alsoallowed discussions about the current topics affecting medicalstudents and I’ve been able to feed their issues back to theASiT Council.

Andy put a huge amount of effort into creating a detailedone-stop resource for students with an interest in surgery onthe student pages of our website. I’ve added to his efforts byincreasing the details on differences between the surgicalspecialties and providing more information on undergraduateevents.

The student session at last year’s conference receivedtremendous feedback and I’m hoping this year will match itssuccess. I’m currently working to publicise the event and itsrelevant prizes amongst students and encourage theirattendance and abstract submission.

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EWTD for Surgical TraineesAugust 2009British Orthopaedic Trainees Associationc/o The British Orthopaedic Association35-43 Lincoln’s Inn FieldsLondon, WC2A 3PNwww.bota.org.ukT: 020 7405 6507F: 020 7831 2676E: [email protected]

IntroductionThe coming weeks and months will doubtless prove to be a difficult time for many surgicaltrainees as new rotas and working patterns are adopted, set against a backdrop ofinsufficient staff with which to fill these increasingly thin rotas.

"If you can keep your head when all about you are losing theirs,it's just possible you haven't grasped the situation."

This document aims to provide a simplified, practical guide specific to surgical trainees,giving an overview of the relevant issues, answering some of the most common queries,and setting out EWTD and New Deal law as it currently standsWhat this guide cannot do is give recommendations about what is right for you. A

decision to opt out remains your choice. What is important is that you fully understand therisks and benefits of doing so - and equally of not doing so, and continuing to work or trainbeyond your allotted hours.In preparing this document we have brought together the latest advice from a range of

organisations, including the surgical Royal Colleges, the British Medical Association andNHS Employers. Where their advice is unclear we have sought to clarify this and theoutcome of our correspondence forms the basis of this guide. Where ambiguity remains wehave highlighted this.ASiT and BOTA are not trade unions. Whether we should be is a discussion for another

day, but in not currently being so we are restricted in the detailed advice we can offersurgical trainees.If having read this guidance you remain in any doubt about these issues it is important

that you seek further guidance. This may mean contacting relevant professional associationssuch as Remedy UK, the Hospital Consultants & Specialists Association or the BMA. Yourindemnity organisation may also be able to offer you more specific advice.The bottom-line is that you need to be pro-active to protect your own training while at the

same time remaining professional and ensuring the safety of your patients.You also need to be pro-active in making certain you are contractually safe and legally

indemnified for the hours you choose to work and train. Make sure you cover yourself andalways let your clinical leads and NHS Trust know what is happening.We hope this guide provides clarity on the key issues surrounding EWTD and enables

surgical trainees to remain, as always, one step ahead of the game.

Ed FitzgeraldCharing Cross Hospital, LondonPresident, Association of Surgeons in Traininghttp://www.asit.org

The Association of Surgical Trainessat The Royal College of Surgeons35/43 Lincoln’s Inn FieldsLondon, WC2A 3PEwww.asit.orgTelephone: 0207 973 0302Fax: 0207 430 9235E: [email protected]

Ben CaesarRobert Jones and Agnes Hunt Orthopaedic and DistrictHospital, OswestryPresident, British Orthopaedic Trainees Associationhttp://www.bota.org.uk

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Background to the EWTD

“We got into this mess because a group of professional people, surgeons, have had their hours ofwork defined for them by others with little or no knowledge of the work concerned”

John Black, August 2009

This month has seen the implementation of the final stage of the European Working Timedirective, ending the exemption for junior doctors that was originally established in 1993.This controversial piece of European legislation was aimed at protecting the health andsafety of the worker. It initially excluded a number of defined groups, including doctors intraining. Since this exemption was over-tuned in 2000, we have seen the introduction of anaverage 58-hour working week from 1 August 2004, 56-hours fromAugust 2007 and now 48-hours.The reduction in surgical training opportunities associated with EWTD implementation

thus far is real and has been well documented, with numerous academic papers detailing thedecline in operative exposure.Surgical trainees remain opposed to this restriction of working hours for several reasons.

As a craft speciality, surgery is particularly vulnerable to the inevitable reduction in trainingopportunities and experience that accompanies this. Patient safety will be jeopardised in theshort-term through reduced rota cover, multiple handovers, and a lack of continuity inpatient care. In the longer term, the reduction in training opportunities and inevitable focuson service will clearly impact on the clinical and operative experience of surgical traineeswith an eventual deleterious effect on service delivery and patient outcomes.Finally, we believe the assertion that EWTD is essential health and safety legislation is

disingenuous given that the resulting shift work will result in more irregular hours andlonger periods of on-call. This scenario is unlikely to result in well-rested doctors or thehealthier work-life balance that some have sought to promote.It is true to say the NHS and medical profession have had a many years to prepare for

this. Surgical trainees have watched the Department of Health’s implementation scheduleclosely during this time. ASiT first published a specific position statement outlining EWTD-related concerns in 2006. Since then, and despite numerous further warnings, we have seenno significant change in the provision of surgical training within the NHS in order to addressthese concerns; nor is there any evidence the NHS is planning to address these in the future.Given that the introduction of any compensatory changes in training will now inevitably

take several years to establish, we continue to call for the current legislation to be repealed inorder that the patients of today and tomorrow get the first-class care they deserve.In the meantime we need to remain constructive and work around current legislation to

ensure training time is protected, while at the same time developing and promoting newtraining initiatives across the country.

EWTD and New Deal RulesThere is frequent confusion over the rules governing junior doctor’s working hours.

There are two relevant areas of legislation:1. Working Time Regulations (the UK implementation of the EWTD)2. New Deal Contract (the junior doctor contract)

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The current legislation limiting working hours, together with mandatory breaks and restperiods, are now formed by a combination of these.Whilst the New Deal only applies to junior medical staff, the EWTD rules apply to all

workers (including Consultants) across all sectors.

The New Deal Contract included the following key points:• Working time should not exceed 56-hours of work per week.• Actual duty hours depend on working pattern implemented (eg full, partial, etc).• Eight consecutive hours rest between full shifts.• Natural breaks of 30-minutes per four-hours worked.• Minimum of 24-hours rest every 7-days, or 48-hours rest every 14-days.

EWTD regulations include the following key points:• Working time not exceeding 48-hours per week, averaged over 26-week period.• Eleven consecutive hours of rest per 24-hour period.• Minimum of 24-hours rest every 7-days, or 48-hours rest every 14-days.• Twenty minutes break per 6-consecutive hours worked.• Four weeks paid annual leave.

Direct.gov: What counts as EWTD work?As well as carrying out your normal duties, your working week includes:• Job-related training.• Job-related travelling time.• Paid and some unpaid overtime.• Time spent 'on-call' (note: non-resident on-call doctors only count the hours actually spentworking as ‘work’).

If you work two jobs you could either:• Consider signing an opt-out agreement with your employers if your total time worked isover 48 hours or reduce your hours to meet the 48-hour limit.

Direct.gov: What does not count as EWTD work?Your working week does not include:• Breaks when no work is done, such as lunch breaks.• Normal travel to and from work.• Time when you are 'on call' away from the workplace and not working (i.e. non-residenton-call).

• Travelling outside of normal working hours.• Unpaid overtime that you have volunteered for, for example staying late to finishsomething off.

• Paid or unpaid holiday.

EWTD and Personal ‘Opt-Outs’If you wish to, you may apply to opt-out of the EWTD working time limits. However, it isimportant to note:• You cannot opt out of the EWTD or New Deal rest requirements.• Opting out does not exempt you from the 56-hour New Deal working time limit.

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Opting out does not necessarily result in extra training time. You may find the extra hoursworked are taken up by further service commitments. You will need to weigh up carefullywhether these will further your clinical experience and training.If you sign an opt-out you are free to cancel this agreement at any time by giving betweenone week and three months' notice to the Director of HR (the notice period depending on thewording of the opt-out agreement you have signed up to).

It is important that any opt-out you choose to pursue is of your own volition:• Your employer cannot ask or pressurise you to opt out from EWTD limits.• Opting out of EWTD limits must not be a requirement for your employment.

There is currently no nationally agreed system for opting out of EWTD working time limitsin the NHS. Opting out must be agreed with your employer in writing.

Sample opt-out letters are available from a number of sources:• Direct.gov Sample opt out agreement letterhttp://www.direct.gov.uk/en/Employment/Employees/WorkingHoursAndTimeOff/DG_10029426

• BMA Sample opt out agreement letterhttp://www.bma.org.uk/images/Junior_WTR_Optout_tcm41-189137.doc

• ASGBI: Opting out of the 48-hour working weekhttp://asgbi.org.uk/download.cfm?docid=D37CD92E-0877-4389-BD56AC60590EF438

We are also aware of a sample opt-out letter drafted by NHS Employers for use in the eventof a pandemic flu epidemic causing substantial impact on NHS services.

• A copy of this letter can be viewed at the following link:http://www.nhsemployers.org/PlanningYourWorkforce/Pandemic-influenza/Pages/Working-time-regulation-opt-out-agreement.aspx

Remuneration for Opting-OutAny additional work undertaken after opting-out of EWTD limits should be remunerated byyour employing organisation. How you are paid is open to local negotiation with your NHSTrust. However, it is important to note that your pay banding will not necessarily changeshould you choose to opt out.This can be through paid hourly locum rates at least equal to the nationally agreed locum

scale, or through the conventional banding system. The latter approach would requireformal monitoring in order to establish appropriate remuneration, and is best suited toregular additional work as opposed to ad hoc shifts.Current nationally agreed locum rates are detailed in the pay circulars listed in the

reference section of this document.

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EWTD and Medical Indemnity

Key points

• Ensure your educational supervisor, clinical lead and NHS Trust know that you areworking in excess of your ‘allotted hours’ for training purposes.

• Keep a record of any correspondence relating to this issue.• Ask your NHS Trust for specific details of local indemnity arrangements.• Please let us know if you are prevented by your NHS Trust from undertaking

reasonable training outside your normal ‘allotted’ working hours.

Trainees have rightly raised serious concerns regarding their medical indemnity for workundertaken over and above their 48-hour compliant rota. Given the propensity of hospitalmanagement to distance themselves from any adverse outcomes, trainees are right to becautious and question what support, if any, the NHS will offer.

Two specific scenarios have been identified:1. Where clinical workload necessitates staying beyond your allotted hours.2. Where you attend for training in your own time outside your allotted hours.

The first scenario is likely to be indemnified. However, if this is a recurring scenario then itmay be more appropriate for the employer to acknowledge this, re-design the rota, and re-band your post as appropriate.The second scenario is less clear-cut. While in theory NHS indemnity should still apply,

the caveat may be whether the employing organisation knows this ‘work’ is occurring, andwhether the supervising Consultant is prepared to take clinical responsibility for this.

The NHS Litigation Authority has previously been asked to clarify this issue and releasedthe following statement:

“Any activity carried out by clinicians which would be the subject of anindemnity if carried out during ‘allotted’ hours will be treated nodifferently under our schemes because that work was being done outsidethese hours”.

Stephen Walker, Chief ExecutiveNHS Litigation Authority, November 2007

We asked the Medical Defence Union for their opinion and received the following response:

“…we would need to know in what capacity the surgeons in training areattending cases 'for their own education outside of the EWTD workinghours'. If they are merely observing such cases and are not in any wayproviding clinical care but are just an observer, the question of indemnitywould not arise. If, however, they are attending cases as part of the medicalteam providing care or treatment, we would expect that they are doing soas part of their employment and in that case they will be covered by NHSindemnity and there would be no need to inform the MDU. In the firstinstance we would advise any doctor who was working outside the EWTDhours to check with the NHS employer for whom he or she is contracted towork these additional hours what the indemnity arrangements are.”

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We asked the Medical Protection Society for their opinion and received the following response:

“Clarification has been sought which confirms that the NHSLA (NationalHealth Service Litigation Authority) has reassured Doctors treating NHSpatients beyond the limits of their contractual duties that they would beindemnified for claims by the NHSLA. However, it would be wise todiscuss the views and options locally if working beyond contracted hoursis not for service provision, but for educational purposes. Claims whicharise from patients receiving NHS hospital care should therefore becovered by Trust indemnity. MPS would assist in matters which arise fromclinical work undertaken outside of core contractual hours for non claimsmatters, such as GMC or disciplinary investigation.From a risk management perspective junior doctors should consider theappropriateness of volunteering for extra work if they are tired, despitethere being a good training opportunity. They must obviously ensure theirown and the patients welfare as a priority. Ultimately, trainees areaccountable for the decisions which they make, and they will be expectedto always put the interest of the patient first.”

It is therefore clear that in the event of any adverse clinical incident occurring, a surgicaltrainee would be expected to have shown a professional regard for their rest periods, andnot put a patient at risk as a result of their own tiredness.Regardless of indemnity, in the second scenario a trainee may still find themselves in

breach of their employment contract by undertaking these additional hours (see nextsection).

EWTD Non-ComplianceIt is just as important that those wishing to adhere to a 48-hour compliant rota are able to doso.Trainees concerned that their EWTD rota is in fact not 48-hour compliant over the

reference period of 26-weeks should raise this issue with the Director of their HumanResources department and clinical leads.If this concern is valid, the employer has a duty to then reduce working hours through

rota amendments such that compliance is met.A number of sanctions and penalties are available for NHS Trusts that fail to implement

or knowingly run non-compliant rotas (excluding those for which derogation has beenapplied). These include:• An improvement notice• Prohibition notice• Fine (£5000 per employee per week)• Imprisonment of the responsible authority

EWTD and Employment Contracts

Key points

• Check the wording of your contract before undertaking additional hours.• Ensure your NHS Trust is aware of contractual barriers to you undertaking any

additional work for either service provision or training.• Keep a record of any correspondence on this issue.

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Trainees may find themselves in breach of their employment contract and/or terms andconditions of service by undertaking additional hours over and above those included in theirEWTD-compliant rota.This is dependant on the definition of ‘work’ as applied to surgical training and this (as

far as we are aware) has not yet been legally defined in this scenario. It will also depend onthe exact wording of your contract, which may differ widely from hospital to hospital.It is therefore vital that trainees wishing to undertake either paid locum work, or

additional training beyond their contracted hours are aware of the specific wording of theircontract.

Typical contractual statements preventing such work may be worded as follows:

“You agree not to undertake locum medical or dental work for this or anyother employer where such work would cause your contractual hours (oractual hours of work) to breach the controls set out in paragraph 20 of theTerms and Conditions of Service.”“Your hours and duties are as defined in the attached job description [forrotations, the job description may differ for each individualpost/placement]. You will be available for duty hours which in total willnot exceed the duty hours set out for your working pattern in Paragraph20 of the Terms and Conditions of Service.”

In a worst-case-scenario breach of these contractual obligations may be considered groundsfor dismissal. At the very least it is likely your NHS Trust will seek to use this in theirdefence should any adverse incident occur during hours worked over-and-above yourcontractual obligations.We are aware of some NHS Trusts who, despite including these clauses in their

employment contracts, are then asking medical staff to work additional hours to fill rota-gaps. Such incongruities should be highlighted to the employing NHS Trust.

What Can Trainees Do Now To Protect Training?

Key points

• You must be pro-active in protecting and maximising your own training time!

• Record when training occurs out of hours.We are working to ensure that this becomes an option in training logbooks.

• Ensure your current rota and banding adequately reflects the work you are undertaking.• Any new rota should be appropriate to the work required and be agreed in consultationwith your Consultants.

• Make sure training opportunities are protected in any revisions of your rota and alert yourConsultants, educational supervisors, programme directors and NHS Trust if this is notthe case.

• Maximise study-leave for the benefit of your training.• Please respond to the EWTD surgical survey that surgical trainee groups, in combinationwith the RCSEng, will be distributing at the start of September.

• Remember: keep records of your correspondence on any of these issues.

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References and Further Reading• ASiT EWTD Position Statement - January 2009 http://www.asit.org/assets/documents/ASiT_EWTD_Position_Statement.pdf

• BOTA Position Statement on the European Working Time Directive and Training in Trauma & Orthopaedic Surgery -January 2009http://www.bota.org.uk/uploads/cms/00178/BOTA%20EWTD%20Statement.pdf

• BMAEuropean Working Time Directive briefing paper (31 July 2009)http://www.bma.org.uk/employmentandcontracts/working_arrangements/hours/euroworktim.jsp

• EWTD briefing paper from the BMA Junior Doctors Committee: facing the challenges of the EWTDhttp://www.bma.org.uk/employmentandcontracts/working_arrangements/hours/euroworktim.jsp

• HSG (96)48: NHS indemnity arrangements for handling clinical negligence claims against NHS staffhttp://www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/Healthserviceguidelines/DH_4018270

• England & Wales Pay Circular: (M&D) 1/2009 http://www.nhsemployers.org/Aboutus/Publications/PayCirculars/Documents/Pay%20Circular_MD_1_09_090409.pdf

• Scotland Pay Circular: PCS(DD)2009/03 http://www.sehd.scot.nhs.uk/pcs/PCS2009(DD)03.pdf• Northern Ireland Pay Circular: HSS TC8 1/2009 http://www.dhsspsni.gov.uk/pay-circular-2009-2011.pdf• BMA JDC Guide to calculating rota banding, rules governing rotas, etchttp://www.bma.org.uk/images/FinalCountdown_tcm41-158037.pdf

• ASGBI: The Impact of EWTD on Delivery of Surgical Services: A Consensus Statementhttp://asgbi.org.uk/download.cfm?docid=F3FAB184-01E1-414A-BA7C0CE07BBEDD7F

• ASGBI: Coming to terms with the Working Time Regulationshttp://asgbi.org.uk/download.cfm?docid=E8AB16C6-CF3D-416B-A4CE7D74D698E6C5

• RCSEng President's Newsletter - August 2009 http://www.rcseng.ac.uk/about/president/current_newsletter.html• RCSEng: The Working Time Directive 2009: Meeting the challenge in surgeryhttp://www.rcseng.ac.uk/service_delivery/documents/WTD%202009%20Meeting%20the%20challenge%20in%20surgery.pdf

• RCSEng: Safe Shift Working for Surgeons in Traininghttp://www.rcseng.ac.uk/publications/docs/Shift_working_for_surgeons_in_training.html

• The Royal College of Surgeons of England / Royal College ofAnaesthetistsWorking TimeDirective 2009 Project report:WTDImplications and Practical Solutions to Achieve Compliancehttp://www.rcseng.ac.uk/service_delivery/working-time-directive/docs/RCS RCoA%20WTD%20Project%20Report.pdf

Further Reading• RCSEng EWTD Resources http://www.rcseng.ac.uk/service_delivery/working-time-directive• ASGBI EWTD Resources http://asgbi.org.uk/en/publications/working_time_regulations.cfm• Healthcare Workforce EWTD Resources http://www.healthcareworkforce.nhs.uk/workingtimedirective.html• NHS Employers Working Time Directive Resources - Frequently Asked Questions for Trust implementation teamshttp://www.nhsemployers.org/SiteCollectionDocuments/WTD_FAQs_010609.pdf

• Open Europe: TIME’S UP! The case against the EU’s 48 hour working weekhttp://asgbi.org.uk/download.cfm?docid=0A0DC209-DA70-4E0E-88B9C6B1EAAC441B

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PRESS RELEASE

Surgical Trainees Worried as TrainingDeteriorates Under European WorkingTime RegulationsUNDER EMBARGO UNTIL 00.01 WEDNESDAY 4 NOV 2009

British Orthopaedic Trainees Associationc/o The British Orthopaedic Association35-43 Lincoln’s Inn FieldsLondon, WC2A 3PNwww.bota.org.ukT: 020 7405 6507F: 020 7831 2676E: [email protected]

Survey results released today reveal growing alarm amongst junior doctors over the impactof the European Working Time Directive (EWTD) on surgical training and patient safety.

Over 1,600 surgeons-in-training from all specialties responded to a survey by theAssociation of Surgeons in Training (ASiT) and the British Orthopaedic Trainee Association(BOTA).

Over two-thirds of trainees reported deterioration in their surgical training since EWTDimplementation in August, with only 1% of respondents experiencing any improvement.

67% of surgical trainees are attending work while off-duty to protect their training andgain adequate experience operating. These additional unregulated hours are likely to exceedthe limits set down by the EWTD.

Other key findings include:• 84% of surgical trainees are working in excess of their rostered hours to maintain the

quality of the service provided and ensure patient care is unaffected.• 48% have no specific time allocated in their rota for dedicated handover of patient care,

contrary to professional guidelines, with over 74% of respondents handing over care toother surgical teams 2 or more times during each 24 hour period.

• 17% of trainees were aware of formally reported adverse critical incidents, usingestablished hospital reporting systems, directly arising from reduced working hours orincreased frequency of handovers associated with EWTD implementation.

• 67% of surgeons-in-training plan to opt-out of the EWTD; 15% of trainees have alreadydone so; however 10% have been prevented from doing so by their NHS Trust.

• 86% of surgical trainees working an EWTD compliant rota have seen their work lifebalance deteriorate or remain unchanged with the theoretical reduction in working hours.

Surgical trainees have been campaigning against the continued introduction of the EWTDand calling for improved training for several years, with reports highlighting anticipatedtraining difficulties published in 2006 and 2009.

Ed Fitzgerald, President of the Association of Surgeons in Training commented “As apost-graduate craft-specialty, surgical trainees are deeply troubled by the reduction in

The Association of Surgeons in Trainingat The Royal College of Surgeons35/43 Lincoln’s Inn FieldsLondon, WC2A 3PEwww.asit.orgT: 0207 973 0302F: 0207 430 9235E: [email protected]

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working hours forced on us by the EWTD. Careful, supervised exposure to patients andtheir operations is vital for producing safe, confident and experienced surgeons in thefuture.”

“Surgical training is being driven underground through unreported and unregulatedhours of work. We are witnessing the rise of the ‘grey rota’, whereby hours worked bear littleresemblance to those set out on paper by employers. The result is that we will know evenless about the hours that surgical trainees are actually working, a situation that is potentiallymore unsafe than a modest increase in regulated hours.”

“The survey confirms our fears that the NHS cannot currently deliver surgical trainingwithin the hours officially available to us. Nobody wants a return to the potentially unsafeexcessive hours of the past. What we require is a fundamental modernisation of surgicaltraining, and a sensible compromise on the hours that surgical trainees are allowed to work.We call on the NHS to work with us to prioritise surgical training and support ourConsultant trainers.”

Benjamin Caesar, President of the British Orthopaedic Trainees Association commented"This Survey confirms the fear that Surgical Trainee organisations have held for some years,that the effect of the EWTD on the craft specialities, such as surgery, has been devastating,with deterioration in both surgical training and patient care.”

“Single working weeks of 90-hours are still permitted under the directive’s terms, and canoccur frequently when balanced with rostered time off during a 26-week reference period.This survey demonstrates that the majority of trainees (67%) are having to attend on these‘rostered days off’ to protect their training. The impact of this legislation is therefore toexacerbate rather than relieve fatigue. This survey demonstrates that the shift patterns beingimposed as a result of the Working Time Directive are having exactly the opposite effect onsurgical trainees to those it proposes. They are more fatigued, less well trained and have apoorer work-life balance.”

“The methods of training safe, competent, and confident Consultant Surgeons for thefuture need to be significantly reviewed to accommodate any changes in working patterns,and the Government needs to listen to the leadership from Surgery in presenting acompromise solution to the hours required to train surgeons and to deliver a safe service,whilst modernising surgical training and service delivery."

Lesley Bentley, demitting Lay Chair of the Patient Liaison Group at the Royal College ofSurgeons of England commented "It would be of concern to patients if changes in workinghours were to compromise training, continuity of care and high quality outcomes, allcrucially important for patients, now and in the future."

Notes to EditorsThe Association of Surgeons in Training (ASiT) is a registered charity which works topromote the highest standards in surgical training. Founded in 1976, its membership consistsof over 2,000 surgical trainees from all nine surgical specialties. ASiT remains independent ofthe Surgical Royal Colleges and other professional medical organisations, and is run bytrainees, for trainees. For more information please visit: www.asit.org

The British Orthopaedic Trainee's Association (BOTA) was established in 1987, specificallyto represent the views of orthopaedic surgical trainees. It subsequently became affiliated tothe British Orthopaedic Association. Its membership has increased to the current level in theorder of 1,400 Specialist Registrars. For more information please visit: www.bota.org.uk

ASiT and BOTAwork closely together to improve surgical training in the UK. Theircurrent work involves active lobbying of the Surgical Royal Colleges, the Joint Committee onHigher Surgical Training, and numerous other NHS working groups and committees.

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Optimising Working Hours to ProvideQuality in Training and Patient SafetyA Position Statement by The Association of Surgeons in TrainingRatified by ASiT Council on Friday 16 January 2009

The Association of Surgeons in Trainingat The Royal College of Surgeons of England35-43 Lincoln’s Inn FieldsLondon WC2A 3PETelephone: 0207 973 0301Fax: 0207 430 9235Web: www.asit.orgEmail: [email protected]

Authors: Mr Ben Cresswell (President),Mr Conor Marron (Honorary Treasurer),Mr Will Hawkins (Honorary Secretary),Mr Ewen Harrison (Past-President),Mr Edward Fitzgerald (Vice-President) andMr Alex von Roon (Vice-President)

1 Executive Summary1.1 The Association of Surgeons in Training (ASiT) represents UK trainees from all

surgical specialties and has over 2200 members. ASiT has been concerned about theEuropean Working Time Directive (EWTD) since its introduction. In May 2006 wepublished a report on the impact of the EWTD in Surgery highlighting concerns andurgent actions required to limit potentially detrimental effects on surgical training1.

1.2 ASiT continues to believe that reducing working hours has impacted on surgicaltraining and continuity of patient care. The majority of surgical trainees wouldwelcome the opportunity to work in excess of the hours permitted by the EWTD1,2.

1.3 ASiT has conducted the largest survey of surgical trainees to date on the EWTD, with1096 responses from trainees representing all nine surgical specialties and regions inthe UK.

1.4 Results from the ASiT survey confirm that there is significant underreporting of hoursworked by surgeons in training. As a result, the number of non-compliant posts is farhigher than previously thought, making achievement of EWTD targets unlikely.

1.5 Within units purporting to be EWTD compliant, a significant problem has beenidentified whereby “rota gaps” (created by a failure to recruit non-training doctors),have been filled by rearranging internal cover so that hours may appear compliant“on-paper”. The reality of such solutions however is that individuals are working inexcess of the reported 48 hours.

1.6 Shift working has been shown to lead to more fatigue and increased medical errorswhen compared to 24 hour on-call rotas3-18. Those working full shift rotas havereported a deterioration in the quality of training over the last two years.

1.7 The ASiT survey suggests that surgical trainees wish to continue working out-of-hours on-call rotas and that the majority would welcome the opportunity to workbeyond the 48 hours imposed by EWTD. Overall 80% favoured either an individual ora specialty opt-out.

1.8 ASiT suggest that to ensure optimal training, with adequate time for exposure andhigh quality patient care with increased continuity, it is necessary to return to aworking week of approximately 65 hours. For higher specialty trainees (ST3 andabove), on-call rotas rather than shift working would best protect trainingopportunities, and would be the optimal arrangement where workload permits.

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2 Introduction2.1 The Association of Surgeons in Training (ASiT) represents UK trainees from all

surgical specialties and is one of the largest specialty trainee organisations in the UKwith over 2200 members.

2.2 In May 2006 ASiT published its report on the impact of the European Working TimeDirective (EWTD) in Surgery, focussing on the effects on surgical training, patient care,health of the worker and lifestyle1. The report was endorsed by all of the majorprofessional surgical organisations and circulated to the Prime Minister, Secretary ofState for Health and numerous European bodies, with a request for urgent action to betaken.

2.3 ASiT continues to believe that the restrictions imposed by the EWTD willdetrimentally affect the quality of training of junior surgeons and therefore the qualityof surgical service provision in the future. We believe that the current EWTDrestrictions will ultimately be detrimental to patient care1,2,18-21.

2.4 ASiT has recently performed a survey of its trainee members from all surgicalspecialties and, with 1096 responses, can now provide an accurate reflection of currentworking practices and aspirations of those training for a surgical career with regardsto the EWTD.

3 Background3.1 The current EWTD limit of 58 hours per week is due to be further reduced to 48 hours

in August 2009. The current limit has seen a fall in total available training hours from32,000 to 21,000, and from August this will be limited to a maximum of 18,000 duringthe 8-year core and specialty training periods.

3.2 The effects of the reduction in hours have been further compounded by the SiMAPand Jaeger rulings of the European Courts of Justice22. These decree that all time spentin the workplace should be regarded as 'work', whether at rest or not.

3.3 Surgery is a craft specialty and requires significant exposure to “hands-on” training.Operative and procedural skills define the surgical craft and these are finite innumber, with the majority to be gained during working hours. It is recognisedhowever that in order to provide a high quality service, an exposure to out-of-hoursemergencies remains essential.

3.4 One effect of the initial reduction in working hours to a maximum 58 per week hasbeen the significant reduction in the number of logged Index procedures performedby surgical trainees. Studies have consistently shown a greater than 20% reduction inoperative cases performed1,2,23-33. With a contraction in working hours to 48, thenumber of procedures performed by trainees will inevitably be further reduced, as theproportion of time spent working out-of-hours will increase relative to the normalworking day34,35.

3.5 Though much work and effort has been put in to the development of EWTDcompliant rota design, significant numbers of individual units are struggling toaccommodate the new restrictions. There is a strong belief that some units achievingEWTD compliance have done so to the detriment of training, and in some instancesby inaccurate hours reporting and bullying. The ASiT survey has confirmed theseconcerns and shown that current working practices are both far from being EWTDcompliant and have adversely affected the quality of training.

3.6 Expanding the number of doctors on a rota dilutes training for all involved. Tomaintain future standards of care the available training opportunities can onlysupport a finite number of trainees.

3.7 In an effort to produce compliant rotas, some Trusts create extra rota spaces to befilled by doctors outside of formal training schemes - jobs to which they have thenstruggled to recruit to. A separate survey with 466 respondents considered the

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problem of ‘rota gaps’ specifically. The creation of “rota gaps” has been reported by53% of survey respondents, with 78% of rotas with gaps purporting to be 48-hourcomplaint. This leads to trainees being taken out of their usual daytime commitmentsto cover service issues. 69% of those with gaps on rotas have lost procedural trainingopportunities to provide cover, and 62% have no additional daytime support to coverpatient care or service issues. Out of hours cover was provided by “internal locums”in 57% of cases which, although permitting a compliant rota on paper, results innoncompliant hours for those individuals acting as locums. This is of serious concernin relation to patient safety and 64% of trainees working with ‘rota gaps’ feel thatpatient care has suffered as a result.

3.8 The Institute of Medicine in the United States of America has recently recommendedthere be no further reduction in the limit of 80 hours per week. This has been based onconsiderations of patient safety and worker health as well as medical education andtraining. Instead, changes have been made to the mechanisms of achieving rest ratherthan focusing on number of hours worked36.

4 ASiT EWTD Survey Data4.1 Demographics

A total of 1096 responses were received, with proportional representation of allsurgical specialties and geographical regions in the UK.

4.2 Current Actual Hours Worked90% of trainees reported exceeding their rostered hours on at least a weekly basis, and85% reported that they had attended procedural sessions during a rostered day off,the majority doing so on a regular basis. 57% of respondents have been required toattend on a rostered day off in order to support service provision and to ensure thatpatient care is maintained. Only 25% of respondents felt that the working patternsheld by their Human Resources Departments, and on which their contracts are based,accurately reflected their actual hours worked. Although 51% of trainees report amaximum shift length of 13 hours, a significant proportion (31%) still work 24 hoursor greater as a single on-call period with a maximum reported continuous duty periodof 72 hours.

4.3 Pressure to Declare False Working Hours55% of trainees report having been pressurised to falsely declare their actual hoursworked and that pressure was reported to have come from Managers, Consultants,Peers and themselves in almost equal measure.

4.4 The Effect of Shift-Working on Training and Work/Life Balance68% of respondents reported a deterioration in the quality of their training over thelast two years as a result of shift-working, with their operative skills having sufferedthe most. Similarly, 71% report that reductions in working hours have not led to anyimprovements in their work/life balance and 74% report that new shift patterns haveled to pressures on their social relationships.

4.5 Trainees and EWTD80% of surgical trainees responding to the survey would support an “opt-out” ofEWTD to protect their training and a further 10% “didn’t know”.


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5 An “Ideal” Job Plan5.1 A single ideal job plan is impossible to produce owing to the inevitable differences

between the working pattern and requirements of individual surgical specialties andindividual units. Several generic principles do apply to all specialties however, andthe following suggestions relate to higher specialty trainees (ST3 onwards).

5.2 Shift working has been shown to result in a large reduction in the proportion ofoverall hours spent in daytime training activities, with a corresponding increase inout-of-hours service provision. Whilst it is accepted that cross-cover between surgicalspecialties may be appropriate at core training level, very few units afford asufficiently heavy workload to require shift working by specialty trainees and a returnto an on-call system (whether resident or non-resident) is strongly recommended. Thiswould result in fewer daytime training opportunities being missed whilst maintainingexposure to out-of-hours emergency work, improving continuity of care and hencepatient safety and reducing the number of doctors required on the rota tier with thepotential for financial savings. The ASiT consensus for the optimal frequency of on-call duties is a 1:6 pattern, which would effectively reduce to 1:5 with prospectivecover.

5.3 Daytime sessions offer the greatest number of training opportunities and the increasein staffing numbers required to cover compliant rotas has led to competition betweentraining and non-training grades. Ideally, trainees should have access to three half-dayoperating lists a week, two outpatient sessions, a special interest session (such asendoscopy) and time protected for research / audit and administrative tasks toinclude teaching of juniors. In addition, most specialties involve some form of inter-specialty interaction and attendance at multi-disciplinary team meetings (MDT) isessential to education. It is recognised that various specialties will have their ownunique requirements, for instance a requirement for a greater number of MDTmeetings, outpatient clinics or specialist sessions. The timetable would therefore becustomised for the individual specialty and unit, but the overall hours requirementwould remain similar. A sample timetable for an individual trainee would thereforeappear thus:

Monday Tuesday Wednesday Thursday FridayAM Outpatients Theatre On-call Academic MDT/

Activities Outpatients

PM Endoscopy Theatre Emergency Off TheatreTheatre List

Night On-call

5.4 Based on a normal working day of 8am to 6pm, with 1:6 evening and weekend on-calls this would require a total working time of 65 hours per week, when averagedover a 6 week rota cycle.

6 Summary6.1 Surgical training has inevitably suffered with reducing working hours and,

shiftworking has led to a significant increase in reported fatigue, a deterioration inwork/life balance and a loss of continuity in patient care, prompting serious concernsfor patient safety.


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6.2 The majority of surgical trainees would strongly welcome the opportunity to work inexcess of the hours permitted by the EWTD2,37.

6.3 As an organisation, we feel that a high quality training process is not achievablewithin the constraints of a 48 hour week and would suggest a return to longerworking hours in order to protect Patients of the future.

References1 Marron C, Shah J, Mole D, Slade D. European Working Time Directive, a Position by the Association of Surgeons in

Training. In: Training AoSi, ed. London 20062 Lowry J, Cripps J. Results of the online EWTD trainee survey. Ann R Coll Surg Engl (Suppl) 2005; 87: 86-73 Akerstedt T. Consensus statement: fatigue and accidents in transport operations. J Sleep Res 2000 Dec; 9(4): 3954 Bamford N, Bamford D. The effect of a full shift system on doctors. J Health Organ Manag 2008; 22(3): 223-375 Barger LK, Cade BE, Ayas NT, Cronin JW, Rosner B, Speizer FE, et al. Extended work shifts and the risk of motor

vehicle crashes among interns. N Engl J Med 2005 Jan 13; 352(2): 125-346 Chow KM, Szeto, CC, Chan, MHM, Lui, SF. Near-miss errors in laboratory blood test requests by interns. Q J Med

2005; 98: 753-67 Connor J, Whitlock G, Norton R, Jackson R. The role of driver sleepiness in car crashes: a systematic review of

epidemiological studies. Accid Anal Prev 2001 Jan; 33(1): 31-418 Fletcher KE, Davis SQ, Underwood W, Mangrulkar RS, McMahon LF, Jr, Saint S. Systematic review: effects of resident

work hours on patient safety. Ann Intern Med 2004 Dec 7; 141(11): 851-79 Fletcher KE, Saint S, Mangrulkar RS. Balancing continuity of care with residents' limited work hours: defining the

implications. Acad Med 2005 Jan; 80(1): 39-4310 Folkard S, Lombardi DA, Tucker PT. Shiftwork: safety, sleepiness and sleep. Ind Health 2005 Jan; 43(1): 20-311 Folkard S, Tucker P. Shift work, safety and productivity. Occup Med (Lond) 2003 Mar; 53(2): 95-10112 Harrington JM. Shift work and health - a critical review of the literature on working hours. Ann Acad Med Singapore

1994 Sep; 23(5): 699-70513 Hobson J. Shift Work and doctors' health. Student BMJ 2004 November; 12(11): 412-314 Horne JA, Reyner LA. Sleep related vehicle accidents. BMJ 1995 Mar 4; 310(6979): 565-715 Nicol AM, Botterill JS. On-call work and health: a review. Environ Health. 2004 Dec 8; 3(1): 1516 Scott-Coombes D. European working time directive for doctors in training. Reduction in juniors' hours abolishes

concept of continuity of care. BMJ 2002 Mar 23; 324(7339): 73617 Spurgeon A. Working Time. Its impact on safety and health: International Labour Organization 200318 Cairns H, Hendry B, Leather A, Moxham J. Outcomes of the European Working Time Directive. BMJ 2008; 337: a94219 Pounder R. Junior doctors' working hours: can 56 go into 48? Clin Med 2008 Apr; 8(2): 126-720 Murray A, Pounder R, Mather H, Black DC. Junior doctors' shifts and sleep deprivation. BMJ 2005 Jun 18; 330(7505):

140421 Lowry J, Cripps J. The EWTD and retirement intentions: a survey of surgical consultants.Ann R Coll Surg Engl (Suppl)

2005; 87: 272-422 Sindicato de Medicos de Astsencia Publica (SiMAP) v Clnsellaria de Sandid y Consumo de la Generalidad Valencia

C-303/98. EC 200023 Marron CD, Byrnes, CK, Kirk, SJ. An EWTD Compliant Shift Rota Decreases SHO Training Opportunities. Ann R Coll

Surg Engl (Suppl) 2005; 87: 246-824 Anwar M, Irfan S, Daly N, Amen F. EWTD has negative impact on training for surgeons. BMJ 2005 Dec 17; 331(7530):

147625 Benes V. The European Working Time Directive and the effects on training of surgical specialists (doctors in training):

a position paper of the surgical disciplines of the countries of the EU. Acta Neurochir (Wien) 2006 Nov; 148(11):1227-33

26 Chan YC. European working time directive for doctors in training. Profession needs to modernise surgical training.BMJ 2002 Mar 23; 324(7339): 736-7

27 Chesser S, Bowman K, Phillips H. The European Working Time Directive and the training of surgeons. BMJ 2002; 325:S69-70

28 Garg D, French J, Bradburn M. Shift work and surgical training: an observational study in one district general hospital.Ann R Coll Surg Engl (Suppl) 2003; 85: 196-8

29 Lim E, Tsui S. Impact of the European Working Time Directive on exposure to operative cardiac surgical training. EurJ Cardiothorac Surg 2006 Oct; 30(4): 574-7

30 Morris-Stiff G, Ball E, Garris D, Foster M, Torkington J, Lewis M. Registrar operating experience over a 15-year period:more, less or more or less the same? Surg J R Coll Surg Edinb 2004; 2(161-164)

31 Soo A, Alam M, Mitchell T, Healy DG, Nolke L, Wood AE. A step towards being EWTD compliant: a single institutionstudy of the cardiothoracic surgery experience. Ir Med J 2007 Oct; 100(9): 596-8

32 Stephens M, Pellard S, Boyce J, Blackshaw G, Williams D, Lewis W. Influence of EWTD compliant rota on SHOoperative experience. Ann R Coll Surg Engl (Suppl) 2004; 86: 120-1

33 Tait MJ, Fellows GA, Pushpananthan S, Sergides Y, Papadopoulos MC, Bell BA. Current neurosurgical trainees' perceptionof the European Working Time Directive and shift work. Br J Neurosurg 2008 Feb; 22(1): 28-31; discussion 2-3

34 Ahmed-Little Y. The European Working Time Directive 2009. Br J Health Care Manag 2006(12): 373-635 Ahmed-Little Y. Implications of shift work for junior doctors. BMJ. 2007 Apr 14; 334(7597): 777-836 Iglehart JK. Revisiting duty-hour limits - IOM recommendations for patient safety and resident education. N Engl J

Med 2008 Dec 18; 359(25): 2633-537 Horrocks N, Pounder, M.D. Working the Night Shift. An audit of the experiences and views of specialist registrars

working a 13-hour night shift over 7 consecutive nights. 2004 [cited; Available from:http://www.rcplondon.ac.uk/news/ewtd_nightshift.asp


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The ISCP Evaluation Report byProfessor Michael ErautResponse to the JCST Discussion Document by the Association of Surgeonsin Training.

April 2009

Authors: Mr Edward Fitzgerald, Mr Tom Edwards, Mr Charles Giddings, Mr WillHawkins, Mr Roddy O’Kane, Mr RamMoorthy andMr Sunil Bhudia on behalf of theASiT Executive & Council.

1 Introduction1.1 The Association of Surgeons in Training (ASiT) is a charitable organisation supporting

the professional development of surgical trainees. Our association represents UKtrainees from all surgical specialties and is one of the largest specialty groups in theUK with over 2200 members.

1.2 ASiT has previously noted the troubling content of the ISCP Evaluation Report byProfessor Michael Eraut and welcomes the opportunity to contribute to the ongoingdebate surrounding the ISCP and the future of surgical training.

1.3 We believe Professor Eraut’s report correctly highlights the broad failings currentlyfound in UK surgical training, over and above the original remit of his report. GivenProfessor Eraut’s position as a non-surgical, independent observer of internationalstanding in the field of education, this serves to emphasise the profound problemsfaced by surgical trainees, and which ASiT has sought to draw attention to for severalyears.

1.4 This response paper represents the consensus opinion of current surgical traineesfollowing online discussion by ASiT Council.

1.5 Given the recent period of uncertainty regarding the use and implementation of theISCP, ASiT would welcome further open debate in this area.

1.6 In the following document we respond in turn to questions posed by the JCSTDiscussion Document.

• ASiT Response

• Curriculum for surgical training• Allowing for the environmental factors identified in the Eraut Report, is theISCP ‘fit for purpose’ as a curriculum for surgical training?

• What is good?• What needs development?

2.0 The development of a surgical curriculum is to be welcomed but it is clear that this iswork in progress and the finalised curriculum is still to be achieved. As such, it is notcurrently “fit for purpose” and unfortunately the principles of the ISCP have nottranslated into practice.

2.1 To use it properly is time-consuming and time is not allocated for this purpose.2.2 The understanding of the customers (i.e. trainees and trainers) is sadly deficient in

relation to the intentions of the ISCP. Workplace based assessments are generally notunderstood with regards to what they are actually for. All too often both the traineeand especially the trainer view these as summative and not formative tools; there is noclear validation of their utility for either role.

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2.3 We do not believe that all Consultants that are allocated as trainers agree with theprinciples behind the ISCP and until this is achieved it will be difficult for trainees togain the maximum benefit from it. This ultimately requires a paradigm culturalchange to achieve understanding of this by both trainees and more so Consultanttrainers.The charging of a trainee fee for the JCST has unfortunately changed the wholeemphasis of this initiative, with trainees rightly wanting the ISCP to be fully readyand “fit for purpose rather” than work in progress.

• Quality of surgical training

What steps should be taken to ensure surgical trainers are ‘engaged’ with ISCP?• Are surgical trainers equipped to deliver the ISCP?• Is there a need for a new programme of faculty development, and if so who should deliver it?

• Should trainers be formally accredited? How and by whom?

3.0 Many trainees believe that the tools need to be fully developed and validated before itis worth developing the faculty and training them in these.

3.1 However, with regard to the faculty, “Training the Trainer” and TAIP are good but areoften undertaken as a “cosmetic exercise” to certify ability to train. The role of Schoolsof Surgery should become more prominent; regular involvement and staffdevelopment should be a recurring theme.

3.2 Surgical trainers are frequently not equipped to use or deliver the ISCP. One majorfactor in trainee dissatisfaction with the website results from the current system ofregistering trainers with their trainees. Trainees email their educational supervisor,who then accepts them, and then the programme director activates this. This shouldhappen automatically, as these steps are causing delays of months, making the websiteunusable during many four or six month attachments.

3.3 All users should require formal training and accreditation. Trainers need both a formaltraining ‘carrot’ and also a ‘stick’ approach to ensure they fully engage in theassessment process. This may be achieved through accreditation, incentivising andbuilding training activities into Consultant job plans.

3.4 As trainees are now paying a fee, consumerism has been created. Trainees willdemand that assessors are educated and accredited so they can provide the servicethat is now being paid for.

• Culture of surgical training

• Does the modern NHS provide a suitable training environment?• How can a training culture be developed within a target driven service?

4.0 The current culture of the NHS has changed since many of our senior Consultantswere trainees. The target driven and service orientated training culture that we allwork in is not conducive to training. As the Eraut report states, this has developedover a number of years but the current direction of travel continues to disadvantagetrainees.

4.1 The NHS did previously provide the service base for an apprenticeship-style system,but now the experience obtained is thin and needs supplementation with higherquality training. The increasing numbers of trainees currently in the system alsodilutes training opportunities further.

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4.2 A significant amount of central money is given to trusts for training (both salary costsand other budgets) and greater transparency and control of this money is required.

4.3 Until training targets are set and Trust performance measured against these targets,then training will continue to be an after-thought. As the Darzi and Tooke reportshave stated, the money must follow the trainee, and Trusts that no longer train willhave to accept the increased costs of service provision.

4.4 There must be separation of the Deanery from the SHA, as their primary purpose isdiametrically opposed. If Deans remain employed by the SHA, then they will be inconflict with the primary aim of their employer and therefore cannot independentlyact as a champion for training excellence.

• Standards for delivery of surgical training

• Is there a requirement for a more robust and explicit set of standards forsurgical training?

• What form should these standards take?• How could they be enforced?

5.0 While there is undoubtedly a role for standards in the future, currently there is aconcern that while we concentrate on developing a robust and explicit set of standardsthe actual training delivered is essentially unchanged.

5.1 When standards are set in the future they should be both to ensure maintenance andimprovement in training, and also to allow development of training targets againstwhich the regulator can enforce financial penalties for the failing service.

5.2 Problem areas need to be identified quickly and training places removed promptlywhen problems are found. Continuing training in a failing post is risible, but too oftenhappens.

5.3 Exactly who enforces this is less important than the fact they must have statutoryauthority, together with the “teeth” and willingness to effect change.

• Time for surgical training

• Is there enough time to deliver the training? • Can the time frame be extended?• What strategies could be employed to deliver training in the shortened time frame?

6.0 It is imperative that in the current training climate surgery as a speciality is allowed toopt-out of the EWTD, allowing trainees to work up to 65-hours per week asappropriate. This demand is driven by the representative surgical trainee bodies basedon the views of their membership, and supported by the Surgical Royal Colleges andSpeciality Associations.

6.1 Once this is achieved, training can be further optimised if the environment andworking practices are altered to the benefit of training eg ward time as appropriate tothe speciality, dedicated training lists, and clinics optimised for training rather thanservice.

6.2 With trainees primarily used as a service provider, then there is never going to besufficient time for adequate surgical training. As the Eraut report states, junior traineesspend an unnecessary amount of time on the wards and a balance must be achieved.

6.3 Novel strategies could be introduced such as utilizing a non-clinical trainingcoordinator who marries experience and training needs to the potential trainingopportunities in a unit eg taking into account numbers based deficiencies in logbooks/competence etc.


6.4 Simulation, good quality regional training days and adequate ‘study leave’ fundingfor specialist courses are all important in delivering training in the allotted time.

6.5 Trainees should only be allocated to units that have been shown to provide adequatetraining. As not every unit provides good training (nor can all units provide it),ultimately and realistically this means that the number of training places needs toreduce to ensure that all training is of high quality.

6.6 The level of a CCT must be maintained and not diluted.

• What is the purpose of surgical training

• Is every trainee on a CCT programme expected to achieve a consultant post?• Is it necessary to review the future of the surgical workforce?

7.0 The purpose of surgical training in its broadest sense is to provide the surgicalexpertise which at the very least maintains the current level of surgical care and allthat this entails (including continued tuition of the proceeding generation, serviceorganisation and leadership and academic advancement of surgical care provision).

7.1 Every trainee enrolled on a programme ending in a CCT qualification should have aConsultant post at the end of training and after the CCT has been awarded.

7.2 With regards to reviewing the surgical workforce, an honest debate at Governmentand NHS employer level is required to discuss how they wish to provide surgicalservices in the future. Both patients and the profession are under the impression thatthis must continue to be Consultant based or led. If the Government or NHSE wish toalter this model then it must be debated with both the profession and public alike.

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Surgical Leadership DevelopmentIain Yardley, SpR Paediatric SurgeryClinical Advisor to the Chief Medical Officer and WHO Patient Safety

Surgical leadership has often been considered the preserve of medical directors, collegepresidents and the like. Perhaps something surgeons may take on later in their careers asclinical work loses its freshness and the eyesight begins to fail. The reality, however is that atwhatever level we operate, being effective as a surgeon requires effective leadership. The rolethat we play requires us to take difficult decisions, enact management plans and direct theclinical team, be that in the operating theatre, on the ward or in outpatients. Out with clinicaldecision making, even as SHOs we need to provide leadership and supervision to thefoundation doctors below us. As registrars we are expected to manage the surgical take andperhaps co-ordinate rotas.The intrinsic need for leadership in our daily roles may partly explain the dispro-

portionate number of medical directors who are surgeons around the country and theprominence of surgeons in very senior roles in the Department of Health, most notably LordDarzi as a health minister and Sir Bruce Keogh as NHS Medical Director. There is also a needfor surgical leadership at every level in between, from individuals running their ownpractice through clinical directors and upwards, and in parallel organisations such as thedeaneries and their schools of surgery and the royal colleges. This need for clinicians toshow leadership has been recognised centrally, most notably in High Quality Care for All,the final report of Darzi’s Next Stage review. High Quality Care for All acknowledged theneed for strong clinical leadership in the NHS. It strongly advocated the role of clinicians indeveloping services and emphasised the potential benefits in areas such as quality andsafety. One of its recommendations was the setting up of the NHS National LeadershipCouncil (NLC) which happened in 2009.Even for those who do not choose to make leadership a significant strand of their future

careers, management and leadership skills have become an essential part of the surgicaltraining curriculum for all surgical specialty trainees. Previously, for specialist registrars, therequirement to gain a CCT was simply attendance on a management course. Now the ISCPsyllabus explicitly acknowledges the role each surgeon needs to take as a manager andleader, stating in the generic “Professional Skills and Behaviour” section that in order to gaina CCT a surgeon must be able to “manage and lead a surgical team”. The syllabus then setsout competencies expected at every stage from the basic submission of operating lists at ST1to “[functioning] effectively within the NHS [and] playing an active role in its development”at ST8.Demonstrating these skills will continue to be essential beyond CCT level as management

and leadership become integral to the appraisal and revalidation/recertification process. TheGeneral Medical Council have issued guidance for doctors involved in management inManagement for Doctors. This document sets out basic standards expected of doctors actingin management or leadership roles. The NHS Institute for Innovation and Improvement andthe Academy of Medical Royal Colleges have published the Medical LeadershipCompetency Framework which describes in more detail the competencies required ofdoctors who lead in the health service. These documents are likely to form the basis of a“management” component to the recertification of surgeons.Two of the five priorities of the NLC are the development of clinical leadership generally

and, more specifically, the development and encouragement of young, emerging leaders.That developing clinical leaders has been given such a high profile is reflected in the numberof leadership development programs that have been established around the country. Theseinclude the Chief Medical Officer’s Clinical Advisors scheme, Darzi Fellows, NHS London’s

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Prepare to Lead and NHS North West’s Clinical Leadership Fellowship scheme wherespecialty trainees have the opportunity to complete the NHS management training schemein parallel with their clinical training. The British Association of Medical Managers (BAMM)has also set up a junior doctors’ division, BAMMbino. All these initiatives intend to identifyjunior doctors who have an interest in leadership or management beyond their immediateclinical practice and provide them with opportunities and support to develop their potential.The number and diversity of the different schemes available reflects the speed at which

the involvement of junior doctors in management and management training has occurred. Italso has lead to some confusion about the nature of the schemes. The NLC has sought toaddress this by bringing fellows from the different schemes together to try to identify keyrequirements of junior doctors seeking to give leadership a significant role of their futurecareers. In the future, these schemes may become more streamlined and cohesive. There hasbeen the suggestion that a CCT in management should be created that can be awarded as adual accreditation alongside a clinical CCT. This would formally recognise those doctorswho have undertaken management training and choose to make it part of their portfolio ofskills to present when seeking consultant posts.The arena of clinical leadership is rapidly developing. There is currently considerable

political will to involve clinicians in service development. Other areas such as surgicaleducation and training, recertification and academia will also always need young surgeonsto step up and take on leadership roles. Whilst we all have a duty to engage with leadershiptraining and ensure we are adequately equipped for our consultant careers, for those surgicaltrainees who are interested, there are many ways in which the necessary opportunities andtraining can be gained to prepare them for a future as leaders in the profession.

References and Further ReadingClinical Leadership: Bridging the Divide. Eds. Stanton E, Lemer C, Mountford J. Quay Books 2009High quality care for all: NHS Next Stage Review final report. Lord Darzi of Denham. Department of Health 2008.http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_085825Management for Doctors. General Medical Council 2006Medical Leadership Competency Framework 2nd edition. NHS Institute for Innovation and Improvement andAcademy of Medical Royal Colleges. NHS Institute for Innovation and Improvement 2009.http://www.institute.nhs.uk/medicalleadership

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The Checklist - From Theory to ActionSukhmeet S Panesar, Clinical Advisor to the Medical Director, National Patient SafetyAgency, London, Edward Fitzgerald, President, Association of Surgeons in Training,Andrew Carson-Stevens, Chair of the Wales Chapter for Healthcare Improvement, WalesCentre for Health, Cardiff, Suzette Woodward, Director of Patient Safety, National PatientSafety Agency, London andMark Emerton, Consultant Orthopaedic Surgeon, ChapelAllerton Hospital, Leeds Teaching NHS Hospitals & Senior Fellow, NHS Institute forInnovation and Improvement

‘‘In 1935, the US Army Air Corps held a flight competition for airplane manufacturers vying to buildits next-generation long-range bomber. In early evaluations, the Boeing plane had trounced otherdesigns. The flight ‘competition’ was regarded as a mere formality. With the most technically giftedtest pilot in the army on board, the plane roared down the tarmac, lifted off smoothly, and climbedsharply to three hundred feet. Then it stalled, turned on one wing, and crashed in a fiery explosion.Two of the five crew members died, including the pilot. An investigation revealed that nothingmechanical had gone wrong. The pilot had forgotten to release the new locking mechanism on theelevator and rudder controls. A few months later, army pilots were convinced the plane could fly andinvented something that would be used on the few planes that had been purchased... A checklist, withstep-by-step checks for takeoff, flight, landing, and taxiing. With the checklist in hand, the pilots wenton to fly the model (B-17) a total of 1.8 million miles without one accident, and helped the US armylaunch its successful bombing campaign across Nazi Germany1.’’

Similarly, it has been stipulated that medicine has entered a similar phase and substantialaspects of clinical practice are too complex for clinicians to carry them out reliably frommemory alone. And the checklist is born...Some 4.2 million surgical operations are carried out every year in England alone. That

equates to one operation for every twelve people each year2. In the UK, most people willhave surgery at some point in their life. Surgery has been categorised as a very unsafeindustry with a rate of fatal adverse events (catastrophic events per exposure) of 1 per10,000. In trauma surgery, the rate of serious complications is 1 per 100 patient exposures. Incontrast, in civil aviation, railway transport and nuclear power, the rate of death is less than1 per million exposures3. Whilst surgery has largely focused on technical advances withoutrecognising the potential for the additional benefits of non-technical skills (human factors),other high-risk industries have made great progress in managing these challenges andreduced harmful events by several orders of magnitude. They have accepted that errors areinevitable and provide opportunities to learn and improve, built systems that reliably deliverwhat is required, identify errors that occur and mitigate these to prevent them causing harmand used an understanding of human factors to make the right thing the easiest thing, createteams of employees trained in technical and non-technical skills and developed formalmodels of communication7. Most of the errors that occur in surgery can be attributed tofailures in situation awareness, decision making, communication and teamwork andleadership8.In January 2007, the World Health Organization began a programme aimed at improving

the safety of surgical care globally. The initiative, called Safe Surgery Saves Lives aims toidentify minimum standards of surgical care that can be universally applied across countriesand settings. A core set of safety checks was identified in the form of a WHO Surgical SafetyChecklist that can be used in any surgical setting and operating theatre environment4. Eachstep on the checklist is simple, widely applicable, and measurable, and it has already beendemonstrated that its use can reduce death and major complications5. An adapted version ofthe checklist has been developed by the National Patient Safety Agency (NPSA) in

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collaboration with a multi professional expert reference group for use in England and Wales.The vehicle chosen for dissemination of the checklist is Patient Safety First, which is led by ateam of experienced frontline clinicians9.The checklist outlines essential standards of surgical care and is designed to be a simple

tool to improve surgical safety6. It consists of three key phases. A Sign In prior to anaesthesiaensures adequate preparation is made for any predictable difficulties and that the expectedpatient is about to receive anaesthesia. The Time Out just prior to incision is the final checkthat everything is in place for the procedure to take place in the safest environment possible.It is the final check that the right thing is about to be performed on the right patient, thateveryone knows what the surgeon and anaesthetist are thinking or expecting, that the rightequipment is available, required imaging is displayed and that appropriate infection andvenous thromboembolism prophylaxis is in place. The Sign Out ensures the correctinformation will be given to recovery staff, that nothing is missing from the scrub trolley andthat key specimens are correctly labelled. This is shown in Figure 16.

Figure 1 - The WHO Surgical Checklist

Furthermore, key adjuncts could be added in the checklist process. Performing a safetybriefing before the start of a list creates a sense of familiarity and confidence amongst teammembers. It ensures everyone understands plan A& plan B. It reduces glitches and delaysby focusing team members on the purpose of the day. It prepares everyone for specificmoments when a plan may change or higher risk steps are taken. It allows those with aspecific reason for suboptimal performance to express it early on. At the end of the day, a de-brief allows the team to learn from the events of the day and record issues that made itdifficult to run the list safely and efficiently. It also allows a safe environment for reflectionon the team’s performance7.Dissemination of the surgical checklist has primarily been aimed at senior professionals.

Whereas this is important in part, it eliminates the key role that junior doctors have inpromoting the use of the checklist. They need to be empowered and move away from thestatic nebula of passivity that they find themselves in. We attempted to contribute to altering

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this dynamic through facilitating a grass-roots initiative aimed at enhancing patient safety inthe context of surgical care. Junior surgical and anaesthetic doctors were encouraged todiscuss, and if necessary institute, improvements in surgical practice through use of theWorld Health Organization’s (WHO) Safe Surgery checklist. This was done through thePatient Safety First campaign in England, which encouraged junior doctors to becomechange agents through a nationwide initiative called Project SAVED (Surgical checklist AndimproVing the Experiences of Doctors in training), which was launched during the UKPatient Safety Week10.Our target population of 5500 juniors were contacted by email and advertisements via the

associations that represent junior surgeons and anesthetists. Fellow junior doctors challengedtheir peers to undertake a briefing, use the WHO checklist, and undertake a debriefing forone operating list during the week. On completion, participants filled in a simple onlinesurvey of five questions to assess the impact of this exercise. An agreed incentive to take partwas a certificate for the doctors’ professional development portfolios.Despite being a bottom-up initiative that was led and managed by junior doctors, and

concerning a theme to which all clinicians’ would be able to relate to, only 0.96% of thoseinvited (53/5500) however participated. 45/53 (85%) of those who participated agreed thatthey would want their doctors to use this checklist if they were patients. A furtherbreakdown of key results is given in Table 1.

Table 1 - Perceptions after using the checklist

We cite several reasons for this poor uptake. The checklist is a form of disruptivetechnology and as such will only be embraced by bold and venturesome individuals towhom the adoption of a surgical checklist is a no-brainer11. Furthermore, there is thepossibility that the proposed intervention (briefings, checklist and debriefings) were notdeemed to be clinically useful, pressures of workload, or perhaps most worryingly of all,apathy and/or demoralisation12. However, our results may echo the sentiments of seniorclinicians who wish to maintain the current status quo and ensure their hegemony pervadesthrough the junior ranks. We can only empathize with trainees keen to adopt ourintervention who may not wish to challenge their senior colleagues.The checklist has been shown to improve surgical outcomes. However, it may also

improve handovers between clinical staff. There is furthermore, as a result of the increasedefficiency, potential for theatre over-runs to be minimized, as well as possible anticipation ofcritical events, which could help free up more time for training.


The checklist story is an exciting one and is a rare opportunity for junior doctors to act askey agents for positive change. Their role remains crucial in bringing their teams on boardwith the surgical checklist. Each one of us can act as a leader and drive the use of thechecklist in our hospital. Surely we all want to be part of a smooth theatre list where patientshave better outcomes, junior doctors and medical students get higher quality training(European Working Time Directive issues) and we all get to go home on time. The checklistis there for the taking - let’s embrace it!

References1 Gawande A. The Checklist. The New Yorker 10th December 2007. Available online at

http://www.newyorker.com/reporting/2007/12/10/071210fa_fact_gawande?currentPage=all Last accessed on 30thDecember 2009

2 Royal College of Surgeons of England. Surgery and the NHS in numbers. Available online athttp://www.rcseng.ac.uk/media/media-background-briefings-and-statistics/surgery-and-the-nhs-in-numbers Lastaccessed on 30th December 2009

3 Amalberti R, Auroy Y, Berwick D, Barach P. Five system barriers to achieving ultrasafe health care. Ann Intern Med.2005; 142(9): 756-64

4 World Health Organisation (WHO) (2007). Available online athttp://www.who.int/patientsafety/safesurgery/en/index.html Last accessed on 30th December 2009

5 Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, Herbosa T, Joseph S, Kibatala PL, LapitanMC, Merry AF, Moorthy K, Reznick RK, Taylor B, Gawande AA. Safe Surgery Saves Lives Study Group. A surgicalsafety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009; 360(5): 491-9

6 National Patient Safety Agency (NPSA) (2009).The Safer Surgery Alert. Available online athttp://www.npsa.nhs.uk/nrls/alerts-and-directives/alerts/safer-surgery-alert/

7 Last accessed on 30th December 20098 Helmreich RL. On error management: lessons from aviation. BMJ 2000; 320(7237): 781-59 Yule S, Flin R, Maran N, Rowley D, Youngson G, Paterson-Brown S. Surgeons' non-technical skills in the operating

room: reliability testing of the NOTSS behavior rating system. World J Surg 2008; 32(4): 548-5610 Patient Safety First. Reducing harm in peri-operative care. Available online at

http://www.patientsafetyfirst.nhs.uk/Content.aspx?path=/interventions/Perioperativecare/ Last accessed on 30thDecember 2009

11 Project SAVED. Available online at http://www.patientsafetyfirst.nhs.uk/Content.aspx?path=/Campaign-support/patientsafetyfirstweek/periop-care-one-new-step/ Last accessed on 30th December 2009

12 Rogers, E. M. 2003. Diffusion of Innovations (5th Edition). New York: Free Press.13 Smith R. Why are doctors so unhappy? BMJ 2001; 322: 1073-74

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A New Breed’s Take on the Old Dogs’ Concerns

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A New Breed’s Takeon the Old Dogs’ConcernsMelanie Orchard, F2 applying for Core SurgicalTraining, Adam Sykes, CT1 Trauma andOrthopaedics and Tom Cosker, SpR, Trauma andOrthopaedics, Royal Berkshire Hospital

A conversation took place between a Surgical Consultant andhis F2 junior... “You don’t know how easy you have it these days,we used to work twice as many hours as you do!” he said.“Really”, replied his junior, “we have just as many patients sodoes that mean we’re twice as efficient?”With the advent of the European Working Time Directive

(EWTD), a new breed of junior surgeon is emerging. Thesedoctors are only allowed to work 48 hours a week in order tofulfil both their clinical duties and their educational needs. Manyare becoming increasingly disgruntled and discouraged whenthis doesn’t seem possible. Concerns are widely being raisedregarding the balance between service provision and learningopportunities, as well as the loss of continuity of patient care.Furthermore, medicolegal concerns have been raised andquestions have been asked about whether or not work outsidethe EWTD hours will be covered by standardmedical indemnity.The NHS Litigation Authority has recently confirmed that

claims arising from work performed outside normal workinghours, be it due to high workload or for training purposes, willstill be covered by NHS indemnity in the usual manner. TheMedical Protection Society, along with other defenceorganisations, has stepped forward to confirm that they canalso provide assistance with the other medicolegal problemsthat can arise in such circumstances. However, the MPS hasalso reminded trainees that it is important to remember theirown welfare and, more importantly, that of their patients, whenworking extended hours and the increased potential for harmfulmistakes being made.With the decrease in the number of hours spent in the work

place, the main concern seems to centre on the actual hoursavailable for training purposes. However, with earlierspecialisation and the pending introduction of a third CT year insome deaneries, the number of hours spent in a chosenspeciality is actually comparable to the previous system.Comparable, but still fewer, so what can this new breed oftrainee do to maintain the standards that are expected?Efficient use of time will become an increasingly key

attribute for every junior surgeon in order to maximise theireducational gains while at work. The few minutes betweencases in theatre will cease to be a coffee break and will becomechances to complete evaluations and assessments with theirsupervisors or an opportunity to add a few more slides to theaudit presentation they are preparing. Time off after nights andannual leave will also be useful to perform other activities suchas research projects, reading and attending relevant courses.

In many cases some of the best learning opportunities willarise outside the trainee’s “allotted hours”. It will then be downto that doctor to decide whether or not they are willing tosacrifice some of their “rest” time in order to advance theirknowledge and ultimately their career. Realistically, a trainee willonly get out of a rotation what they are willing to put into it andthat can only be a good thing.The onus cannot be solely placed upon the trainee,

however. With fewer available training hours, consultants andsupervisors will have to become more efficient and morecreative in engineering these learning opportunities for theirjuniors. A supervisor who is willing to teach and has beenappropriately trained to do so will become an even greaterasset to their surgical team. They will be able to use therestricted time available to turn everyday clinic and theatresituations into impromptu case-based discussions andprocedural-based assessments.With the introduction of the EWTD, all hospital-based

doctors are increasingly becoming shift workers with regularhandovers between incoming and outgoing shifts. The game of‘Chinese Whispers’ that occurs will have ever more players andtherefore more chances for details to be missed and patientsafety potentially compromised. All trainees must uphold aconscientious approach to developing a robust handoverregime to ensure patient safety is maintained at the highstandards that we have all come to expect. A certain amount ofpride in the job they do will go a long way to achieving this andpromoting a similar ethos in the team around them will help tocontinue the pursuit of excellence.

The EWTD has forced a radical rethink in our approach tosurgical training. As with all changes in the world of medicine,the effects are not just measured by the standards in trainingbut also by patient satisfaction and clinical outcomes. The newsystem is far from perfect but with the correct attitude to timemanagement and self motivation, surgical trainees can ensurethat their education and experience it is not compromised. Weface challenging times ahead, but with a positive approach anda creative determination to both train and be taught, we willhopefully continue in a tradition of superb surgical training.

The Medical Protection Society supports this article. It is confident the issuesraised highlight many of the concerns felt by surgeons in training affectingpatient safety, training as well as critical security of indemnity arrangements.

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Training & Education - The New IMRCS Exam

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The New IMRCS ExamWill Hawkins, Director of Education, ASiT

It is no secret that surgical education is in a state of flux. Somany factors are influencing the direction of travel that I do notwish to go into them here. With the adage that assessmentdrives learning, it was inevitable that the format of surgicalexaminations was going to be involved in the metamorphosis ofsurgical training in the United Kingdom.

In September 2008 the old style Intercollegiate Membershipof the Royal Colleges of Surgeons Examination (IMRCS) waschanged. The two written (multiple-choice/single bestanswer/extended matching questions) papers have stayedlargely the same, but the viva voce and clinical examinationshave now become an Objective Structured Clinical Examination(OSCE), a format of examination that has been embraced bymedical schools across the United Kingdom over the last fifteenyears or so. The OSCE format is easy to standardise and thishas led to its popularity in undergraduate education, theproblem comes when trying to identify content for each station.The timeframe for a station is set and this can becomerestrictive, sometimes leading to reliability and validity beingsacrificed in favour of practicality and feasibility. The written andOSCE parts of the IMRCS are also intended to becomplemented, and in some areas replaced by, workplacebased assessments that appeared along with ModernisingMedical Careers a few years ago.

The IMRCS remains a high stakes examination and is thegatekeeper into higher surgical training (ST3 for mostspecialties, ST4 for neurosurgery). It must therefore be a robust,fair examination that assesses a high enough level to maintainthe confidence and safety of our patients. A number ofinterested parties, including some examiners, have raisedconcerns over the ability of the OSCE format to deliver thesegoals. Foremost of these concerns is the issue of whether basicsciences, that have traditionally underpinned surgical practice,can be adequately assessed when there is an emphasis onclinical scenarios and communication skills during theexamination. Anatomy is a subject that has been particularlyhighlighted, especially since teaching in this area at medicalschool level is perceived to have ebbed away over the lastdecade. Perhaps the Surgical Colleges should be reinforcingthe importance of this subject through their examinations?

Mr Chris Oliver, Chair of the Intercollegiate Committee forthe Basic Surgical Examinations and an orthopaedic surgeon inEdinburgh, has now invited a trainee representative to sit on theCommittee and the relevant subgroups. Importantly they seemto value our input and do listen to our opinions. As part of thisrole, Steve Hornby (ISCP representative to ASiT council) and Iobserved an OSCE and produced a document critiquing theexamination in May 2009 (this can be viewed in ‘Articles anddocuments’ in the ‘Resources’ section of the ASiT website).

Overall the examination seemed to be well organised andfeedback was collected from all candidates and examiners tobe fed back to the organising committee. There were elementswhich seemed to be positive; additions such as a patient safetyand pre-operative management station, more thought seems to

have been put into the communication skills stations and thehistory taking stations were also found to work well. We did,however, identify issues with the assessment of clinical skillsand basic sciences, the main points that were highlighted are:

• Anatomy stations had an element of choice and in onestation were unmanned, reducing the depth and quality ofthe examination. Although this section is intended to assess‘Anatomy and Surgical Pathology’, very little pathology wasassessed

• The critical care station did not explore knowledge ofphysiology sufficiently

• The candidate is only asked to physically examine twopatients (and could choose two of four) during the OSCE,which we felt to be insufficient for a high stakes examination

• There were two stations for interpreting data, but thetimeframe for these stations was not long enough to allowthe candidates to do themselves justice

• ‘Direct Surgical Skills’ assesses the ability to scrub up,cannulate, take blood cultures or remove a simple skinlesion. We felt that these simple skills were adequatelyassessed elsewhere, including as part of foundation yeartraining, and were not relevant to this level of examination

I am pleased to report that in response to our document,along with pressure from the interested parties and the EnglishCollege in particular, it has been proposed that the format is tochange from 2010 to address most of these issues.Unfortunately, the Direct Surgical Skills station is to stay butperhaps we will see more contextual skills being assessed? It isproposed that the OSCE will run in two venues on one day, withcandidates moving from the Colleges to a hospital for theclinical part of the OSCE. There will be more assessment ofanatomy, pathology and physiology and slightly less choice forthe candidates, ensuring a wider breadth of knowledge isassessed. We hope that this will not increase the stress of theexamination for candidates, rather ensure that those who arebest prepared have the opportunity to display their knowledge.PMETB are still to approve these changes but it is likely thatthey will.

To complement these changes, a new curriculum for theearly years of surgical training has been drafted and now largelyapproved. The document makes the syllabus more accessibleand concise, making it more of a revision aid than previousincarnations. It also references specific texts giving surgicaltrainees a better guide to the depth of knowledge that they areexpected to have acquired by the time that they sit the IMRCS.This draft curriculum and a brief response from ASiT are alsoavailable on the ASiT website.

Overall the signs are encouraging. The examinations aredeveloping and this is to the benefit of trainees, the surgicalcommunity and, of course, our patients. The Royal College ofSurgeons of Ireland, however, continue to use the old format ofthe MRCS because Ireland (and the rest of the world) has notadopted the Modernising Medical Careers training model. Thenext challenge is to make the IMRCS truly intercollegiate andcreate an examination that is relevant and robust enough to beused at home and abroad. ASiT is in a position to influencethese changes and we always welcome feedback from ourmembers to allow us to do this more effectively.

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Training & Education - Applied Basic Surgical Sciences for the IMRCS OSCE Course Review

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Applied Basic SurgicalSciences for theIMRCS OSCE CourseReviewAbeyna Jones, Core Trainee 2 Surgery,East Surrey Hospital

The Royal College of Surgeons have recently changed theformat of the MRCS exams from the old Part 1 and 2 written,now called Part A, and the new Part B OSCE (ObjectiveStructured Clinical Examination) which was previously Part 3Vivas. Although Part 3 Vivas are still available for those whohave taken their first parts in the old system, it will eventually bephased out.

In conjunction with changing the format of the examination,candidates will need to adopt a different approach whenstudying and preparing for the Part B OSCE exams comparedto the old Part 3. The RCOS have thus adapted their 2 weekMRCS Viva course to suit these new changes and have nowintroduced the 5 day Applied Basic Surgical Sciences for theIMRCS OSCE Course.

The course is aimed at Core Surgical Trainees at a CT1-2level who are preparing for the Part B IMRCS OSCE Exam.Foundation Year trainees planning to enter surgery who havealready passed the Part A MCQs exam can also attend.

The deciding factor for my attendance on the course wassimply because I needed guidance as to the key areas thatwere being examined in the new format of the exam.Introduction of the new IMRCS OSCE has produced a greatdeal of uncertainty as to what is required of the examinationcandidate. Colleagues who have passed the Part 3 Viva beforeadvised me on books and methods of studying for the oldformat; however some of this information is somewhatobsolete. Despite this, the most recurrent piece of advice Ireceived was to attend the course run by the Royal College ofSurgeons.

The IMRCS OSCE Applied Basic Surgical Sciences courseis a 5 day tutorial which covers approximately 40% ofknowledge required for the Part B IMRCS OSCE Exam;Anatomy and Surgical Pathology, Critical Care and Physiology.Although the course is deliberately deficient in the other areas,advice is given on how to prepare and approach these stations.

The course convener Professor Mahadevan, the CollegeBarbers’ Company Reader in Anatomy, gave us detailed insightinto the format of the exam, the core areas in which we werebeing examined and the outcome marking system. This wassubsequently followed by an intensive 5 days of anatomydemonstration in the form of lectures and wet prosections,2 highly invaluable spotter sessions under mock examconditions ‘The Grand Mahadevan Steeple Chase’, and a fewsessions with Professor Madden and Mr Vaughan whodemonstrated example questions in Applied Physiology and

Critical Care, with comprehensive revision sessions oncommon topics.

Private study time was allocated one evening at theWellcome Museum of Anatomy and Pathology at the RoyalCollege of Surgeons which gave us the opportunity tofamiliarise ourselves with a large variety of anatomicalspecimens on display in addition to taking advantage of theCollege library services.

Depending on the number of applicants to the course therewould be a maximum of 30, however I was fortunate to be in asmall group of 10 which informalised the learning experienceand allowed all to ask questions which may have been fearedin larger groups.

It was a privilege to have Prof Mahadevan, Prof Maddenand Mr Vaughan teaching on the course; it enhances thelearning experience like no bounds. We were frequentlyentertained by the several anecdotes, analogies and fascinatingtopical discussion by Professor Mahadevan. You leavewondering why you ever found anatomy difficult to rememberor learn.

One of the keys to exam success is in the coreunderstanding of anatomy and applying this to surgicalpractice. This course helps you to focus on both generic andyour chosen speciality anatomy, which will aid you in passingthe exam. The consensus is that most candidates who fail theexam do so not because of a lack of knowledge, but becauseof adequate exam preparation.

A hearty lunch is provided on a daily basis in the RoyalCollege of Surgeons Canteen and an end of course party withsome of the faculty and Raven Department of Education staff isdefinitely something to look forward to!

The course costs a hefty £1,000, however there is adiscounted rate for those already enrolled in the STEP Course.Costs include refreshments, lunch and two popular books usedfor viva preparation - Applied Surgical Physiology Vivas (Kananiand Elliot) and Surgical Critical Care Vivas (Kanani).

Attending this course revealed a few revelations that wouldnot have become apparent had I not attended. I feel moreadequately prepared for the Applied Basic Surgical Sciencesaspect of the course. However I may consider attending othercourses nearer to the exam date in order to consolidate otheraspects of the exam including clinical examination techniques

I would highly recommend this course if you are consideringtaking your Part B OSCE in the next few months as it isprovided by the faculty who are heavily involved in writing,preparing and invigilating for the exam itself.

For those attending the course it is imperative to rememberthis is a revision course. Don’t expect to be taught new topics.I found it useful to read the books provided and revise coresurgical anatomy before attending the course.

Although this course replaces the old two week viva course,it still provides an adequate foundation for examinationpreparation, despite the controversy created by the new OSCEformat of the exam.

Training & Education - The Provision of Excellence in Training

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The Provision ofExcellence in TrainingWill Hawkins, Director of Education, ASiT

I am not sure where the Association of Surgeons in Training’smotto, “In the pursuit of excellence in training”, came from, whosuggested it or even how they imagined it would be interpreted.Perhaps that is one for the archivists, but over the years ASiThas primarily been involved with representation, campaigningfor improvements and in many cases advising on how weenvisage this to be achieved. However we have also beenworking towards our motto by providing the training.

ASiT Council naturally attracts those with an interest inteaching and education, so creating a portfolio of coursesseems an obvious use of these skills. The embryonic stages ofthis portfolio arose from the enthusiasm ofmembers of the ASiTExecutive, notably Dom Slade and Conor Marron. Initially thiswas to encourage attendance at the conferences in Edinburghand Belfast and local knowledge and facilities lead to therunning of a basic laparoscopic skills and a trauma courserespectively. These were run at low cost, with a high ratio offaculty to delegates and attracted high quality faculty memberswho had links with the Association. The positive feedback thatwe received from the delegates was incredible and we have runincreasing numbers of equally successful courses each year,with six currently planned for Hull 2010.

The most successful course that has been developed so faris the Foundation Surgical Skills (FSS) course. This course wasprimarily conceived and developed by Conor Marron and hasnow been given endorsement from the Royal College ofPhysicians and Surgeons of Glasgow, where the course is runa few times a year. Its simple design leads to the success of thiscourse. It also fills a demand from medical students and juniortrainees who wish to demonstrate their enthusiasm for surgeryand be able to participate in theatre. Importantly, this comeswith a low price tag breaking - it typically runs for under £50 perdelegate. This course is easily reproducible and we are happyfor other interested groups to use the template to run their owncourses for students and trainees locally.

From these beginnings a new branch of ASiT hasdeveloped - ASiT’s Surgical Skills Education and TrainingScheme (ASSETS). This builds on the ethos of the earlycourses, providing cheap, high quality courses with expert

faculty. As has been presented at previous ASiT conferences,research shows us that practicing techniques in the classroomshortens the learning curve and can protect patients. In Irelandthis has been embraced and is an integral part of surgicaltraining, but in the UK we are lagging behind. It remains earlydays, but the long term aim is to continue designing surgicalskills courses that can be easily reproduced across the countryand are so low cost that trainees will want to attend more thanonce. This would give trainees more control over their skillsacquisition, speed up their learning curves and ultimatelyimprove patient safety. Aside from the FSS course, we havealso developed a laparoscopic suturing and stapling course(which will hopefully be run regularly in Portsmouth andpossibly in Newcastle), a laparoscopy for urologists course andthe basic laparoscopic skills course will be relaunched in Hullwith the intention to run this regularly in the West Midlands.Courses relating to research, writing clinical papers, leadershipand medicolegal matters continue to be run as part of ourportfolio but require more specific expertise and will continue tobe purely conference based for the time being. The ASiTExecutive is wary of being seen as a General Surgicalorganisation and acknowledges that these courses appeallargely to our general surgical members. We are thereforealways interested to hear from trainees in the othersubspecialties who have ideas on realistic courses that we canrun according to our ethos and that they are willing to helpdesign. We have had some ideas from plastic and paediatricsurgery, but have found it difficult to find courses that have amarket because of the courses that trainees in those specialtiesare already required to attend as part of their formal training.

The costs of our surgical skills courses are kept low byavoiding the use of expensive synthetic models, beinginnovative with how we demonstrate techniques and throughour strong partnerships with industry. A number of companieshave large training budgets and increasingly they are seeingASiT as a way to get this to the surgical trainees in the UnitedKingdom. We have been fortunate to build excellentrelationships with industry and this has helped further increasethe number of opportunities that we can offer our members.

Aside from the courses mentioned above, in 2009 alonethrough our links particularly with Covidien, Ethicon, the PelicanCentre in Basingstoke and the Royal Society of Medicine, ourmembers have been given:

• 39 free and 4 half price places on courses• 24 trips to Covidien’s training unit in Elancourt, Paris• 8 trips to Ethicon’s unit in Hamburg• 2 three month bariatric fellowships in Bruges• 2 travelling fellowships worth £2500

How we distribute these benefits of membership is notalways easy. We have to be seen to be fair, so we will only offerplaces to trainees who are members of ASiT when they apply.Some courses are very specialised and it is only appropriate tooffer them to those with the relevant interest and experience inthe subject, so these are offered on a competitive basis. Somehavemore generic appeal and are awarded on a first come, firstserved basis. They are always advertised on the ASiT websiteand email group, but if there is clear specialist appeal we willalso advertise through the specialty organisations, to ensure

Training & Education - The Provision of Excellence in Training

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that as many of our members are aware of them as possible. Inorder to speed up the short listing process you will now usuallybe asked to provide a short statement detailing why you shouldbe offered the place. CVs are also requested because this willhelp back up claims made in these statements but alsobecause our industry sponsors like to see the calibre of thosetrainees attending their events to ensure that this financialsupport continues. When using the statements we look at theapplicants’ enthusiasm for the course or fellowship, their priorexperience, commitment to the area of interest (research andcareer progression) and in some cases seniority.

All of this organisation takes a lot of time, so at the 2009AGM it was decided to create a new executive role of Directorof Education that I was elected into. It has been very rewardingto see the educational portfolio grow so quickly this year and Ihope to see this continue. I would like to see a series of coursescreated that concentrate on generic surgical skills and builds onthe success of the FSS course, but covers a wider range oftechniques. Using the ethos described above, if we can makethese cheap to attend I hope it will encourage future surgicaltrainees to develop more skills in the classroom and help themmaximise their opportunities when they do get to the operatingtheatre.

I would like to thank our sponsors for their continuedsupport and I hope that we can continue to work togethertowards these objectives.

Thanks to the Freedom of Information Act, this work waspre-empted by Dr Foster and The Times in 2001 and by theGuardian in 2005 which published named-surgeon mortalitydata from hospital administrative systems. Putting this sortof information into the public domain has led to fears thatsurgeons may become more risk averse, but the SCTS datadoes not support that with falling mortality despite anincreasing incidence of risk factors. Data such as these arepowerful tools both for good and ill.

The good that comes from reporting outcomes is oftenreferred to as the “Hawthorne Effect”, a term coined in 1955by Henry A. Landsberger when analyzing experiments from1924-1932 at the Hawthorne Works (a Western Electricmanufacturing facility outside Chicago)6. A study had beencommissioned to examine the effect of ambient light levelson productivity. The workers' productivity seemed toimprove when any change was made and declined when thestudy was over. It was suggested that improvement inperformance related more to the effect of being studiedrather than any changes made. Similarly in medicine,awareness of our own comparative outcomes stimulatesreflective practice and may drive up standards of care. It isnoteworthy that the evidence from North America suggeststhat putting the data in the public domain may drive datacollection but does not further contribute to driving qualityimprovement.

There is however, considerable potential for ill. Data arecomplex and false conclusions can easily be drawn unlessconfounding variables such as levels of co-morbidity andsocial deprivation are considered. Outcomes must be riskadjusted before meaningful comparisons can be made.

It is therefore incumbent upon the medical profession toguide the development of information technology whichgives ready access to meaningful performance data -making what matters measurable, not what is measurablematter. The need for such data is even more topical as thespecifics of revalidation are clarified. The Academy of theMedical Royal Colleges in 2009 produced a checklist of thetypes of information it would expect to be presented forrevalidation7. The need for logbooks and audit of outcomeswas explicit in this document. Some Trust informationsystems can now produce this automatically.

The Joint Advisory Group (JAG) has published qualityand safety standards for gastrointestinal endoscopy such ascolonoscopy completion rates, polyp detection and levels ofsedation8. Many of the commercially available electronicendoscopy reporting systems now capture these data itemsfor the endoscopist. This represents the paradigm; makingdata capture integral to clinical activity. Electronic reportingof patient contacts with performance data an automatic byproduct, without the need for any external agency to capturedata. Endoscopy is however a relatively simple example.Clinical practice is hugely varied and difficult to structure,necessitating sections of clinical practice being subject todetailed clinical audit by methods additional to the regularday to day work of the clinician. Within our own field ofcolorectal surgery, there are examples of successful audit atlocal, regional and national level.

Locally in our own institution, the basic principle of makingdata capture integral to clinical activity was embraced

Training & Education - Information Technology and Audit: Making What Matters Measurable

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InformationTechnology and Audit:Making What MattersMeasurableSarah Mills and Mike Bradburn, ConsultantSurgeons, Northumbria Healthcare NHS Trust

Information technology (IT) is central to delivery of healthcare inthe 21st century, but the NHS has been slow to wake up to itspotential. The earliest computer systems in the NHS were thePatient Administration Systems (PAS) which were largelyadministrative tools, but the more widespread use ofcomputers started in the 1980s with the advent of the personalcomputer (PC). Some visionaries in the early days saw thepotential and developed databases to aid patient management,produce correspondence and provide easy access to auditdata. They were however limited by both hardware andsoftware capabilities and were generally lone voices crying inthe wilderness. Few saw the need to change beyond paperbased systems, and even fewer the need for auditing ones’own outcomes.

In 1998 the government published its strategy for IT(Information for Health)1. The NHS plan in 20002 furtherstressed the role of IT in the modern NHS and the Wanlessreport in 2002 recommended doubling IT spend, centrallymanaged national standards for IT and development of aNational Programme3. This body (National Programme forInformation Technology - NPFiT) came into being in April2005. Its development has been bedevilled by difficultiesand many of its core aims are well behind schedule.Nevertheless as hardware has become cheaper and morepowerful and software more user friendly, computers havebecome embedded in the daily life of the medicalprofession. Information technology is however merely a tooland the use to which it is put determines its eventual utility.The increased spending on the NHS flowing from the NHSplan came with the strings of targets. Most management ITactivity is directed towards monitoring these targets andclinicians have been slow to realise the potential formeaningful audit and outcomes analysis. Lord Darzi’s review‘High Quality Care for All’ in 2008 aims to put quality of careat the heart of healthcare delivery and will require allhospitals to produce ‘quality accounts’4.

The cardiac surgeons have led the way in national audit.The enquiry into the paediatric cardiac deaths at BristolRoyal Infirmary stated “…Clinical Audit must be fullysupported by Trusts. They should ensure that HealthcareProfessionals have access to the necessary time, facilities,advice and expertise in order to conduct auditeffectively…”.5. The Society for Cardiothoracic Surgery inGreat Britain and Ireland (SCTS) defined a dataset and hasworked with the Healthcare Commission & latterly the CareQuality Commission since 2005 to report robust, validated &risk-adjusted hospital outcomes, reported on the web.

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Training & Education - Information Technology and Audit: Making What Matters Measurable

relatively early on by the general surgical department. Since1997, every routinely produced clinical record (clinic letter,operation note, discharge summary and MDT letter) has beendictated to proforma. The dictated data items and clinicalrecord are entered into a sql server database (SIRIS© Xentec)by the departmental secretaries. Latterly, that process is part-automated through the use of digital dictation & voicerecognition software (G2 Speech©). The database is availableto all users for the purposes of audit, with the facility to exportboth predefined queries and queries constructed by the user.The dataset captured is much larger than that of the hospitaladministration system with automatic clinical validation sincethe clinicians are determining the input. It does howeverrequire discipline from clinicians to dictate to proforma andsuffers therefore from being incomplete since not all are yetpersuaded of the importance of local data ownership. Dataexports are used routinely for departmental audit and govern-ance activities, in preparation for annual appraisal, contributeto departmental clinical research activity and are madeavailable in the public domain (http://www.northumbria.nhs.uk/subpage.asp?id=245692). This data is an integral partof our consent process and the weblink is provided to allpatients undergoing elective colorectal resections.

Regional audits into the management of colorectalcancer have been performed in the Lothian region9, Trent &Wales10 and Wessex11. The longest running of these is theNorthern Region Colorectal Cancer Audit (NORCCAG) in theformer Northern Region of England. NORCCAG is funded bythe SHA and employs specially trained audit facilitators tocapture a defined dataset (demographics, process, staging,surgical, pathological, oncological and outcomes data).Funding is however insufficient to allow the 2 staff toperform all data capture & the audit is reliant on clinicianinvolvement and increasingly trust information teamscompleting proformas and downloads from local softwaresystems. The level of support within trusts for data capturevaries considerably and NORCCAG has developed bespokesolutions over the years between hospitals to accommodatelocal strengths and weaknesses. The audit staff have animportant role validating submitted data & ensuring dataquality. NORCCAG produces annual comparative reports,shares data with NYCRIS and the national bowel canceraudit and publishes outcomes data by surgeon and hospitalvolume. It has demonstrated year on year improvement insome quality measures such as rates of restorative surgeryand nodal harvest.

The National Bowel Cancer Audit Programme(NBOCAP), part now of the National Clinical Audit SupportProgramme, has tried to collect similar data nationally since2001. It has produced powerful annual reports, but is stilllimited by incomplete national coverage. Data is variouslysubmitted by individuals, trusts or local audits such asNORCCAG. The NBOCAP team have found that the qualityof data submission across the country is very variable, withsome areas doing well with case ascertainment, but poorlywith data quality and completeness and others thereverse12. There are issues around duplication of tumourrecords and conflicting treatment information where patientcare crosses Trust boundaries. These issues do support thecase for the continuation of regional audits which can ensureconsistent coding and good data quality as evidenced by

the relatively complete coverage of the former NorthernRegion in the 2009 NBOCAP annual report.

Making what matters measurable rather than what ismeasurable matter requires strong clinical support andleadership. The upcoming needs of professional revalidationshould be a powerful motivator to all of us to own our owndata. Data capture and audit should be as integral to ourworking lives as attending our operating lists and clinics. Wecommend the endoscopy reporting system paradigm;contemporaneous data capture as part of routine clinicalactivity. We owe it to our Trusts, patients and to ourselves todemonstrate that our performance is within acceptednorms.

References1 Department_of_Health. Information for health: an information strategy for

the modern NHS 1998-2005 - executive summary. 1998 [cited ]; ]. Availablefrom: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4002944

2 Department_of_Health. The NHS Plan: a plan for investment, a plan forreform. 2000 [cited; Available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyandGuidance/DH_4002960

3 Wanless D. Securing Our Future Health: Taking a Long-Term View. 2002.4 Darzi A. High quality care for all: NHS Next Stage Review final report. 2008

[cited; Available from: http://www.dh.gov.uk/en/publicationsandstatistics/publications/publicationspolicyandguidance/DH_085825.

5 Kennedy I. Learning from Bristol: the report of the public inquiry intochildren's heart surgery at the Bristol Royal Infirmary 1984-1995 2001[cited; Available from: http://www.bristol-inquiry.org.uk/final_report/report/index.htm

6 Landsberger H. Hawthorne Revisited. 1958: Ithaca.7 Academy_of_the_Medical_Royal_Colleges. Revalidation Standards for

Surgery. 2009 [cited; Available from: http://www.rcseng.ac.uk/standards/revalidation/documents/Surgery%20Framework%20Nov%202009.doc

8 JAG. Accreditation for Colonoscopy. 2008 [cited; Available from:http://www.thejag.org.uk/Portals/0/General%20Forms/General%20Guidance/Accreditation%20in%20Colonoscopy%2017.06.09%20PDF.pdf

9 Carter DC and Consultant Surgeons and Pathologists of the Lothian andBorders Health Boards, Lothian and Borders large Bowel cancer project:immediate outcome after surgery. British Journal of Surgery 1995. 82:888-90

10 Mella J, et al. Population-based audit of colorectal cancer management intwo UK health regions. British Journal of Surgery 1997. 84(12): 731-36

11 Smith JAE, et al. Evidence of the effect of "specialization" on themanagement, surgical outcome and survival from colorectal cancer inWessex. British Journal of Surgery 2003. 90: 583-92

12 Smith J, et al. The National Bowel Cancer Audit Project 2007. QualityImprovement & Open Reporting. 2007 [cited; Available from:http://www.nbocap.org.uk/resources/reports/report2007.pdf

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Training & Education - IT in Training and Beyond

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IT in Training andBeyondChris Macklin, Consultant Colorectal Surgeon,Mid Yorkshire Hospitals NHS Trust

Information Technology and the internet are revolutionising theway that we learn and communicate with each other. Websitesaccomplish many tasks from managing portfolios to surgicallearning and information technology can aid surgeons intraining to maximise revision time to ensure success in post-graduate examinations.

I hope to give some tips regarding these aspects of using ITin your professional life.

Websites for Trainees

Eportfolio for FY TraineesEnsure that you can login to your portfolio. It is yourresponsibility to complete your portfolio and it pays to get onwith it early and make sure that you read the sections oninformation resources and frequently asked questions -especially as your supervisor may not be au fait with the use ofthe website and so would be best guided by yourself.

A foundation doctor should read and become familiar withthe following:• Foundation Programme Curriculum -

www.foundationprogramme.nhs.uk• The New Doctor (GMC 2007) - www.gmc-uk.org• Good Medical Practice (GMC 2006) - www.gmc-uk.org• The Rough Guide (latest version July 2007) -

www.foundationprogramme.nhs.uk• The Summary of Evidence Presented -

www.foundationprogramme.nhs.uk

ISCP for Surgical Trainees - www.iscp.ac.ukRemember the following in the surgical trainees role:• The trainee is required to take responsibility for his/her

learning and to be proactive in initiating appointments toplan, undertake and receive feedback on learningopportunities.

• The trainee is responsible for ensuring that a learningagreement is put in place, that assessments are undertakenand that opportunities to discuss progress are identified.This puts the onus firmly on the trainee to take the

responsibility for managing their training and assessments. It isuseful to look for information on the websites of ASiT, ASGBIand your particular speciality organisation.

So Many Websites…With somanywebsites to look at how can you keep up to date?• Email lists such as the ASiT email list which can be joined

via the ASiT website www.asit.org allows you not only topost relevant questions but also to review and searchthrough past emails for answers.

• Email alerts are available for many of the major journals

such as BJS and Lancet so that the most recent table ofcontents can be sent to your inbox.

• RSS feeds - RSS stands for Really Simple Syndication andessentially is a way of accessing new information fromresources such as the ASiT website and journals etc. RSSfeeds can be read via most email clients, web browsers,PDAs and even mobile phones.

Websites for LearningThere are a multitude of websites that offer medical informationfrom searching for journals and articles to specialist websitesand specific learning modules. Here are some suggestions:

PubMed - www.ncbi.nlm.nih.gov/pubmed

Google - www.google.co.ukhttp://scholar.google.co.uk

The Dukes’ Club Forum - www.thedukesclub.org.uk(>40,000 views of past questions)

Medscape - www.medscape.com

The Cochrane Collaboration - Cochrane Reviews - meta-analyses - www.cochrane.org

Surgical-tutor.org.uk - A free on-line surgical resource - lightexam revision relief mainly for SHOs but you can test yourselfin a few topics. Good revision for your non-specialist topics -www.surgical-tutor.org.uk

The Medical Algorithms Project home page - POSSUM,APACHE, etc. Look up all those scoring systems you'veforgotten! - www.medal.org

Gastrosource - great for the slides but you can also read it likea textbook - www.gastrosource.com

Gastro Resource Centre - The web site is derived from the 3rdedition of the textbook, "First Principles of Gastroenterology" -www.gastroresource.com

NeLH: Dictionaries & Searching - A good page for looking upmedical terms www.library.nhs.uk

whonamedit.com - Useful for eponymous syndromes -www.whonamedit.com

Online text booksABC series available to most hospitals & BMA members, RCSmembers

BMA free online library for members - www.bma.org

ACS online textbook - www.acssurgery.com

In addition more modern ways of learning are available:Audio and video podcasts are available through iTunes to playon iPods and iPhones. YouTube has a multitude of videocontent including BMAtv and specific websites provide video

Training & Education - T in Training and Beyond

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content specifically for surgeons such as WebSurg(www.websurg.com )

IT and Exam RevisionIT can help your exam revision by maximising your learningopportunities whilst fitting round your busy schedule.

• A modern printer can print online articles or revision bookchapters as booklets (double sided and 2 pages per sheetto fit in your pocket easily) - use the 5 minutes betweencases to scan over a chapter.

• Listen to audio notes on your commute or during your sparetime (even in the gym!) to help you revise main facts - myown audio notes are available www.colorectalsurgeon.org.uk and audio podcasts can be downloaded from iTunes

• PDF files - many articles or book chapters are available fordownload as Adobe Acrobat (PDF) files and can be viewedon many platforms including PC, Pocket PC, PDA andsome phones.

Beyond TrainingYou’re a Consultant now! 40-80% of patients look up theirConsultant on the internet prior to consultation. What to do(especially if you are considering private practice):• Google yourself – find out whatever other people will find

out when they Google your name and ‘surgeon’ or‘Consultant’

• Beware your namesakes! Protect your online reputation byensuring that you hit first in Google - register for Twitter,Facebook, Myspace etc. if only to stop others registeringyour name. Alternatively, get some to do this for you:www.uksurgeon.co.uk can provide Online ReputationManagement

• Get yourself a website - but you need to think why you needone:•• patient information•• professional information•• both•• personal

• If it is for private practice then:•• Is it worth it?•• Time to maintain it?•• Cost?

• What are the alternatives• Informative Webpage• Private Hospitals Site• Dr Foster• UK Surgeon Entry - www.uksurgeon.org

The presentation that I gave to ASiT on this subject is availableat www.uksurgeon.org/asit

Please feel free to contact me for more information concerningany of the above: [email protected]

Training & Education - A Guide to Less Than Full Time (LTFT) Training

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A Guide to Less ThanFull Time (LTFT)TrainingMandy Chadwick, SpR North West Deanery

IntroductionLTFT training is not new. It’s been around since 1969 and wasoriginally introduced to retain doctors who would haveotherwise had to stop their training usually because of familyresponsibilities. LTFT training is more prevalent in other medicalspecialities than surgery. The introduction of the EuropeanWorking Time directive (EWTD) led to the expectation thatdemand for LTFT posts would decrease with the overallreduction in doctors’ hours. However, with the increase in thenumber of female doctors and the sharing of domestic roles,there has been an increase in the demand for LTFT training.

All trainees, both men and women are eligible to apply forLTFT training. Those wishing to do so must show that trainingon a full time basis would not be practical for them.

The Application ProcessIt is stated that the application process can take up to threemonths, but from personal experience it is much longer.

EligibilityYou must first seek advice on eligibility from the post graduatedeanery representative and it is for the associate dean todetermine whether a trainee’s request to train LTFT isappropriate. Deaneries assess eligibility on the following twocategories:

Category 1Those doctors in training with:• Disability or ill health• Responsibility for caring for children• Responsibility for caring for an ill/disabled partner• relative or other dependent

Category 2Those doctors in training with:• Unique opportunities for their own personal/professional

development (eg training for national/international events)• Religious commitments• Non-medical professional development

(eg management courses)

Category 1 applicants have priority and deaneries will supportall category 1 applications.

Requirements of the LTFT ApplicantFor training approval, LTFT trainees have to work a minimum of5 sessions (50%) though the norm is 60%. Day time working,on call, and out of hours duties should be undertaken on a pro-rata basis to that worked by full time trainees in the same gradeand speciality.

Post SelectionWhere possible, two LTFT trainees will be placed in a slot or jobshare occupying a full time post with each working 60% offulltime. This allows the deanery to only have to provide anadditional 20% of funds on top of a whole time equivalent. If aslot share is not possible, then working reduced hours in a fulltime post could be considered. It is possible to work up to 80%as a LTFT trainee with full time on call.

Only if a slot share or reduced hours full time post areimpossible will a supernumerary post be considered. Theseposts are themost difficult to arrange as the basic salary comesfrom the deanery LTFT budget, but the host trust has to meetthe banding cost. In the future, as trust budgets becomeincreasingly restricted, these posts may become more difficultto acquire.

Timetable ApprovalTimetable approval is done by the SAC in general surgery. AnLTFT timetable needs to accommodate protected regionalteaching and personal study within the normal working week. Itmust be of equivalent quality to fulltime training and be EWTDcompliant.

For example, a typical 60% LTFT 6 session rota for acolorectal trainee would include:• 2 operating lists• 1 endoscopy list• 1 outpatient clinic• 1 personal study session• 1 session for regional teaching

The normal annual RITA process applies as for full time trainingand trainees retain their NTN.

PMETB ApprovalIndividual PMETB approval is not normally required. Eachdeanery informs PMETB of their capacity for flexible trainees ineach specialty. PMETB gives generic approval for thesetrainees and the responsibility for training reverts back to thedeanery. There should be no concerns about PMETB approvalunless there is a sudden large influx of flexible trainees within aspecific speciality.

Changing PostsTrainees are expected to rotate between posts on the samebasis as a full time trainee. This ensures they receive aneducationally comparable training programme. The process oftimetable approval must be repeated for every post. This willbecome easier with time as recognised LTFT posts will becomethe norm with funding already established. LTFT trainees canreturn to full time training at any stage providing there is anavailable full time slot. Your time required in training and newCCT date will be calculated by the SAC. Three months of totalmaternity/sick leave can count towards training.

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Summary (Step by Step Guide)

Personal PerspectiveI am currently on my second period of maternity leave. I havefound LTFT training allows me a better work life balance.However, with this you have to accept the prolonged durationof training and the reduction of salary.

It is with mixed feelings that I watch my original CCT datecome and go and my peers apply for consultant jobs. I am surethat LTFT training will mean that I have the advantage ofmaturity and an increased experience when my trainingeventually comes to an end. I feel that the amount of trainingand exposure that I gain exceeds the 60 percent that I work.

The LTFT application process can at times be frustratingand it usually takes much longer than the recommended threemonths. In my experience I have found it very difficult to set upa new supernumerary LTFT post within a trust. I am veryfortunate as within the North West region there are alreadyseveral LTFT trainees in surgery and several hospitals haveestablished LTFT posts making the application process easier.

More information can be found on the Royal College ofSurgeon’s website.

Step 1 Contact regional LTFT training advisor and talk to an LTFT trainee in your region.

Step 2 Contact the associate post graduate dean or the LTFT deanery representative and fill in an eligibilityscreening form.

Step 3 Gain programme directors approval.

Step 4 Approach Consultants at a hospital willing to have a LTFT trainee on advice of regional LTFT trainingadvisor. Write up timetable to include protective study/research session and regional teaching.

Step 5 Complete deanery flexible training form. This requires a signature from the programme director andthe trust’s financial manager if supernumerary.

Step 6 SAC timetable approval and calculation of new CCT date.

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An alarm bell rang in my head. 'Tell Dr G to order two pintsof blood and send the patient straight up to theatre - diagnosis,ruptured spleen", I told the nurse.

I examined the young patient in the anaesthetic room. Whiteas a sheet, tachycardic and, when I gently palpated hisabdomen, he cried out and clutched his left shoulder; awonderful example for my students to see of referred pain fromdiaphragmatic irritation. I removed the shattered spleen and thepatient did well.

If it had not been that Dr G was going to send a patienthome from Casualty without consulting me first, I doubtwhether I would have made this spot diagnosis on the basis ofthe nurse's telephone message - the most brilliant diagnosis Ihave made in a long surgical career!

Training and Education - My Most Brilliant Diagnosis

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My Most BrilliantDiagnosis

Harold Ellis CBE, FRCSEmeritus Professor of Surgery,University of LondonNow Clinical Anatomist, Guys Campus, London

I have never regarded myself as a great diagnostician; safe, butcertainly not great. I always taught that ‘common diseasesoccur most commonly’ and that a difficult diagnostic problemwas more likely to be an unusual manifestation of a commondisease than a common presentation of a rare condition. I haveseen many odd presentations of acute appendicitis, but onlyone example of torsion of the omentum.

When I was the great Norman Tanner's senior housesurgeon at the old St James' Infirmary in Balham (now a blockof flats), the urologist there had a great reputation among thelocal GPs as having a superb opinion on the acute abdomen.He made a steady income being called out by them ondomiciliary visits to see their emergencies. One day, I asked himto tell me the secret of his diagnostic success. "I examine theirgroins carefully to see if they have got a strangulated rupture",he said. "If they haven’t, I send them in as an acute appendicitisand I'm usually correct".

Once, however, many years ago, I did excel myself:

In 1953, I was RSO (Resident Surgical Officer) at the oldSheffield Royal Infirmary. These posts at the major hospitals,jobs which sadly no longer exist, were a marvellous opportunityfor a young surgeon. He would be the senior in the residents'mess. As the name implies, he would live in, and indeed seldomleave, the hospital. He would keep the house surgeons out oftrouble and, with his fairly recent FRCS Diploma in his pocket,he would deal with the bulk of the surgical emergencies comingthrough the door. In Sheffield in those days, these includedcoal-dust encrusted miners and badly injured steel workers.The only snag in this otherwise perfect job was one of myCasualty Officers - I had better just call him ‘Dr G’; frankly, hewas awful. He would take no clinical decision on his own, butwould call me down to Casualty to see the most trivial casesbefore allowing them home.

One Saturday afternoon, I was in the operating theatretaking out a gangrenous appendix, assisted by a couple ofstudents, when a nurse came in with a message for me. Dr Ghad seen a boy in Casualty who had come off his bicycle. Helooked pale and was complaining of pain in his left shoulder.Dr G had X-rayed the shoulder; the X-ray was quite normal andDr G was’ going to send him home’ - the first time, as far as Iknew, he had ever taken this bold step.

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Training and Education - Silver Scalpel Award Winner 2009

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Surgical Training:What is the RightAttitude?

Reflections by the 2009 Silver ScalpelAward Winner

David Khoo, Consultant, Upper GI andLaparoscopic Surgeon, Queens Hospital, Romford

“To hold him who has taught me this art as equal to my parentsand to live my life in partnership with him, and if he is in need ofmoney to give him a share of mine, and to regard his offspringas equal to my brothers in male lineage and to teach them thisart - if they desire to learn it - without fee and covenant; to givea share of precepts and oral instruction and all the other learningto my sons and to the sons of him who has instructed me andto pupils who have signed the covenant and have taken an oathaccording to the medical law, but no one else.”

The Hippocratic Oath

It may seem strange that, when I heard about winning thisaward, I was completely taken by surprise. “Surely everysurgeon trains juniors” was my only thought. Now I have hadtime to reflect on the Silver Scalpel Award and prompted tothink by the symposium of recent winners and runners upwhich took place in Leeds recently, I believe my chief asset inthe field of surgical training is a passion to train. I want to train.As a doctor, my desire to train comes second only to my desireto treat patients. To see my trainee succeed in performing as asurgeon gives me a certain excitement; to use the vernacular, a

kick, thrill or perhaps buzz. I don’t know whether my traineesturn out the best at their craft. I know I am not the best clinicianor even the best surgeon. But I do know of my own love oftraining. The Hippocratic Oath contains the words quotedabove and gives an ancient foundation for the sort of attitude intrainer and trainee which remains pertinent to the present day.

But in the same breath as I say that, I realise that thispleasure is becoming so, so hard to fulfil. We all know that theEuropean Working Time Directive has led to loss of trainingopportunities for the trainee, but the real difficulty is a newatmosphere of surgical practice for the trainer consultant whois beset with more and more demands on time and resource.Pressure of expectation to deliver a high-class service militatesagainst having time to train. The transfer of much surgicalpractice to non-training environments such as the independentsector treatment centres and private practice is an ethosseemingly endorsed from our politicians. I don’t intend here todwell on these well-repeated issues that have led to the currentcrisis in surgical training, but instead, I want to air what I believeis the appropriate response of the surgical profession to thecrisis in terms of attitude.

What then is the true ethos of surgical training? Is it just totrain individuals to do the job of a surgeon so as to earn asalary? Is it just to create a workforce for the future as dictatedby political masters? Is it about raising surgical standards?Surely it is about all of these things, but I believe there is also anancient pattern of apprenticeship, mentorship or evendiscipleship that is intrinsic to the craft of medicine which weare in danger of losing and which is so important in the transferof skills and attitudes to a future generation. There is anintangible force here which we have almost lost. It is as ifsurgeons are tempted to pull up the drawbridge of their careersand retreat towards retirement. “I’m alright now, safe in mycareer. Stuff the trainees.” This attitude is not new, but is gettingharder to avoid. I must confess also that I have recently foundit very hard to maintain any consistency in my practice oftraining. Surgeons need to maintain a desire to train.

This, then, is the guiding light to lead us through the fog ofbureaucracy of the modern NHS and the logistic nightmarecreated by the working time directive. What we need, then, is adetermination to promulgate the ancient art of training andapprenticeship against all the odds. A sort of Battle of Britain‘do or die’ mentality. The alternative is to create a practice ofsurgery whose watchwords are expediency and mediocrity. Itwill also be not much fun.

My suggestions for surgical training then, are aboutrestoring the relationship between trainer and trainee, masterand apprentice, to promote these attitudes.

Selection of TraineesThe improvement of surgical training starts from the veryselection of our medical graduates and the surgical trainees ofthe future. A learning attitude and a teaching attitude often gohand in hand. It is often said that to learn something well, youhave to teach it. So with surgery, an aptitude to recreate whatyou have been taught, to form a synthesis and to make thepractice your own so you can teach another is something to belooked for in whatever psychometric analyses are used at theentry to medical school or onto surgical rotations. It is strikingto me how my very best trainees can be observed to be


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teaching their juniors. Being ‘consciously competent’ is the finalstage of skills acquisition and when this point is reached, thesurgeon is truly in a position to teach, because without thisability, the subject being taught or the skill being transmitted isnot truly based on understanding.

Selection of TrainersIt is clear that many consultant surgeons are not natural trainersat all and it would seem inappropriate for such individuals to bein a position of trainer. It is a somewhat vexed issue, however,for unless an individual has a record of training, how can thatperson be judged? How should the judgement be made andwho should make it? These matters are really for the market todecide: trainers should lay out their stall, so to speak, and makeit clear by their practice what is on offer. This should not bedone in any stiff, bureaucratic, form-filling manner. I give anexample: I had one junior who was on another firm and whoperchance ended up working with me on call. Because I usedthe opportunity to teach, that junior became aware of theopportunity for training on my firm and asked the rotationorganisers to come to my firm on the next placement.Reputation for training, like surgical outcome, is as good as thelast opportunity

Then again, what does a consultant gain by having atrainee? Is it kudos? Is it a better pair of hands to look after thepatients on the firm? I think not.

Not all Consultants to be TrainersIt is more from the forces that dictate a new kind of surgicalpractice that some consultants will be without trainees in thefuture. A systematised surgical practice that is consultant-ledwill be just that and trainees are not then essential. Such apractice can be extremely good, but will tend to exist in ahermetically-sealed environment where no trainees are to befound. Private practice is exactly like this. To be a trainer is toinvite trainees. To fail to train is to repel them. Such consultants,in all probability, have no desire to train and have no pleasurefrom it. Happily, I believe that there are few consultants like this.

Matching Trainees and TrainersOne of the biggest failings of our current system is the way inwhich trainers and trainees seem to be at the mercy of aprogramme director alone. This is bad insofar that there is noopportunity for trainees and trainers to ‘choose’ each other. Sodoing sets the framework for a happy working relationship andan understood agreement that the relationship will be for thepurpose of training. In former times, there was no ‘run through’programme and interviews were held every year or two toprogress to another post. These interviews acted as a matchingscheme for the trainer/trainee partnership. Similarly, for ourcurrent trainees, finding an overseas fellowship in a specific unitor in a specialist unit in this country produces a similarmatching. It is not desirable to get rid of full training rotations,but there is a need for a competitive edge to this job matchingfrom all parties.

Close Working RelationshipsThe duration of placement is currently only 6 months with agiven trainer. This is too short for the sort of apprenticeshipmodel I have been speaking of to fully develop especially in aclimate of limited opportunities for training. I have found

occasion when a trainee has booked leave during the same 6-month period as I have. When night duty is taken out and otherstudy leave, there is very little time in that 6 month allocation todevelop any working relationship of note. I would argue verystrongly for these periods to be a year particularly if there is alimitation on who should be trained and who should be doingthe training as I have argued above.

In reality, training firms should have multiple consultantsworking together in close partnership to include the training ofthe juniors. This role model is clearly joint and is a good one forthe trainee to be a part of and learn from.

Interdependence is a very important element of the surgicalteam of the future. Lone practices in the current environment ofpeer review, Dr Foster, Care Quality Commission to name a few,is hazardous and unpleasant. The trainee should be assimilatedinto the team and share the joys and pain. Taking onresponsibility in that team is a major element of training and thiscan only take place where the trainee is absorbed into the firm.Loyalty is learned and given. The backing of a trainer for atrainee is earned from the mutual loyalty demonstrated whenworking on the firm. I have never knowingly ever asked a juniorto work beyond the working time directive, but will often findthem with me as I work into the evening for the good of apatient, which is, after all, the natural behaviour of a surgicalprofessional.

This leads to the issue of professionalism. This is the part ofpractice where the surgeon aspires to a standard above thatwhich any outside body could invent; the standard which saysthat I know no better way that I should practice. It assumeshonesty in all matters professional. This is an attitude whichcannot be taught, but can only be absorbed in anapprenticeship manner.

Every Encounter is TrainingOne inevitable outcome of the attitude of training is that everyopportunity can be used for training. Even situations where asurgical trainee does not actually do the operation or the patientencounter, teaching can take place. More important thanteaching the steps in a procedure is to pass on the attitude ofresponsibility that underlies the practice.

Expectations of the TraineeOne of the features I have noted of the occasional trainee is acertain mercenary attitude. The reluctance to do that little bitextra for the benefit of the firm can make it difficult to train. Ibelieve that trainees should understand clearly that for trainingto take place requires significant input. It is hard to teach on asubject when there is no evidence of background reading orinterest in the subject, for example. It is difficult to teachoperative technique to someone who has not met the patientbefore and knows nothing about the condition. Happily, I havefound that even this attitude is trainable and a happyrelationship based on commitment by the trainee is easilyinduced by the appropriate commitment to the trainee. Thecommitment of trainee to trainer is a key element to the successof training; it implies respect and not subservience. I remainloyal to those who trained me and those whom I have trainedremain friends.

And the Outcome?Cynically, I can imagine that someone will invent an MCQ and


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a psychological profiling method to find and assess trainers andtrainees. I hope we don’t go there, but instead increaseopportunities for the sort of human interaction which promotesthe future of our profession. For me, training is like theatre – fullof unexpected events which make surgical practice interestingand the opportunity to have fun and enjoy my job. Dealing withyoung surgeons is a refreshing experience which is a powerfulantidote to the drudgery of management which now fills muchof my professional life. Humour and enjoyment are a significantpart of what our job should be. If it should cease to be, to usethe words of one of my trainers, ‘I would rather eat worms.’ Itrust any reader who is a trainer can identify with this sentiment.

For my part, I believe that we can train trainees even withinour current constraints if the ethos of training I have outlined isfostered. It is this ethos that fights against those constraints.With this, the future is bright.

Training & Education - Silver Scalpel Award Symposium

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Silver Scalpel AwardSymposium5-6 November 2009,LeedsBettina Lieske, SpR Surgery, Oxford

Since its inception by the then ASiT President DavidO’Regan in 2000, the Silver Scalpel Award has become aprestigious symbol for excellence in training surgeons oftomorrow. Over the past decade the Silver Scalpel Awardhas played a vital part in recognising trainers going the extramile for their trainees, while at the same time promoting thehighest standards of surgical training. At a time of constantflux in the NHS, with training increasingly squeezed bydemands on service and EWTD-related working timerestrictions, it is more important than ever that good trainersare recognised and rewarded.

Having awarded the Silver Scalpel to one outstandingtrainer each year for a decade, with two further candidateseach year being shortlisted as the final three for the award,prompted reflection and finally the organisation of a meetingof these excellent trainers along with interested trainees byDavid O’ Regan, Chris Munsch (JCST) and Ed Fitzgerald(ASiT), to deliberate on educational and training issues, aswell as working on defining the attributes of an excellenttrainer.

The meeting was set over two days in Oulton Hall,Leeds, an incredible, mid 18th century mansion withbeautiful gardens and adjacent golf course.

The faculty was ably supported by RDL, a team of highlyqualified business psychologists and developmentconsultants who specialise in developing people andorganisations. Lisa Hadfield-Law and John McKenna actedas external experts and observers, providing feedbackthroughout the meeting.

The meeting started with a reception, followed by dinner,giving the delegates, facilitators and faculty time andopportunity to get to know each other and start exchangingideas and opinions. The following morning saw everyoneready for business after what had been a late night for some.

Chris Munsch welcomed everybody and David O’Reganprovided some background information on the selection andaward process of Silver Scalpel to set the scene.

Following this Carol & Chris from RDL took over and ledus through the programme.

Small group exercises in varying constellation providedinsight into trainers’ and trainees’ views on habits of highlyeffective trainers and their key qualities. These wereinterspersed with plenary sessions to bring the groups backtogether and identify the habits outstanding trainers have incommon, which differentiate them from their peers; andwhich of the key qualities matter most, culminating in the

identification of 5 key qualities that an excellent trainershould possess. The facilitators had the attending trainerscomplete personality type questionnaires (PF16) prior to themeeting, and evaluation of the results provided someinteresting findings and insights, defining great surgicaltrainers as people who find teaching personally stimulating,are optimistic about trainee’s potential and wanting them tosucceed, interpersonally sensitive, able to adapt their ownstyle to suit the trainee, self-confident and willing to let go ofwork, able to provide honest feedback and willing to betough when necessary.

The meeting was concluded with work on severalstrategies on how to take our discoveries and insightsforward to disseminate the key messages, translate theminto practice and allow successful and sustainableimplementation.

We expect further work on this to be published in thenear future.

We would like to thank all delegates who made thismeeting the success it was, as well as the RDL Projectsteam and the following sponsors:B Braun Medical LtdCardio Solutions (UK) LtdCovidien (UK) Commercial LtdCryolife Europa LtdMedtronic LtdMoney DoctorsVascutek, Terumo

AGM - Trauma in the Tropics

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Trauma in the TropicsDavid Nott, Consultant General & VascularSurgeon, Chelsea & Westminster/Charing CrossHospitals, London

This short article relates to the presentation on surgery in thetropics which I gave in Nottingham to the Association ofSurgeons in Training in March 2009. Although being a full-timeconsultant at Charing Cross Hospital, Chelsea andWestminster, and the Royal Marsden hospital I take one monthunpaid leave per year to work with the aid agency MedicinsSans Frontieres (MSF). The missions vary greatly and caneither be in the middle of a full-blown war conflict or lookingafter thousands of refugees or being part of a team taking overa hospital where the healthcare system of that country hascompletely collapsed. Over the past 14 years I have been toSarajevo-Bosnia, Afghanistan twice, Sierra Leone, Liberia, IvoryCoast, Chad, Congo, Darfur, Iraq and in October 2009 toYemen. As I have been fortunate enough to work in both EastWest and Central Africa, this short article relates to the tropicalsurgical problems I have been involved in those countries.

To begin practicing in any country that you are sent to, onehas to adopt situational awareness of the religious, cultural andenvironmental circumstances and issues relating to eitherthe indigenous or displaced population including theirpsychological status which may have been affected badly bysocial deprivation, war and famine. Early and carefulexplanation about the condition may require the help of aninterpreter. In cases where an amputation is eventuallynecessary, the offer of this planned operation is stubbornlyresisted in some parts of the world and patients may preferlifelong crippledom or even death to the social degradation ofbeing without part of an arm or a leg. Part of the history takingshould concern the patient's home district, as it is sensible tostart making arrangements early in his illness or after care andrehabilitation. If the patient has come from a long distance, thismay mean asking relative to find accommodation for near thehospital so that outpatient treatment and supervision can be

continued after discharge. Discharging a patient from a hospitalbed to his temporary accommodation, and this may be a tent30miles away with no provision for outpatient care, may quicklycause the demise of someone you have spent a long time intaking care of at the hospital. All these factors must be takeninto consideration. One must remember that sometimes youare the only surgeon in the hospital, and although the nursingstaff may be attentive, it is always best to remain on one'sguard. For example a complaint of pain inside a plaster may betreated by the nursing staff by an injection of pethidine oranother analgesic but you must be prepared to cut a window inthe plaster over the painful spot and establish whether apressure sore is present or not, children especially are seldomhypochondriacal and complaints of pain inside a plaster ordressing should always be taken at face value.

The basic physiology of man is the same all over the world,extremes of climatic conditions evoke special responses whichmust be taken into consideration when dealing with injuredpatients: a patient with a compound fracture of the femurtransported to 80 miles in the back of an open truck at atemperature of 35°C in the mean humility of 80% will needtreatment which differs from that of a man with similar injurytransported to a hospital and ambulance at the temperate zone.In temperate climates, adults imbibe about 3L of water in 24

Aspiration of pus from septic knee

Typhoid perforation

Femoral fracture

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hours. Water is lost partly as urine (1500ml), partly as insensibleperspiration (1000ml) and partly as moisture in the breath(500ml). A man working in a hot climate may lose 3000ml ofsweat in 24 hours and with severe exercise, this may increaseto 1 liter per hour. Although there are no hard and fast rulesabout fluid balance, one must have an idea especially in thosecases that have also lost an amount of blood through injury.There are sometimes no other investigations apart from ahaemoglobin estimation and clinical judgment becomesparamount.

In the majority of MSF hospital, facilities are available forcollecting and the storing of blood and testing of donors for HIV,hepatitis B andmalaria is mandatory. Themajority of donors arerelatives of patients and sometimes a policy is adopted for amoral acceptance of a unit of blood for a hospital stay. No childunder the age of 18 is used as a donor and also the nutritionalstatus of donors must be taken into consideration as routinehaemoglobin may be in the order of 10g/liter. In any regionwhere syphilis or yaws is common, a proportion of donor bloodwill contain spirochetes; however, these do die after 24-hourstorage. There is some experience of using auto transfusion incases of severe haemorrhage, for example significanthaemothorax or splenic injury where the blood can be filteredand then returned directly to a patient.

In all tropical areas, the spleen is commonly palpable due tomalaria or other endemic diseases, which means that it is theleast three times its normal size. An enlarged spleen is moreliable to rupture than a normal sized one and this is particularlyso with the malarial spleen as the surrounding perisplenitismakes it adhere, particularly to diaphragm and stomach.

One of the most upsetting bleeding problems relates topostpartum haemorrhage, where in one mission in Chad therewas a one in four maternal death at time of caesarean section.The refugees that arrived at our little hospital had been inobstructed labour for at least a week. The majorities of patientshad malaria and were severely toxic from the effects of a deadfetus in utero and often had disseminated intravascularcoagulation at the time of surgery. With no intensive care unit,80 per cent of those undergoing postpartum hysterectomy foruncontrolled bleeding died.

Nutrition is the most common cause of anaemia in tropicalcountries due to infestation with various nematodes, in

particular hookworm, and the inherited haemoglobinabnormalities especially sickle cell disease account for the rest.Haemoglobinopathies, and the special forms of osteomyelitisand osteitis that may contemplate them, often leads topathological fracture, and considerable numbers of these occurthrough segments of bone weakened by osteomyelitis due toorganisms of the salmonella group. Osteomyelitis with all itssequelae is relatively common and involucrum fractures at thesite of a large sequestrum are not uncommon and the surgeryinvolves removing this sequestrum if it is involved in abscess orsinus formation. Neonates are particularly prone to septicarthritis of the hip or knee, usually due to Staphylococcusaureus, haemophilus and salmonella; urgent drainage andantibiotics are required.

The single most common cause I have found of large bowelobstruction in Africa is sigmoid volvulus, the most commonestcause of small bowel obstruction is incarcerated inguinalhernia. The cause of sigmoid volvulus has not been fullyelucidated and although a high residue diet has been proposedas the major factor it still remains a mystery. I have operated onmany children with massive megacolon. If it had occurred inSouth America, then obviously this would have been due toTrypanosome Cruzi, so-called chagas disease but this wasHirschsprungs disease, the cause was no doubt hereditary andwas very common in the Ivory Coast.

Open operating theatre in Darfur

Dressing station - Darfur

Forequarter amputation

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I have seen many cases or bowel obstruction in childrendue to worms, most notably Ascaris Lumbricoides, in youngchildren and this will cause an intussusception. I have not founda case of bowel obstruction due to Ascaris in adults, but manyvictims of abdominal gunshot wounds have a belly full ofroundworms swimming in the blood. It is very important whenyou perform a bowel anastomosis to use two or even threelayers of sutures otherwise the worms will try and burrowthrough a single layer anastomosis. In Yemen, rectal prolapseis common in children due to heavy infections with whip-worm and pharmacological treatment usually resolves thesituation.

Species of salmonella cause only a small proportion ofdiarrhoeal infections but the most important surgicalemergency is that of intestinal haemorrhage and perforationdue to ulceration of the Peyer’s patches. Treatment typicallyinvolves oversewing of the perforation, with the usual 2/0 vycryl,adequate lavage and antibiotics.

Much of the trauma one encounters comes from gunshotwounds and knife or machete wounds. Trauma principles applyusing tourniquets for limb catastrophic haemorrhage followedby airway, breathing and circulation. Contaminated wounds arenever closed but are left open and treated by delayed primaryclosure with dressing with fluffed up gauze for five days; if noinfection is seen, wounds are either closed or skin grafted atthat time. Although I have performed various vein bypasses forsignificant arterial damage from gunshot wounds, the oldadage of life above limb holds true but it has to be rememberedthat there may not be prosthetic appliances available and thepatient may succumb to a dreadful life and that is why I try andpreserve limbs if possible.

Burn injuries due to kerosene kitchen fires are a verycommon occurrence and are mainly seen in mothers andchildren. The treatment is exactly as it is in the UK, whichinvolves making a distinction between superficial and deepburns and treating appropriately. This involves careful cleaning,application of silver sulphadiazine, tulle gras dressings andsubsequent skin grafting. I have, in the past, used banana leafdressings which seem to be equally effective in achievingwound healing and offering pain relief and subsequent re-epithelialisation. Many patients both young and old turn up withsevere contractures due to old burns and you have to be

prepared for excision of wounds and skin grafting using a splitskin graft taken with a handheld dermatome.

It is interesting that most of the limb fractures that one seesare due to long bone fractures that are of the humerus or thefemur. I very rarely put on an external fixator because I havefound that patients will leave the hospital rapidly and it will besold in the local market in the subsequent weeks. It is best totreat femoral fractures with a styman pin placed through theproximal tibia and subsequent traction. Fractures of the upperlimb and lower leg are best treated using plaster of Paris.Occasionally one may find a Thomas’s splint or make one upingeniously and apply skin traction. In children, who usuallyfracture one femur, I usually put them in bilateral Gallowstraction as it is easier to maintain a perineal hygiene.

There are a lot of old men who wander around with acatheter bag having gone into urinary retention. They oftensuffer from recurrent urinary tract infections. I often offer thema transvesical prostatectomy if rectal examination confirms it isa smooth prostate. It is an operation hardly performed now butwhen I was an SHO, it was fairly routine but I fear it is a skill thatwill die out in due course.

The anaesthesia is often delivered by a nurse anaesthetistand in the majority of cases a spinal anaesthetic or ketaminewill suffice. I have performed a retrosternal thyroidectomy fordyphagia, all types of abdominal and thoracic procedures

Severe burn necessitating rotational scalp flap

Haemorrhage control in gunshot wound to elbow

Ascaris Lumbricoides



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under Ketamine without major complication. I have performedmajor surgery outdoors with the whole village looking on inremote areas in Darfur under ketamine anaesthesia given by aCanadian accident and emergency consultant who had nevergiven an anaesthetic in her life. This was for the people of avillage who had been the victims of a Janjaweed attack.

Whilst abroad, I often contact my colleagues via mobiletelephone if I am not sure of the diagnosis especially inspecialties such as paediatric surgery. I have had somewonderful responses from my colleagues enabling me toundertake complex surgery that I was not familiar with, forinstance, in performing surgery on a neonate with an ectopicbladder which I had never seen before. I received somenotoriety last year asking my colleague at the Royal MarsdenHospital to help me through a forequarter amputation. AlthoughI thought nothing of it at the time, it appears that it was the firstoperation via text message of its kind. With technologyimproving all the time, I am sure that tele-medicine in the future

will fill the gap that training cannot offer. I am extremely worriedthat surgeons who wish to work with aid agencies such as MSFwill not have the skills to be a fully rounded surgeon and be ableto cope not only with every region of the body but also tounderstand the various specialties. To this end, I am workingwith the aid agencies to try and create a training programme forjuniors to go out to the field with a senior trainer. After longdiscussions with the deanery, PMETB and his trainers at home,the first trainee was all set up to come out with me in October2009. However, the mission to Yemen was deemed sodangerous by MSF that the trainee unfortunately had hismission cancelled. Other factors such as security, threat ofkidnap and where one’s passport is issued from, play a big partnow. Certainly the world in the last decade has become amuchmore dangerous place for the humanitarian surgeon to work in,which is a shame as going to far flung places used to be a lotof fun.

All Basic and Higher Surgical Trainees are encouraged to join

ASiT (Association of Surgeons in Training). Membership is open to trainees

from all of the surgical disciplines and is available for a nominal fee.

With a strong and active membership your Council can accurately represent

the views of the surgical trainee to the Royal Colleges

of Surgery, the Specialist Associations and the Department of Health.


AGM - How to Write a Surgical CV

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How to Write aSurgical CVGillian Tierney, Consultant Surgeon

When asked to give this talk, I initially considered that onemightargue there was no longer a role for a formal curriculum vitae(CV). The majority of jobs are now applied for usingstandardised application forms and most short listing done inan anonymous fashion. However, as an intellectual exercisealone, it’s good practice to maintain a CV. It’s of use later inyour career when applying for fellowships and grants. It’s a niceprop to carry when having a pre-interview visit and gives thoseyou visit a framework about which to chat.

It’s traditional to stick to a familiar running order in your CV.Personal details are followed by a list of education andqualifications. Present post is then followed by a list of jobs todate. It’s useful to list clinical skills and experience (often as anattached log book). Research, audit, publications andpresentations follow. Management and leadership experienceare listed as your career progresses. Lastly you should list yourreferees, but only after asking their permission!

Personal details should include all methods of contactingyou including email and mobile numbers. You should also listyour training number if appropriate, GMC number and yourdefence organization.

When listing qualifications it’s debatable whether youinclude school examinations and I guess the older you are, theless likely these are to be listed.

You should then make a clear and concise careerstatement, clearly it should be relevant to the particular post.If the post for which you apply has a teaching component, thenlist your relevant teaching experience.

All surgically relevant courses should be listed includingCCrISP, ATLS (instructor status) and any speciality specific RCScourses undertaken.

Your interests should be listed to make you look like a wellrounded individual but not so lengthy that you look a slacker!

As with all important documents, you should initially draft it,read and re-read. Then ask someone whose opinion you valueto check it for you and take their comments on board.

Over the months and years you should redraft and update.Sloppiness is to be avoided. Use a consistent format with a fontno less than 12pt (most readers will have presbyopia) on goodquality paper. Reams of free text should be avoided, bulletpoints are good. Avoid clichés such as “a busy DGH”. Youshould be scrupulously honest as lies are always discovered.

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AGM - Providing a Global Service - The Trainee’s Contribution

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Providing a GlobalService - TheTrainee’s ContributionRobert Lane, Programme Director for InternationalAffairs ASGBISurgical Advisor to The Tropical Health andEducation Trust

IntroductionIn this article I shall highlight some discrepancies in GlobalHealth Care, indicate why needs are greatest in Africa andthen discuss how a surgical trainee can make a contribution.

Discrepancies in Global Health CareThe situation in Africa is far worse than anywhere else in theworld with 46 out of 53 countries facing a critical shortage ofhealth care workers. It is estimated that the number needsto increase by 139% to address health needs in Africa andthat translates into one million more health care workers.Africa has 24% of the global health burden but only 3% ofthe global health work force whereas the United States ofAmerica has 10% of the global health burden and 37% ofthe global health work force (figure 1). These stark facts putthe situation into perspective and are reflected by thedistribution of health care workers (figure 2) and basic healthindicators (figure 3) for selected countries both within Africaand outside this for comparison.

You have to ask yourself why there are so few health careworkers in Africa. The answer is both migration andemigration. Migration occurs within the country from its ruralareas to its cities where doctors can earn more money.There is also migration out of clinical practice into publichealth and this may be for similar reasons. Emigration to thedeveloped world leads to higher income and moreopportunity. Many graduates shun surgery because of thelong training, difficult exams, poor remuneration and theincreased risk of HIV/AIDS. The situation with regard to lackof front line health care workers is deplorable. Approximately1 in 20 women die in labour but this may not necessarily bedue to lack of health care workers. Deficient infrastructure inthe rural areas also plays a part. Sixty percent of thepopulation have no access to emergency drugs.

Figure 1 - Distribution of health workers by level of health expenditureand burden of disease, by WHO region

Figure 2 - Distribution of health workers for selected countries

Figure 3 - Basic health indicators for selected countries

UK’s Contribution to Solving the Capacity IssuesRecent interest shown by HMG resulted in ‘Global HealthPartnerships’, written by Nigel Crisp and published in 2007,which highlighted the opportunities for the UK to contributeto health care in developing countries. The Government’sresponse to Nigel Crisp’s report in 2008 was positive andacknowledged that individuals and organisations in the UKfind international work professionally and personallyrewarding and that such opportunities may also contributeto NHS recruitment and retention by providing employeeswith additional challenges. They also suggested that thePostgraduate Medical Education and Training Board(PMETB) should work with the Department of Health, RoyalColleges, Medical Schools and others to facilitate overseastraining and work experience. Sir John Tooke, in his reporton the independent enquiry into modernising medicalcareers (2008), reinforced the Government’s response toNigel Crisp’s report and in particular that doctors should beallowed to interrupt their training for one year or longer, byagreement, to seek alternative experience that enhancestheir career and contribution to the NHS, having regard toservice need; details of which are set out in A ReferenceGuide for Postgraduate Specialty Training in the UK (TheGold Guide) 2009. These arrangements, which need theapproval of the local Postgraduate Dean, cover taking timeout of training to support trainees in:• Undertaking PMETB prospectively approved clinical

training which is not part of the trainees specialtyprogramme.

• Gaining clinical experience which is not approved butmay benefit the doctor or help support the health needsof other countries.

• Undertaking a period of research, and• Taking a planned career break from the Specialty

Training Programme.

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AGM - Providing a Global Service - The Trainee’s Contribution

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There is thus a very positive attitude by Government andits agencies for trainees to spend some part of their trainingworking abroad in the underdeveloped world. How does onego about finding an attachment? There are several avenuesto pursue. Personal recommendation, say, from a consultantfor whom you have worked or a colleague who has spenttime abroad. There maybe a formal link between theUniversity/Hospital Trust where you are working and anInstitution in Africa.

Mission Hospitals provide 40% of health care in Africaand there are often openings here. The VSO can help findsuitable posts but they are usually for one year. Universityresearch departments are another possibility and the RoyalColleges and Specialty Associations in the UK also havelinks abroad. Once you have made the decision as to whereyou want to go, the next problem to address is when youwant to go. In some respects, this depends on whether youwish your time abroad to count towards a CCT. Pleaseremember that PMETB now recognises Out Of ProgrammeExperience for Training (OOPT) and Out Of ProgrammeExperience for Research (OOPR) which must beprospectively approved by PMETB if it is to count towardsthe award of a CCT. However, be aware that you must havebeen accepted for Specialty Training and have an NTNbefore OOPT and OOPR can be approved by PMETB forpurposes of a CCT. If you go abroad during core training youwill not be protected by employment law on your return andcontinuation of service may be affected. What waspreviously known as Out Of Programme Experience (OOPE)is now defined as “out of programme clinical experience”and does not count towards the award of a CCT. Similarly,“time out of programme for career breaks” (OOPC) does notcount towards a CCT and hence does not require PMETBapproval. See the Gold Guide (2009) for further details.PMETB requires information on the following from theDeanery in order to process and approve applications forout of programme training or research (please note thatthere is no form to fill out, just documentation whichaddresses the three points):1. A formal covering letter from the Deanery to PMETB

seeking prospective approval of the OOPT or OOPRplacement and confirming that it has Deanery supportalong with the following essential information - trainee’sfull name, date of birth, GMC number, NTN Number andspecialty.

2. Confirmation that the specialty, through the appropriateSAC, is aware of and supports the OOPT and OOPRplacement. The SAC require a CV, job description,timetable, education contract and letter of support fromProgramme Director and OOPT form signed by the Deanprior to going and a log book together with Trainer andTrainees reports on return. The SAC will decide, prior todeparture, whether all or part of OOPT will count towardsa CCT.

3. A statement detailing the purpose and structure of theOOPT or the OOPR placement including confirmationthat the placement is subject to quality management inline with PMETB requirements.

However, prospective approval by PMETB forplacements in developing countries is often not possiblesimply because the quality of training and supervisioncannot be guaranteed and therefore many trainees regardexperience in developing countries as additional to their UKtraining and not a substitute. PMETB approval may beawarded but you should be aware that this is not common -in which case you need to apply for OOPE which stillrequires Deanery and SAC approval because the latter mayneed to revise your CCT date.

Other matters which need attention prior to departureinclude making sure that your salary and pension areprotected. If in doubt seek advice from the BMA. I stronglyrecommend that you remain registered with the GMC whilstyou are out of the country because it is expensive and takestime to re-register on your return.

Remember matters relating to insurance and personalhealth, especially appropriate immunisation, anti malarialsand HIV/AIDS precautions.

The BMA have recently published an excellent guide totaking time out to work and train in developing countriesentitled “Broadening your Horizons” (2009). I thoroughlyrecommend that you read this if you propose workingabroad.

I suggest that you seriously consider taking some timeout to work in the developing world. You will see much morepathology and the surgery will, in the main, be similar to thatin the UK. I just wish that I had taken such opportunitieswhen I was training. Good Luck and Bon Voyage.

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AGM - Damage Control Resuscitation

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Damage ControlResuscitationMatthew Reeds and Adam Brooks, ConsultantSurgeons, Department of Trauma, Emergency &Critical Care Surgery, Nottingham UniversityHospitals NHS Trust

IntroductionDamage Control Surgery (DCS) is a well-established conceptinternationally. Damage Control Resuscitation (DCR) is howevera newer concept. It was established in order to reduce themorbidity and mortality of coagulopathy of traumatic shock[COTS]/acute traumatic coagulopathy [ATC] (synonymous termsused interchangeably internationally). The morbidity andmortality associated with such coagulopathy averages between40-50%. Furthermore, the mortality associated with MassiveTransfusion is between 30-60%. For this reason, the principlesof DCR were first established in order to address these issues byJohn B Holcomb and David B Hoyt in 2006. Since that time,DCR has rapidly become an accepted principle worldwide andis used to prevent the resultant consequences of deleteriousphysiology and hypoperfusion causing ischaemic tissues1.

Much of the initial basis for DCR was derived from USmilitary experiences. This has evolved over the past few yearsto become an accepted standard for application in the civiliantrauma setting. Whilst the methodologies and principles of DCRare extremely wide and varied, this resume will provide a usefulinsight into the relevance and principles of DCR for any clinicianinvolved in trauma care.

Damage Control Resuscitation (DCR)Unlike Damage Control Surgery (DCS), DCR is a principle oftrauma care relevant to all specialties involved in treatingtrauma patients. It ought to be employed from the outset at thetime of initial injury and continued throughout the patient’streatment (including in the pre-hospital field, emergencydepartment, radiology, operating room and critical care units).The aim of DCR is to address the significant morbidity andmortality associated with COTS/ATC which, to a great extent, isreadily avoidable with early and aggressive resuscitation. DCRwas therefore established and implemented to address theproblems originally associated with the ‘Lethal Triad’ of traumadeaths2.

The Lethal Triad is an inter-dependent relationship betweenthree separate variables (coagulopathy [consumptive anddilutional], acidosis and hypothermia), each of which increasethe morbidity and mortality associated with trauma. Each ofthese consequences triggers exacerbation of the othervariables, resulting in an out-of-control spiralling effect.

Recent AdvancesThe above is however an over-simplified reasoning of the causeof morbidity and mortality. Recent research has demonstratedthat other factors have an overriding effect on trauma patientoutcomes. These include hypoperfusion, activation of thethrombin switch mechanism, systemic anticoagulation,decreased fibrinogen utilisation and hyperfibrinolysis.Furthermore, inflammation has a substantial influence oncoagulation. Indeed, coagulation is now considered to be asub-set of a wider inflammatory response.

Damage Control Surgery RelationshipDamage Control Surgery (DCS) was re-introduced into currenttrauma surgery practice by Alec Walt in 19693 but becameaccepted due to the influence of Michael Rotondo et al in19934. Prior to the reintroduction of DCS, many patientsunderwent long surgical procedures and were repairedanatomically but died as a result of failing to have their adversephysiology restored. The massively traumatised patient lacksthe physiological reserve to survive the rigours of complex andprolonged definitive surgery. DCS is now considered a sub-group of DCR (due to the vitally important reliance and inter-relationship between the groups).

The re-introduction of DCS principles greatly improvedmorbidity and mortality associated with trauma surgery. Thisfollows the accepted concept that trauma patients die due totheir detrimental physiology rather than a failure to restore theiranatomy. DCS follows a sequential process of restoringphysiology → preventing pathology → correcting anatomy.

Relationship between DCR and DCS

The Lethal Triad each of which increase the mobility and mortalityassociated with trauma

Principles of damage control

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A simplified analysis of this can be understood whenconsidering that trauma patients, upon admission, need urgentcorrection of their deteriorating physiology (haemorrhagecontrol, prevention of sepsis and reintroduction of perfusion).This is achieved by simple, rapid damage control surgeryprinciples during the initial emergent surgery. The patient is thentransferred to the critical care unit for continuation of DCRprinciples (in order to correct Multi-Organ DysfunctionSyndrome [MODS] and prevent Multi-Organ Failure [MOF}).Correction of the patient’s physiology (using these principles)will limit the traumatic insult upon the patient. As a result, thepatient will then be able to undergo delayed/stage definitivesurgical repair, without a substantial increase in morbidity andmortality (due to COTS/ATC, MODS, MOF etc).

CoagulopathySevere injury is associated with the presence ofcoagulopathy on hospital admission. These patients are insevere shock and are subjected to tissue hypoperfusion.Indeed patients who are not shocked do not developCOTS/ATC and these are associated with a higher mortalityrate (46%-v-10%)5.

Clinical patient data from the current conflicts in Iraq andAfghanistan have yielded much information in relation tocoagulopathy in trauma and the avoidance of such usingDCR. A single study during Operation Iraqi Freedom (OIF)evaluated the mortality outcomes of 243 patients whoreceived massive transfusion (>10 units of packed red bloodcells each - as part of massive haemorrhage protocols). Thestudy showed a correlation between traumatic coagulopathyon admission and increased mortality (mortality rate - 30%with admission INR >1.5, mortality rate -5% with admissionINR <1.5)6.

Clinically, coagulopathy has traditionally been diagnosedas generalised non-surgical bleeding. However we do notcurrently have any accurate laboratory tests which can trulymeasure the coagulopathic state of patients. Coagulation isin a constant state of flux. The longstanding coagulationcascade model of the intrinsic and extrinsic pathwaysforming the common final pathway has now been discardedas wholly inaccurate with numerous flaws. Indeed, PT andPTT do not evaluate cellular interactions of coagulation.There are also no functional aspects to these tests nor dothey reflect changes in body temperature. Furthermoredelays in the ‘more accurate’ coagulation tests haveconfounding bias in that they do not reflect the current ‘realtime’ situation - merely the effects of coagulation/anti-

coagulation on the patient’s circulation at the time that theblood sample was taken.

Targeted massive haemorrhage control therapies withdifferent coagulation factor proteins (based on whole bloodviscoelastical assays such as TEG/ROTEM) do have thepotential to improve patient care. These assays evaluate thefunctional changes in coagulation over a period of time(including clot formation, clot stability/cross-linking poly-merisation and clot breakdown [hyperfibrinolysis]). Despitethe advantages of these viscoelastical assays, the resultsonly relate to the interaction of the circulating productswithin the patient’s blood volume at the time of the test, anddo not reflect the impact of any massive haemorrhagecontrol products administered thereafter.

AcidosisCoagulopathic trauma patients experience a metabolicacidosis. This is a result of the underlying anaerobicmetabolism caused by tissue ischaemia and hypoperfusion,which causes a lactic acidosis. However, if the hypo-perfusion is severe, tissue necrosis occurs and cellularmetabolism (anaerobic or otherwise) becomes impossible.Irrespective of the acidosis caused by tissue hypoperfusion,the acidosis is independently worsened by the admini-stration of chloride rich fluids.

Acidosis has other adverse effects on the homeostasis ofthe trauma patient’s physiology. It inhibits coagulation via anumber of different modalities. It substantially reduces thefunction of Factor VIIa by up to 90% (at pH 7.0). It also hasa profound inhibitory effect on thrombin generation andactivates the thrombin switch mechanism, resulting inincreased production of Fibrinogen Degradation Products(FDPs).

Unrelated to coagulopathy, acidosis also decreases thebody’s response to catecholamines. The acidosis decreasesmuscular contraction (it creates an unfavourable environ-ment for ATP production of the myocytes). The acidosis alsoincreases the vasodilatory tone of the circulation andtherefore reduces the vascular resistance. All of thesefactors lower cardiac output. Additionally, the acidosiscreates an irritable myocardium and increases thepredisposition to arrhythmias.

HypothermiaThe many effects of hypothermia on coagulation includeinhibition of platelet activation and adhesion. It alsodramatically slows the metabolic rate of coagulation co-factor enzymes. At 35.0°C (without dilution), there is adecrease in the function and metabolic rate of allcoagulation factors and Factors XI and XII are functioning at65% their normal level. At colder temperatures, thefunctioning levels are even less (at 32.0°C Factor XIfunctions at 17% of its normal function and Factor XIIfunctions at 32% of its normal function).

Hypothermia results primarily from body heat loss duringconvection and radiation, as well as evaporation. Loss alsooccurs during operative surgery, fluid resuscitation andreduced heat production (caused by tissue hypoperfusionleading to reduced metabolism and reduced oxygenconsumption).



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ResuscitationAggressive fluid resuscitation has multiple sequelae. Theseinclude rebleeding, hypothermia and dilution. These havethe potential to perpetuate and worsen traumaticcoagulopathy. Haemodilution precipitates haemorrhage(haemorrhage quickly depletes fibrinogen and platelets).Replacement with intravenous fluids rapidly leads todilutional coagulopathy.

1) Hypotensive Resuscitation - The concept pre-dates WorldWars I & II and recommends the principle of fluidadministration to a safe but lower than normal bloodpressure (perfusion of vital organs level). The goal is tominimise re-bleeding caused by dislodgement of the initialblood clots, whilst maintaining perfusion of vital organs.

2) Permissive Hypotension - A well established concept whichhas been recommended for decades. It is supported byNICE, ATLS and various other organisations. This acceptsthe adverse physiological sequelae of hypoperfusion whichresults in consideration of the benefits of reduced bleedingand coagulopathy.

3) Haemostatic Resuscitation - This aims to address theintrinsic coagulopathy of trauma. It supports early utilisationof blood components to restore perfusion and achievehaemostasis by correcting coagulopathy. It minimises useof crystalloid fluid and limits the further dilution of alreadydeficient coagulation factors. Instead, it recommends theadministration of Packed Red Blood Cells (pRBCs) : FreshFrozen Plasma (FFP) : Platelets in the ratio of 1:1:1 in orderto achieve haemostasis.

4) Controlled Hypotension - This is a high flow - low pressureconcept devised in recent times by Richard Dutton. The aimof this concept is to maintain flow to vital organs withhaemostatic products. Flow maintains perfusion to the vitaltissues; thereby preventing hypoperfusion and the resultingcoagulopathy. The low pressure model (maintained byinducing deep anaesthesia) prevents clot displacement andreduces the risk of bleeding. The induction of deepanaesthesia causes vasodilation. This reduces the patient’sblood pressure and systemic vascular resistance; therebyalso increasing flow and tissue perfusion.

A number of studies have been performed which evaluatedthe results of massive blood product administration. One study(by Borgman et al) evaluated the ratio of blood productstransfused and its effect upon the mortality of patients receiving

massive transfusions at a combat support hospital. Itconducted a retrospective chart review of 246 casualties (whoreceived a massive transfusion of >10 units of packed redblood cells (pRBCs) and identified an improved survival in thosepatients who received a greater proportion of FFP:pRBCs (ratioof 1:1.4 respectively). Since this decreases the death fromtraumatic haemorrhage, the authors recommended that a ratioof 1 unit pRBCs:1 unit FFP should be used7.

Following a retrospective database analysis by Gonzalezet al, 97 patients were identified who had undergone massivetransfusion. They ascertained that coagulopathy was present athospital admission but, more importantly, that it persistedfollowing ITU admission. There was also an identified failure tocorrect coagulopathy during ITU admission. Furthermore theseverity of coagulopathy at admission was associated withworsening survival outcomes (p=0.02). The authors recom-mended that the administration of FFP should be given earlierto patients who require massive transfusion8.

A retrospective two group cohort study evaluating the effectof DCR on traumatic vascular extremity injuries was conductedby Fox et al. It compared the DCR group (n=16) with the groupthat received traditional resuscitation (n=24) and identified thatthe DCR group had more subjects who experienced completerestoration of physiology after vascular reconstruction than thesubjects in the traditional resuscitation groups. There was nodifference in early amputation rates or mortality (0%) betweenboth groups9.

Another aspect of DCR which needs to be addressed is theuse of anti-fibrinolytics. These prevent clot breakdown/instability and have a perfunctory role in preventing/limitinghyperfibrinolysis. These agents include Aprotinin (now onlyavailable in the U.K. on an off-licence prescription) andTranexamic Acid. Their use is commonly required in the controlof massive haemorrhage. Not only do those anti-fibrinolyticsprevent clot breakdown/destruction but they also have thepropensity to reduce the ultimate overall transfusionrequirement of packed RBCs, FFP, platelets, recombinantFactor VIIa and cryoprecipitate.

Adverse EffectsAs with any clinical intervention, there are a number of potentialcomplications that can result. These include hypocalcaemiaand hyperkalaemia (partly due to the massive transfusion ofblood products). The hypocalcaemia attributable to bloodproduct storage is in fact now less of an issue than is widelyperceived (due to the use of more modern blood storagetechnologies that are currently utilised nowadays).

Administration of packed RBCs results in a depletion ofclotting factors (especially Factor VIIa). Therefore, theadministration of recombinant Factor VIIa will usually berequired. However the patients who will benefit from suchadministration cannot easily be determined. Furthermore, theresults of the CONTROL study which concluded prematurely inlate 2008 (reported in February 2009) could not identify thepatients that would benefit from its administration, due to theconsiderably lower than expected mortality in the groups whichwould prevent any statistically significant result from beingultimately obtained or concluded.

Another effect of aggressive/adequate DCR is the resultanteffects of reperfusion syndrome that can occur followingcorrection of temporary states of hypoperfusion immediatelyfollowing injury.

Sequence of aggresive fluid

Prehospital fluids

Dilutional Coagulopathy

Dilutional Coagulopathy Delay to thaw FFP

Emergency DepartmentPRB

FFP



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Haemostatic AgentsA number of haemostatic agents have been developed whichpromote haemostasis. Whilst most of these promotehaemostasis in external cavities and wounds, a number of pro-coagulant haemostatic agents have been developed for intra-cavity use. Other alternatives are available which utilisethrombin and fibrinogen to promote local haemostasis at intra-abdominal bleeding points. These act by concentratingendogenous clotting factors. Some of these are powder based.Others are collagen impregnated sponges or pro-coagulantimpregnated gauzes.

Technical AdvancesA number of technical advances (each of which are individualcomponents of DCR) have been effective in promotinghaemostasis and reducing coagulopathy (thereby improvingmorbidity and mortality). These involve, but are not restricted to,DCS (including the use of temporising vascular shunts) andextra-peritoneal pelvic packing. It is well reported thathaemodynamic instability from pelvic fractures results in amortality in excess of 50%. A study performed by Tötterman etal in Norway in 2007 concluded that mortality exceeds 40% inthose who are subjected to haemodynamic instability resultingfrom pelvic fractures. They demonstrated a decrease inmortality to 25% in those patients who underwent extra-peritoneal pelvic packing10. Following this and the work ofPohlemann et al on extra-peritoneal pelvic packing, it hasbecome a useful procedure within the trauma surgeon’sarmamentarium to control haemorrhage and limit coagulopathyas a DCR technique.

Areas for Consideration and Future DevelopmentGiven the advances in both DCS and DCR, there are a numberof considerations which ought to be addressed in determiningchanges in recommendations which will improve patientoutcomes. These include:• the time to surgery (ie the stage at which surgery should be

commenced during the DCR process);• the benefits and consequences of cross-clamping the

descending thoracic aorta/abdominal aorta;• whether 1:1:1 transfusion ratios result in improved out-

comes for non-massive haemorrhage control transfusions;• the role and timing of administration of recombinant Factor

VIIa (with the results of the CONTROL trial in February2009);

• use of anti-fibrinolytics (such as Aprotinin and TranexamicAcid) in improving patient outcomes and reducingtransfusion requirements;

• whether DCR can significantly improve patients physiologyto such an extent as to enable definitive surgery to beundertaken at the primary surgical procedure, rather thanthe current requirement for DCS;

• strategies to prevent and mitigate hypocalcaemia andhyperkalaemia;

• the development of pro-coagulant topical and impregnatedagents as an adjunct in abdominal/thoracic/pelvic packingprocedures; and,

• strategies to prevent hypoperfusion and to mitigatereperfusion syndrome for those trauma patients who aresubjected to periods of tissue hypoperfusion.

References1 Holcomb JB. Damage Control Resuscitation. J Trauma 2006; 62(6):

S36-S372 Jansen JO, Thomas R, Loudon MA, Brooks AJ. Damage Control

Resuscitation for Patients with Major Trauma. BMJ 2009; 338: b17783 Walt AJ. The surgical management of hepatic trauma and its

complications. Ann Roy Coll Surg Engl 1969; 45: 319-3394 Rotondo MF, Schwab CW, McGonigal M, et al. Damage control: an

approach for improved survival in exsanguinating penetrating abdominalinjury. J Trauma 1993; 35: 375-383

5 Brohi KH, Singh J, Heron M, et al. Acute Traumatic Coagulopathy.J Trauma 2003; 54(6): 1127-30

6 Niles SE, McLaughlin DF, Perkins JG, et al. Increased MortalityAssociated With the Early Coagulopathy of Trauma in Combat Casualties.J Trauma 2008; 64(6): 1459-65

7 Borgman MA, Spinella PC, Perkins JG, et al. The Ratio of Blood ProductsTransfused Affects Mortality in Patients Receiving Massive Transfusionsat a Combat Support Hospital. J Trauma 2007; 63(4): 805-813

8 Gonzalez EA, Moore FA, Holcomb JB, et al. Fresh Frozen Plasma Shouldbe Given Earlier to Patients Requiring Massive Transfusion. J Trauma2007; 62(1): 112-119

9 Fox CJ, Gillespie DL, Cox ED, et al. The Effectiveness of a DamageControl Resuscitation Strategy for Vascular Injury in a Combat SupportHospital: Results of a Case Control Study. J Trauma 2008; 64(2): S99-S107

10 TottermanA, Madsen JE, Skaga NO, et al. Extraperitoneal Pelvic Packing:A Salvage Procedure to Control Massive Traumatic Pelvic Hemorrhage.J Trauma 2007; 62(4): 843-52


Nick Taffinder Travelling Fellowship Award 2009

53

Nick TaffinderTravelling FellowshipAward 2009Ben Griffiths, Salford and Bruce Levy, Guildford

Nick Taffinder was a Consultant Colorectal Surgeon with a loveof the mountains who died at a tragically young age. In 2009 thefirst two travelling fellowships were awarded to UK colorectaltrainees in his name with an awarded sum of £750 that allowedattendance to the annual, 10th Alpine Colorectal meeting, heldin Verbier, Switzerland.The meeting lasts for 3 days and hasearly morning and late afternoon sessions with ampleopportunity to ski or enjoy the scenery in between. Thesessions consist of updates in several developing orcontroversial areas of colorectal surgery and are presented byeminent surgeons in that area. This year, sessions included‘Extending the indications for laparoscopic colorectal surgery’and ‘Liver metastases’, whilst the seventh Marc-Claude Martilecture was given by Dr R Maddoff from Minneapolis and wasentitled ‘What in the world shall we do about AIN?’ We wereexpected to present an interesting case for discussion at one ofthe sessions with interaction with a distinguished audience.The meeting has an informal feel to it but the academic contentis of extremely high quality and we found the lectures invaluablefor our training with the intercollegiate exam approaching.In summary the fellowships are an excellent opportunity forcolorectal trainees to attend this highly-regarded meeting withan international audience, in beautiful and relaxingsurroundings. We strongly recommend it to colorectal traineesin future years and we are grateful to Professor Mortensen andCovidien for allowing us this fantastic opportunity.Further information can be obtained fromwww.alpinecolorectal.org and the fellowship application detailsappeared on the Dukes club website www.thedukesclub.org.uk

Scientific - What’s New in Hernia Surgery

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What’s New in HerniaSurgeryAndrew Kingsnorth, Professor of Surgery,Peninsula Medical School, Plymouth

This is a selective and subjective review of publications thathave recently caught my imagination during the last year orso. Several of them will make their mark on hernia surgery foryears to come, whereas others have been chosen becausethey give an unusual insight into how surgeons treatuncommon problems.

The place of laparoscopic surgery in inguinal hernia repairhas been defined by NICE and has found a place in surgicalpractice in the UK. Two recent papers emphasised thesuperiority of laparoscopic repair for recurrent inguinalhernias1,2. All three papers were published by authors fromScandinavia; Kouhia and colleagues studied 99 patients withrecurrent inguinal hernia whom they reviewed at 5 to 10years by telephone. They found a re-recurrence rate of 6.4%after Lichtenstein repair and 0% after total extraperitoneal(TEP). Chronic pain was present in 28% of the Lichtensteingroup and only 13% of the TEP group. Sevonius andcolleagues reviewed 12,104 cases from the Swedish HerniaRegister between 1992 and 2006. They found that the risk offurther re-operation increased with the number of previousrepairs. Laparoscopic repair provided the best surgicaloutcome.

Two publications have provided useful classifications ofuncommon abdominal wall problems. Dennis reviewed 1,549CT scans requested on patients with abdominal and pelvicblunt trauma during a one-year period in 2005/063. Ninepercent of these CT scans showed an abdominal wall injury(AWI). Retrospectively, a grading system was applied asfollows: (I) subcutaneous tissue contusion, (II) abdominal wallmuscle haematoma, (III) a single abdominal wall muscledisruption, (IV) complete abdominal wall muscle disruption,(V) complete abdominal wall muscle disruption withherniation of abdominal contents and (VI) completeabdominal wall disruption with evisceration. The incidencewas respectively (I) 53%, (II) 28%, (III) 9%, (IV) 8%, and(V) 2%. There was no association with AWI and seat belt useor injury severity score. The important conclusion from thispaper is that an abdominal wall haematoma seen on a CTscan after blunt trauma may seem trivial but after 6 to 9months the underlying disruption of the abdominal wall mayresult in hernia. These occur often in young people, aredisfiguring and difficult to manage.

Staying with the classification theme, Moreno-Matiasexamined 75 patients with parastomal hernias who had alsohad CT scan4. A clinico-radiological classification wasproduced for these patients, 44% of whom had hernias asfollows: (I) hernia sac containing the stoma loop, (II) saccontaining omentum, (III) sac containing a loop of bowelother than the stoma. All type III parastomal hernias weresymptomatic and the combined clinical and radiologicalprevalence of parastomal hernia was 60.8%. All three typesof hernia present particular challenges for repair and this

paper points out the very high incidence of this conditionfollowing construction of a stoma whether it is a colostomy,ileostomy or ileal conduit. This high incidence of incisionalhernia at a stoma site was confirmed by Guzman-Valdiviawho identified an important risk factor: any other co-morbidity5. A further study by De Raet identified waistcircumference as an independent risk factor for thedevelopment of parastomal hernia after permanentcolostomy6. Patients with a waist circumference of morethan 100 cm had a 75% probability of developing parastomalhernia6.

Although chronic pain is now identified as the mostimportant complication following inguinal hernia repair,quantifying this has remained elusive. Four recentpublications have attempted to clarify this issue byproducing validated pain questionnaires7-10. Any investigatorstudying chronic postherniorrhaphy groin pain shouldcarefully examine these four papers and decide which is theappropriate one to use. My choice would be the validatedInguinal Pain Questionnaire (IPQ) and Brief Pain Inventory(BPI) produced by Franneby and validated at three yearsafter surgery.

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Scientific - What’s New in Hernia Surgery

An important Cochrane Systematic Review by Den Hartogfound eight randomised controlled trial eligible for inclusioncomparing different techniques of open incisional herniarepair11. They concluded that (1) recurrence was morefrequent after sutured repair compared with mesh, (2) of thetwo open techniques (sublay/retromuscular or subcutaneous/onlay) there was no difference in terms of operativecomplications or outcome. Comparing lightweight andstandard weight mesh, there was a trend for higherrecurrence after lightweight mesh. Interestingly, they foundinsufficient evidence to advocate the use of the componentsseparation technique which abdominal wall surgeons nowconsider to be one of the most significant advances in therepair of large abdominal wall hernias that has occurred in thelast 10 to 15 years.

Two excellent papers contradicted long-held beliefsabout risk factors for the development of inguinal hernia, ieobesity and smoking12-13. Ruhl and Everhart studied 5,316men and 8,136 women participating in the first NationalHealth and Nutrition Examination Survey (1971 to 1975) andfollowed to 1992/3 for a diagnosis of inguinal hernia. Ninety-six percent of the baseline cohort was re-contacted. Duringthe approximately 20-year period the cumulative incidenceof inguinal hernia was 13.9% for men and 2.1% for women.In the overweight and obese and people of black race, therewas a lower incidence of inguinal hernia (less than 60%)compared to white individuals. There was no increased riskamong current or former smokers. This excellent studycontradicts the widely held belief that smoking results incollagen degeneration which causes abdominal wallherniation. Rosemar carried out a community based study of7,483 men aged 47 to 55 years who were followed up frombaseline (1970-73) for a maximum of 34 years. In this study1,017 men (13.6%) developed groin hernias at a mean followup of 23 years. This is remarkably similar to the Ruhl study.Rosemar also found that for each BMI unit (3 to 4kg) therelative risk of hernia decreased by 4%. It was concludedthat obese men had a 43% lower risk of hernia and also thatheavy smokers had a 25% lower risk of hernia.

The investigation and management of post-herniorrhaphy pain is problematic. Kehlet’s group havepublished widely on this topic and report concerning theusefulness of MRI scan in patients with a painful groin afteringuinal hernia surgery14. The findings in 32 patients fromtwo blinded observers were significantly different and non-conclusive. The authors found that no particular pathologicalMRI findings were significantly associated with clinicalsymptoms. MRI cannot be recommended as a guide orindication for surgical treatment of persistent post-herniorrhaphy pain. Therefore in most of these cases asimple ultrasound will provide all the information requiredand only selected patients should have an MRI, thus savingvaluable resources. Concerning the prophylactic treatmentof post-herniorrhaphy pain Zieren studied the impact ofilioinguinal nerve excision on this condition15. In somestudies this procedure has been shown to reduce theincidence of post-herniorrhaphy pain although leaving somenumbness in the groin. In addition Zieren showed that in asmall group of patients who had received excision of theilioinguinal nerve, the rate of new sexual dysfunction was 7%compared with 21% in the group that had preservation of theilioinguinal nerve.

Finally, a new self-gripping, semi-resorbable mesh thatapplies itself like Velcro to the posterior inguinal wall hasbeen reported that could increase the ease and reduce thetime taken for inguinal hernia repair16-17. Chastan hasdeveloped this innovative mesh and reported initial results in52 patients with 70 hernias. At one year follow up, patientdiscomfort was minimal and there had been an early returnto strenuous activities. An experimental study with the meshby Hollinsky has shown that at five days the strength ofincorporation of the mesh in a rat model was as strong asthat imparted by staples, whereas the strength with fibringlue or no fixation was less than a third of this strength. Thesmall resorbable micro hooks on the posterior surface of themess thus provided relatively immediate and secure fixation.

In five-years’ time it will be interesting to see whether anyof the above papers reviewed have had a sustainable impacton the practice of abdominal wall surgery.

References1 Kouhia ST, Huttunen R, Silvasti SO, Heiskamen JT, Antola H, Uotila-

Nieminen M, Kiviniemi W, Hakala TJ, Joensuu J Lichtensteinherniaplasty versus totally extraperitoneal laparoscopic herniaplasty intreatment of recurrent inguinal hernia - a prospective randomized trial.Ann Surg 2009; 249: 384-7

2 Sevonius D, Gunnarsson U, Nordin P, Nilsson E, Sandblom G. Repeatedgroin recurrences. Ann Surg 2009: 249: 516-8

3 Dennis RW, Marshall A, Deshmukh H, Bender JS, Kulvatunyou N, LeesJS, Albrecht RM. Abdominal wall injuries occurring after blunt trauma:incidence and grading. Am J Surg 2009; 197: 413-7

4 Morena-Matias J, Serra-Aracil X, Darnell-Martin A, Bombardo-Junca J,Mora-Lopez L, Alcantara-Moral M, Rebasa P, Aygnavives I, Navarro-Soto S. The prevalence of parastomal hernia after formation of an endcolostomy. A new clinico-radiological classification. Colorect Dis 2009;11: 173-7

5 Guxman-Valdivia G. Incisional hernia at the site of a stoma. Hernia 2008;12: 471-4

6 de Raet J, Delvaux G, Haentjens P, van Nieuwenhove Y. Waistcircumference is an independent risk factor for the development ofparastomal hernia after permanent colostomy. Dis Colon Rectum 2008;51: 1866-9

7 Franneby U, Gunnarsson U, Andersen M, Nordin P, Nyren O, Sandblom G.Validation of an inguinal pain questionnaire for assessment of chronic painafter groin hernia repair. Br J Surg 2008; 95: 488-93

8 Staal E, Nienhuijs SW, Keemers-Gels ME, Rosman G, Strobbe LJA. Theimpact of pain on daily activities following open mesh inguinal herniarepair. Hernia 2008; 12: 153-7

9 Loos MJA, Houterman S, Scheltinga MRM, Rosman RMH. Evaluatingpostherniorrhaphy groin pain: visual analogue or verbal rating scale.Hernia 2008; 12: 147-51

10 Heniford BT, Walters AL, Lincourt AE, Novitsky YW, Hope WW,Kercher KW. Comparison of generic versus specific quality-of-life scalesfor mesh hernia repair. J Am Coll Surg 2008; 206: 638-44

11 Den Hartog D, Dur AHM, Tuinebreijer WE, Kreis RW. Open surgicalprocedures for incisional hernias. Cochrane Database of SystematicReviews 2008, Issue 3, Art No CD 006438

12 Ruhl CE, Everhart JE. Risk factors for inguinal hernia among adults inthe US population. Am J Epidemiol 2007; 165: 1154-61

13 Rosemar A, Angeras U, Rosengren A. Body mass index and groinhernia: a 34-year follow-up study in Swedish men. Ann Surg 2008; 247:1064-8

14 Aasvang EK, Jensen KE, Furgaard B, Kehlet H. MRI and pathology inpersistent postherniotomy pain. J Am Coll Surg 2009; 208: 1023-9

15 Zieren J, Rosenberg T, Menenakos C. Impact of ilio-inguinal nerveexcision on sexual function in open inguinal hernia mesh repair:a prospective follow-up study. Acta Chir Belg 2008; 108:409-13

16 Chastan P. Tension-free open hernia repair using an innovative self-gripping semi-resorbable mesh. Hernia 2009; 13: 137-42

17 Hollinsky C, Kolbe T, Walter I, Joachim A, Sandberg S, Koch T,Rulicke T. Comparison of a new self-gripping mesh with other fixationmethods for laparoscopic hernia repair in a rat model. J Am Coll Surg2009; 208: 1107-14

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and improved outcome for their patients, interest developedaround a novel concept of surgery with minimal or no scars.This has lead to the development of lesser invasivetechniques of natural orifice transluminal endoscopicsurgery (NOTES) and single incision surgery (SIS)laparoscopic techniques. Use of hybrid novel techniquesincluding robotics is currently being evaluated10.

Performing surgery via natural orifices aims to achievethe ultimate goal of totally scarless surgery. Natural orificesurgery uses external orifices for introduction of instrumentsbut has to perforate hollow viscus to gain entry to theabdominal cavity. A lot of research work has gone to furtherexplore the potential of this novel idea. Techniques using acombination of approaches have been described11.

Although the Russian gynaecologist Demitri Ottperformed a vaginal laparoscopy, or ‘ventroscopy’ usingrigid instruments in 1901, the use of modern NOTES usingflexible instruments was seen when Kalloo and colleaguesdemonstrated transgastric laparoscopy to be feasible inanimal models in 200412.

Following successful animal studies, the first humanprocedures were performed on humans and techniques forappendicetomy13 and cholecystectomy14 amongst othersare currently described. Although the perceived benefitsdriving the development of NOTES are lack of visiblescaring, reduced surgical trauma, reduced pain, andimproved recovery times, there is lack of evidence toconfirm these claims15-16. The concerns surrounding NOTESthat limits its uptake relate to access and orientation withinthe abdomen, secure closure, infections associated withopening of a hollow viscus17-19 and training15. Extensiveresearch is in progress addressing access problems20 andorientation issues21. In future we hope to see furthertechnological advances to help address these difficulties. Ofinterest is that despite the reservations of medicalprofessionals, patients are still willing to accept a smallincrease in risk in order to achieve totally scarless surgery22.

Concerns over the limitations associated with NOTEShave resulted in a recent surge of interest in SIS (SingleIncision Surgery). This was perceived to be a backwardconcept initially from the novel concept of NOTES, but itgained rapid acceptance within the surgical communities.As it is based on established principles of laparoscopicsurgery, surgeons have found this concept more adaptableto their ongoing surgical practices.

The first simple single incision laparoscopic procedureswere performed in the 1960s (again by the gynaecologists)performing sterilization23. More complex proceduresfollowed later. The first SIS appendicetomy, another firstby a gynaecologist, was performed in 199224 and chole-cystectomy (performed by a surgeon this time!) in 199725.

Proponents of SIS claim that by using only one incision,the potential patient benefits of NOTES are maintainedwhilst eliminating the infection risk associated withdeliberate visceral puncture26.

The usual transumbilical incision used for most SIStechniques conceals the scar giving effectively a ‘virtually’scarless surgery. The use of umbilical access also affords aview of the peritoneal cavity familiar to surgeonsexperienced in traditional laparoscopic work thus reducingthe problems with disorientation associated with NOTES26.

Scientific - Moving Paradigm Towards Scarless Surgery

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Moving ParadigmTowards ScarlessSurgery

James Pollard, Speciality Trainee, GeneralSurgery, The Royal Oldam Hospital and IrfanAhmed, Senior Lecturer, University of Aberdeen

Surgery is a branch of medicine employing operative ormanipulative treatment for disease or injury. Surgery has alwaysbeen associated with trauma and pain.

The art of surgery dates as far back as the history ofhuman civilisation. Archaeologists have found evidence thatsurgery, in the form of trepanning (making holes in the skullto relieve pressure), has been performed in the ancient Incacivilisation since as long ago as 10,000 BC. Since that time,surgeons have been striving to reduce the pain and traumaassociated with surgery. Initial progress was made throughdevelopment of surgical skills (eg a limb amputation done inonly 30 seconds prior to the anaesthesia), and then to thetechnological advances such as the introduction of ether tosurgery in 1846.

Throughout the ages, advancement of both surgicaltechniques and technology has continued in unison to allowsurgery to be performed with less resultant trauma. It wasstill vital to visualise and safely reach the surgical field.“Bigger the incision, better the surgeon” remained anaccepted dogma for the surgical apprentices until recently.But the introduction of minimally invasive techniques haschanged the face of surgery forever.

It was a German gynaecologist, Conrad Langenbeckwho performed the first minimally invasive procedure, avaginal hysterectomy in 1813. But modern development ofminimally invasive techniques started with the move fromopen to laparoscopic surgery using multiple small incisions.Gynaecologists pioneered this, describing laparoscopy inthe 19501-3. The first general surgical procedure performedlaparoscopically was an appendicetomy... again by agynaecologist4. One of the most revolutionary advances inrecent times was the application of laparoscopic techniquesto cholecystectomy initially described by Erich Muhe in19855. Since then multiple port laparoscopic surgery hasdeveloped to enable a range of procedures to be undertakenand remains in widespread use in the modern era.

As laparoscopic techniques evolved, surgical robotswere developed to facilitate complex procedures byaddressing the problems of visualisation and instrumentmanipulation6. The perceived benefits of these roboticdevices are 3-D vision, improved ergonomics, betteroperator comfort and ease of instrument manipulation7.Although there is continued interest among surgeons to userobots8, prohibitive costs as well as limited evidence of theirbenefits to patients have limited its widespread use7,9.

As surgeons are always in the quest of better techniques


There however, inherent potential problems with thistechnique. The close placement of instruments in SIS hasthe potential disadvantage of leading to sub optimal viewsand clashing instruments whilst operating27-28. We arecurrently seeing rapid development of better optics andinstruments to overcome these problems.

Despite high levels of interest and increasing uptake ofSIS, concerns exist over the lack of quality evidence provingthe perceived benefit of SIS to patients when compared toestablished practice28. There are currently six registeredtrials ongoing, (four of which are RCTs) that compareoutcome following single incision cholecystectomy toestablished laparoscopic cholecystectomy. These willprovide vital data to help guide future practices. In themeantime, SIS continues to develop with the descriptionof both new procedures and introduction of newtechnologies29. Whatever the outcome of the current trials,the future of surgery is sure to be driven by the continueddesire to reduce the pain and scaring associated withsurgery, just as it has always been.

The art of surgery began from the ancient Incascivilisation, and continued to develop in the medieval ages.Though the initial emphasis was to master the art of surgery,the combination of science and surgery has revolutionized itfor the betterment of our patients. The aim now is to performmore complex procedures safely and effectively hence

extending the quality of offered treatment by minimallyinvasive methods. Hence in the past few decades emphasishas shifted to how we can inflict minimal trauma in surgeryto achieve our goal effectively and safely. The aim is to ‘doless and achieve more’ as long as the results are similar orbetter.

References1 Palmer R. The results of celioscopy in latent genital tuberculosis in

women. Gaz Med Fr 1955 Jul; 62(13): 1075-72 Palmer R. Celioscopy in extra-uterine pregnancy. Gaz Med Fr 1956 Jul

10; 63(13): 1235-93 Palmer R. First attempts at photocinematography during gynecological

celioscopy. C R Soc Fr Gyncol 1956 Jan; 26(1): 43-44 Semm K. Endoscopic appendectomy. Endoscopy 1983 Mar; 15(2): 59-645 Muhe E. Laparoscopic cholecystectomy - late results. Langenbecks

Arch Chir Suppl Kongressbd 1991: 416-236 van der Schatte Olivier RH, Van't Hullenaar CD, Ruurda JP, Broeders

IA. Ergonomics, user comfort, and performance in standard and robot-assisted laparoscopic surgery. Surg Endosc 2009 Jun; 23(6): 1365-71

7 Corcione F, Esposito C, Cuccurullo D, Settembre A, Miranda N, Amato F,et al. Advantages and limits of robot-assisted laparoscopic surgery:preliminary experience. Surg Endosc 2005 Jan; 19(1): 117-9

8 Guru KA, Hussain A, Chandrasekhar R, Piacente P, Bienko M,Glasgow M, et al. Current status of robot-assisted surgery in urology:a multi-national survey of 297 urologic surgeons. Can J Urol 2009 Aug;16(4): 4736-41; discussion 41

9 Gutt CN, Oniu T, Mehrabi A, Kashfi A, Schemmer P, Buchler MW.Robot-assisted abdominal surgery. Br J Surg 2004 Nov; 91(11): 1390-7

10 Phee SJ, Low SC, Huynh VA, Kencana AP, Sun ZL, Yang K. Master andslave transluminal endoscopic robot (MASTER) for natural OrificeTransluminal Endoscopic Surgery (NOTES). Conf Proc IEEE Eng MedBiol Soc 2009; 1: 1192-5

11 Dallemagne B, Perretta S, Allemann P, Asakuma M, Marescaux J.Transgastric hybrid cholecystectomy. Br J Surg 2009 Oct; 96(10):1162-6

12 Kalloo A, Singh V, Jagannath S, Niiyama H, Hill S, Vaughn C, et al.Flexible transgastric peritoneoscopy: a novel approach to diagnosticand therapeutic interventions in the peritoneal cavity. GastrointestEndosc 2004 Jul; 60(1): 114-7

13 Palanivelu C, Rajan P, Rangarajan M, Parthasarathi R, Senthilnathan P,Prasad M. Transvaginal endoscopic appendectomy in humans: aunique approach to NOTES - world's first report. Surg Endosc 2008May; 22(5): 1343-7

14 Marescaux J, Dallemagne B, Perretta S, Wattiez A, Mutter D,Coumaros D. Surgery without scars: report of transluminalcholecystectomy in a human being. Arch Surg 2007 Sep; 142(9):823-6; discussion 6-7

15 Kobiela J, Stefaniak T, Mackowiak M, Lachinski A, Sledzinski Z. NOTES- third generation surgery. Vain hopes or the reality of tomorrow?Langenbecks Arch Surg 2008 May; 393(3): 405-11

16 Gutt C, Müller-Stich B, Reiter M. Success and complication parametersfor laparoscopic surgery: a benchmark for natural orifice transluminalendoscopic surgery. Endoscopy 2009 Jan; 41(1): 36-41

17 de la Fuente SG, Demaria EJ, Reynolds JD, Portenier DD, Pryor AD.New developments in surgery: Natural Orifice Transluminal EndoscopicSurgery (NOTES). Arch Surg 2007 Mar; 142(3): 295-7

18 Thele F, Zygmunt M, Glitsch A, Heidecke C, Schreiber A. How dogynecologists feel about transvaginal NOTES surgery? Endoscopy2008 Jul; 40(7): 576-80

19 Ponsky LE, Poulose BK, Pearl J, Ponsky JL. Natural orificetranslumenal endoscopic surgery: myth or reality? J Endourol 2009May; 23(5): 733-5

20 Kim C, Chun H, Kim J, Jang J, Kwon Y, Park S, et al. Accessibility ofperitoneal organs according to the routes of approach in NOTES.Korean J Gastroenterol 2008 Nov; 52(5): 281-5

21 San José Estépar R, Stylopoulos N, Ellis R, Samset E, Westin C,Thompson C, et al. Towards scarless surgery: an endoscopic-ultrasound navigation system for transgastric access procedures. MedImage Comput Comput Assist Interv Int Conf Med Image ComputComput Assist Interv 2006; 9(Pt 1): 445-53

22 Hagen M, Wagner O, Christen D, Morel P. Cosmetic issues ofabdominal surgery: results of an enquiry into possible grounds for anatural orifice transluminal endoscopic surgery (NOTES) approach.Endoscopy 2008 Jul; 40(7): 581-3

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Painting 1 - “The Anatomy Lecture” of Dr Nicholaes Tulp (1632) byRembrandt van Rijn (Dutch), 1606-1669Currently in Mauritshuis Royal Picture Gallery, The Hague, Netherlands

Painting 2- SILS (Single Incision Laparoscopic Surgery) (2009)Displayed at the annual meeting of ASGBI 2009, Glasgow


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23 Wheeless CJ. Elimination of second incision in laparoscopicsterilization. Obstet Gynecol 1972 Jan; 39(1): 134-6

24 Pelosi MA, Pelosi MA, 3rd. Laparoscopic appendectomy using a singleumbilical puncture (minilaparoscopy). J Reprod Med 1992 Jul; 37(7): 588-94

25 Navarra G, Pozza E, Occhionorelli S, Carcoforo P, Donini I. One-woundlaparoscopic cholecystectomy. Br J Surg 1997 May; 84(5): 695

26 Zhu J. Scarless endoscopic surgery: NOTES or TUES. Surg Endosc2007 Oct; 21(10): 1898-9

27 Merchant A, Cook M, White B, Davis S, Sweeney J, Lin E. TransumbilicalGelport access technique for performing single incision laparoscopicsurgery (SILS). J Gastrointest Surg 2009 Jan; 13(1): 159-62

28 Canes D, Desai M, Aron M, Haber G, Goel R, Stein R, et al.Transumbilical single-port surgery: evolution and current status. EurUrol 2008 Nov; 54(5): 1020-9

29 MacDonald ER, Ahmed I. Another step towards scarless surgery, ArchSurg 2009; 144: 593-4

Low RiskNode negative and all of the following -pT <2cmGrade 1HER 2 negativeAge >35 yrsAbsence of LV1Endocrine responsive

Intermediate RiskNode negative and at least one of the following -pT >2cmGrade 2-3HER 2 positiveAge <35 yrsNode positive (1-3 lymph nodes) with HER 2 negative

High RiskNode positive (1-3 lymph nodes) and HER 2 positive or4 or more lymph nodes positive

To reduce the risk of systemic relapse, recommendationsare to consider only endocrine treatment in low risk group withhormone sensitive tumours. In high risk group, if the tumour ishormone positive and patient is fit, both chemotherapy andendocrine treatment are given. Potential benefit of chemo-therapy in intermediate risk women with hormone sensitivecancer is small and management should be decided on anindividual basis.

Adjuvant ChemotherapyMore than 50% of patients with node positive cancer willexperience relapse. Adjuvant treatments are offered to reducethis risk. The benefit of chemotherapy depends on the riskfactors mentioned earlier (prognostic markers) as well ashormone (ER and PR) and HER 2 status (predictive markers).Patient’s characteristics including age, performance status,fertility issues and co-existing illnesses are also taken intoconsideration. The relative and absolute benefits ofchemotherapy on disease free and overall survival can beestimated using ‘adjuvant on line’, an online application. Thissoftware is in the process of upgrade to take into account theHER2 status.

Anthracycline based regimens (such as FEC/Epi CMF etc)are superior to non-anthracycline based treatments. EBCTCG2005 has shown that chemotherapy reduces relative risk ofbreast cancer recurrence by 23% and death by 17%. Theaddition of anthracyclines reduces the recurrence rate byfurther 12%where as absolute reduction in risk of recurrence is3.2%7.

The use of anthracycline and taxane based regimen(TAC/FEC-D etc) has been evaluated in the adjuvant setting. Ithas shown an additional small survival benefit. There is anincreased risk of neutropenic sepsis with this regimen and inour practice prophylactic G-CSF is routinely used. Newer nonanthracycline based chemotherapy regimen (TC/TCH etc) canbe used in patients with cardiac problems to avoidcardiotoxicity.

Our approach to the management of breast cancertreatment is changing with the identification of gene expressing

Scientific - Breast Cancer: Non-surgical Treatments

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Breast Cancer:Non-surgicalTreatments

Ghazia Shaikh, SpR and Mohammed Rizwanullah,Consultant Clinical Oncologist, The Beatson,West of Scotland Cancer Centre

Breast cancer is the most common malignancy in women andthe second most common cause of cancer related death. In2006, there were 45,822 new cases of breast cancer diagnosedin the UK1. This means 1 in 9 will women have breast cancer.There is a recent decline in post menopausal breast cancerincidence possibly due to reduced use of HRT. In the 1970s, 5out of 10 patients survived beyond 5 years; this is now 8 out of10. Management of breast cancer has changed dramatically inthe last few decades both surgical and non-surgical. The use ofmodern chemotherapeutic and molecular targeting agents hascontributed in improving overall survival. In this article, we willconcentrate on non surgical treatments that are being used inadjuvant and metastatic settings.

Ductal Carcinoma in Situ (DCIS)The incidence of DCIS has increased since the introduction ofpopulation based screening. Approximately 30% of newlydiagnosed breast tumours are DCIS. The aim of treatment is toreduce local recurrence and progression to invasive cancer2.The recommended treatment for DCIS in the past wasmastectomy. Wide local excision with clear resection marginhas now emerged as standard practice. Radiotherapy is givenin the adjuvant setting after local excision. It may be used inpatients who have had mastectomy if there is a risk of positivemargins. Risk of progressive DCIS is 30% at 10 years.Approximately 50% of recurrences are associated with invasivecancer. Various trials have confirmed reduction in the incidenceof local recurrence to at least half with the addition ofradiotherapy. The NSABP B-17 showed that the addition ofradiotherapy to surgery reduced incidence of recurrent breastcancer by 58%3. The EORTC trial, with more than 1000women, demonstrated a local recurrence free rate of 85% in theirradiated group compared to 74% in the surgery alone group4.A UK based trial showed similar results with reduction of localrecurrence from 14% down to 6% at 53 months. However,addition of Tamoxifen did reduce the recurrence rate of DCISbut had no effect on recurrence of invasive cancer5.

Invasive CancerFollowing surgical treatment of invasive breast cancer, adjuvanttherapy is considered on the basis of prognostic and predictivefactors to estimate the risk of relapse. Patients are divided in thefollowing risk categories6.


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micro array profile of luminal A, B, HER2 and basal-likesubtypes. This will increase the likelihood of clinical success.The results from ongoing TAILORx and MINDACT trial willprovide level 1 evidence to incorporate genomic assays intoclinical practice. This will spare patients who will not benefitfrom chemotherapy from its side effects.

Adjuvant TrastuzumabTrastuzumab (Herceptin) is the first humanized monoclonalantibody used for the treatment of breast cancer. It targets thepritient product of protooncogene HER-2/neu. HER 2 overexpression and amplification is observed in 20-30% ofinvasive breast cancer. These tumours are likely to be poorlydifferentiated, associated with positive axillary lymph nodesand decreased expression of estrogens and progesteronereceptors. These characteristics are associated with anincreased risk of cancer relapse and death. There is someevidence to suggest increase responsiveness to anthracyclinebased chemotherapeutic agents in patients with amplificationof HER2/neu.

In 2005, four large multicenter trials were reported whichproved the efficacy of trastuzumab as adjuvant therapy aftersurgical treatment of breast cancer. All these trials showedimprovement in recurrence free survival and reduction in riskof recurrence by 50%.We follow the HERA protocol8 and offer3 weekly Trastuzumab for a year. The optimum duration ofadjuvant Trastuzumab may be more apparent once data fromthe HERA trial becomes available.

There is significant risk of cardio toxicity with the use oftrastuzumab. Addition of trastuzumab to chemotherapyincreases the 3 year incidence of NYHA class 3 and 4congestive heart failure risk from 0.8% to 4% compared withchemotherapy alone. Concurrent chemotherapy andtrastuzumab has been more effective but at the cost ofincreased cardiotoxicity. Comparison of all trastuzumab trialshave shown reduced cardiotoxicity after sequentialadministration of chemotherapy and trastuzumab. Closemonitoring of ejection fraction is needed through out thetreatment. This is reversible and ejection fraction mostlyreturns back to normal once the treatment is stopped.

Adjuvant Endocrine TherapyOvarian AblationOvarian function can be ablated by surgery, irradiation orpharmacological intervention. All modalities have similarresponse rate. Surgical ablation is the fastest means ofdeterring oestrogen production. Radiation induced ablationeffects more slowly and can also cause other side effects suchas gastrointestinal disturbances.

LHRH AgonistThis is used in premenopausal women. Trials have shown thisto be equivalent to 6 cycles of CMF chemotherapy in ER andnode positive cancer9. This may be considered for patients whoare unfit for chemotherapy treatment.

TamoxifenTamoxifen has been used for decades in both pre and postmenopausal women with hormone responsive tumours. Itreduces the annual mortality rate by 31%7. The benefits fromprolonged treatment with Tamoxifen (beyond 5 years) have not

been shown by the NSABP B-14 trial. The results of other trialsare not published yet10.

Aromatase Inhibitors (AI)They are found to be more effective. Trials such as ATAC11 andBIG I-9812 showed that upfront anastarzole and letrozole for 5years improves disease free survival compared to Tamoxifen.Switch after 2-3 of Tamoxifen to Exemestane has shownmodest improvement in overall survival13.

Extended adjuvant therapy with aromatase inhibitor after 5years of Tamoxifen was tested in MA17 Trial and showedimprovement in disease free survival. There was also modestimprovement in over all survival in node positive patients14.

Patients with high risk factors5 are at risk of early relapse;our practice is to use upfront AI for 5 years in this group.Intermediate risk patients are offered extended adjuvant 5 yearsof Tamoxifen and 3 years of AI or 2.5 years of Tamoxifen and2.5 years of AI.

In view of a small risk of osteoporosis, patients should getbase line Dexa scan before commencing AI treatment.

Adjuvant RadiotherapyBreast irradiation is recommended in all post lumpectomypatients. Multiple trials have shown reduction in localrecurrence by up to 70% with radiotherapy. Meta analysis ofradiotherapy trials has suggested that in addition to localcontrol, radiotherapy also improves overall survival. There isalso evidence that additional radiotherapy boost to the tumorbed, especially in female less than 40 years of age, improveslocal control by more than 9%. Its benefit reduces with increasein age15. Standard radiotherapy involves irradiating the wholebreast with boost to tumor bed.

In mastectomy patients, trials have reported 9-10% survivalbenefit at 10 yrs from addition of RT to systemic therapy.However, it is not considered necessary in patients with low riskof recurrence. It is indicated in patient undergoing neo-adjuvanttreatment and also in those who had heavy node positivity(lymph nodes >4), advanced disease (>pT 3) and positiveresection margin. There is increased risk of SCF (supra-clavicular fossa) involvement in these women. Therefore SCF isincluded in the radiotherapy field and 3 field techniques areapplied. Patients who are node positive on axillary samplinggets 4 field radiotherapy which includes breast, axilla and SCF.

Radiotherapy planning involves having CT scan intreatment position with both arms above the head. Theradiotherapy field placement is done on virtual simulator. Forradiotherapy to the breast only, two tangential fieldarrangements are used which cover the whole breast alongwith 1cmmargin all around. Photons beams are used to deliverthe treatment (figure 1).

Boost is planned after localization of tumour bed onplanning CT scan. It is delivered using electrons. Sometimes itis difficult to visualize this area properly on the scan especiallyif patient had undergone oncoplastic procedure. It is useful tohave all the information including mammogram/USS report,surgical notes, surgical clips and pathology report to correctlytarget the tumour bed.

Side effects of radiotherapy are divided into acute (occurduring and with in 6 months of treatment) or late (after 6 monthsof radiation). Acutely, patients may experience tiredness, skinerythema and chest wall pain. Late side effects include skin


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changes, breast distortion, lymphadema, lung fibrosis, cardiactoxicities and increased risk of second malignancy. With newerplanning techniques, it is possible to shield proportion of lungand heart from radiation field (figure 2) and hence there isdecline in late radiation damage to the cardiac tissue.

Hyopfractionated radiotherapy (meaning higher dosedelivered per fraction at shorter period of time) has shown to beas effective as conventional radiotherapy. START trial data16was published recently which has confirmed that at 6 years theclinical outcome and side effects of 40 Grays in 15 fraction ofradiotherapy is same as 50 Grays in 25 fractions. This haschanged practice and most centres in the UK are nowdelivering 15 fractions for 2 field breast radiotherapy. Severaltrials are underway to test the hypothesis of partial breastirradiation which is to give radiotherapy to the tumour bed withsome margins and sparing the normal breast tissue from longterm side effects.

Locally Advanced Breast Cancer (T3-4 N2-3)/Inflammatory Breast CancerMost patients with locally advanced tumours are offered neo-adjuvant (primary) treatment. This may allow breastconservation rather than mastectomy, and theoretically, mayalso be useful in eradicatingmicroscopic metastasis disease. Inpremenopausal women, chemotherapy is preferred. At eachcycle, assessment is made for tumour response. Minimum of 6cycles of anthracycline based regimen are given. Sequentialuse of Taxane can increase rate of successful breastconservation surgery. About 75% of patients respond clinicallyto neo-adjuvant chemotherapy and various case series havereported up to 10-15% complete pathological response.Trastuzumab in neo-adjuvant setting is being tested in clinicaltrials.

In less fit post menopausal women, aromatase inhibitorinstead of chemotherapy is the preferred choice. It has beenshown to give higher response rates compared to Tamoxifen.

Patients with good response to neo-adjuvant treatmentshould then under go breast conserving surgery/mastectomyand axillary clearance followed by radiotherapy. Biomarkers arebeing identified in neo-adjuvant setting. This will help to identifyappropriate patients for selective treatment. This means thatfewer patients will be needed to obtain results in phase 3 trials.

Metastasis Breast Cancer3-5% of breast cancer patients present with metastaticdisease. Median survival is 2-3 years but 10% of the patientsmay survive 10 years. In this situation, the main aim is to delaydisease progression, palliate symptoms, and improve survivaland quality of life. Important aspects to consider are patient’sage, fitness and co-morbidity. Patient should have full staginginvestigation done to assess the extent of the disease. Tumourmarkers such as ER, PR status and HER-2 assay are crucial toplan the future management.

Patients with bone metastases should be offeredbisphosphonates. There is strong evidence that it not onlyrelieves bone related pain but also reduces the incidence ofskeletal events. There is a small risk of osteonecrosis with thistreatment, and it is important to assess the dental status beforeand during this treatment.

Palliative Hormone TreatmentAsymptomatic patients with hormone responsive tumour andminimal visceral disease are considered for primary hormonetreatment. Pre-menopausal patients who have been exposedto anti estrogens therapy are considered for ovarian ablationwith or without aromatase inhibitor. In post menopausalpatients, it has shown advantage over Tamoxifen17.

Palliative ChemotherapyIn patients with symptomatic bulky visceral disease,chemotherapy is considered for first line treatment. Singleagent chemotherapy is preferred as there are less side effectscompared to combination agents. Common practice is toconsider anthraccycline (if not used previously) or Taxane basechemotherapy. Chemotherapy can be delivered weekly in unfitwomen who are needed to be monitored closely. Other agentswhich are used for subsequent treatments are Capcitabine,Vinorelbine, Platinum base regimen etc.

Trastuzumab, in combination with chemotherapy, is used inHER 2 positive patients. There is evidence that response rateand progression free survival is better (figure 3). The responserate of single agent trastuzumab is around 35% and is used if

Figure 2 - Left breastradiotherapy with 3-fieldtechnique (breast and SCF isincluded in the field) with bottomleft half of the field shielded toavoid irradiating the heart

Figure 1 - 2-field radiotherapy targeting the entire breast tissue. Tumourbed is also visible

Figure 3 - Synergistic effect of chemotherapy and Trastuzumab inmetastatic breast cancer patient. Patient presented with skinmetastases (left) and just after one treatment, had good clinicalresponse (right).The response was maintained for several months


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patients are unfit to have chemotherapy. As this does not crossthe blood brain barrier, there are increased incidences ofisolated brain metastasis in women on Trastuzumab. In thissituation, our practice is to deliver whole brain radiotherapy andcontinue with trastuzumab. The hypothesis behind this is thatradiation breaks the blood brain barrier which allows theTrastuzumab to get into brain tissues.

There are few other molecular targeted agents which havebeen tested in various clinical trials. Lapatinib is an oral tyrosinekinase inhibitor of EGFR 1/erbB1 (epidermal growth factor)and 2 (HER2/erb B2). Its combination with Capcitabine hasshown improvement in progression free survival in patients whohave progressed on Trastuzumab18. Bevacizumab (Avastin),monoclonal antibody against VEGF (vascular endothelialgrowth factor) receptor, has shown modest improvement indisease free survival when used in combination with Paclitaxelchemotherapy19. Both agents have not been approved by NICEand SMC.

ConclusionWith recent advancement in breast cancer management, weare observing improved response rate to newer treatmentsresulting in improved survival. Patients are living much longerand their disease is behaving like a chronic disease than acancer. We need effective collaboration for conductingmulticentre trials with translational component which will lead tofaster access to have cost effective right drug for right patient.

References1 CRUK2 Ernster EL, Barclay J. Incidence and treatment of ductal carcinoma of

the breast. JAMA 1996; 275: 913-83 Fisher B, Dignam J. Lumpectomy and radiation for NISABP17. JCO

1998; 6: 24 Bijker N, Mijnen. Breast conserving treatment with or without

radiotherapy in DCIS. EORTC 10853 J Clin Oncol 2006; 24: 3381-875 Houghton J, George W D. Radiotherapy and tamoxifen in patients with

completely excised DCIS of breast in UK, New Zealand and Australia.Lancet 2003; 362: 95-102

6 Goldfish A, Ingle J. Threshold for therapies; highlights of St Gallons. AnnOncol Aug 2005

7 Effects of chemotherapy and hormone therapy for early breast cancerrecurrence and 15 year survival; an over view of the trials. Lancet 2005;365: 1687-1717

8 Piccart -Gebhart MJ, Procter M, Leyland-Jones B, et al. Trastuzumabafter adjuvant chemotherapy in HER2-positive breast cancer. NEJM2005; 353: 1659-1672

9 Jonet W, Kaufmann M.Goseraline versus cyclophosphamide,methotrexate and 5FU chemotherapy in pre menopausal patients withnode positive breast cancer. J Clin Oncol Dec 2002; 20: 4628-35

10 Fisher B, Dignam J. Five years versus more than five years of tamoxifenfor lymph node negative breast cancer. Updated findings from NSABP-14 trial. J Natal Cancer Inst 2001; 93

11 Effects of anstrozole and tamoxifen as adjuvant treatment of earlybreast cancer. Lancet Oncol 2008; 9: 45-53

12 Coats A, Keshaviah A. Five years of Letrozole compared with Tamoxifenas initial adjuvant treatment in post menopausal women. Update ofstudy BIG 1-98. J Clin Oncol 2007; 25

13 Coombs RC, Kilburn LS. Survival and safety of exmestane versusTamoxifen after 2-3 years of Tamoxifen (Intergroup Exmestanestudy).Lancet 2007; 369: 559-570

14 Goss P, Ingle J. Randomized trial of Letrozole following Tamoxifen inreceptor positive breast cancer. Updated findings from NCIC CTG MA 17.J Natl Caner Inst Nov 2005; 97

15 Bartelink H, Horiot JC. Recurrence rates after treatment of breastcancer with standard radiotherapy with or without additional radiation.NEJM 2001; 345: 1378-87

16 The UK standardisation of breast radiotherapy. Lancet 2008; 371: 1098-107

17 Mauri D, Pavlidis. Survival with AI versus us standard hormonal therapyin advanced breast cancer; a metanalysis. J Natl Cancer Inst 2006; 98:1285-91

18 Geyer CE, Forster J. Lapatinib plus capcitabine for Her-2 postiveadvanced breast cancer. NEJM 2007 April 5; 356(14): 1487

19 Miller KD, Wang M.A randomized phase 3 trial of paclitaxel plusbevacizumuab as first line treatment for locally recurrent or metstaticbreast cancer. SABCS 200; Abstract 3

the selective uptake of radiolabelled markers in malignanttissue with the anatomical precision of CT scanning.

• In the context of head and neck squamous cell carcinoma,it can be utilised and is effective in various clinical scenarios:o Pretreatment: diagnosis of the primary tumour, disease

staging and prognosis and identification of the unknownprimary

o In organ-sparing protocolso Monitoring response to therapy: detecting recurrence

and post-radiotherapy neck dissectiono It is of most benefit in the management of unknown

primary and detection of recurrent disease

BackgroundPositron emission tomography (PET) is an imaging modalitythat was developed over 30 years ago but is becomingincreasingly prominent in the staging and assessment of headand neck cancer1. β-decay is the process whereby a proton ina radioactive nucleus converts to a neutron, a positron and aneutrino. When the positron subsequently encounters andannihilates an electron, a pair of photons is emitted at almost180°. These photons are detected by an array of photo-multipliers and their three dimensional position calculated in asimilar manner to computed tomography (CT).

Not all isotopes undergo this sort of decay but tracersubstances containing the radioactive isotopes 11C, 13N, 15Oand 18F can be taken up by body tissues and this uptake canbe correlated anatomically. Tumours are known to haveincreased metabolism compared to healthy tissue and inparticular their rate of glycolysis is elevated. This results in adifferential uptake of tracer between healthy and diseasedtissue and allows abnormal tissue to be highlighted.

The first use of PET for the identification of head and neckcancer occured in the 1980s when patients who had beengiven 13N-labelled ammonia were found to have increaseduptake in metastatic cervical lymph nodes2. [18F]fluro-2-deoxy-D-glucose (FDG) was first synthesised in 19773 and has nowbecome the most commonly used radiopharmaceutical forPET1. The initial FDG-PET scans were of low resolution andalthough the metabolic information provided by the scans wasfelt to be useful, it was often difficult to precisely identify theanatomical structures with increased uptake. Correlation withseparately performed CT scans improved localisation but wascompromised by inaccuracy particularly if there was a delaybetween acquiring the two separate images4.

Sensitivity / % Specificity / % Positive predictive Negative predictivevalue / % value / %

PET/CT 98 92 88 99

CT 74 75 63 83

PET 87 91 85 92

Table 1 - Accuracy of PET/CT versus CT or PET alone6

The solution to this was acquisition of functional (PET) andanatomical (CT) images sequentially with a single scanner. Thefirst combined PET/CT scanner was developed in Pittsburgh in19995. These scanners produce high resolution CT imagesoverlaid by images of high tracer uptake. These combinedimages highlight areas of pathology and have been shown tobe significantly superior to PET or CT alone in the

Scientific - PETCT in HNSCC

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The Role of CombinedPositron EmissionTomography andComputedTomography (PET/CT)in Head and NeckSquamous CellCarcinoma

Jonathan Hobson, ENT SpR, Jonathan Hill,Professor of Radiology and John Pde Carpentier, ENT Consultant, LancashireTeaching Hospitals NHS Foundation Trust,Fulwood, Preston

AbstractBackground: PET/CT relies on the increased uptake ofradiolabelled glucose metabolites in neoplastic tissue. Thepositrons emitted by the tracer molecules are detected andfusedwith CT images to produce functional imageswhich allowmore accurate detection and localisation of head and necktumours.Objective of review: To answer the question “What is the roleof PET/CT in head and neck squamous cancer?”Type of review: A narrative review.Search strategy: A structured literature search was conductedacross multiple databases supplemented by searchingreference lists of relevant papers.Results: Data are presented under various clinical scenarios ofpre-treatment (diagnosis of the primary tumour, disease stagingand prognosis and identification of the unknown primary), usein organ-sparing protocols, monitoring response to therapy(detecting recurrence and post-radiotherapy neck dissection).Conclusions: PET/CT can provide helpful staging informationin head and neck squamous cell carcinoma but is particularlyuseful in the management of the unknown primary anddetection of recurrent disease. This modality can identify anunknown primary tumour in 20-30% of clinically negativepatients and is capable of detecting residual or recurrentcarcinoma with a sensitivity of 94% and specificity of 82%.More information is needed on cost-benefit and long-termsurvival implications of using PET/CT but its use represents aquantum step in themanagement of carcinoma of the head andneck.Key Points• PET/CT combines the functional information provided from


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demonstration of head and neck malignancy6 (table 1). Most ofthe units in the UK use PET/CT or are in the process ofupgrading from PET to PET/CT7.

There are only ten static PET/CT scanners in the UK atpresent and these have been financed by charitable donations,public/private partnerships or universities. The majority ofscans over the next five years will be provided by theindependent sector. Mobile units provide additional support,provided by Alliance Medical in the North and In-Health in theSouth of the country. The scanner in the Lancashire TeachingHospitals NHS Trust combines 64 slice helical CT with PETdetection. In addition, there is a cyclotron on site for themanufacture of FDG and other isotopes. FDG has a half-life of110 minutes and thus the cyclotron on-site allows distributionto reasonably distant centres. At present there are fivecyclotrons providing this service in the UK7.

The impact of PET/CT in the management of carcinomas inspecific groups has been profound. In all cancer groupsPET/CT has resulted in a change of management in around onethird of cases8. Head and Neck carcinoma provides a difficultPET/CT challenge because there is pronounced physiologicaluptake in the tongue, salivary glands and tonsils as well as inreactive changes in nodal groups. Nevertheless, with strictprotocols (including silence by the patient during head andneck examinations to reduce tongue uptake), these artefactscan be minimised. The comprehensive nature of PET/CT as atotal body scan has resulted in the detection of unsuspecteddisease, with second primaries, including lung and coloncarcinoma, identified in 3-8% of patients9.

MethodsThe objective of this review is to answer the question “What isthe role of PET/CT in head and neck squamous cancer?” Thereviewwill present the evidence in support of the role of PET/CTin head and neck cancer, focusing on its role in staging,detection of unknown primaries, radiotherapy planning andassessment of treatment response. The review will alsomention some of the challenges of PET/CT scanning and willexplore future advances.

This narrative review was based on a literature searchperformed on the MEDLINE, PubMed and COCHRANEelectronic databases using the MeSH subject headings:carcinoma, (squamous cell), head and neck neoplasms andpositron-emission tomography. The search included all articlespublished in English up to November 30th, 2008. Relevantreferences from selected articles and review articles were usedto identify any other studies. This review preferentiallyreferences articles on PET/CT where they are available, but intheir absence reference is made to studies using PET alone.However, as PET/CT appears to be slightly more accurate thanPET, the PET clinical effectiveness results presented here canbe extrapolated to cover PET/CT7.

ResultsPET/CT scanning has been demonstrated to play a valuablerole in the diagnosis and management of head and necksquamous cell cancer (HNSCC). These roles are subdividedbelow.

Pre-treatmenti. Primary tumourClinical and endoscopic examination will determine the size of

the primary tumour in most cases10. Cross-sectional imagingwith CT and magnetic resonance (MRI) will provide furtherinformation about neurovascular, cartilage and bony invasionwith good sensitivity and specificity11. The addition of PET tocharacterise and identify the primary tumour has beendescribed12 and indeed a systematic review of PET in theassessment of head and neck squamous cell carcinoma hasdescribed a sensitivity and specificity of 85% and 67%respectively which is not dissimilar to traditional cross-sectionalimaging. These findings suggest that the addition of PET doesnot appear to confer any additional benefit over CT and MRI13.

ii. Disease staging and prognosisThe nodal status is the most important prognostic factor inHNSCC with survival decreasing by 50% in a node positivepatient14. Clinical examination alone is thought to under-stagenodal status, having a sensitivity of approximately 60%15,16. CTand MRI are thought to have false negative rates of 10-30%because metastatic lymph nodes without central necrosis andof borderline size may not be reported as positiveradiologically17. Several studies report the superiority of PET toCT or MRI in the localisation of regional metastases in theclinically N0 neck. A systematic review of over 1,200 patientsfound the sensitivity and specificity of PET to be 79% and 86%overall but only 50% and 87% in patients with a N0 neck18. Thespatial resolution of PET is still limited to 5mm and positivenodes of this size or smaller were present histologically havingbeen missed on PET scanning13,19.

A further investigative modality has been employed byKovács et al - 38 patients with oral and oropharyngealsquamous cell carcinoma with PET negative necks underwentsentinal node biopsy. Five patients had positive nodes andunderwent neck dissection. The remaining patients werespared surgery but two relapses were seen at a median follow-up of 35 months; both were PET uptake positive20. The authorssuggest that the combination of PET/CT and sentinel nodebiopsy may reduce the need for extensive neck dissection inthe N0 neck.

In addition to loco-regional metastatic disease, PET candetect distant metastases and second primaries, the presenceof which may render radical treatment futile. The mostimportant risk factor in HNSCC is tobacco use whichpredisposes to synchronous second primary tumours of theupper aero-digestive tract. Chest radiography (CXR) has beenthe traditional imaging modality of exclusion but has beensuperseded in recent years by chest CT21. Wax et al reported59 patients of whom synchronous lung lesions were identifiedin 15 (25%) on PET scanning. They report a sensitivity of 100%for PET and compare this to bronchoscopy (37.5%), CXR(62%) and Chest CT (87%)22.

PET also has the ability to perform whole body scanningand hence distant metastases are more likely to be identifiedespecially in the higher risk patients with advanced (stage IIIand IV) disease. Distant disease has been identified in between15 and 25% of patients23,24 although when correlated withhistological diagnoses, Fakhry found that 17% of increaseduptake on PET/CT was false positive25.

The identification of clinically or radiologically absentmetastatic disease is likely to alter the patient’s proposedmanagement and PET/CT has been found to alter the TNMclassification in up to one-third of patients with an alteration intreatment seen in a similar proportion of patients8,23,26,27.


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Interestingly, PET itself may be prognostic. The amount oftracer taken up is known as the standardized uptake value(SUV) and there is an association between high SUV anddecreased survival rate28,29 although there does not appear tobe a correlation with locoregional recurrence30. An arbitraryvalue of 10 delineates high and low uptake tumours. SUV >10predicts significantly worse outcome that, on multivariateanalysis, is independent of T and N stage. It is thought that theSUV may distinguish more biologically active tumours31 andmay relate to increased expression of the glucose transporterprotein (Glut-1) seen in malignancy32,33.

iii. Identification of the unknown primaryMetastatic squamous cell carcinoma from unknown primarytumours account for 5% - 10% of head and neck cancers34,35.The traditional management of these patients has involvedconventional imaging and ‘panendoscopy’ accompanied byblind biopsies of the post-nasal space, pyriform fossae, tonguebase and tonsillectomy36. Grevin et al found an unacceptablyhigh false positive rate of 46% from PET albeit from a smallstudy of 13 patients37. There is also a false negative rate,influenced by the resolution of PET/CT which is limited totumours larger than 5mm. Furthermore, basal uptake of FDG inthe lymphoid tissue of Waldeyer’s ring may obscure detectionof tumours at this site. Nevertheless, several systematic reviewshave been published showing that PET can identify anunknown primary tumour in 20-30% of clinically negativepatients1,7,38,39. Identification of the primary allows for moreappropriate and accurate surgical resection or radiotherapy;limiting the morbidity of wide field irradiation40.

Use in organ-sparing protocolsThe increased usage of concomitant chemoradiotherapy inhead and neck squamous cell carcinoma is designed to alloworgan-sparing; anatomically and functionally41. PET/CT willallow monitoring of the tumour response to these treatmentmodalities. Intensity-modulated radiation therapy (IMRT) is amodality that has the potential to conform the radiotherapydose more closely to the target, thus sparing normal tissues42.PET/CT provides superior localisation for IMRT planning thanCT alone43,44.

Monitoring Response to Therapyi. Detecting recurrenceThe standard evaluation of post radiotherapy or chemo-radiotherapy recurrence is clinical evaluation combined withendoscopy, biopsy and cross-sectional imaging. Promptdiagnosis of recurrence allows for rapid salvage surgery ifappropriate or palliative intervention if required. The meta-analysis by Isles et al. of twenty-seven studies of PET alone fordetecting residual or recurrent carcinoma shows a pooledsensitivity of 94% and specificity of 82%45. This compares withtwo other systematic reviews of this scenario39,46 and lendscredence to the authors proposed guideline of monthly post-treatment clinical assessment followed by PET or PET/CTscanning at ten weeks. Clinical suspicion or positive PET at theprimary site should undergo biopsy with salvage surgery ifpositive. Clinical suspicion or positive PET in the neck shouldprompt neck dissection.

ii. Post-radiotherapy neck dissectionControversy exists around the indications for neck dissectionfollowing chemoradiotherapy. The proponents of post-radiotherapy surgery state that it improves disease specificsurvival47; however, some authors feel that the morbidity ofneck dissection is not insubstantial48. Proponents of a watchand wait policy following chemoradiation counter that inpatients who exhibit a complete clinical response, therecurrence rate is less than 10%49,50. Argiris et al found nosurvival benefit from planned neck dissection in patientsrendered clinically disease-free with chemoradiotherapy. Fiveyear progression free survival was 68% with neck dissectioncompared to 71% without51. It is clear that a ‘watch and wait’policy can only be instigated if the detection rate of recurrentand residual disease is high. Isles et al. found a negativepredictive value of 96% in their pooled data, suggesting thatnegative PET scan of the neck is highly predictive of completeresponse following chemoradiation45. The senior author of thatmeta-analysis is currently conducting a multicentre trial of aPET/CT guided watch and wait policy compared to plannedneck dissection for advanced nodal disease52 and the results ofthis are eagerly anticipated.

DisadvantagesAmalgam artefacts that affect conventional CT will obviouslyremain in PET/CT scans53. Physiological uptake of FDG in non-neoplastic tissue has already been alluded to and minimisationof false-positives is enhanced by increasing radiologicalfamiliarity of normal scans. The interpreting radiologist will oftenrely on the presence of asymmetry to predict abnormality;however, this is not always a reliable marker of physiologicalprocesses. For example, supraphysiological uptake can beseen on the contralateral larynx of a patient with vocal cordpalsy and normal physiological uptake can have an asymmetricappearance in a patient who has had previous surgery54.

The cost of PET/CT is in the region of £800-1000 per study.This compares to £100 for a CT of the neck and chest. There isalso the capital cost of £1.3 million for a new combinedscanner55. The cost of FDG (£200-400 per scan) is incorporatedin the overall figure quoted above, but it does need to bepurchased or made in an on-site cyclotron which will increasethe capital cost. Cost-effectiveness data from other countries isdifficult to extrapolate to the UK; one American study thatutilised PET imaging to avoid neck dissection in patients withN0 necks quoted a figure of $8718 per year of life saved, or$2505 per quality-adjusted life-year48. The radiation dose of aPET/CT scan is approximately 25mSv which is higher than14-18mSv for a diagnostic CT56.

The FutureCarbon rather than fluorine-based radiolabeled tracers providethe opportunity to study basic metabolic pathways as well asallowingmonitoring of drug interventions, including themode ofexcretion and metabolism of the drug itself. 11C-choline hasbeen shown to have equivalent diagnostic accuracy to FDG inhead and neck cancers but with shorter examination time andreduced muscle uptake57. Carbon compounds are moredifficult to prepare and suffer from a shorter half life(approximately 20 minutes) that limits distribution. In the future,the prospect of radiopharmaceuticals labelled with antibodiesto tumour markers such as epidermal growth factor mayprovide improved detection of sub-millimetre tumours58.


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ConclusionsPET/CT can provide helpful staging information in head andneck squamous cell carcinoma but is particularly useful in themanagement of the unknown primary and detection ofrecurrent disease. More information is needed on cost-benefitand long-term survival implications of using PET/CT but its userepresents a quantum step in the management of carcinoma ofthe head and neck.

AcknowledgmentsThe authors would like to acknowledge the help of Dr J PCoffey for comments on the manuscript and Alliance Medicaland the Lancashire Teaching Hospitals NHS Foundation Trustfor allowing us to quote costs and data from the PET/CTscanner at Preston.

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24 Teknos TN, Rosenthal EL, Lee D, Taylor R, Marn CS. Positron emissiontomography in the evaluation of stage III and IV head and neck cancer.Head Neck 2001, Dec; 23(12): 1056-60

25 Fakhry N, Barberet M, Lussato D, Cammilleri S, Mundler O, Giovanni A,Zanaret M. [Role of [18F]-FDG PET-CT in the management of the head andneck cancers]. Bull Cancer 2006, Oct 1; 93(10): 1017-25

26 Connell CA, Corry J, Milner AD, Hogg A, Hicks RJ, Rischin D, Peters LJ.Clinical impact of, and prognostic stratification by, F-18 FDG PET/CT inhead and neck mucosal squamous cell carcinoma. Head Neck 2007, Nov;29(11): 986-95

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28 Allal AS, Slosman DO, Kebdani T, Allaoua M, Lehmann W, Dulguerov P.Prediction of outcome in head-and-neck cancer patients using thestandardized uptake value of 2-[18F]fluoro-2-deoxy-d-glucose. Int J RadiatOncol Biol Phys 2004, Aug 1; 59(5): 1295-300

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33 Kunkel M, Reichert TE, Benz P, Lehr HA, Jeong JH, Wieand S, et al.Overexpression of glut-1 and increased glucose metabolism in tumors areassociated with a poor prognosis in patients with oral squamous cellcarcinoma. Cancer 2003, Feb 15; 97(4): 1015-24

34 Miller FR, Hussey D, Beeram M, Eng T, McGuff HS, Otto RA. Positronemission tomography in the management of unknown primary head andneck carcinoma. Arch Otolaryngol Head Neck Surg 2005, Jul; 131(7): 626-9

35 Kutler DI, Wong RJ, Schoder H, Kraus DH. The current status of positron-emission tomography scanning in the evaluation and follow-up of patientswith head and neck cancer. Curr Opin Otolaryngol Head Neck Surg 2006,Apr; 14(2): 73-81

36 Kothari P, Randhawa PS, Farrell R. Role of tonsillectomy in the search fora squamous cell carcinoma from an unknown primary in the head and neck.Br J Oral Maxillofac Surg 2008, Jun; 46(4): 283-7

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58 Verel I, Visser GW, Boellaard R, Stigter-van Walsum M, Snow GB, vanDongen GA. 89Zr immuno-pet: Comprehensive procedures for theproduction of 89zr-labeled monoclonal antibodies. J Nucl Med 2003, Aug;44(8): 1271-81

affect the outcome of surgery18. It is important to note, however,that the mesh size used for LH repair is significantly larger thanthat used for open repair with the commonest size of meshused being 15 by 10cm. The standard Polypropylene mesh,Vicryl-prolene (polypropylene + polyglactin 910, VyproII™), andlight weight partially absorbable mesh (poliglecaprone 25 andpolypropylene, UltraPro™, Parietex™) have commonly beenemployed in laparoscopic repair. The meshes outlined are flatand can be used for either the TAPP or TEP approach, but forthe TEP approach, many advocate the use of a pre-shaped ‘3Dmesh’. This mesh has the advantage of not requiring fixationwith its high cost weighed against avoidance of tacks19

(3DMax™ Light Mesh). The evidence promoting the use of alight-weight mesh, however, remains controversial with its mainbenefit leaning towards possible improvement in long termfunctional outcome and comfort20.

Mesh Fixation vs Non-fixationFixationThe choice of fixation has largely been at the discretion of thesurgeon. Many techniques and fixation devices have beenemployed to try and improve the outcome in hernia repair withan emphasis on reduced recurrence and improved ‘comfort’.There are no guidelines or recommendations in the choice offixation with many advocating no fixation techniques withcomparable results21,22. No fixation is becoming commonlyemployed with the use of tacks potentially causing either nervedamage or visceral injury, thereby increasing the morbidity ofsurgery and possibly contributing to long term groin pain.

Types of Hernia Staplers AvailableMulti-fire Endo Hernia™ stapler: It rotates 360 degrees aroundits axis. The titanium clips are acceptable for use with MRI andNMR procedures up to 3 Tesla.

Pro-Tack™: It is a single use 5mm device made up of helicaltitanium which secures to the tissues snugly. ProTack™ comesin a 30 tack configuration.

Absorba Tack™ Fixation device: It is also single use 5mmdevice constructed of an absorbable synthetic polyestercopolymer derived from lactic and glycolic acid. It absorbscompletely within a year.

Fibrin Glue (Tisseel™)It is a highly concentrated fibrinogen aprotinin solution, alongwith Factor XIII, and a solution of thrombin and calciumchloride. It should be sprayed at a distance of 1-2cm. Oneshould fix or hold the glued part for 30-60 seconds. SolidifiedSealant reaches its ultimate strength after about 2 hours (70%after about 10 minutes).

Though fibrin glue was first reported to be used in 1998 inthe UK23, it has not gained popularity in spite of its provenefficacy. It is, however, very widely used in Europe. Cost-effectiveness is an important co-factor along with substantialscientific evidence restricting its use in National Health Service.Over a period of years, however, the cost has reducedsignificantly and now the rates are comparable to tacks.

Comparison of Tacks with Fibrin GlueMany randomized controlled trials have shown no difference inrecurrence rates between tacks and fibrin glue. Howeverchronic post-op pain, complications, and quality of life

Scientific - Fixation Techniques in Laparoscopic Groin Hernia Repair

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Fixation Techniques inLaparoscopic GroinHernia RepairNehal Shah, SpR General Surgery andAali Sheen, Consultant General and HepatobiliarySurgeon, Department of Surgery, ManchesterRoyal Infirmary

IntroductionFrom a historical perspective, hernia surgery has continued toevolve ever since it was first described by Cellsus1. Bassini’srepair has since been replaced by the tension free Lichtensteinrepair which to date remains the gold standard2-5. Thelaparoscopic era has now added a new and welcomeddimension to hernia surgery6. A variety of new approaches havebeen developed with hernia surgery continuing to evolve; themain emphasis still being the need for attention to anatomicaldetail in the hernia repair. This article provides a brief overviewof groin (inguinal) hernia surgery with an emphasis on fixationtechniques commonly employed to try and combat long termchronic groin pain with improvement in quality of life for patients(QoL)7.

Laparoscopic Groin Hernia repair vs Open RepairLaparoscopic hernia (LH) repair was first introduced in 19776.The main techniques employed involve the breach ofperitoneum with a transabdominal approach (Trans abdominalpre-peritoneal, TAPP) or a totally extra-peritoneal approach,which relies on creating a space between the layers of therectus sheath (total extra-peritoneal, TEP). To date, no directcomparison has been made in a randomised controlled trialsetting. However the results are similar in terms of recurrenceand long term groin pain, with both providing a quicker returnto work/normal activities as compared to open repair8,9. Somereports have suggested TEP may have a reduced morbidityalthough it is technically more challenging10. Understandably,as a consequence of the ‘learning curve’, the initial years oflaparoscopic surgery noted a slightly higher recurrence ratethan that of open surgery, but experience and improvedtechniques have seen comparable data to that of open surgerywith possible suggestions of a downward trend in the risk oflong term groin pain11-14.

National Institute of Clinical Excellence (NICE) guidelineshave recommended that the laparoscopic approach should beconsidered in patients with bilateral and recurrent hernia15; thishas now been revised to include unilateral hernia in view of thesuperior recovery rates and reduction of post-operativepain16,17. Importantly, NICE has strongly suggested thatpatients undergoing hernia repair should be advised on the riskof recurrence and long term chronic groin pain.

Types of Mesh AvailableIn laparoscopic hernia repair, many types of mesh have beenused. Interestingly, the choice of mesh has been shown not to

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Protack™ 5mm Fixation Device Absorba Tack™ 5mmfixation device

Multifire Endo Hernia Stapler™ 10mm


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demonstrated a trend favouring fibrin glue fixation14,16,24. Thismay suggest that the risks associated with tacks in terms ofnerve and visceral injury could potentially be avoided.

Non-fixationThere have been numerous studies comparing tacks to non-fixation. They have not shown any increase in the recurrencerates or chronic post-operative pain when the mesh is notfixed25, with a possible improved outcome with non-fixation21,22,25. No fixation carries the advantage of reducedcost as fixation devices are not required, but this cannotcompensate for any possible mesh slippage/migration.

What is New with Mesh Fixation?Micro hooks located on the under surface of self-gripping mesh(PG™ = pro-grip)26 employs ‘hooks’ to provide anchoragepoints into the tissue. A recent animal study comparing tacks,fibrin glue, non-fixation and PG mesh demonstrated asubstantially stronger strength of incorporation in muscle tissuewith PG in comparison to other fixation systems, but furtherstudies are required as well as data on its laparoscopic use27.

SummaryLaparoscopic Hernia repair is well recognised and providesbetter outcome (chronic pain and QoL) in comparison to openmethod in experienced hands. TEP is becoming the preferredtechnique largely as a consequence of avoiding the breach ofthe peritoneum with possible bowel complications, althoughthese have been reported in TEP repair as well10. Fibrin glueand no fixation technique has been shown to be comparable inhernia surgery (see table), although tacks and sutures willprovide greater tensile strength than fibrin glue and nofixation27. A large multi-centre comparative study on fixationtechniques may be warranted in the near future, which maydetermine any possible differences in long-term outcome andchronic groin pain.

References1 Celsus AC. Of Medicine. Translated by James Grieve, London: England

1756; 4192 Bassini E. Nuovo metodo per la cura radicale dellʼ ernia inguinale. Atti

Congr Associ Med Ital 1887; 2: 1793 Bassini E. Neue Operation-Methode ue Radicalbehandlung der Schenkel-

hernia. Arch Klin Chir 1894; 47: 14 Lichtenstein IL. Hernia Repair Without Disability, 2nd ed. St Louis, MO:

Ishiyaku Euroamerica: 19865 Lichtenstein IL, Shulman AG, Amid PK. The cause, prevention and

treatment of recurrent groin hernia. Surg Clin North Am 1993; 73: 5296 Ger R, Mishrick A, Albert P, Worth MH Jr. Endoscopic extraperitoneal

herniorrhapy versus conventional hernia repair: a comparative study. CurrSurg 1993; 17: 46

7 Nienhuijs S, Staal E, Strobbe L, et al. Chronic pain after mesh repair ofinguinal hernia: a systematic review. Am J Surg. 2007; 194(3): 394-400

8 Tantia O, Jain M, Sen B, et al. Laparoscopic repair of recurrent groin hernia:results of a prospective study. Surg Endosc. 2009; 23(4): 734-8

9 Bobrzynski A, Budzynski A, Biesiada Z, et al. Experience - the key factor insuccessful laparoscopic total extraperitoneal and transabdominalpreperitoneal hernia repair. Hernia 2001; 5(2): 80-3

10 Dulucq JL, Wintringer P, Mahajna A. Laparoscopic totally extraperitonealinguinal hernia repair: lessons learned from 3,100 hernia repairs over 15years. Surg Endosc 2009; 23(3): 482-6

11 Picchio M, Lombardi A, Zolovkins A, Mihelsons M, La Torre G. Tension-freelaparoscopic and open hernia repair: randomized controlled trial of earlyresults. World J Surg 1999; 23(10): 1004-7; discussion 1008-9

12 Eklund AS, Montgomery AK, Rasmussen IC, et al. Low recurrence rateafter laparoscopic (TEP) and open (Lichtenstein) inguinal hernia repair: arandomized, multicenter trial with 5-year follow-up. Ann Surg 2009; 249(1):33-8

13 Butters M, Redecke J, Köninger J. Long-term results of a randomizedclinical trial of Shouldice, Lichtenstein and transabdominal preperitonealhernia repairs. Br J Surg 2007; 94(5): 562-5

14 Lovisetto F, Zonta S, Rota E, Mazzilli M, Bardone M, Bottero L, Faillace G,Longoni M. Use of human fibrin glue (Tissucol) versus staples for meshfixation in laparoscopic transabdominal preperitoneal hernioplasty: aprospective, randomized study. Ann Surg 2007; 245(2): 222-31

15 NICE guidelines December 200516 Kouhia ST, Huttunen R, Silvasti SO, et al. Lichtenstein hernioplasty versus

totally extraperitoneal laparoscopic hernioplasty in treatment of recurrentinguinal hernia - a prospective randomized trial. Ann Surg 2009; 249(3):384-7

17 Shah NS. Sheen AJ. A prospective study evaluating quality of life andoutcome of patients undergoing laparoscopic hernia repair using fibrin glue- UK experience. Hernia 2009; (13): 33-43

Parietex™ - 2D and 3D weave (light weight)

Prolene™ UltraPro™ - lightweight

Figure 1 - Standard and lightweight mesh

Figure 2 - Hernia staplers

Figure 3 - DuploSpray MIS regulator and applicator



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18 Langenbach MR, Schmidt J, Ubrig B, et al. Sixty-month follow-up afterendoscopic inguinal hernia repair with three types of mesh: a prospectiverandomized trial. Surg Endosc 2008; 22(8): 1790-97

19 Bell, Price. Laparoscopic Inguinal Hernia Repair Using an AnatomicallyContoured Three-Dimensional Mesh. Surg Endosc 2003; 17: 1784-88

20 Agarwal BB, Agarwal KA, Mahajan KC. Prospective double-blindrandomized controlled study comparing heavy- and lightweight poly-propylene mesh in totally extraperitoneal repair of inguinal hernia: earlyresults. Surg Endosc 2009; 23(2): 242-7

21 Koch CA, Greenlee SM, Larson DR, et al. Randomized prospective studyof totally extraperitoneal inguinal hernia repair: fixation versus no fixation ofmesh. JSLS 2006; 10(4): 457-60

22 Taylor C, Layani L, Ghusn M, et al. Laparoscopic inguinal hernia repairwithout mesh fixation, early results of a large randomised clinical trial. SurgEndosc 2008; 22(3): 757-62

23 Jourdan IC, Bailey ME. Initial experience with the use of N-butyl 2-cyano-acrylate glue for the fixation of polypropylene mesh in laparoscopic herniarepair. Surg Laparosc Endosc 1998; 8(4): 291-3

24 Schwab R, Willms A, Kröger A, et al. Less chronic pain following meshfixation using a fibrin sealant in TEP inguinal hernia repair. Hernia 2006;10(3): 272-7

25 Garg P, Rajagopal M, Ismail M, et al. Laparoscopic total extraperitonealinguinal hernia repair with nonfixation of the mesh for 1,692 hernias. SurgEndosc 2009; 23(6): 1241-5

26 Chastan P. Tension-Free Open Inguinal Hernia Repair Using an InnovativeSelf-Gripping Semi Resorbable Mesh. Journal of Minimal Access Surgery2006: 139-43

27 Hollinsky C, Kolbe T, Walter I, et al. Comparison of a new self-gripping meshwith other fixation methods for laparoscopic hernia repair in a rat model.J Am Coll Surg 2009; 208(6): 1107-1

28 Boldo E, Armelles A, Escrig J, et al. Pain after laparoscopic bilateralhernioplasty: Early results of a prospective randomized double-blind studycomparing fibrin versus staples. Surg Endosc 2008; 22(5): 1206-9

29 Lau H. Fibrin sealant versus mechanical stapling for mesh fixation duringendoscopic extraperitoneal inguinal hernioplasty: a randomized prospectivetrial. Ann Surg 2005; 242(5): 670-5

30 Leibl BJ, Kraft B, K Bittner R, et al. Are postoperative complaints andcomplications influenced by different techniques in fashioning and fixing themesh in transperitoneal laparoscopic hernioplasty? Results of a prospectiverandomized trial. World J Surg 2002; 26(12): 1481-4

Author Year Study No. of Comparison Follow-up Post-op pain RecurrenceDesign patients Median P-value P-value

Taylor C22 2008 RCT 360 Tacks vs *No fixation 8 months P=0.003Boldo E28 2008 RCT 22 Staples vs *Fibrin 6 months P<0.05

Lovisetto F14 2007 RCT 197 Staples vs *Fibrin 12 months P<0.05 P=NSKoch CA21 2006 RCT 40 Staples vs *No fixation 19 months P=NS

Lau H29 2005 RCT 93 Staples vs *Fibrin 15 months P=0.03Liebl BJ30 2002 RCT 360 Staples vs Sutures 1 month P=NS

Table - Brief summary of published RCT on laparoscopic mesh fixation

* = The method of fixation marked with an asterisk is associated with significant reduction in post-op pain. There was no statistical difference noted inrecurrence. NS = non significant, RCT = Randomised contolled trial


show that such information decreases anxiety, analgesicrequirements and length of stay (LOS)6.

On the day of surgery, patient should be allowed clear fluidsup to 2 hours before surgery including clear carbohydratedrinks, which have been shown to decrease the sensation ofthirst, perioperative insulin resistance and lead to a minordecrease in muscle catabolism. Preoperative bowelpreparation, especially for segmental resections, have been thefocus of a recent metaanalysis, which concluded that it isunnecessary and might increase the risk of septiccomplications and aggravate preoperative dehydration5.

Surgery initiates a complex metabolic, neuroendocrine, andinflammatory stress response, and indeed most postoperativeorgan dysfunction and morbidity can be attributed at least inpart to the stress responses. Intraoperative management isaimed at reducing the stress of surgery, and facilitating earlyfeeding and mobilization after operation4.

Minimally invasive surgical techniques (MIS) reduce theinflammatory component of the stress response, and aregenerally associated with reduced pain and shorter LOS.However, when fast track principles are applied to perioperativecare, the differences in median LOS between open and MIStechniques becomes less marked. Kehlet has suggested thatMIS techniques should be further evaluated within a fast trackprogram to assess their impact on LOS and perioperativemorbidity7.

Even in the absence of MIS techniques, pain andpulmonary dysfunction are reduced where more anatomicaltransverse or oblique incisions are used instead of traditionalvertical incisions and these approaches should be adoptedwherever possible8.

There is increasing evidence to suggest that nasogastrictubes are not indicated for lower GI surgery as they may lead toprolonged paralytic ileus and may even predispose topulmonary aspiration9. Surgical drains similarly slow therecovery of bowel function and make pain control moredifficult10.

Anaesthetic techniques which lead to rapid recovery withminimal side effects should be used (total intravenoustechnique or short acting inhalational agents). A seriousconsideration should be given to the use of Thoracic EpiduralAnalgesia when traditional open surgery is planned. There is nodefinite evidence so far to suggest that it leads to decreasedsurgical mortality post operatively11. However, the evidencedoes suggest that it provides better pain relief, earlierambulation, reduced pulmonary complications (upper gastrointestinal surgery) 6 and can reduce paralytic ileus (especiallyafter colorectal surgery) as compared to using intravenousopioid analgesia12.

Multimodal strategies should be used to decrease theincidence of post operative nausea and vomiting (PONV) andpain, which causes significant patient distress and discomfortand delays oral intake.

There should be careful monitoring of the patient’stemperature throughout surgery and in the post operativeperiod. Intraoperative hypothermia has been shown to increasewound infection, lead to greater blood loss, aggravate thestress response, cause additional patient discomfort (whenawake postoperatively) and may even lead to coronary events.Forced air warming devices, warm humidified gases andwarmed intravenous and lavage fluids should be used4.

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Fast Track Surgery(also called EnhancedRecovery afterSurgery [ERAS])

Prit Anand Singh, Specialty Trainee, Anaestheticsand Grant Haldane, Consultant Anaesthetist,Hairmyres Hospital, East Kilbride

Surgery is slowly undergoing revolutionary changes due tonewer approaches to pain control, the introduction oftechniques that reduce the perioperative stress response, andthe use of minimally invasive surgical techniques.Subsequently, traditional lengths of hospital stays have beenreduced and many surgical procedures are being carried out onan outpatient basis1.

What is Fast Track Surgery?Fast-track surgery was pioneered by Professor Henrik Kehlet ofDenmark in the early 1990s and since then has been taken upworldwide2,3. The term refers to a multimodal package oftechniques and care requiring multidisciplinary collaborationwith a collective aim of reducing the neurohumoral stressresponse following surgery. This can lead to less postoperativeorgan dysfunction and complications, thereby greatlyshortening the time to full recovery. Each aspect is evidencebased and these are structured into a seamless programme ofclinical care4.

RequirementsMultidisciplinary team collaboration is required for the successof a fast track surgical programme. The team consists of thesurgeon, anaesthetist, nursing staff (including pre assessment,peri-operative and ward staff), acute pain team and the patientsthemselves. Every individual should be fully informed andeducated about their roles within the programme and thereshould be an integrated programme of good postoperativefollow up and support for each patient. A well organizedprospective audit is also an important part of the whole process

Perioperative ManagementFast track surgery was initially described in colorectal surgerywhere surgical dogma dictates that surgery should beperformed on a well-prepped bowel in a fully fasted patient,with a nasogastric (NG) tube in situ and a stepwise introductionof fluids prior to the introduction of diet. Evidence stronglysuggests that such an approach prolongs the length of stay ofthe patient (6-10 days) and it should be challenged5.

Preoperatively, patients should be assessed by ananaesthetist to ensure optimal organ function and stabilizationof any co existing disease. Patients should be given informationabout their anticipated post operative course includinganalgesia, mobilization and discharge. There is evidence to

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Ideal peri-operative fluid management continues to becontroversial, with advocates for both ‘liberal’ and ‘restrictive’fluid regimes. Individually tailored goal-directed fluid therapyseems an optimal approach, the goal being maintenance oftissue perfusion and cellular oxygenation. Various non invasivetechniques like the Oesophageal Doppler have been used tooptimise fluid therapy. Several recent studies have shown thatsuch individualised approaches to fluid management decreaseLOS and duration of paralytic ileus and should be incorporatedinto fast track programmes13.

Postoperatively, patients should receive good qualitymultimodal analgesia, as this helps to facilitate earliermobilisation, resumption of normal activities and potentiallyearlier discharge from Hospital. They should be regularlyreviewed by the acute pain service, and any problemsencountered should be promptly treated to optimise analgesia.Consideration should be given to a combination oflocal/regional anaesthetic techniques along side the use ofsimple analgesics, NSAIDs and other adjuvants (asappropriate).

Adequate nutrition is important as it enhances woundhealing, and aids in maintaining muscle strength. Early enteralnutrition should be emphasised, as it has been shown todecrease gut permeability reducing bacterial translocation, andthus infection. Evidence suggests that early return to oral intakeis safe even after bowel resection14.

Patients should be given a high fractional inspiredconcentration of Oxygen (intra-operatively and in the immediatepost operative period) as it has been shown to hasten woundhealing. Patients should be encouraged to mobilise early, as itcan enhance gut mobility and decrease the risk of pulmonarydysfunction. This can only be achieved with optimal analgesiafollowing surgery.

In addition, traditional prolonged bed rest is undesirable asit increases muscle weakness and loss. It can also give rise tovenous stasis which may predispose to thromboembolism.Excessive bed rest coupled with patient’s poor compliance withPhysiotherapy may also increase the risk of pulmonarydysfunction, hypoxia and other end organ dysfunction.

ConclusionThe successful development of a fast track surgical programmeis best coordinated through the development of a multi-disciplinary implementation group. This group should meetregularly and have representation from all areas of pre throughpost operative care. Each representative should ensure that thecare is optimal in their respective area and consistent with theprinciples of Fast Track Surgery. The whole programme requiresgood team work with a clear patient care pathway and welldefined goals. All staff involved should understand and bemotivated by the fast track approach (Table 1).

Although this approach was initially pioneered in ColorectalSurgery, it can be used in any type of surgical intervention andshould have a positive impact on post op outcome and LOS.Once again, it is important to ensure the process is audited toensure compliance with the programme as well as ensuringthat the perceived benefits are achieved. Lastly, it is importantto set sensible initial goals for length of stay & ensure thatcommunity practitioners are aware of the change in surgicalpractice.

The 17 key elements which define fast track programmes incolorectal surgery are15:

1. Preoperative counselling2. Preoperative feeding (up to two hours prior to surgery)3. No bowel preparation4. No premedication5. Fluid restriction (or at least optimisation)6. Perioperative high oxygen concentration7. Active prevention of hypothermia8. Epidural analgesia ( if appropriate)9. Laparoscopic or minimally-invasive incisions10. No routine use of NG tubes11. No routine use of drains12. Enforced postoperative mobilisation13. Minimal systemic opioid use14. Standard laxatives (oral magnesium)15. Early removal of urinary catheters16. DVT prophylaxis17. Enhanced preoperative and postoperative nutrition

via supplements

Table 1 - Components of Fast Track Surgery programme4

References1 Wilmore DW, Kehlet H. Management of patients in Fast Track Surgery.

British Medical Journal 2001; 322: 473-62 White PF, Kehlet H, Neal JM, Schricker T, Carr D. The role of the

anesthesiologist in fast-track surgery: from multimodal analgesia toperioperative medical care. Anesth Analg 2007; 104: 1380-96

3 Kehlet H. Fast-track colorectal surgery. Lancet 2008; 371: 791-34 Kitching AJ ,OʼNeill SS. Fast track surgery and anaesthesia. Continuing

Education in Anaesthesia, Critical Care & Pain 2009 9(2): 39-435 Guenaga KF, Atallah AN, Castro AA, et al. Mechanical bowel preparation for

elective colorectal surgery. Cochrane Database Syst Rev 2003;2: CD001544. Update in Cochrane Database Syst Rev 2005; 1: CD001544

6 Kehlet H, Wilmore DW. Multimodal strategies to improve surgical outeome.Am J Surg 2002; 183: 630-41

7 Kehlet H, Kennedy RH. Laparoscopic colonic surgery - missionaccomplished or work in progress? Colorectal Dis (2006) 8: 514-7

8 Vertical compared with transverse incisions in abdominal surgery.Teodor P.Grantcharov, Jacob Rosenberg. The European Journal of surgery 2001;167: 4

9 Nelson R, Edwards S, Tse B. Prophylactic nasogastric decompression afterabdominal surgery. Cochrane Database Syst Rev (2007) 3. CD004929

10 Jesus EC, Karliczek A, Matos D, et al. Propylactic anostomotic drainage forcolorectal surgery. The Cochrane Database of Systematic Reviews 2006Issue 2. John Wiley and Sons Ltd

11 Rigg JR, Jamrozik K, Myles PS, et al, MASTER Anaesthesia Trial StudyGroup. Epidural anaesthesia and analgesia and outcome of major surgery:a randomised trial. Lancet 2002; 359: 1276-82

12 Marret E, Remy C, Bonnet F, and the Postoperative Pain Forum Group.Meta-analysis of epidural analgesia versus parenteral opioid analgesia aftercolorectal surgery. British Journal of Surgery; 94 Issue 6; 665-73

13 Bundgaard-Nielson M, Holte K, Secher NH, Kehlet H. Monitoring of peri-operative fluid administration by individualised goal-directed therapy. ActaAnaesthesiol Scand 2007; 51: 331-40

14 Andersen HK, Lewis SJ, Thomas S. Early enteral nutrition within 24h ofcolorectal surgery versus later commencement of feeding for postoperativecomplications. Cochrane Database Syst Rev 2006; 4: CD004080

15 http://behindthemedicalheadlines.com/articles/fast-track-surgery-and-enhanced-recovery

For copies of the Hairmyres Hospital Fast Track Colorectal Protocol contactDr Haldane on [email protected].

of hospital stay. The development of APS is supported by theRoyal College of Anaesthetists.

Consequences of Poor Pain ReliefIt is important to understand that poor pain control can have anumber of significant detrimental effects on patients. As well assignificant suffering and distress, severe pain following surgeryproduces a neurohumeral response with the release ofcatecholamines and activation of the sympathetic nervoussystem. This results in a number of physiological changes:

CardiovascularTachycardia, hypertension, increased myocardial oxygenconsumption, myocardial ischaemia.RespiratoryDecreased lung volume, atelectasis, decreased cough, sputumretention, infection, hypoxia.GastrointestinalDecreased gastric & bowel motility, Ileus.GenitourinaryUrinary retention.MetabolicIncreased catabolic hormones eg cortisol, glucagon, growthhormone, etc.Reduced anabolic hormones eg insulin, testosterone.PsychologicalAnxiety, fear, sleep disturbances.

In addition, a number of other detrimental outcomes haverecently been identified which may in fact be improved bybetter quality analgesia postoperatively, particularly with theuse of regional analgesic techniques. The first of these ischronic pain after surgery7. This phenomenon is still poorlyrecognized but many patients following elective surgery can goon to develop prolonged and problematic pain as a direct resultof the surgical intervention. The incidence varies, with certainsurgical procedures such as thoracotomy or hernia surgeryhaving a particularly high incidence. Surgical, patient andanaesthetic factors are thought to be important in thedevelopment of this complication and often those who developchronic pain have had particularly severe and poorly managedacute pain post operatively. It is thought that more aggressiveacute pain management immediately postoperatively canreduce the incidence of chronic pain even in high risk patientsundergoing high risk surgery.

Deranged postoperative physiology as a result ofuncontrolled postoperative pain can ultimately lead to patientmorbidity and delay postoperative recovery. At the very least,patients who are sore are more likely to remain in bed and notbe capable of following postoperative regimes such as chestphysiotherapy or deep breathing exercises. This can lead topostoperative complications such as chest infection, deepvenous thrombosis, MI, etc.

A final potential benefit of a more structured approach topostoperative pain management is the development ofadditional outreach care8. Acute pain services have long beenrecognized as an effective model of care for screening ‘at risk’patients on surgical wards and identifying those patients whoare developing difficulties postoperatively. This is due in part tothe fact that surgical complications can often present as anincrease in intensity or character of pain, leading to APS review

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Acute PainManagement in AdultSurgical PatientsGrant Haldane, Consultant Anaesthetist,Hairmyres Hospital, East Kilbride

SummaryPain is defined as ‘an unpleasant sensory and emotionalexperience associated with actual or potential tissue damage ordescribed in terms of such damage’. In other words, it indicatesthe potential for damage to the organism and is usuallyassociated with behavioural responses designed to minimisethe impact of any painful stimulus.

Many myths have been associated with pain managementand this has led to poor analgesia in the past. Newunderstanding and techniques have allowed us to developimproved strategies for analgesia and to promote educationin their use. Contrary to traditional teaching, poor analgesiafollowing surgery can have considerable consequences leadingto chronic pain states and potential harmful effects on all organsystems. This can lead to considerable morbidity and possiblemortality. Therefore, adequate pain relief is not only humane butimproves recovery. With good quality analgesia following upperabdominal surgery, for example, patients can cough and clearpulmonary secretions effectively and mobilize more readily thuspreventing deep venous thromboses, chest infections andother postoperative complications. This may reduce length ofhospital stay. This is best achieved if patients are managed in astructured peri-operative care programme optimizing allaspects of postoperative care as well as analgesia1. In addition,knowledge of pain and pain management may aid diagnosiswhen the colic of bowel obstruction changes to a diffuseperitonitis following perforation or after surgery when a changein the intensity of pain postoperatively can signify a surgicalcomplication eg anastomotic leak following colonic surgery. Forall of these reasons, education in pain management should befundamental to all health care professionals.

The IssueTraditionally, acute pain following surgery, although predictable,has not been prioritised as part of postoperative care with aresulting lack of education and understanding by staff leadingto deficiencies in the quality of pain relief provided to patients.This has been highlighted in numerous national audits andreviews2,3,4,5. The recognition of these deficiencies led to thedevelopment of acute pain services (APS) in the UK, and thepresence of an APS is now seen as a prerequisite for all acutehospitals undergoing a significant volume of elective andemergency surgery.

The introduction of an APS has been shown to improve thequality of analgesia provided and reduce analgesia-related sideeffects7. There is also growing evidence that good quality paincontrol can be associated with other significant benefits,including reduced postoperative morbidity and reduced length

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and further investigation. In addition, as APS are often run byanaesthetists, access to critical care expertise is often availableto identify and manage patients who are failing to thrive in ageneral ward environment.

Who Should Treat Pain?Most of us will encounter patients in pain of some degreeduring our working lives and it is therefore important that allmedical professionals have some understanding of the basicprinciples of pain management. However, the advent of acutepain teams as part of an Acute Pain Service allows a moreaggressive and structured approach to pain management andis the established role model for hospital based postoperativepain management.

Pain Pathways (Anatomy and Physiology)Pain receptors or nociceptors are naked nerve endings in theskin. They are stimulated by many different modalities all ofwhich share the common role of being potentially harmful.These nociceptor fibres amalgamate into nerve axons whichrun from their peripheral site in the skin to the spinal cord wherethey synapse with second order nerves in the substantiagelatinosa of the dorsal column of the cord. Two different typesof peripheral pain nerves exist. One is myelinated (Aδ fibre) andtransmits quick and focused pain information, the second isunmyelinated (C fibre) and conducts more slowly. This secondnerve type is responsible for the vague and more generalizedpain that develops after initial injury. After entering the spinalcord, these nerves cross over and ascend to the Thalamus inthe controlateral, lateral spinothalamic tract, eventuallyradiating from here to the sensory cortex. Pain is consciouslyperceived initially at the level of the thalamus.

The substantia gelatinosa is an area of particular interest asit also receives input from peripheral sensory fibres (Aβ fibres)and descending inhibitory fibres from the cortex. These fibresare responsible for controlling the transmission of painfulimpulses through the substantia gelatinosa and have beenpostulated to act as a gate to the transmission of painfulstimulae. This is a complex set up involving multiplemediators/neurotransmitters and we are only beginning tounderstand its complexity. It therefore serves to remind us thatpain management is far from straight forward and may requirecomplex multi-factorial strategies to achieve adequate relief.

Pain AssessmentAll patients are different and will respond differently to thesame surgical process and subsequent analgesic regimen. Wemust recognise this and tailor our analgesia appropriately. Inorder to do this properly, we require a reliable method ofpain assessment. Pain can be assessed either objectivelyor subjectively. Objective assessment is based on theinterpretation of a patient’s pain and behaviour by a third party.It therefore tends to reflect that individual’s prejudices andunderstanding of pain management rather than truly assessingpatient discomfort. As a result, it is of limited value but maybe the only tool available in situations of poor communication -confused patient, foreign speaking, etc. A much more validtool is the subjective pain score. This is a direct assessment,from the patient, about their pain and its significance. Manymethods are available to perform subjective pain scoringand amongst the simplest is a Verbal Numerical Rating Scale(see Appendix A).

In this example, the patient is told that a score of zerorepresents no pain and a score of 4 represents the worst painthey can imagine. The patient picks a number on this scalewhich best describe their pain. If they find this difficult, simplyask if the pain is mild, moderate, severe or the worstimaginable. These pain scores are charted regularly and usedto gauge the effectiveness of analgesic interventions. It isimportant to stress that these scores are charted in response tomovement eg coughing or deep breathing as this gives a muchmore reliable indicator of the effectiveness of any pain relief. Inaddition, it is important to establish acceptable pain scoresindicating effective analgesia. It is unrealistic to assume thatpatients will be pain free postoperatively without the use ofinvasive local anaesthetic based techniques such as epiduralanalgesia but using the above system a pain score of less than2 on movement would indicate effective analgesia. This kind ofpain relief should facilitate coughing/mobility and thuscontribute to recovery. Ideally the pain score should beassessed and charted at the same time as other vital signs areassessed.

Using this type of assessment, postoperative pain can beclassified into two broad groups depending on the type ofsurgical insult:

Mild to moderate pain (Pain score <3) - These patients willoften achieve effective analgesia with simple oral analgesicformulations eg paracetamol, codeine and/or non steroidal anti-inflammatory drugs (NSAIDS) such as diclofenac andibuprofen. Such patients would be undergoing relatively minorsurgery (varicose vein surgery, laparoscopy, hernia repair, etc).

Moderate to severe pain (pain score >3) usually requires theuse of parenteral (intravenous/subcutaneous/intramuscular)opiates.

How Do We Monitor for Adverse Effects?Patients differ in their pain threshold and response to analgesia.Older patients and young children generally need lessanalgesia, although this must be carefully assessed andmonitored closely. The greatest area of concern in themanagement of acute pain is the potential to induce respiratorydepression with the use of parenteral opiate drugs egmorphine. It is always safer to titrate these drugs to effectparticularly when establishing analgesia. This allows careful

Appendix AReproduced courtesy of Hairmyres Hospital Acute Pain service



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assessment of the effects of the drugs as there is always a lagtime from administration to peak effect.

Respiratory DepressionThe traditional teaching of counting respiratory rate to indicatepotential respiratory depression is over simplified. Amuchmoresubtle way of identifying problems with respiratory depressionis by using a sedation scoring system. Sedation scoring ischarted on a scale of 0-3 as shown:0 Patient not sedated, wide awake1 Patient reports feeling tired but still fully alert2 Patient drowsy and readily falls ‘asleep’ when not

stimulated3 Patient unresponsive to deep stimulus

If sedation score is increasing, this should lead to cautionconcerning continued administration of opiate drugs. Asedation score of 3 or a sedation score of 2 with a lowrespiratory rate require urgent intervention to prevent arespiratory arrest and mandate the use of intravenousnaloxone.

AimUsing these fundamental tools of pain assessment andsedation scoring, we can aim to provide effective analgesia(a pain score of less than 2) and allow regular and aggressivedelivery of opiate drugs without excessive respiratorydepression (sedation score of greater than or equal to 2). Theidea is that every time a patient has their pain assessed, theyalso have their sedation score assessed. Pain should indicatethe delivery of additional analgesia as long as there are noconcerns with sedation. At all times a high sedation scoreoverrides a high pain score to prevent worsening of the problemwith the delivery of additional opiate drugs.

MonitoringAs well as regular assessment of vital signs, pain and sedationscores, it is recommended that patients receiving regularopiates should receive supplemental oxygen where available.Patients should also be regularly assessed for complications orside effects of treatment and offered appropriate treatment asrequired. Adequate analgesia, regular physiotherapy, earlyreturn to oral intake and mobilisation should aid recovery.

Pain Management TechniquesSimple TechniquesOral analgesia - suitable for patients with mild to moderatepostoperative pain. Two important concepts underline the useof oral analgesics in modern medical practice:1. World Health Organisation Analgesic LadderThis serves to remind us to escalate the potency of analgesicdrug interventions as pain increases starting with the simplestand often safest interventions first. Although initially designedfor the management of cancer pain, the concept can equallyapply to the postoperative patient.2. Multimodal or balanced analgesiaThe use of a range of drugs and techniques to optimiseanalgesia is now seen as standard. In particular, opiate-basedanalgesia regimes such as patient-controlled analgesia shouldalways be augmented by other adjuvant analgesic drugs.These drugs, such as non-steroidal anti-inflammatory drugs(NSAIDs) and paracetamol, have a different mechanism of

action to the opiate and can lead to improved pain control,which is usually achieved with less total opiate use. This opiatesparing effect is thought to reduce the incidence of trouble-some opiate side effects, such as sedation and nausea andvomiting.

The 2 techniques can be combined as indicated above withthe continuation of adjuvant analgesia as opiate potencyincreases.

In addition, there is now evidence available to suggestwhich oral analgesic drugs are most effective in themanagement of postoperative pain. The number needed totreat (NNT) is an evidence based medicine concept to indicatethe effectiveness of various therapeutic interventions. Analgesicdrugs have been subsequently ranked with those drugs withsmaller NNTs at the top of a league table of analgesics9. Thisallows us to confidently recommend their use and move awayfrom less effective drugs. In particular, all NSAIDs have NNTsaround 2 and are thus very effective. Paracetamol has an NNTof around 4 and is surprisingly effective in the management ofsignificant pain postoperatively. Also codeine 30 withparacetamol 500 (Tylex, Kapake) preparations are veryeffective. All this information can be collated into an oralanalgesic regime (see Appendix B).

Acute Pain Management in Adult Surgical PatientsWorld Health Organisation Analgesic Ladder

Appendix BReproduced courtesy of Hairmyres Hospital Acute Pain serviceFor more information see www.jr2.ox.ac.uk/bandolier/painres/

NSAIDS/COX2

INHIBITOR

CONTRAINDICATIONS



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Parenteral OpiatesSubcutaneous morphine - suitable for patients withmoderate to severe painThis technique is increasingly used instead of traditional intra-muscular (IM) analgesia. The characteristics of absorption andsubsequent analgesia are no better with this technique but dueto the frequency of injections it is more comfortable for patientsto use an indwelling subcutaneous catheter if possible. The realbenefit of this technique lies in the rigid use of a protocol (seeAppendix C). Traditional IM analgesia is based on patientweight but this has been replaced by utilising patient age topredict dose. Analgesia is allowed frequently and there is theability to titrate the dose to effect built into the protocol. Theprotocol also contains advice about the management ofrespiratory depression and as before the administration ofanalgesia is guided by the use of pain scoring and sedationscoring.

Complex or Specialized InterventionsIntravenous morphine infusions - These should only beutilised in critical care environments such as HDU/ICU becauseof the increased potential for respiratory depression.

Patient controlled analgesia (PCA) - This technique is thecornerstone of any acute pain service and has revolutionisedmodern pain management. Many different devices exist whichcan be programmed to varying degrees. All have a reservoir ofdrug (usually morphine 1mg/ml) connected to the patient’sintravenous drip by means of a one way antisyphon valve andthe administration of analgesia is controlled by a device foractivating morphine delivery, usually a button of somedescription. Essentially the technique allows patients to taketotal control of their own analgesia and therefore allows forindividual variability in pain perception and management. Themachines are programmed in a standard fashion according tolocal protocol with various safety features providing a morecontrolled administration of morphine than a continuousinfusion.

PCA is a very effective method of maintaining analgesia butpatients must be appropriately ‘loaded’ with morphine prior toits introduction. As most PCA machines are introduced post-operatively this has usually been achieved by administeringintravenous morphine in theatre and in the recovery area untilthe patient is comfortable. As PCA allows patients to controltheir own pain by pressing a button to demand analgesia it alsohas a significant placebo effect which helps with pain control.

Regional anaesthesia - A number of review articles10,11 haveshown that regional analgesic techniques are capable ofproviding good quality analgesia following surgery with areduced side-effect profile, and that they can considerablyenhance return to normal function after surgery. Both centralneuraxial blocks and peripheral nerve blocks can also reducepostoperative morbidity and possibly mortality12,13. In addition,recent evidence has suggested a role for peripheral nerveblocks (paravertebral block) in diseasemodification by reducingthe incidence of recurrence of breast cancer following electivesurgery14. As a result, these techniques are increasingly beingused in the fight to control postoperative pain and distress andimprove patient outcome following surgery.

Epidural analgesia - This is a highly specialised form ofanalgesia involving the insertion of a small catheter into apotential space around the dura of the spinal cord. The catheterallows the intermittent or continuous administration of paincontrol medication directly to the central nervous system.

Contraindications to NSAIDS/COX-2 drugs• Renal impairment/dehydration• Aspirin-sensitive asthma or other history of adverse effect to

one or both groups of drug• Gastric Ulceration• Patient on warfarin therapy• Any platelet dysfunction/coagulopathy• Age >80• COX-2 drugs are contraindicated in the following patients -

Thrombotic history ie Stroke, MI, known IHD• Patient already on NSAID

If oral analgesia is inadequate -• Consider stopping Cocodamol 30/500 in favour of the

Oxynorm regime or S/C morphine regime (see algorithm).Continue with paracetamol and NSAID/COX-2 if the patientis taking medications orally.

• Consider other/additional adjuvant medications eg tricyclicantidepressants (amitriptlyine), anticonvulsants (Gabapentin)if neuropathic pain is suspected.

Appendix CReproduced courtesy of Hairmyres Hospital Acute Pain service

Subcutaneous Analgesia Protocol


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Amixture of local anaesthetic and opiate has been shown to bemost effective to control pain, particularly on movement bypreventing the transmission of painful impulses throughperipheral nerves to the brain. This allows us to maintain anarea of ‘numbness’ over the surgical incision to allow thepatient to mobilise completely free of pain postoperatively. Thistechnique can be very effective but because of its specialisednature can only be offered to specific patients who will benursed postoperatively in a critical care environment egHDU/ICU or a well staffed surgical ward.

Peripheral nerve blocks - These techniques have the capacityto produce profound analgesia and can be used as alternativesto general anaesthesia for surgery in the distribution of theblock. They are particularly well suited for the management ofperipheral limb injuries and trauma. However, use of thesetechniques requires skill and expertise which may not beavailable locally. Local anaesthetic infiltration can also be usefulfor the management of pain related to small wounds/incisionseg hernia repair, caesarean section wound, etc but are ofunproven benefit in larger laparotomy type wounds.

Transversus abdominis plane block - This new technique forproviding analgesia of the anterior abdominal wall has recentlybeen described and offers many potential benefits in bridgingthe gap between the ‘Gold Standard’ of epidural analgesia andPCA morphine following abdominal surgery. It appears tobe particularly effective in lower abdominal surgery andprovides prolonged analgesia from a single bolus of localanaesthetic15,16.

Other techniques - Entonox, Transcutaneous Electronic NerveStimulation (TENS) and acupuncture are also available andused occasionally in specific situations.

FutureUndoubtedly, new techniques and drugs will be developed thatwill prove to be significant advances in the management ofacute postoperative pain. However, as there is still a significantlack of appreciation of the extent of the problem and itssignificance, it is likely that the greatest advances will comeabout by greater education of the staff dealing with thesepatients every day and with the greater use of simplemultimodal analgesic strategies, as well as the standardisationand optimisation of current regimes embracing the principlesand educational resources laid out in this article.

References1 Basse L, Kehlet H et al. A Clinical Pathway to Accelerate Recovery After

Colonic Resection July 2000; Annals of Surgery2 Breivik H, Stubhaug A. Management of acute postoperative pain: still a

long way to go! Pain 2008; 137: 233-43 Powell AE, Davies HTO, Bannister J, et al. Rhetoric and reality on acute

pain services in the UK: a national postal questionnaire survey.Br J Anaesth 2004; 92(5): 689-93

4 The Royal College of Surgeons of England. Report of the working partyon pain after surgery. London: RCSENG - Professional Standards andRegulation; 1990

5 Dolin SJ, Cashman JN, Bland JM. Effectiveness of acute postoperativepain management: I. Evidence from published data. Br J Anaesth 2002;89(3): 409-23

6 M Harmer, KA Davies. The effect of education, assessment and astandardised prescription on postoperative pain management.Anaesthesia 1998; 53: 424-30

7 Macrae WA. Chronic post-surgical pain: 10 years on. Br J Anaesth2008; 101(1): 77-86

8 Counsell DJ. The acute pain service: a model for outreach critical care.Anaesthesia 2001; 56: 925-6

9 www.jr2.ox.ac.uk/bandolier/painres/10 Richman JM, Liu SS, Courpas G, et al. Does continuous peripheral

nerve block provide superior pain control to opioids? A meta-analysis.Anesth Analg 2006; 102(1): 248-57

11 Block BM, Liu SS, Rowlingson AJ, et al. Efficacy of postoperativeepidural analgesia: a meta-analysis. JAMA 2003; 290(18): 2455-63

12 Rodgers A, Walker N, Bennett D, et al. Need for an updated overview toassess the benefits of epidurals. Anesth Analg 2003; 97(3): 923-4

13 James R Hebl, Sandra L Kopp, Terese T Horlocker, et al (Mayo Clinic).A Comprehensive Anesthesia Protocol That Emphasises PeripheralNerve Blockade For Total Knee and Total Hip Arthroplasty. JBJS 2005;87A: supplement 2

14 Exadaktylos AK, Buggy DJ, Moriarty DC, Mascha E, Sessler DI. CanAnaesthetic Technique for Primary Breast Cancer Surgery AffectRecurrence or Metastasis? Anesthesiology 2006; 105: 660-4

15 John G McDonnell, et al. The Analgesic efficacy of TransversusAbdominis Plane Block after Abdominal Surgery: A ProspectiveRandomized Controlled Trial. Anesth Analg 2007; 104: 193-197

16 John G McDonnell et al. The Analgesic Efficacy of TransversusAbdominis Plane Block after Cesarean Delivery: A RandomizedControlled Trial. Anesth Analg 2008; 106:186-191


histologically confirmed columnar metaplasia above theendoscopically defined gastro-oesophageal junction. Its mainaetiological factor is gastro-oesophageal reflux, and it is alsoassociated with hiatus herniae6. Dysplasia, if present, isconsidered either low or high grade (figure 1).

Barrett’s oesophagus is a risk factor for adenocarcinomaand its presence necessitates regular surveillance endoscopy inthose who would be fit for resection or other radical procedureif a cancer were to develop. In most patients, intestinalmetaplasia either remains unchanged or some may progresstransiently to low grade dysplasia (LGD). Some patientsprogress to high grade dysplasia (HGD) which is associatedwith a risk of oesophageal cancer of 2-10% per patient year7.However, the progression from intestinal metaplasia throughlow grade dysplasia to high grade dysplasia is not inevitable.Some will progress without being identified as having dysplasiain the intervening period8. This may be due to sampling error ordisagreement between pathologists on the degree of dysplasia,but there is also evidence that the metaplasia → dysplasia →carcinoma sequence does not proceed in a linear fashion4. Theprognosis of oesophageal cancer is grim with 15-20% 5-yearsurvival. The challenge is therefore to identify and treat thosewho are likely to progress to carcinoma before its development.

At present, the management of intestinal metaplasia andLGD is ongoing endoscopic surveillance with acid suppression.However, when HGD is identified on two separate biopsies(usually 3 months apart) and confirmed by 2 differentpathologists, the patient should be staged for carcinoma,discussed at the Oesophagogastric Multidisciplinary Meetingand considered for resection6. However, HGD does notinevitably progress and the patient may unnecessarily undergomajor surgery (oesophagectomy) which not only carries amortality of 5-10% but also causes significant morbidity andresults in long term functional problems9.

Local Ablative Therapy for Barrett’s OesophagusInterest has recently focused on local ablative therapies andtheir ability to ablate dysplastic epithelium, without recourse tosurgical resection, not only for those considered unfit forsurgical resection but also for those in whom oesophagectomymight be considered. There are several methods available.Endoscopic mucosal resection (EMR) can be performed toexcise an area of dysplastic Barrett’s epithelium. This has theadvantage that a specimen is retrieved for histologicalexamination. It has the limitation that it is only suitable forshort segment Barrett’s or focal mucosal abnormalities.Unfortunately, it is associated with a risk of perforation andstricture formation. Thermal ablation with either argon beam ormultipolar electrocoagulation has also been used. This can beused over larger areas of mucosa. However, the depth of burnis user dependent and has also been associated with strictureformation and perforation10.

Photodynamic therapy (PDT) has shown more promise. Aphotosensitizer is injected into the patient and then the Barrett’ssegment is exposed to endoscopic laser. The photosensitizerbinds to neoplastic epithelium and when exposed to laser, itinduces cell death. A phase III trial of this modality showed thatPDT was able to induce regression of the dysplasia and reducethe risk of progression to carcinoma7,11. However, regression ofdysplasia only occurred in 50 % of patients and 13% of thosehaving PDT progressed to carcinoma. In addition, there is a

Scientific - Radiofrequency Ablation and Barrett’s Oesophagus

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RadiofrequencyAblation and Barrett’sOesophagus

Natasha Henley, SpR General Surgery, andSimon Galloway, Consultant Oesophago-gastricSurgeon, University Hospital of SouthManchester

Norman Barrett first described Barrett’s Oesophagus in 1950.He thought at the time he was observing a congenitally shortoesophagus1 but it was not until 3 years later that Phillip Allisonproved that it was the tubular oesophagus lined with glandularepithelium2. The underlying aetiology of Barrett’s oesophaguswas not demonstrated until 1970 when Bremner et al showedthat it developed due to chronic gastro-oesophageal reflux(GORD)3. The prevalence of the condition is not knownprecisely but has been found to be present in 12% in patientsundergoing endoscopy for GORD4.

BackgroundBarrett’s oesophagus or columnar lined oesophagus is definedas replacement of the normal oesophageal squamousepithelium with columnar epithelium containing goblet cells5.A diagnosis of Barrett’s can be made if there is a segment of

Figure a Figure b

Fig 1 - Endoscopic appearances of a) intestinal metaplasia,b) low grade dysplasia c) high grade dysplasia

Figure c

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significant incidence of side effects. The incidence of stricturesis 20-36% and all patients experience photosensitivity and assuch are advised to avoid bright lights and wear sun protectiveclothing in sunlight for 30 days12. A further problem with PDT isthe need for multiple treatments which therefore has a costimplication.

The main concern about ablative therapies is the presenceof “buried” glandular tissue. The therapies have the effect ofablating the superficial dysplastic mucosa and allowingregeneration of neo-squamous mucosa but may leave islandsof glandular mucosa behind. Genetic studies of theneosquamous mucosa left behind after PDT have shown that itstill has malignant potential13. Surveillance must, therefore, becontinued not only because there may remain islands ofabnormal tissue but that the neosquamous tissue may alsoretain malignant potential. Despite these short comings,endoscopic ablative therapy appears to have a similaroutcome, in terms of survival, from oesophageal cancercompared with surgery14.

Radiofrequency Ablation for Barrett’s OesophagusRadiofrequency ablation (RFA) has been used for a number ofyears in solid tumours. It involves the delivery of electricity viaa bipolar electrode to abnormal tissue to induce cell death.Delivery of RFA to Barrett’s epithelium is via the HALO 360system (BARRX Co, Sunnyvale CA) (figure 2). Essentially asizing balloon is placed endoscopically which measures thediameter of the oesophagus to be treated. The ballooncatheter is then placed and this is connected to an RFAdevice which delivers energy to the balloon at 12J/cm3 over

a very short period of time (<300ms). The balloon consists of60 electrode rings spaced narrowly together (250µ apart) in abipolar fashion. Energy is then transmitted via the ballooncatheter to the oesophageal mucosa (figure 3). Theoesophageal wall is suctioned onto the balloon catheter toensure mucosal contact. The arrangement of the wires on theelectrode ensures uniform depth of ablation to theoesophageal mucosa. Each firing of the RFA balloon ablatesa 3cm segment; therefore multiple firings are often needed.The mucosa is observed to slough off after each firing(figure 4). At follow up endoscopy, if islands of Barrett’smucosa are found, these can be further ablated using theHALO 90 catheter (figure 5) which can deliver RFA in a focalarea.

There are several advantages to the HALO system: Uservariability is abolished because the balloon delivers apredetermined depth of ablation; the epithelium and themuscularis mucosa is ablated, while preserving thesubmucosa, which is important in producing neosquamousepithelium. Avoidance of submucosa reduces strictureformation and the chance of perforation and the majority ofpatients only require a single session of RFA althoughsurveillance continues.

Radiofrequency Ablation in Non-dysplastic Barrett’sSeveral studies have examined the use of RFA in Barrett’soesophagus. Initially it was trialled in patients immediately priorto oesophagectomy for carcinoma. This was in order to gatherhistological and clinical information on the effect of ablation15.The AIM I trial was performed in patients with intestinalmetaplasia only. Regression of metaplasia on subsequentbiopsy occurred in around 70% of patients at 1 year followup16,17. The safety profile was good with no oesophagealstrictures identified and no evidence of buried glands onhistological examination. The AIM II trial, which was anextension to AIM I and followed up these patients, showed thatregression of intestinal metaplasia occurred in 98.4% with nostrictures and no buried glands18. These results certainly seemimpressive, however, it must be borne in mind that the chanceof these patients progressing to HGD or oesophageal adeno-carcinoma is around 10%19. Therefore, it is apparent that if all

Fig 2 - HALO 360 Generator

Fig 3 - HALO 360 catheter is inserted into the lower oesophagus at thearea of Barrett’s and the area is ablated

Fig 4 - Mucosa after ablation.The ablated areas will slough off

Fig 5 - Any residual islands ofmucosa can be ablated with theHALO 90 catheter



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patients with intestinal metaplasia were offered RFA, wemay beover treating a large proportion of them. The counter argumentis that 50% of patients who progress from intestinal metaplasiato adenocarcinoma or HGD display no dysplasia at all in theintervening period8.

The question of whether RFA is cost effective may precludeits routine use in patients with intestinal metaplasia. A study byInadomi et al (2009) analysed the cost effectiveness of RFA inHGD, LGD and non dysplastic Barrett’s. They concluded that inpatients without dysplasia, RFA would only be cost effective ifit permanently ablated Barrett’s in at least 40% and thesepatients did not continue to require regular surveillanceendoscopy. The cost per QALY (Quality Assured Life Year)gained was $100,00020. To put this into context, NICE’s “rangeof acceptable cost effectiveness” is £25,000-£30,000 per QALY(source: www.nice.org.uk).

Radiofrequency Ablation in Dysplastic Barrett’sIt seems that the most likely routine clinical application of RFAwill be in patients with dysplasia. A number of cohort studieshave now been published showing that the remission ofdysplastic Barrett’s following RFA is in the region of 80-90%,with no evidence of buried glands and no evidence of strictureformation21,22. However, in the study by Ganz et al whichlooked at patients with concurrent HGD and intestinalmetaplasia, the remission rate for intestinal metaplasia waslower at 54.3%22. This would suggest that RFAmay not be ableto achieve complete ablation of Barrett’s in all patients andcontinued endoscopic surveillance may be necessary.

A multicentre randomised controlled trial of RFA comparedwith a sham procedure has recently been published. 60patients with LGD and 60 patients with HGD were randomisedto RFA with Halo 360 or a sham procedure which involved anendoscopy only. Following this, patients were followed up for ayear with regular endoscopy and biopsy. The studydemonstrated a remission rate of LGD in the treatment group of90.5% compared with 22.7% in the placebo group. In the HGDgroup the remission rate was 81% in the ablation groupcompared to 19% in the control group. Overall, there wascomplete eradication of intestinal metaplasia in 77.4%23. Thisstudy again demonstrates the success of RFA in ablatingdysplastic Barrett’s epithelium.

Shaheen et al also reported a stricture rate of 6% (all ofwhich required intervention) and one patient had an uppergastrointestinal haemorrhage which required endoscopictreatment only in the treatment arm of their study. In addition,histological examination of the biopsy specimen from thetreated group demonstrated subsquamous intestinalmetaplasia in 5.1%23. Compared with the observed stricturerate in PDT (20-30%), the stricture rate is much smaller. Thesignificance of the subsquamous intestinal metaplasia is notknown. PDT has been shown to leave buried glandular tissue inup to 50% of patients and this tissue retains malignantpotential13. However, in patients undergoing RFA, theneosquamous mucosa that regenerates has been shown to befree of genetic abnormalities suggesting that it does not havemalignant potential24. Therefore, RFA overall appears to have abetter safety and side effect profile than PDT.









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The cost utility benefit of RFA in HGD Barrett’s suggeststhat compared with continued surveillance or oesopha-gectomy, RFA appears to be more effective and less costly20.The cost per QALY is estimated to be $6000. However,ultimately, the question is whether RFA halts progression tooesophageal carcinoma. The studies performed thus far haveonly had relatively short follow up, so this question remainsunanswered. Shaheen et al observed a significantly increasedrisk of progression to oesophageal carcinoma in the shamprocedure group23. However, these results need to be treatedwith some caution as the number of patients in their study wasrelatively small and the shift of one incident cancer between thetwo groups would have resulted in a loss of significance. Thepresence of carcinoma may also have been due to samplingerror, in that the cancer was simply missed at the first biopsy.

Radiofrequency Ablation for All?RFA seems to be an effective treatment in the short term forablation of Barrett’s mucosa, with acceptable side effects andcomplications compared with established therapies.Enthusiasm is growing for this modality of treatment. However,long term follow up is still required to evaluate the risk ofoesophageal carcinoma. As yet, there have been no studieslooking at quality of life in RFA compared with surveillanceor oeosphagectomy. It is still not known if RFA affectsoesophageal motility or compliance and if it is associated withfunctional oesophageal problems. At present, RFA is an adjunctto surveillance rather than replacement of surveillance as westill do not knowwhat the risk of oesophageal cancer is in thesepatients. The persistence of intestinal metaplasia after ablationsuggests that there may still be an increased risk of carcinoma.

The conundrum facing health care providers now is whoshould we treat? We know that oesophageal carcinoma has adismal prognosis and we now have a potentially effectivetreatment that can remove the precursor lesion. So should wetreat all patients with Barrett’s regardless of the presence or notof dysplasia? At present, the answer appears to be probablynot. Its use appears justified in the presence of dysplasia. Itsuccessfully ablates dysplastic mucosa and these patientshave a higher risk of development of carcinoma. In patients withintestinal metaplasia, RFA is not always successful and its costseems to preclude it from routine and widespread use. Until wecan identify which patients with intestinal metaplasia are likelyto progress, its use does not appear to be justified in this group.RFA does have the benefit that it can be combined with othermodalities of treatment. It has been used with EMR and if HGDis not ablated by repeated attempts at RFA or if the patientprogresses, oesophagectomy can still be performed.

References1 Barrett NR. Chronic peptic ulcer of the oesophagus and 'oesophagitis'.

Br J Surg 1950; 38(150): 175-82]2 Allison PR, Johnstone AS. The oesophagus lined with gastric mucous

membrane. Thorax 1953; 8(2): 87-1013 Bremner CG, Lynch VP, Ellis FH, Jr. Barrett's esophagus: congenital or

acquired? An experimental study of esophageal mucosal regenerationin the dog. Surgery 1970; 68(1): 209-16

4 Peters JH, Hagen JA, DeMeester SR. Barrett's esophagus.J Gastrointest Surg 2004; 8(1): 1-17

5 Spechler SJ. Clinical practice. Barrett's Esophagus. N Engl J Med 2002;346(11): 836-42

6 Guidelines for the diagnosis and management of Barrett's columnarlined oesophagus. A report of the working party of the British Society ofGastroenterology. http://www.bsg.org.uk. 2005. Ref Type: Report

7 Overholt BF, Lightdale CJ, Wang KK, Canto MI, Burdick S, Haggitt RC,et al. Photodynamic therapy with porfimer sodium for ablation of high-grade dysplasia in Barrett's esophagus: international, partially blinded,randomized phase III trial. Gastrointest Endosc 2005; 62(4): 488-98

8 Sharma P, Falk GW, Weston AP, Reker D, Johnston M, Sampliner RE.Dysplasia and cancer in a large multicenter cohort of patients withBarrett's esophagus. Clin Gastroenterol Hepatol 2006; 4(5): 566-72

9 Williams VA, Watson TJ, Herbella FA, Gellersen O, Raymond D,Jones C, et al. Esophagectomy for high grade dysplasia is safe,curative, and results in good alimentary outcome. J Gastrointest Surg2007; 11(12): 1589-97

10 Tomizawa Y, Wang KK. Changes in screening, prognosis and therapyfor esophageal adenocarcinoma in Barrett's esophagus. Curr OpinGastroenterol 2009; 25(4): 358-65

11 Overholt BF, Wang KK, Burdick JS, Lightdale CJ, Kimmey M, Nava HR,et al. Five-year efficacy and safety of photodynamic therapy withPhotofrin in Barrett's high-grade dysplasia. Gastrointest Endosc 2007;66(3): 460-8

12 Overholt BF. Photodynamic therapy strictures: who is at risk?Gastrointest Endosc 2007; 65(1): 67-9

13 Krishnadath KK, Wang KK, Taniguchi K, Sebo TJ, Buttar NS,Anderson MA, et al. Persistent genetic abnormalities in Barrett'sesophagus after photodynamic therapy. Gastroenterology 2000;19(3): 624-30

14 Prasad GA, Wang KK, Buttar NS, Wongkeesong LM, Krishnadath KK,Nichols FC III, et al. Long-term survival following endoscopic andsurgical treatment of high-grade dysplasia in Barrett's esophagus.Gastroenterology 2007; 132(4): 1226-33

15 Ganz RA, Utley DS, Stern RA, Jackson J, Batts KP, Termin P. Completeablation of esophageal epithelium with a balloon-based bipolarelectrode: a phased evaluation in the porcine and in the humanesophagus. Gastrointest Endosc 2004; 60(6): 1002-10

16 Sharma VK, Wang KK, Overholt BF, Lightdale CJ, Fennerty MB,Dean PJ, et al. Balloon-based, circumferential, endoscopic radio-frequency ablation of Barrett's esophagus: 1-year follow-up of 100patients. Gastrointest Endosc 2007; 65(2): 185-95

17 Aviles A, Reymunde A, Santiago N. Balloon-based electrode for theablation of non-dysplastic Barrett's esophagus: ablation of intestinalmetaplasia (AIM II Trial). Bol Asoc Med P R 2006; 98(4): 270-75

18 Fleischer DE, Overholt BF, Sharma VK, Reymunde A, Kimmey MB,Chuttani R, et al. Endoscopic ablation of Barrett's esophagus: amulticenter study with 2.5-year follow-up. Gastrointest Endosc 2008;68(5): 867-76

19 Fleischer DE, Sharma VK. Endoscopic ablation of Barrett's esophagususing the Halo system. Dig Dis 2008; 26(4): 280-84

20 Inadomi JM, Somsouk M, Madanick RD, Thomas JP, Shaheen NJ.A cost-utility analysis of ablative therapy for Barrett's esophagus.Gastroenterology 2009; 136(7): 2101-14

21 Pouw RE, Gondrie JJ, Sondermeijer CM, ten Kate FJ, van Gulik TM,Krishnadath KK, et al. Eradication of Barrett esophagus with earlyneoplasia by radiofrequency ablation, with or without endoscopicresection. J Gastrointest Surg 2008; 12(10): 1627-36

22 Ganz RA, Overholt BF, Sharma VK, Fleischer DE, Shaheen NJ,Lightdale CJ, et al. Circumferential ablation of Barrett's esophagus thatcontains high-grade dysplasia: a US Multicenter Registry. GastrointestEndosc 2008; 68(1): 35-40

23 Shaheen NJ, Sharma P, Overholt BF, Wolfsen HC, Sampliner RE,Wang KK, et al. Radiofrequency ablation in Barrett's esophagus withdysplasia. N Engl J Med 2009; 360(22): 2277-88

24 Pouw RE, Gondrie JJ, Rygiel AM, Sondermeijer CM, ten Kate FJ,Odze RD, et al. Properties of the neosquamous epithelium afterradiofrequency ablation of Barrett's esophagus containing neoplasia.Am J Gastroenterol 2009; 104(6): 1366-73


Scientific - Evaluating the Effectiveness of the Mini-CEX in the Modern NHS - Trainee’s Perspective

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Evaluating theEffectiveness of theMini-CEX in theModern NHS -Trainee’s PerspectiveIlyas Arshad, SpR Surgery, University ofNottingham, Loaie Maraqa, SpR Surgery,Kings Mill Hospital, Karim Jamal, SpR Surgery,St Peter’s Hospital, Chertsey andReg Dennick, Professor of Medical Education,University of Nottingham

AbstractIntroduction: The Mini-Clinical Evaluation Exercise (Mini-CEX)has been validated and shown to be reliable in the USA. On thebasis of this and a pilot study carried out by the Royal Collegeof Physicians1, it is being used in the UK. Is the Mini-CEX beingused as intended? Does it require modification to improve itsfeasibility in the modern NHS? To answer these questions, aprospective quantitative study was carried out to evaluate theeffectiveness of the Mini-CEX as a Work Place BasedAssessment (WBPA) tool in the modern NHS.Methods: Trainees were involved in a structured focus groupinterview. This was analysed and formed the basis for theconstruction of a questionnaire to evaluate the effectiveness ofthe Mini-CEX in the modern NHS. Main outcome measuresincluded whether the Mini-CEX was being used as intended.The questionnaires were completed by trainees and the resultswere analysed.Results: In our sample, 70% of Educational Supervisors do notcarry out the Mini-CEX as intended. Of the Mini-CEX’s that arereported to be carried out as intended, 48% are not carried outas intended on closer inspection. Sixty four percent of traineesare not observed for 15-20 minutes. Fifty six percent of traineesdo not receive 5-10 minutes of feedback. Eighty eight percentof trainees do not believe that all Mini-CEX trainers are trainedin their use. Eighty eight percent Mini-CEXs are carried outretrospectively.Conclusions: Most Mini-CEX’s are not carried out as intendedand therefore lose their educational and training value. TheMini-CEX is in need of modification if its use is to be continued.Recommendations include: Time ring fenced in job plans fortrainers, importance of medical education to be incorporated inundergraduate curriculum, rewards for good trainers andregular audit of this assessment process.

IntroductionModernising Medical Careers (MMC) laid the foundation fornumerous radical changes within postgraduate medical trainingin the UK2. MMC attempted to train trainees more efficientlywithin the NHS. Structured teaching and training programmesreplaced ‘ad hoc on the job learning’. Reasons included

establishing greater patient safety in an era of reduced time fortraining, greater accountability and responding to the mediaspotlight which had focussed firmly on recent controversies inmedicine eg the Bristol Case3. How do we know which doctorsare performing competently and which doctors’ requireassistance or further training to enable them to perform better?The answer to this deep question relies in part to the role ofWork Place Based Assessment such as the Mini-CEX.

The Mini-CEX is an example of a Work Placed BasedAssessment (WPBA). It is a method for simultaneouslyassessing the clinical and professional skills of trainees whilstalso offering them formative and summative feedback. Itassesses trainees in their unique clinical environment adding toits face validity. The assessment involves a trainer observing thetrainee interact with a patient in a ‘real’ clinical encounter.

The Mini-CEX demonstrated good reproducibility4 validityand reliability5,6 in the medical field in America. Mini-CEX is wellgrounded in educational theory, but requires carefulcollaboration and scheduling by the trainee and trainer whomay have different priorities in a time restricted environment.This study aims to explore the trainees’ perspectives of theMini-CEX in an attempt to evaluate the effectiveness of theMini-CEX as an assessment tool in the modern NHS and, ifpossible, to offer improvements if there are shortcomings.

The opinions and perceptions of the Mini-CEX by thetrainees’ are important. The Mini-CEX has an important role asan educational tool for the benefit of trainees’ and to safeguardthe public by providing competent doctors. But is the Mini-CEXcarried out in practice as it was originally intended to? Do thetrainees obtain constructive feedback? Do appropriatelytrained trainers actually perform the Mini-CEX assessments? Isthere enough time set aside for training and assessment in themodern NHS? These were some examples of questions posedto the trainees in an attempt to evaluate the Mini-CEX inpractice.

MethodsThis study was a prospective quantitative study involving aqualitative study design in order to evaluate the effectiveness ofthe Mini-CEX in the modern NHS. Doctors were invited for astructured focus group interview from East Sussex NHSHospital Trust. They required previous experience of beingassessed with the Mini-CEX. Participation was entirelyvoluntary. A total of six questions were asked, allowing up to tenminutes for completion of the discussion by trainee doctors.The focus group interview was audio-taped with consent fromeach participant. The tape was analysed and a questionnairewas formulated reflecting the views and concerns ofrepresentative sample of trainee doctors.

The questionnaire was designed to be short in order toobtain maximum response. The questionnaire contained 15closed set of questions, taking approximately five minutes tocomplete. It was distributed for completion to all doctorsassessed by the Mini-CEX based at East Sussex NHSHospitals Trust. All completed questionnaires were collectedafter completion.

Data from the questionnaire was manually entered intoMicrosoft Excel© spreadsheet package. Data was thenincorporated from Excel into SPSS© (Statistical Package forSocial Sciences Version 14) for statistical analysis.

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ResultsA total of 50 completed questionnaires were returned from 70questionnaires distributed (71% response rate). Figure 1depicts the number of completed questionnaires returned fromfemale andmale doctors. This percentage is consistent with theincrease in number of female doctors in the UK7.

The Mini-CEX has been fully incorporated into foundationprogramme8 and is currently being evaluated to see whether itis useful as a tool in speciality training. The results depicted infigure 2 illustrate that 80% of doctors who responded werefrom the foundation programme.

Figure 2 - Relative number of grade of doctors who completed thequestionnaire in the sample

Figure 1 - Male to female ratios in sample

Figure 3 - Results of the Questionnaire

Of 52% of trainees that said they had a Mini-CEX carriedout correctly, 42% (11/26) had not been observed for 15-20minutes during their Mini-CEX.

Of 52% of trainees that said they had their Mini-CEX carriedout correctly, 31% (8/26) had not received 5-10 minutesfeedback during their Mini-CEX.

DiscussionWilkinson et al had concluded that it was feasible to carry outMini-CEX in the UK9. He noted that his trainers had “onlywritten instructions on how to use the Mini-CEX with no formaltraining” and also that “low completion rate highlights feasibilityproblems”. He went on to suggest that that lack of time was themain factor preventing completion. Our study demonstratesthat Mini-CEX is not feasible in the NHS in its current state.There are a number of issues that combine to give this result.They include: type of training received, motivation of trainer andtrainee and more importantly, time exclusively reserved forassessment. A study carried out in Argentina concluded thatthe Mini-CEX is not feasible within the current circumstancesin Argentina either10. Mini-CEX is an important tool for theassessment of doctors and also for maintaining patient safety.As it stands, less than half of the doctors in this study wereassessed properly. Assessment of doctors’ performance is animportant issue reinforced by high profile cases of malpracticeand the re-design of medical training (MMC). Assessing doctorsin an honest and objective manner is an essential part of theGeneral Medical Council’s guidance document Good MedicalPractice 200111.

Not being observed for 15-20minutes invalidatesMini-CEXfrom being performed correctly. Figure 4 highlights that thenumber of trainees who have had a Mini-CEX performedcorrectly may actually be lower. Assessors have manypressures on their time especially as clinical governance issueshave mushroomed over the last few years. Consultants have toattend more meetings and non-clinical events. This is timetaken away from clinical and training activities. PostgraduateMedical Education Department needs to recognise this fact soit can work with consultants to help free time dedicated forteaching and training. Consultants may also need moreexposure in medical education to help them in their role as

Figure 4 - Cross Tabulation of results from Question 1 and 4

Figure 5 - Cross Tabulation of results from Question 1 and 5

Questionnaire Yes No

1 Is the Mini-CEX carried out as intended? 52% 48%

2 Is the Mini-CEX carried out similarly to CBD? 66% 34%

3 Do you think trainers know the difference between Mini-CEX and CBD? 34% 66%

4 Have you ever been observed for 15-20 mins? 36% 64%

5 Have you ever received 5-10 mins feedback after observation? 44% 56%

6 Has your Education supervisor carried out Mini-CEX as it was intended to be? 30% 70%

7 By planning the timing of the Mini-CEX in advance will it be carried out properly? 72% 28%

8 If the Mini-CEX was carried out as intended would it be useful? 76% 24%

9 Are most Mini-CEX carried out retrospectively? 88% 12%

10 Is the feedback given useful? 74% 26%

11 Do you feel the feedback given is a box-ticking exercise? 72% 28%

12 Do you believe all Mini-CEX trainers are trained in their use? 12% 88%

13 If informed Education supervisor in advance would it be carried out properly? 44% 56%

14 Videoing consultation is achievable considering workload? 14% 86%

15 Watching video consultation with consultant is good idea for feedback? 50% 50%



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trainers and to reinforce the value of teaching. This may requirean incentive to make teaching more attractive and worthwhile.This is of paramount importance given that the etymology ofthe word ‘Doctor’ comes from the verb ‘docere’ which means‘to teach’. Teaching is increasingly being recognised asimportant. It is included in guidelines for doctors by the GMC2006 in “GoodMedical Practice”12. Morton et al acknowledgedthat time should be written into the job plans of clinical teachersto facilitate these assessments13. Excellence in teaching mustalso be acknowledged and rewarded. Steinert believes thatacademic vitality depends on faculty members’ interest andexpertise, and staff development has a critical role to play inpromoting educational excellence, innovation and vitality14.

Seventy two percent of trainees felt that the feedback givenmade Mini-CEX appear as a box- ticking exercise. Beard et alassessed the type of feedback given by different trainergroups15. His study showed that trainees valued feedbackgiven by academic trainees (teaching and research fellows).This may be because they discuss and record action plansmore often than any other groups including consultants andthey are more likely to identify positives and areas forimprovement in a trainee’s performance.

Seventy percent of education supervisors do not carry outthe Mini-CEX as intended. This statement reveals the need toinvestigate the training and education that is received byeducation supervisors, with a view to making improvements.Despite Mini-CEX not being carried out thoroughly byeducation supervisor 76% of trainees felt that if the Mini-CEXwas carried out as intended, it would be useful.

These results highlight that trainees do not have faith in theirtrainers’ knowledge of tools used in assessment. This is a sorrystate of affairs and it is no wonder that trainees may feel‘frustrated and disillusioned’. This has a cost to patients too, astheir doctors are not being properly assessed and thereforetrained.

Limitations of this study include the sample size of 50trainees, all from the South Coast of the UK. This maymean theresults are not generalisable to other parts of the Country;however, we can not think of any obvious reasons why theremay be any significant differences in opinion of trainees.

This study only addressed trainees’ opinions on theeffectiveness of the Mini-CEX. To make this evaluation morebalanced, perhaps a separate questionnaire could be producedto ascertain the trainer’s opinions. However, this is a separatestudy in its own right.

ConclusionTrainees appreciate the value Mini-CEX can have in theirtraining and they value the feedback given to them by theirconsultants. The Mini-CEX is in need of modification. It is notbeing used as it was intended and as such, it is not feasible inthe modern NHS.

There is overwhelming evidence for its effective use in theUS. However, this does not give it legitimacy to be used in theUK. There are many substantial differences in medicaleducation, training and funding between the US and the UKmaking the two incomparable.

The problems with the Mini-CEX that our study identifiesinclude:• Trainees are not being observed for 15-20 mins• Trainees do not receive 5-10 mins of feedback

All Basic and Higher Surgical Trainees

are encouraged to join

ASiT (Association of Surgeons

in Training). Membership is

open to trainees from all of the

surgical disciplines and is

available for a nominal fee.

With a strong and active

membership your Council can

accurately represent

the views of the surgical

trainee to the Royal Colleges

of Surgery, the Specialist Associations

and the Department of Health.



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• Trainers do not know the difference between a Mini-CEXand a CBD

• Mini-CEX is being carried out retrospectively and similarly toa CBD

• Trainees do not believe that by informing their educationsupervisor in advance of the Mini-CEX, it would be carriedout as it is intended to be

• Trainees have faith in the value of a Mini-CEX. However,they have no faith in its practicality within the modern NHS

Trainees value and have faith in the Mini-CEX when it iscarried out as intended. The Mini-CEX has been developedusing and incorporating solid educational theory and as suchshould not be disregarded so easily. We have made somerecommendations that we feel should be implemented urgentlyin order to make the Mini-CEX fit for purpose in the modernNHS.

Recommendations1. All education supervisors or trainers should attend a course

on Mini-CEX before they are allowed to assess trainees. Acourse is necessary to explain to the trainers theimportance of their contribution to the assessment oftrainees. The course also needs to address the underlyingeducational theory, the significance of observing for 15-20mins and importance of 5-10 mins of feedback. It should beemphasised that by carrying this out, they will benefit theirtrainees’ training and patient safety.

2. Individual trainers who obtain good feedback for training bytheir trainees’ should be rewarded by their respective trustsand deaneries. This should reinforce the importance oftraining.

3. Trainers to be accountable for neglecting their responsibilityof training trainees. This will send a strong message that themedical community believe it is unacceptable and an abuseof trainees if they are not receiving training.

4. Time must be ring fenced in the trainers’ working week toallow them to carry out their duty of training. It is recognisedas such by the GMC in their publication Good MedicalPractice 2006.

5. There should be regular audit to see howWPBA are actuallybeing carried out.

References1 Royal College of Physicians Website 2005. Available from

http://www.rcplondon.ac.uk/news/news.asp?PR_id=2562 Modernising Medical Careers. Available from: http://www.mmc.nhs.uk/

medical_education.aspx3 Dyer C. Bristol case surgeon claimed to have been on "learning curve”.

BMJ 1999; 319: 14564 Norcini J, Blank L, Arnold G and Kimball H. The Mini-CEX (Clinical

Evaluation Exercise): A Preliminary Investigation. Annals of InternalMedicine 1995; 123: 295-99

5 Durning S, Cation L, Markert R and Pangaro L. Assessing the Reliabilityand Validity of the Mini-Clinical Evaluation Exercise for InternalMedicine Residency Training. Academic Medicine 2002; 77: 900-904

6 Kogan J, Bellini L, and Shea J. Feasibility, reliability, and validity of themini-clinical evaluation exercise (mCEX) in a medicine core clerkship.Academic Medicine 2003; 78: S33-S35

7 Brettingham M. UK doctors move towards general practice and flexibleworking. BMJ 2005; 331: 1163

8 Modernising Medical Careers. 2007. The Foundation ProgrammeCurriculum. Available from: http://www.foundationprogramme.nhs.uk/pages/home/training-and-assessment

9 Wilkinson J, Crossley J, Wragg A, Mills P, Cowan G and Wade W.Implementing workplace-based assessment across the MedicalSpecialties in the United Kingdom. Medical Education 2008; 42: 364-73

10 Alves de Lima A, Barrero C, Baratta S, Castillo Costa Y, Bortman G,Carabajales J, Conde D, Galli A, Degrange G and Van der Vleuten C.Validity, reliability, feasibility and satisfaction of the Mini-ClinicalEvaluation Exercise (Mini-CEX) for cardiology residency training. MedTeach 2007; 29 (8): 785-90

11 General Medical Council. Good Medical Practice. 2001. London12 General Medical Council. 2006. Good Medical Practice. Available from:

http://www.gmc-uk.org/guidance/good_medical_practice/index.asp13 Morton J, Cumming A and Cameron H. Performance Based

Assessment in Undergraduate Medical Education. The Clinical Teacher2007; 4: 36-41

14 Steinert Y. Staff development for clinical teachers. The Clinical Teacher2005; 2(2): 104-10

15 Beard J, Strachan A, Davies H, Patterson F, Stark P, Ball S, Taylor P andThomas S. Developing an education and assessment framework for theFoundation Programme. Medical Education 2005; 39: 841-51


status and to quantify the degree where malnutrition exists. Italso aids monitoring the efficacy of nutritional support at a laterdate. Screening can be done during outpatient appointmentsand should be repeated weekly for those staying in hospital10.

The first stage in assessment should include a focusedhistory and physical examination. A patient’s risk of malnutritionmay be determined by measuring Body Mass Index in theclinical setting. Mid-upper arm circumference, mid-arm musclecircumference and skin-fold thickness may also be of use inpatients who cannot be weighed or have ascites or oedemawhichmay disguise a lowBMI. Examination should also includeassessment of muscle function including respiratory andcardiac muscles. An assessment of fluid status should includelooking for signs of dehydration including hypotension, dry skin,mucosal xerosis and swollen tongue. Examination should alsoinclude signs of specific nutrient deficiencies such as nervoussystem signs which could indicate vitamin E, B12 or thiaminedeficiency, hypomagnasemia, hypocalcemia or hypokalemia11.

The British Association for Parenteral and Enteral Nutritionproduced the Malnutrition Universal Screening Tool (MUST) inorder to identify those patients at risk of becomingmalnourished, regardless of their weight. MUST takes intoaccount BMI, unplanned weight loss and the effect of acutedisease to create a score which determines the patient’s overallrisk of malnutrition12. Inability to eat and functional impairmentare also risk factors for malnutrition. Early recognition andintervention can reverse and prevent future complications ofmalnutrition.

More complex measures such as biochemical and nutrientanalysis may also have a role in screening. Plasma proteinssuch as albumin, prealbumin and transferrin can indicateprotein-energy malnutrition (PEM) but concentrations areaffected by infection, inflammation, renal and liver disease andtherefore cannot be reliably used in clinical practice13.Laboratory monitoring can be used to measure the efficacy ofnutritional support however.

Nutritional SupportPreoperative nutritional support is more likely to successfullyreplete energy and nutrient stores compared with nutritiongiven postoperatively14. Nutritional support should beconsidered in malnourished patients or those at risk ofmalnutrition as defined by the following:

Malnutrition Risk of MalnutritionA body mass index (BMI) of less Eaten little or nothing for >5 daysthan 18.5kg/m² and/or likely to eat little or nothing

for >5 days

Unintentional Weight Loss of Patients with a poor absorptivegreater than 10% in the last capacity and/or high nutrient3-6 months losses and/or increased nutritional

needs from causes such asA BMI of less than 20kg/m² and catabolism.Unintentional Weight Lossgreater than 5% within the last3-6 months

Table 115

Once a nutritional deficit is identified, support may beimplemented. The aims of nutritional support in the surgicalpatient are to:

Scientific - Nutrition in the Surgical Patient

98

Nutrition in theSurgical PatientJustice Reilly, 4th Year Medical Student, GlasgowUniversity

MalnutritionMalnutrition is a lack of essential nutrients that causesmeasurable harm to body composition, function and clinicaloutcome1. Malnutrition may be the result of an inadequate dieteither in terms of consuming low quantity or quality foods. It istherefore possible for an obese person to be consideredmalnourished. An inadequate diet may lead to nutrientdeficiencies which can manifest as reduced muscle mass andmobility as a result of protein deficiency, frequent infections asa result of an inadequate immune system, or lethargy due to anenergy deficit.

The Surgical PatientA number of studies have identified increased mortality,impaired wound healing and poorer cell-mediated immunityassociated with malnutrition in the surgical patient2. The energyrequirements of a healthy person vary depending on age,gender, basal metabolic rate (BMR) and body composition.Surgery increases a person’s BMR leading to metabolic stresswhich can exacerbate underlying nutritional deficiency. Patientswho are undernourished have a poorer response and outcomefrom illness and surgery than those who are well-nourished asthey lack sufficient energy to cope with an increased BMR. Thepoorer outcomes in these patients are associated withincreased risk of infection, complications, and length of stay.

While obesity is commonly known to adversely affectsurgical morbidity and mortality, malnutrition is also associatedwith a poor prognostic outcome3. It is estimated that 20-40%of patients show evidence of poor nutrition on admission tohospital and that nutritional status deteriorates during inpatientstay4,5. The preoperative patient may become malnourisheddue to a poor appetite, dysphagia, malabsorption, alcoholism,inflammatory bowel disease or malignant disease. Hospitalis-ation may also contribute to malnutrition as patients are kept nilby mouth for investigations prior to surgery. The subsequentphysiological response to surgery further puts patients at risk ofa nutritional deficit as the usual catabolic response increasesenergy and protein requirements. Protein mobilised frommuscle is oxidised to meet the body’s energy requirements,resulting in loss of lean body mass and a negative nitrogenbalance. A positive nitrogen balance is essential for tissue repairafter trauma such as that experienced during surgery6. Poornutritional status therefore has implications for clinicalmanagement and may adversely affect outcome andsubsequent quality of life of the surgical patient7.

Nutritional AssessmentThe relationship between nutritional status and post-operativecomplications has been acknowledged for many years8,9. Theaims of nutritional assessment are to determine nutritional


99

• Enhance wound healing• Reduce postoperative complications• Reduce the period of inpatient stay• Prevent further deterioration

Supplementary feeding in malnourished patients reducesrehabilitation time and the rate of infection and improvesmuscle strength and the rate of wound healing .

Preoperative support often includes blood sugar control indiabetic patients, intravenous hydration in patients withiatrogenic starvation and bowel preparation for thoseundergoing elective gastrointestinal surgery. The latter is toensure the bowel contents are cleared prior to surgery andinvolves a low fibre diet started 3-4 days preoperatively andfluids only for 24-48 hours before surgery . Laxatives are alsogiven the day before bowel surgery to clear it of faecal matter.This preoperative regime reduces normal nutritional intake andmay further exacerbate pre-existing malnutrition.

Postoperative nutritional support may be oral, enteral orparenteral. Oral support comes in the form of fortified foods,additional snacks or sip feeds and can be taken alongside anormal diet. When surgery has not been to the gastrointestinal(GI) tract, an oral diet may be given on the first postoperativeday. Gut motility takes a few days to return after GI surgery, sothese patients must be introduced to a fluid and light diet in thefirst instance.

Enteral feeding is the delivery of nutrients directly into the GItract via a feeding tube. The tube may be inserted through thenose (nasogastric or nasojejunal tube), the oesophagus(oesophagostomy) or directly into the stomach (percutaneousendoscopic gastrostomy - PEG). Enteral feeding is oftennecessary in patients who have undergone oral or upper GIsurgery and are unable to eat. Enteral feeding can be startedimmediately after surgery to achieve an early positive nitrogenbalance and improve sepsis resistance . However abdominalsurgery and low gastric motility can lead to poor tolerance toearly feeding. Surgical patients who are malnourished, asdefined in table 1, and have inadequate or unsafe oral intakebut a functional GI tract should be considered for pre-operativeenteral feeding . Enteral feed may be delivered eithercontinuously or intermittently via a feeding pump or gravity drip.Bolus feeding is less popular and is known to cause diarrhoeaand bloating in some patients. Fine bore nasogastric (NG) tubesare more comfortable for the patient, yet wider bore tubes areless susceptible to blockage. The position of the NG tube mustbe checked and this may be done by aspiration of gastriccontents, epigastric auscultation or a chest and abdominal x-ray. PEG placement is a surgical procedure done underendoscopic guidance. The tube is held in place in the stomachby a balloon or flange and may remain in place for a number ofyears.

Parenteral nutrition is the intravenous delivery of essentialnutrients such as electrolytes, amino acids, glucose, long chainfatty acids, trace elements and vitamins. Short term feedingmay be administered into peripheral veins; however thehypertonicity of combined nutrients necessitate administrationinto a large vein to allow for dilution of the infusion. Parenteralnutrition may be used to complement enteral feeding, or astotal parenteral nutrition (TPN) when it is the only nutritionalsource. TPN is therefore useful in patients who have a non-functioning GI tract, but is associated with a greater risk of

infection.Daily weighing of the patient and observing their blood

sugar and temperature may be used to monitor the efficacy ofnutritional support. Refeeding syndrome is a complicationcaused by too rapid reintroduction of feed after prolongedstarvation . This is more likely to occur in patients who havebeen starved for more than 7 days, lost more than 20% bodyweight in the last 3 months, are chronic alcoholics or those whohave anorexia nervosa. Enteral or parenteral feeding should notbe terminated until adequate intake of nutrients can beachieved orally or by enteral feeding respectively. Abruptcessation of nutritional support can cause inadequatenutritional intake so it should be gradually reduced as the intakeof oral diet increases.

The Role of EnteralFeeding in Patientswith Head and NeckCancerNutritional Issues in Head and Neck CancerHead and neck cancer (HNC) includes malignancies of the oraland nasal cavities, sinuses, salivary glands, pharynx, larynx andlymph nodes. Patients with HNC are particularly prone tomalnutrition. The anatomical location of the tumour may causepain on mastication and poorly fitting dentures leading to adecrease in consumption of solid foods. Frequent history ofalcohol abuse and excessive smoking in this patient groupcontribute to nutritional deficiency through the social andfinancial effects of their dependency . Indeed, one study of 122patients with head and neck disease found that 64%of patientswere nutritionally compromised prior to diagnosis . Cancercachexia syndromemay cause weight loss andmuscle wastingvia a shift towards hypermetabolism as the tumour and hostcompete for nutrients . Management of HNC often comprisessurgery, radiotherapy and chemotherapy, and the improvedoutcomes seen in patients with larger tumours receivingmultimodality treatments has lead to a greater need fornutritional support. Surgical resection causes local pain,dysphagia and odynophagia, while radiotherapy is known tocause xerostomia and rarely, oesophageal strictures.Chemoradiotherapy is associated with stomatitis, andmucositis in patients with HNC . Radiotherapy causing alteredtaste sensation, and chemotherapy causing nausea, anorexiaand diarrhoea further limit appetite, oral intake and contribute toa poor nutritional state. Any patient with dysphagia and inabilityto feed orally is considered at high nutritional risk . Evidenceindicates the outcome of radiotherapy treatment is not asfavourable if interrupted; therefore the need for dieteticintervention should be addressed at diagnosis of HNC beforedefinitive management commences.

The negative impact of malnutrition in patients with cancerhas long been acknowledged and it has been estimated thatmore than 80% of patients with HNC suffer from weight loss


100

during multimodal treatment . The prevention of malnutrition inthis patient group is particularly important to avoid lowimmunity which is a known prognostic indicator, and isassociated with poor wound healing and prolonged recovery29.Additionally, a depressed anti-tumour response results whenmacrophage function is impaired and there is a change in thenumber of cytotoxic T-cells30. Malnutrition may also increasethe morbidity risk of those undergoing salvage surgery. Despitedifficulties with oral intake, patients with HNC usually have anormal stomach and gastrointestinal tract. Therefore, enteralfeeding is more practical and easier in these patients whencompared to parenteral feeding as it preserves the gut mucosalmass, reduces hypermetabolism and enhances nutrientutilisation31.

Enteral Nutrition for Patients with Head and NeckCancerNG feeding is the simplest and most cost effective method ofenteral feeding and is the method of choice in those patientswith a patent and functioning gastrointestinal tract32. Patientpreference has lead to an increase in the use of PEG tubefeeding. PEG feeding was first described in 1980 by Gaudereret al. and soon obtained worldwide acceptance due to its easeand safety over those inserted via laparotomy33. Furthermore,PEG has shown superiority over traditional NG feeding tubes interms of allowing the patient greater mobility, its aestheticappeal, and a reduced incidence of oesophageal reflux andaspiration34. Currently, the use of NG tubes in patients with andrecovering from HNC is limited to those who require short termnutritional support, while PEG should be used for thosepredicted to require enteral nutrition for 4 weeks or more35. Thisis in part due to the added financial cost of PEG placement andalso to avoid the associated risks of sedation and the small riskassociated with the major complications of PEG tube insertion.These include bowel perforation, gastrointestinal haemorrhage,gastrocutaneous fistula and intra-abdominal or peristomalabscess36. PEG tubes that have been placed without apparentcomplications can be used for enteral feeding just four hoursafter placement37.

PEG tubes are commonly used in those patients withadvanced head and neck disease who requirechemoradiotherapy for some weeks, as the risk of tubedisplacement or blockage compared with NG feeding isreduced38. There are no current guidelines for feeding tubeduration in patients with HNC, and limited information on theaverage duration of enteral feeding exists. PEG tubes havebeen favoured in those patients who require prolongednutritional support due in part to lack of patient tolerance tonasal irritation and oesophagitis39,40.

Aspiration pneumonia is a risk most associated withextended NG tube feeding, which may be reduced, but noteliminated by PEG feeding. Extended PEG feeding led Mekhailet al to report a greater need for pharyngoesophageal dilationand less successful swallowing rehabilitation than NGfeeding41.

Patients with HNC are more susceptible to complicationssecondary to poor nutritional status. The prevention of weightloss in cancer treatment is a primary aim as this is related tomorbidities such as dehydration, prolonged hospitalisation,compromised treatment efficacy and decreased survival.Nutritional deficiency is an adverse prognostic factor forpatients with HNC both at the time of diagnosis, and in affecting

the success of treatment42. Prophylactic PEG insertion inparticular can be used to limit weight loss and has furthermorebeen shown to be safe during concurrent chemoradiation inpatients with HNC43,44. Enteral feeding is clearly indicated inthis patient group, though there are no current guidelines todefine whether NG, PEG or prophylactic PEG is necessary.

Prophylactic PEG FeedingPatient preference can play a great role in the decision forprophylactic PEG feeding. They understandably may bereluctant to commence enteral feeding for this extended periodbefore beginning chemoradiotherapy. They should, therefore,be appropriately counselled as to the advantage of prophylacticPEG feeding in limiting weight loss, as opposed toretrospectively facilitating weight gain. If the patient is alreadyindicated for prolonged enteral PEG feeding as part of theirmanagement, they may be more agreeable to have it placedpre-operatively. Ethically speaking, it is important that thepatient appreciates and agrees with prophylactic PEG feeding,as motivations for this feeding option have been questioned, asit is easier to provide nursing care. For this reason any patientcase considered for prophylactic PEG feeding mustdemonstrate a direct nutritional and prognostic benefit.

ConclusionsNutritional status is an independent factor for quality of life andsurvival, yet enteral nutrition alone does not necessarily improvequality of life. Though patients may appreciate the survivalbenefits of enteral feeding, it does not prevent them from feelingnegatively towards the device45,46. Indeed, PEG and NGfeeding tubes serve as a constant reminder to the patient oftheir disease, and deny them the taste, smell and sociabilityfactor that oral consumption allows47.

Nutritional support is advantageous not only in terms ofimproved patient quality of life and reduced complications, butalso in terms of health economics. The reduced postoperativehospital stay experienced in well nourished patients directlytranslates to NHS financial savings48. With an increasing lifeexpectancy and elderly population, the importance ofimproving the nutritional status in the surgical patient isparamount.

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7 Green CJ. The role of perioperative feeding. South African MedicalJournal 1998; 88: 92-8

8 Studley HO. Percentage of weight loss, a basic indicator of surgical riskin patients with chronic peptic ulcer. Journal of the American MedicalAssociation 1936; 106: 458-60

9 Mulholland JH, Tui C, Wright AM, Vinci V, Shafiroff B. Protein Meta-bolism and Pressure Sores. Annals of Surgery 1943; 118(6): 1015-23


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10 National Institute of Clinical Excellence. Nutrition Support in adults: oralnutrition support, enteral feeding and parenteral nutrition. NICE (2006)p10 (online, 20.9.09) http://www.nice.org.uk/nicemedia/pdf/CG032NICE guideline.pdf

11 Jeejeebhoy KN and Keith ME. Clinical Nutrition: 2.2 Clinical Assess-ment of Nutritional Assessment. Oxford: Blackwell Publishing 2005; 17

12 BAPEN Malnutrition Universal Screening Tool (online, 22.9.09)http://www.bapen.org.uk/pdfs/must/must_full.pdf

13 Jeejeebhoy KN and Keith ME. Clinical Nutrition: 2.2 ClinicalAssessment of Nutritional Assessment. Oxford: Blackwell Publishing2005; 21

14 Pudner R. Nursing the Surgical Patient. London: Bailliere Tindall (inassociation with the RCN) 2000; 56

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19 Mainous Mr and Deitch EA. Nutrition and infection. Surgical Clinics ofNorth America 1994; 74: 659-76

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38 Whike M, Berner YN, Gerdes H, Gerold FP, Bloch A, Sessions R, et al.Percutaneous endoscopic gastrostomy and jejunostomy for long-termfeeding in patients with cancer of the head and neck. Otolaryngology -Head and Neck Surgery 1989; 101: 549-54

39 Kenya R and Alobarhan S. Enteral alimentation: administratin andcomplications. Journal of the American College of Nutrition 1991;10: 209-19

40 Gardine RL, Kokal WA, Beatty D, Riihimaki DU, Wagman LD, Tetz JJ.Predicting the need for prolonged enteral supplementation in thepatients with head and neck cancer. American Journal of Surgery 1988;156: 63-65

41 Mekhail TM, Adelstein DJ, Rybicki LA, Larto MA, Saxton JP, Lavertu P.Enteral nutrition during the treatment of head and neck carcinoma. Ispercutaneous endoscopic gastrostomy tube preferable to a nasogastrictube? Cancer 2001; 91: 1785-90

42 Brookes GB. Nutritional status - a prognostic indicator in head and neckcancer. Archives of Otolaryngology - Head and Neck Surgery 1985;93: 69-74

43 Wiggenraad RG, Flierman L, Goossens A, Brand R, Verschuur HP, CrollGA, et al. Prophylactic gastrostomy placement and early tube feedingmay limit loss of weight during chemoradiotherapy for advanced headand neck cancer, a preliminary study. Clinical Otolaryngology 2007;32(5): 384-90

44 Nguyen NP, North D, Smith HJ, Dutta S, Alfieri A, Karlsson U et al.Safety and effectiveness of prophylactic gastrostomy for head and neckcancer patients undergoing chemoradiation. Surgical Oncology 2006;25(4): 199-203

45 Jordan S, Philpin S, Warring J, et al. Percutaneous endoscopicgastrostomies: the burden of treatment from a patient perspective.Journal of Advanced Nursing 2006; 56: 270-81

46 Anis MK, Abid S, Jafri W, et al. Acceptability and outcomes of thePercutaneous Endoscopic Gastrostomy (PEG) tube placements:patientsʼ and care giversʼ perspectives. BMC Gastroenterology 2006;6: 37

47 Bozzetti F. Quality of life and enteral nutrition. Current Opinion in ClinicalNutrition and Metabolic Care 2008; 11: 661-65

48 Bastow MD, Rawlings J, Allison S. Benefits of supplementary tubefeeding after fractured neck of femur: a randomised controlled trial.British Medical Journal 1983; 187: 1589-92

arrest, but more commonly leads to an acute compensatoryphase4. Review of the medical literature shows the commonestsymptoms and signs to be4,5,10-13:• High output cardiac failure (dyspnoea, increased JVP,

pulmonary oedema and widened pulse pressure)• Abdominal bruit and thrill• Palpable abdominal aneurysm• Oliguria• Consequences of regional venous hypertension (leg

oedema with/without cyanosis, pulsating varicose veins,haematuria and rectal bleeding)

• Variable symptoms and signs (shock, abdominal pain,chest pain, low back pain, scrotal oedema, tenesmus,priapism, and poor peripheral pulses)

Diagnosis, Treatment and OutcomeOnce the diagnosis is suspected there are various optionsopen to confirm it providing the patient is stable. Centralvenous blood may have high oxygen saturations14. Dopplerultrasound in the emergency department will show the AAAand may even demonstrate the fistula4,15. Angiography isconsidered the gold standard but only if there is no renalimpairment or shock5. Computed tomography, magneticresonance imaging and radioisotope studies have all beenused to make the diagnosis2,4,5,14,16-18, but pragmatically localresources and expertise are probably the most importantfactors in choice of diagnostic modality.

Diagnosis and surgery before development of shock candouble the chances of survival from 25% to 50%19. Diagnosisbefore surgery is desirable as it allows preparation by thesurgeon for appropriate operative techniques, care by thesurgeon not to dislodge debris into the inferior vena cavacausing a pulmonary embolism13, insertion of a pulmonaryartery catheter for the difficult haemodynamic controlintraoperatively14,20, and avoidance of early fluid overloadworsening the cardiac failure4. In one series mortality was15% if diagnosis was made before surgery in contrast with100% mortality if it was not21. In the semi-elective settingdirect insonation of the IVC with phased Dopplerultrasonography will make the diagnosis by showing thepresence of cardiac-phased high flow. When these fail, moreinvasive methods, including arteriography and venography,with passage of a balloon-tipped catheter through the femoralvein into the IVC to look for pressure gradients, elevatedcentravenous pressures, and increased oxygen content in thevenous blood may be used20.

The diagnosis is sometimes difficult because signs of thefistula may be discrete. Often these patients are operated forruptured aneurysms, and the fistulous communicationbetween the aorta and the IVC is detected only during theprocedure. The failure to demonstrate the fistula by CT maybe a result of timing of the scans or the initial size of thefistula22.

Open SurgeryThe most important feature of surgical repair is proximal anddistal control of both the aorta and the IVC. This isaccomplished either by including the vena cava and the iliacveins in the dissection of the aneurysm, by insertion of balloonsinto the IVC to obtain control of bleeding, or by directcompression of these vessels in the emergency situation. If the

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ManagementStrategies forAortocaval Fistula

Robert Brightwell and Tahir Hussain, Departmentof Vascular Surgery, Northwick Park Hospital,Harrow

Aortocaval fistula (ACF) was first reported by Syme in 18371and is usually a rare complication of abdominal aorticaneurysm (AAA). Its incidence is approximately 1-2% butthis increases to 2-6.7% in the presence of ruptured AAA2.ACF is more common in men (98%) and with an average ageat presentation of 64 years3,4.

Eighty percent of ACF are a result of a spontaneous ruptureof an atherosclerotic aneurysm directly into the adjacent venacava, the remainder are either traumatic (15%) or iatrogenic(5% - eg after lumbar disc surgery)5. There have even beenreports of ACF formation as a late complication of EVARperformed previously for pure aneurysmal disease of the aorta6.

The size of the associated AAA is typically greater than6cm, but frequently much larger than this7. The theory behindthe development of these fistulae is that pressure and tensionfrom large aneurysms produce necrosis of the aortic wall. Thisresults in an adventitial inflammatory reaction and adherence ofthe adjacent veins (IVC to the diseased aorta). The processeventually ruptures the aortic wall/caval interface, creating afistula7,8.

Opening of an arteriovenous fistula results in a drop insystemic vascular resistance (SVR) which is the underlyingpathophysiological change responsible for all the systemiceffects attributable to ACF. This causes the mean arterialpressure (MAP) to drop, central venous pressure (CVP) to rise,the systemic blood flow to decrease and blood to betransferred from the arterial to the venous side of the circulation.A number of compensatory mechanisms attempt to maintaincerebral and coronary perfusion and to raise MAP to normal.This is achieved by increased venous return, heart rate andcardiac contractility all of which act to elevate cardiac output.Coupled with this SVR is increased secondary to directsympathetic effects and to enhanced renin secretion from thekidney9. If slow and gradual erosion occurs the size, andtherefore flow, of the fistula is limited and patients with goodcardiac function can compensate. However, if the fistula ismassive, or the cardiac function impaired, compensation will beonly partial and clinical symptoms and signs of CHFwill appear.

The ‘classical’ presentation of ACF is of a pulsatileabdominal mass, continuous abdominal bruit or thrill, and high-output congestive cardiac failure. Symptoms and signs may beattributable to the high venous return and arterial insufficiencyto other structures caused by the fistula itself or attributable toassociated intraperitoneal or retroperitoneal rupture. Thissudden increase in venous return to the heart along withdecreased peripheral vascular resistance can lead to cardiac

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diagnosis is not suspected before operation and control of theIVC is not obtained, there is an increased risk for massivehaemorrhage or air embolism. The fistula is usually closedprimarily with nonabsorbable suture, although there have alsobeen reports of patch repair of the fistula with Dacron23. Thefistula is usually closed through the opened aneurysm sac, butin difficult cases, ligation of the vena cava or even the aorta(with synchronous anatomical or extra-anatomical recon-struction) may be necessary22. After successful treatment, thesigns of decompensation and impaired renal function due tovenous hypertension quickly vanish9,22. In conventional surgery,improvement is usually seen almost immediately after cross-clamping the aorta.

Comorbidities and pathological changes caused by thefistula complicate any surgical treatment. If a fistula has beenestablished for a long period of time, massive intraoperativeblood loss due to arterialized veins is unavoidable. Even insemi-elective cases, the mortality rate approaches 30%,especially in patients with cardiovascular decompensation7.

Endovascular OptionsEndovascular stent-grafting offers an attractive therapeuticalternative to the open repair of ACF. Boudghene et al reportedsuccessful treatment of ACF with percutaneous stent-grafts inan experimental study in which the ACF was createdpercutaneously in eight sheep24. There have been a number ofreported cases of endovascular stent-grafts in themanagement of traumatic or iatrogenic aortocaval fistulae, andthere is a growing experience of their use in the treatment ofAAA complicated by ACF.

In 2009 Antoniou et al evaluated the outcomes ofendovascular stent-graft repair of all the major abdominalarteriovenous fistulae reported in the literature and in their ownexperience25. The most common aetiological factors for thesefistulae were the presence of an aortoiliac aneurysm andprevious EVAR, accounting for 56% and 13% of allassociations, respectively. The technical success rate was anexcellent 96% (22/23). They observed no perioperative or 30-day mortality during a mean follow-up of 9 months. The mostcommon procedure-related complication was a type IIendoleak, which was found in 22% (5/23) of the patientsexamined, but no standardised imaging modality was used atfollow-up. This event was either self limiting or required minimalpercutaneous intervention to correct. The reader mustremember that there will be considerable bias in favour ofeEVAR in those case reports that have been published.

Endovascular treatment of ACF can be difficult due todilated superficial veins (with increased flow) making dissectionand control of the common femoral artery technicallydemanding. High flow in what is essentially a centralarteriovenous fistula also makes opacification and safevisualisation of the renal arteries difficult26. An unexpectedhaemodynamic phenomenon described by Lau et al is asudden increase of SVR, caused by an abrupt fall of cardiacoutput after occlusion of the ACF upon stent-graft release27.This leads to refractory hypertension requiring invasivemonitoring (if not already being used) and close medicalmanagement. Such change is not observed after open surgery,perhaps due to aortic cross-clamping and associated bleeding.

ConclusionsDespite the low frequency of AVF in aortoiliac aneurysms, acareful physical examination should raise clinical suspicion.Abdominal murmur is the most common sign, sometimesassociated with pain and abdominal mass on palpation.Identifying the fistula before the surgery is crucial for surgicalplanning and reduction in mortality. Endovascular exclusionappears to be an efficacious means of treating ACF andaverting the significant blood loss commonly encountered inconventional repair of these lesions. Such repair of majorabdominal arteriovenous fistulae appears to be a safer andeffective treatment option, with good short and mid-termresults in those cases that have been reported. However, nolong-term data exist, and with it extremely unlikely that arandomised, controlled trial will ever be performed to measureeEVAR’s efficacy in the treatment of ACF (due to smallnumbers of patients seen). Larger series are required to drawmore solid conclusions regarding the outcomes of thismethod.

References1 Gilling-Smith GL and Mansfield AO. Spontaneous abdominal

arteriovenous fistulae: report of eight cases and review of the literature.Br J Surg 1991; 78: 421-5

2 Schmidt R, Bruns C, Walter M and Erasmi H. Aorto-caval fistula - anuncommon complication of infrarenal aortic aneurysms. ThoracCardiovasc Surg 1994; 42: 208-11

3 Davidovic L, et al. Aorto-caval fistula due to abdominal aortic aneurysmrupture. Srp Arh Celok Lek 1997; 125: 370-4

4 Miani S, et al. Spontaneous aorto-caval fistulas from rupturedabdominal aortic aneurysms. Eur J Vasc Surg 1994; 8: 36-40

5 Abbadi AC, Deldime P, Van Espen D, Simon M and Rosoux P. Thespontaneous aortocaval fistula: a complication of the abdominal aorticaneurysm. Case report and review of the literature. J Cardiovasc Surg(Torino) 1998; 39: 433-6

6 Fujisawa Y, et al. Aortocaval fistula after endovascular stent-grafting ofabdominal aortic aneurysm. J Cardiovasc Surg (Torino) 2009; 50:387-9

7 Calligaro KD, Savarese RP and DeLaurentis DA. Unusual aspects ofaortovenous fistulas associated with ruptured abdominal aorticaneurysms. J Vasc Surg 1990; 12: 586-90

8 Alexander JJ and Imbembo AL. Aorta-vena cava fistula. Surgery 1989;105: 1-12

9 Albalate M, Gomez Octavio J, Llobregat R and Fuster JM. Acute renalfailure due to aortocaval fistula. Nephrol Dial Transplant 1998; 13:1268-70

10 Gordon JB, Newman KD and Marsh JD. Angina pectoris as the initialmanifestation of an aortocaval fistula. Am J Med 1986; 80: 514-6

11 Houben PF, Bollen EC and Nuyens CM. "Asymptomatic" rupturedaneurysm: a report of two cases of aortocaval fistula presenting withcardiac failure. Eur J Vasc Surg 1993; 7: 352-4

12 Nemcek A Jr. Elderly man with unusual symptoms. J Vasc Interv Radiol1996; 7: 542-3

13 Potyk DK and Guthrie CR. Spontaneous aortocaval fistula. Ann EmergMed 1995; 25: 424-7

14 Sadraoui A, Philip I, Debauchez M, Ibrahim H and Desmonts JM.Hemodynamic diagnosis of aortocaval fistula complicating abdominalaortic aneurysm. Ann Fr Anesth Reanim 1994; 13: 403-6

15 Daxini BV, Desai AG and Sharma S. Echo-Doppler diagnosis ofaortocaval fistula following blunt trauma to abdomen. Am Heart J 1989;118: 843-4

16 Boraschi R. A spontaneous aortocaval fistula due to an infrarenal aorticaneurysm. Its diagnosis with peripheral venous digital angiography.A case report. Radiol Med 1992; 84: 657-9

17 Pevec WC, Lee ES and Lamba R. Symptomatic, acute aortocavalfistula complicating an infrarenal aortic aneurysm. J Vasc Surg 2009

18 Schott EE 3rd, Fitzgerald SW, McCarthy WJ, Nemcek AA Jr and SoninAH. Aortocaval fistula: diagnosis with MR angiography. AJR Am JRoentgenol 1997; 169: 59-61

19 Ghilardi G, et al. Rupture of abdominal aortic aneurysms into the majorabdominal veins. J Cardiovasc Surg (Torino) 1993; 34: 39-47



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20 Kwaan JH, McCart PM, Jones SA and Connolly JE Aortocaval fistuladetection using a Swan-Ganz catheter. Surg Gynecol Obstet 1977; 144:919-21

21 Brewster DC, et al. Aortocaval and iliac arteriovenous fistulas:recognition and treatment. J Vasc Surg 1991; 13: 253-64; discussion264-5

22 Woolley DS and Spence RK. Aortocaval fistula treated by aorticexclusion. J Vasc Surg 1995; 22: 639-42

23 Magee HR and Mellick SA. Aortocaval fistula as a complication ofleaking aortic aneurysm. Br J Surg 1977; 64: 239-41

24 Boudghene F, Sapoval M, Bonneau M and Bigot JM. Aortocaval fistulae:a percutaneous model and treatment with stent grafts in sheep.Circulation 1996; 94: 108-12

25 Antoniou GA, et al. Endovascular stent-graft repair of major abdominalarteriovenous fistula: a systematic review. J Endovasc Ther 2009; 16:514-23

26 Umscheid T and Stelter WJ. Endovascular treatment of an aorticaneurysm ruptured into the inferior vena cava. J Endovasc Ther 2000;7: 31-5

27 Lau LL, O'Reilly MJ, Johnston LC and Lee B. Endovascular stent-graftrepair of primary aortocaval fistula with an abdominal aortoiliacaneurysm. J Vasc Surg 2001; 33: 425-8








Nottingham SCRUBS described its student-led weeklyanatomy program for pre-clinical students on the undergraduatecourse. These seminars covered anatomy from a theoreticalperspective in preparation for the coming weeks’ cadavericsessions, hoping to make the limited dissection room time moremeaningful and engaging.

A good working relationship with the Anatomy staff at theUniversity also provided the opportunity to develop cadavericanatomy session for students in their clinical years too.Nottingham students reported a good anatomy course early intheir medical training, but a common problem highlighted was thatthis was long forgotten by the time it became most useful andpatients were being encountered in theatre.

Friendly, enthusiastic surgeons and local teaching fellows wererecruited to teach anatomy to SCRUBS members in the clinicalphase of their medical training. Individual cadaveric sessions havebeen run, very much with a clinical emphasis in the hope to refreshknowledge but at the same time give a metaphorical patient-centred ‘peg’ upon which to hang one’s ‘anatomical coat’.

Recruiting surgeons is often difficult as their working hours andother commitments make diaries busy. But we can report thatthose who took part in teaching enjoyed doing so and did so to aproactive and highly motivated group. Getting the timing right,organising sessions well in advance and working closely with thedissection room staff were all a priority to ensure these eventsworked.

Others from around the country reflected on similarexperiences and it was hoped that this could be a platform for allthose at the session from which to develop workable opportunitiesfor students who also felt their anatomy wasn’t what theyconsidered up to scratch.

The student sessions, as with the main ASiT conference,provided a useful forum for surgeons of the future to discussissues they faced in their day to day lives with peers from acrossthe country. 2010 will hopefully provide a similar platform againand build on what was a successful venture for the Association.

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Student PlenarySessions: AnatomyDebate

Matt White, SCRUBS President, Final YearMedical Student, University of Nottingham

The medical student section of the ASiT conference was very wellreceived and more importantly very well attended (particularly onthe Sunday morning, post Gala dinner). Useful careers talks bylocal Trent Deanery surgeons including Jon Lund and Gill Tierneygave the opportunity to discuss committing to a life in surgery andimportantly how to best facilitate this most competitive of careerchoices.

Students have their own agendas and concerns and thus astudent orientated slant to conference gave a large group ofattendees a focussed set of sessions dealing with pertinent issuesin a relaxed but attentive forum.

One contentious area debated was the method, timing andquality of anatomy teaching at medical school. Whilst everyUniversity attempts to fit an ever expanding curriculum into itstimetable, inevitably something has to give. The reduction incadaveric donations post scandals such as Alder Hey have hadtheir effect and thus when in theatre it is not surprising to hear asurgeon utter the words “so what is this…” and commonly lesssurprising to hear the reply “errr… I don’t know”!

There are growing numbers of students who are investing in asurgical career wishing to improve their retention of anatomicalbasics to get more from their time in theatre and understanding ofthe surgical patients they meet. This is a group of young peoplewho do not sit and moan at their misgivings and the Universitythey attend, but who are prepared to invest in their own education;A group happy with their medical school, but aware of the realitiesof higher education in the modern health service.

As President of the University of Nottingham Student SurgicalSociety (SCRUBS), The ASiT conference student sessions gave usthe chance to showcase some of the things we have been involvedwith here in the host City as well as give students from across theUK the opportunity to share ideas and discuss problems in theirregions.

Andrew Pillai, the then ASiT National Student Representative,highlighted Liverpool’s efforts to organise extra-curricularanatomical teaching. In conjunction with their Anatomy facultycolleagues at the University, the Surgical Scousers had managedto formulate a five year rolling dissection and anatomy program.Each year a small number of themed sessions were run by faculty.Thus by attending from year one, students who wanted moreteaching could build a portfolio that encompassed the majoranatomical areas year on year. Repetition of the curriculum onsuch a rolling basis was envisaged to give consistent and broadteaching to students from all years that were willing to use theirtime outside of their normal timetable. This program wasdescribed as being in its infancy and time will tell as to its efficacyand longevity. The 2010 ASiT conference will provide a good forumto explore this again.

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As students seeking a career in surgery it is our duty to raiseawareness amongst our peers of the detrimental effects of the48-hour EWTD. Hopefully, by the time we enter Core SurgicalTraining, the Department of Health will have made thenecessary changes to allow the proposed opt-out of EWTD.However, in the meantime we should aim to make the most ofour student years and proactively seek more time in theatre. Itis important to note the age old saying ‘every cloud has a silverlining’; in this case, being able to see that silver glint of a scalpelmore often may be just that.

References1 Fitzgerald E, Caesar B. EWTD for Surgical Trainees, a guide by the

Associations of Surgeons in Training. Retrieved November, 2009, fromEuropean Working Time Directive- Association of Surgeons in Training:http://www.asit.org/resources/articles/ewtd

2 Black J. EWTD: maintaining the pressure. Bull R Coll Surg Engl 2009Sep 91(8): 258-259

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Finding the SilverLining: Making theMost of the EWTD inYour Student YearsHugo Gemal, Nottingham UniversityRepresentative

Whilst the European Working Time Directive (EWTD) does notsignificantly impact on medical students’ working hours, it iscertainly a constraint that we will be working as junior doctorsin the near future and this may have an impact on our learningopportunities.

Awareness of the EWTD, the controversy that it is causingand its consequences on our future training varies immenselywithin the medical student population. Through the directcontact in place between the Royal Colleges and ASiT,members of student surgical societies are seemingly betterinformed than their colleagues. All medical students should beaware of the implications of the EWTD, but it is especiallypertinent to the future of those of us wanting to enter a careerin surgery.

Having recently completedmy senior surgical attachment inmy final year, I encountered first-hand the frustration that theEWTD is inflicting on surgeons at all levels of training, includingfoundation doctors preparing to embark upon a surgical career.

The overwhelming majority of surgeons I’ve worked withhave opinions reflecting the recent statements of ASiT andRCSEng President John Black regarding the detrimental effectsof the EWTD on continuity of care with increasing handoversand profound negative effects on training opportunities1,2.Contrary to the Department of Health’s image of less tired,refreshed doctors, juniors are under even more pressureworking under rigid timetables, which is not always compatiblewith the nature of the work and significantly reduces theiravailability to teach students. As highly motivated students, weshould seek out learning opportunities wherever possible,especially in light of the reduced training hours that will beavailable to us. It is up to us to take advantage of the EWTD andproactively seek a more hands-on role in teams suffering underthe strain.

Senior students should approach consultants and registrarsto identify surgical procedures short of assistants. Assistingsurgeons in theatre is a powerful learning resource for anymedical student; it allows for a tactile reinforcement ofanatomical knowledge and discussion of management plans,whilst permitting an active involvement in patients’ treatment.

We should become more involved in jobs on a daily basisand take on appropriate tasks of ward doctors, such as formfilling and venepuncture. This could provide the bestopportunity to learn essential aspects of our future roles,display our enthusiasm and aid clinicians in finding time toteach us.

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and at times full additional teams. Overall, it is important todistinguish the anaesthetic team from the surgical team and thenursing staff from the doctors. Being polite and helpful to allstaff present, whilst valuing and respecting their superiorknowledge, will help gain their time and support. It is worthnoting that sometimes it is considered polite to gain permissionfrom not only the lead surgeon but also the theatre nurse beforeobserving a list.

Be aware that each theatre is different, take time to lookaround, check floor markings and note the difference betweensterile and unsterile areas. Many a student (and trainee) hasbeen told off for standing in the wrong place or touching thewrong equipment. You may also not be aware but you shouldnever enter the anaesthetic room when the patient is beinginduced. Often you should avoid this route entirely and onlyenter via the scrub or equipment room.

Get Involved and Help the StaffTheatre staff may sometimes feel doctors are unfairly harsh andthat medical students can act superiorly toward them. Whilstmost students are aware of the fundamental role of differenthealth care professionals, taking on and showing interest intheir varying responsibilities will help combat this discrepancy.Remember although less vital than other staff, you are part ofthe team. Helping move patients, clean surfaces and tiesurgical gowns will speed up changeovers between cases andfree up time for staff to help teach you.

To Scrub or Not to ScrubScrubbing up is exciting. It allows students to feel involved inand get closer to operations, help hold instruments andsometimes perform cutting, suturing or knot tying. Scrubnurses are usually the best at teaching you how to scrub, andif not busy most will happily help when asked. It takes thosewith experience three minutes to scrub for the first operationand one minute in between each new case. However, studentsare expected to take more time, show extra vigilance andsometimes make mistakes. Staff may watch you and offeradvice. Take their suggestions on board; remember theircomments are not personal but about improving patient safety.Try to find out your glove size and know how to open gownsand gloves etc. It may help to borrow a pair of gloves fromtheatre to practice putting them on in a sterile way.

Sometimes, it is not appropriate or less useful to scrub.There may be too many people already involved or gaining thebest sightline requires frequently moving around the room.Quite a few surgeons or their trainees will know whether it’sbest to scrub or not. Don’t be afraid to ask, some may say no,but most only with good reason. If unscrubbed, do maintainenthusiasm; don’t feel you need to stay flat against the wall orin silence for the whole time.

Ask QuestionsWhether at the surgeon’s side or further back, you will want toask questions. This shows the surgeon you are interested andwant to be taught. Even if the operation appears toocomplicated, ask questions about general topics; anatomy hasalready been covered above, but queries about prepping thepatient and the possible complications can be asked in mostsituations.

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Surgical Etiquette:a Guide to Time Spentin Operating Theatres

Jessica Johnston, ASiT Medical StudentRepresentative, Final Year Newcastle Universityand Antonia Mortimer, Fifth Year MedicalStudent, Imperial College London

As a medical student, operating theatres can often feel foreignand intimidating. They are submerged in rules and regulationsto optimise safety and efficacy, and frequently contain severalunfamiliar staff. However, familiarity of the process ofoperations is essential to becoming a doctor and there aredefinite ways of feeling less intimidated and making more ofyour experience. Attempting to build on a recent article in theStudent BMJ1 outlined here is a guide to students so that theirtime spent in theatre can be fully beneficial.

PreparationMeet the PatientsIt is a legal requirement for patients to consent to medicalstudents attending their operations2 and although this is usuallyincluded on consent forms, asking patients directly is not onlygood form, but provides an opportunity to place the operationin context. With this in mind, some surgeons may ask you toleave if you have not met their patients. Obviously, taking timethe night or morning before to clerk the patient is ideal.However, any time spent with the patient is better thannothing.

Know your AnatomySurgery provides the best opportunity to fully understandanatomy. Finding out what’s going to be operated on andrevising anatomy of that area will aid your understanding of theoperation immeasurably. Surgeons generally complain aboutstudents not knowing enough anatomy and many students areaware of their limited knowledge. Being able to ask and answersimple anatomical questions will impress most and make somemore likely to take time to teach you.

In TheatreFamiliarise Yourself with the Staff and SurroundingsResearch from the University of Aberdeen has shown that incomparison to other clinical experiences, students can feelsignificantly unwelcome within theatre and their learning isheavily dependent on the attitudes of the theatre staff3. At anygiven operation there may be more than five members of staffpresent within one theatre, a number dependent on multiplefactors including: patient, hospital, operation, specialty andtiming. Most teams include a lead surgeon with or without ajunior trainee, an anaesthetist with or without an anaestheticnurse/assistant, a scrub nurse and technician. Others presentmay include equipment technicians, multidisciplinary managers

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Asking at the appropriate time is an acquired skill andsurgeons differ. Try to judge tension in the room, and avoidasking when major decisions are being made. Target yourquestions at different people, lead surgeons, trainees and scrubnurses can help with most surgical questions but theanaesthetic team can also provide essential information. Don’tbecome demoralised if you are rebuked for asking a questionout of turn, instead learn from your mistake and use theexperience to better gauge tension in the future. Rememberyour unanswered questions and if they are important to yourunderstanding consider rephrasing them and/or asking afterthe operation has been completed.

Avoid FaintingPossibly a statement of the obvious, but having breakfast andkeeping your blood sugar optimal throughout the day will helpprevent you feeling light headed. Often it is not the operationthat makes people faint but the multiple layers, heat of the lightsand standing for long time periods. Surgeons appreciate thatyou are not used to this environment, but fainting over thepatient is a disaster. If you feel faint, don’t be afraid to standback from the operation table and sit down. You can oftenrecover quickly and if careful, can remain sterile and shortlyreturn to help. If you do feel sick or light headed prior to thebeginning of the operation, think carefully about whether it isnecessary for you to scrub in.

Be ProfessionalHealth professionals fit teaching medical students into theirmultitude of different tasks. Try to be punctual, when notwearing scrubs dress appropriately and introduce yourself todifferent team members. Your behaviour will not only affect yourown learning but may have repercussions on the futureteaching of other students.

After the OperationContinue LearningAt the end of an operation, there is still ample opportunity forlearning. Unanswered questions can be re-asked and readingof the operation notes, a summary written by one of thesurgeons which provides details of the operation itself and anoutline for the patients further management, can help you fullyappreciate the events of each surgery.

Follow the patient through to the postoperative area.Complications can still happen and monitoring the patientcontinues. It is also a great time to learn about the analgesics,anaesthetics and anti-emetics used. Although recovery can beslow, most patients will appreciate being thanked for letting youobserve their surgery. Try to keep a record of the operationsyou’ve seen, this is compulsory at some medical schools, butfor other students is a good habit to get into. Doctors areincreasingly expected to record their learning achievementsand surgical trainees are increasingly asked to providequantifiable evidence of the operations they’ve been involvedin. Details of Surgical Logbooks available to medical studentscan be found on the student pages of the ASiT website4.

Take Home MessageMedical students can be a wonderful hospital resource andtheir learning is essential to the continued success of theprofession. Theatres can be intimidating but they are also theideal place to understand some of the specifics of surgery andcover more general medical topics such as successfulteamwork and anatomical knowledge. The majority of thisarticle is applicable to other situations such as ward rounds andclinics. There are some basic points that, as students, we dooccasionally forget, but try to use the above information to feelless threatened and make the most of your learningopportunities.

References1 Mortimer A. Backstage Hands: theatre experience. Student BMJ

2009:17: b36102 Shaw ASJ. Should medical students attempt to get consent? Student

BMJ 2005; 13: 3263 Fernando N, et al. Undergraduate medical studentsʼ perceptions and

expectations of theatre-based learning: How can we improve thestudent learning experience? The Surgeon 2007: 5: 271-74

4 www.asit.org

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Surgery Has So Many DimensionsIt gives me that constant reminder that life’s too short and howgrateful I am for all that I’m blessed with (3 gorgeous kids and aloving husband). I’m able to be a clinician and hopefully treat mypatients as though they were members of my family.As a surgeon, you get to work as part of a big extended team. Ithas also allowed me to travel places and make friends withsurgeons from all over the world.

There are some downsides to surgery. You do need to invest alot of yourself, both time and determination. Often I have beenboth physically and mentally exhausted. You need to be self-critical and to grow broad shoulders. It’s constantly challenging. Irecently performed my first abdominoperineal resection andlaparoscopic anterior resection (types of major colorectal surgeriesfor rectal cancer) from start to finish.

However the best thing about surgery for me, is when I’moperating, it is the only time in my somewhat hectic life that I havejust one thing to concentrate on. Then I try to do the best I can. Forme, it’s not a bad life.

Student Section - Becoming a Surgeon: a Personal Account of Finding Your Feet on the Surgical Ladder

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Becoming a Surgeon:a Personal Account ofFinding Your Feet onthe Surgical Ladder

Joy Singh, SpR in General Surgery

I guess I have always been interested in medicine; being ‘a good’catholic girl, that old adage of wanting to help people wasdrummed into me from an early stage.

I loved the sciences at school, figuring out how stuff workedand practical things just meant I was a bit of a tomboy… havingtwo brothers didn’t help.

My inspiration for surgery was Captain Hawkeye Pierce fromMASH, (yes I am that old; for younger guys, think Turk fromScrubs). Black comedy was my way of coping with my teenagemelancholy; their approach to life seemed to make sense.

But this was just a distant fantasy, as my classmates wouldridicule me saying I’d need a box to reach the operating table!

Well, I made it to medical school, where I loved anatomy anddid an elective in Medstar Trauma Center in Washington DC -quick action really did save lives. However, the thought of surgerywas banished to the depths after an awful placement at the handsof a true Neanderthal in the guise of a chauvinistic vascularsurgeon at a London teaching hospital. I didn’t want to beassociated with that type of person. I left medical school headingfor a career in paediatrics with my degree and a 3yr old in tow!

It was only after a call to theatre one day in my secondplacement (we did 2 six month posts back then) did I find myselfquestioning my career choice. I was working for a gentle-souledupper GI surgeon and a very cute registrar (who unfortunately wasmarried). In theatre, I loved the banter and the teamwork. Watchingthese skilled surgeons perform difficult surgery was fascinating…and then they started teaching me.

I soon was a regular in theatre and during that 6 months Iperformed 5 appendectomies, 1 over sewing of a duodenal ulcer,drainage of abscesses, below knee amputations and opening andclosing laparotomies. I could even tie surgical knots! Not bad for agirl with little hands and who really did need a stool to reach thetable.

I didn’t actually start general surgery until two years later afterorthopaedics and A&E, followed by a year stint as an anatomydemonstrator. However, I am now approaching the end of mytraining as a colorectal surgeon and when I look back I can’tactually figure out what else I would have chosen to do.

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It has been well versed that “Anatomy is the satellitenavigation of everything we do”2. A good knowledge ofanatomy is key in surgery, and SCRUBS reinforces this idea byholding weekly anatomy tutorials. These sessions are run bymembers of the anatomy cell, allowing pre-clinical students toreceive a ‘head-start’ in their revision for their weekly dissectionassessments, and clinical students to refresh and re-visit theirknowledge. Being student-led means that the sessions are runfrom a student perspective, allowing efforts to be concentratedon the areas that students find most challenging.

SCRUBS is currently organising a ‘theatre experience’ forpre-clinical students, allowing students to appreciate thesignificance of anatomy and observe its application to surgicalprocedures.

Providing resources to help students with exams is animportant part of the work carried out by SCRUBS. SCRUBSannually organises a mock finals OSCE exam, where 5th yearsare examined by both F1 and F2 doctors. Similarly, a mock CP1Osler exam is organised for 3rd years, and a mock anatomyspotter exam is held for 1st years.

Surgery is a hands-on field, at the heart of which manualdexterity plays an integral role. Part of the portfolio-buildingexperience with SCRUBS includes the opportunity to gaintransferable, surgical skills. The Skills cell organises manypractical clinical skills sessions, including basic and advancedsuturing, laparoscopy, cannulation and fluids sessions. Theseclasses are led by a mixture of medical students, teachingfellows and Surgeons. These sessions add a practical aspect tothe society’s activities, and allow students to reinforce theirinterest in surgery. The sessions also act as a prelude to theactivities that students may carry out during their future surgicalcareers, and allow clinical students to gain first-handexperience of skills which they may observe/use (if they’relucky!) on their placements.

As well as working with medical students, SCRUBS alsoworks with those who are considering applying for medicalschool. Through the RCSE and the medical school we haveassisted in pre-med programmes throughout the year, teachingbasic suturing and talking to individuals about why medicalschool might be for them and in particular why a career insurgery can be so exciting.

Making a decision to enter a certain specialty is not alwaysstraight forward or easy; indeed it takes time and investmentresearching into a particular field. Nottingham SCRUBS is avery active society, and aims to equipmedical students with thenecessary tools and resources to make an informed decisionabout entering a surgical career. These tools take many forms,ranging from theoretical sessions to attaining practical skills.Students can build upon their portfolios, and gain a trueaccount of a life in surgery - something which is not alwayspossible to do through using the web or reading informationfrom a textbook.

Surgery is not ideal for everyone, but with the help ofsurgical societies, medical students can take their time toexplore the field of Surgery in an interactive way, and make theright decision for them; for it is commonly said, “you will neverknow unless you try”.

References1 http://surgicalcareers.rcseng.ac.uk/students/medical-students/what-should-

i-do-now 25/10/092 Cited in: RCSE Affiliate Newsletter, The Royal College of Surgeons of

England, 18/05/2007

Student Section - The Role of Surgical Societies in Undergraduate Education

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The Role of SurgicalSocieties in Under-graduate EducationIt is common knowledge that surgery is one of the mostcompetitive fields in medicine; this can be seen through thesteady increase in the number of applications for surgicaltraining in recent times. Student surgical societies at universitiesplay a pivotal role for medical students; these societies ensurethat all medical students can gain an insight into a surgicalcareer, whilst channelling and nurturing the interests of thosewho are already committed to the idea. Here two currentmedical students discuss the role of their societies within theirUniversities.

Sabrina Akhtar, Nottingham University StudentRepresentativeNottingham SCRUBS is the student surgical society at theUniversity of Nottingham. It was started in 2001, and has grownand developed, with more than 900 members at present.SCRUBS society operates in ‘cells’ covering core areas: Careers,Anatomy and Skills. The Society has events at all the major sitesused by the medical school particularly in Nottingham and Derbyand aims its events at members from both the undergraduateand Graduate-Entry Medicine (GEM) courses. The committeeconsists of pre-clinical and clinical students, which allows for thecontinual development of events and links to be formed withclinicians throughout the deanery. This particular organisationensures that individual cells can concentrate on their focusedactivities, whilst allowing scope for interaction amongst the othercells, for larger, broad scope events.

The Royal College of Surgeons of England advises that oneof the main ways to improve your chances of getting intosurgery is to develop a portfolio, showing your interest andcommitment to a surgical career1. Nottingham SCRUBS eventsare designed to facilitate medical students in this process andour events aim to develop and build upon students portfolios,through our various events.

The Careers cell provides first hand information about a lifein the different surgical specialties. One of the key eventsorganised annually is the SCRUBS Surgical Careers fayre. Thisfayre allows students to explore the different specialities aspotential career paths, and gain practical advice on portfolio-building and making an application for surgical training.Students can interact with surgeons from different specialties,and gain a true, reflective perspective of a surgeons’ life -something which most students find invaluable.

Individual seminars are also organised, usually on the backof interest from eager and motivated surgeons within the trust.One of the more recent seminars was on ‘paediatric fracturesand their management’. This seminar combined careerinformation for orthopaedics, anatomy knowledge and the skillsused in diagnosis and management. This event was deliveredin conjunction with the University of Nottingham PaediatricsSociety, Juniors. Nottingham SCRUBS is always looking tocollaborate with other societies to broaden the scope of ourwork and ensure we can run the best events possible.

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Student Section - The Role of Surgical Societies in Undergraduate Education

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Justice Reilly, GUSS PresidentGlasgow University Surgical Society

[email protected]: £3 yearly membership / £10 lifetime membership

What We DoGuest LecturesSurgical Skills Sessions @ Royal College of Physicians andSurgeons of GlasgowSurgery Taster DaysUndergraduate Surgical Conference

Glasgow University Surgical Society (GUSS) was formed in2005 by senior medical students. This relatively young societynow has a prominent voice in the medical school and an ever-expandingmembership. The primary aim of GUSSwas to openup surgical career choices to undergraduates and provide anetwork of students and surgeons who could offer advice.Hosting evening guest lectures by obliging consultant surgeonsensures students get exposure to those smaller surgicalspecialities and subspecialities not experienced throughoutnormal undergraduate teaching. Recent lecture topics includeMaxillofacial, Cardiothoracic, and Plastic Surgery as well astopical lectures covering the changing face of surgical training.GUSS also hosts revision lectures in the exam period on topicssuch as Anaesthetics, Obstetrics and Gynaecology andNeurology and Neurosurgery.

In the standard 5 year Glasgow curriculum, there are a totalof 48 weeks available for potential surgical experience including3 surgical blocks, 2 electives and 5 student selected Modules.GUSS helps students in planning such placements, with manystudents choosing attachments with our guest lecturers, whotypically make enthusiastic supervisors. We also arrange oneday ‘surgery taster’ sessions in transplant surgery so studentscan get a flavour of surgery without committing to a 5 weekplacement.

GUSS organises regular surgical skills sessions at theRCPSG Skills Suite. The courses cover suture, knot tying andlaparoscopic technique and are taught by senior surgicaltrainees. Feedback is positive and from my own experience,confidence in the practical skills gained and discussion withtutors takes the intimidation out of the operating theatreenvironment when students come to do their first surgicalattachment.

In November 2009 GUSS hosted the first annualUndergraduate Surgical Conference at the RCPSG, withdelegates attending from 17 different UK Medical Schools andFY deaneries. GUSS wanted to showcase Glasgow as a centreof excellence in research and surgical training and adviseundergraduates on career choices, which will have to be madeearlier than before. The event comprised 6 lectures byGlasgow’s leading consultants in different fields, including RuthMcKee, previous editor of the General Surgery Syllabus andISCP web tutor and Professor Sir Graham Teasdale,Neurosurgeon and co-inventor of the Glasgow Coma Scale.The afternoon consisted of tutorials on Surgical Skills andSurgical OSCE stations and also allowed students to makeposter presentations on surgical topics for that essential ‘extraline on the CV’.

In the 4 years I have been a GUSS committee member Ihave been privileged to be involved in the development of thesociety. GUSS currently aids students in making decisions ontheir preferred surgical specialty, and directs them toassociations such as ASiT for information and encouragementto compete in the newly-streamlined postgraduate trainingsystem. Overall GUSS has achieved its primary aim and we lookforward to expanding upon the achievements made thus far.

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the heavy-weight nature, the text is easy to dip-into, withheavy use of illustrations, radiographs and line drawings tomake topics clear.

The Anatomy Student’s Self-test Colouring BookKurt Albertine, ISBN 9781853157578Royal Society of Medicine PressSimilar in format to other anatomy colouring books, this newspiral-bound text provides a useful introduction to thenomenclature of human anatomy. With more than 350illustrations, it provides comprehensive coverage withlabelled diagrams and accompanying notes throughout.Although aimed at a more basic medical student level, thosepreparing for MRCS may find it a useful revision aid.

Clinical Surgery: A Practical GuideBaker & Aldoori, ISBN 9780340940846Hodder Arnold PublishingThis newly released text provides a very useful handbook-sized guide to the breadth of surgery-in-general. Thechapters are practical, and frequently problem basedaddressing common surgical problems and emergencies.Well structured throughout, with good use of tables,illustrations and summaries, it is easy to dip into quickly.While clearly readable by all those with an interest in thisarea, it seems particularly well suited to MRCS and juniorregistrars in need of a comprehensive yet concise coverageof topics. Test questions and references at the end of eachchapter are useful for those wanting to learn more about theareas covered.

Oral and Maxillofacial Surgery(Oxford Specialist Handbooks in Surgery)Kerawala & Newlands, ISBN 9780199204830Oxford University PressFor anyone who lived with the OHCM (aka the ‘cheese andonion’) in their pocket during medical school, the format ofthis new addition to the Oxford Specialist Handbooks rangewill be very familiar. Bound with the standard (and practical)wipe-clean plastic covers, this page-at-a-glance pocket-sized guide manages to condense the core knowledge ofOMFS down into 475 quick-reference pages. Easy and fastto dip in and out of, the bullet-pointed concise textaddresses the syllabus for the exit FRCS in OMFS in a clearand practical fashion. With numerous figures andphotographs to illustrate procedures, this is a very usefultext for those progressing through this specialty.

Anatomy Flash CardsRoyal Society of Medicine Press, ISBN 9781853158087This ready-made flash card pack contains 264 colourimages comprehensively illustrating the anatomy of the 10human body systems. The front of each card features titledillustrations with numbered pointers, while on the reverse,each numbered part is matched to its correct name, withexplanatory notes. Although aiming more at the medicalstudent audience, this pack is useful for ‘spotter’ practice, andfor those wanting to revise nomenclature and gross anatomy.

Book Reviews

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Book ReviewsAnatomy Colour-in FlashcardsRoyal Society of Medicine Press, ISBN 9781853159701Many readers will remember to anatomy colouring books ofold; the thought you might learn something while painlesslycolouring it in was always appealing. This new pack takestwo old ideas and combines them, so now not only can youcolour in but you’ve got some portable-sized flash cards torevise with too. There are 264 cards covering all the mainbody systems. The reverse of each card contains detailedanatomical descriptions and answers. While some of theareas are slightly more medical school basic scienceorientated, there is no doubt the anatomical diagrams areuseful in revising anatomical names and relationships. Oh,and 8 colour pencils are included!

OSCEs for the MRCS Part B (Bailey & Love RevisionGuide)Fishman, Elwell & Chowdhury, Hodder, ISBN 9780340985809Arnold PublishingA new addition to the many MRCS revision books available,this text follows a familiar format up-dated in line with thecontinuing evolution of the MRCS. Covering anatomy,surgical pathology, applied surgical science, critical care,patient safety and surgical skills, communication skills, andhistory taking and examination, this book provides acomprehensive test of the core areas.

Human Sectional Anatomy: Pocket Atlas of BodySections, CT and MRI Images (3rd edn)Ellis, Logan & Dixon, ISBN 9780340985168Hodder Arnold PublishingSimilar to the pictorial anatomy atlases that many will befamiliar with from medical school, this book brings acadaver-worth of well photographed and carefully labelledimages into the radiological era. Each colour cross sectionalimage is accompanied by relevant radiological imaging, linediagrams, orientations and annotated notes. This book isnotable for its’ excellent, clear layout and clinical relevance.Ideal for those preparing for exams, or indeed anyone tryingto interpret scans or the radiologists report!

Paediatric Orthopaedics: A System of DecisionMakingJoseph, Nayagam, Loder & Torode, ISBN 9780340889459Hodder Arnold PublishingA serious book with some serious authors - this hardbackreference sets out to provide a comprehensive review ofpaediatric orthopaedics at a level suitable to specialityexams. As a practical reference source from a group ofinternational orthopaedic specialists, it covers deformities,dislocations, limb length discrepancies, joint immobility,paralyses, infections and epiphyseal and physeal problems.As the title suggests, the emphasis throughout is towardstreatment decisions and evidence based practice. Despite

Page 140-141 Book Reviews:Scientific Section 11/5/10 16:32 Page 98

Book Reviews

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MRCS Part 1 in a BoxWoon, Leonny & Overstall, ISBN 9781853156120Royal Society of Medicine PressFollowing the familiar flash-card style revision card format,this pack provides a comprehensive test of the MRCS Part1. Concise questions and answers, together with diagramsto explain these lend itself to a useful self-test resource forthose taking their exams.

Liver and Pancreatobiliary Surgery with livertransplantation(Oxford Specialist Handbooks in Surgery)Sutcliffe, Antoniades, Deshpande, Tucker & HeatonISBN 9780199205387Oxford University PressAnother new edition to the familiar plastic-bound andpocket-sized Oxford Handbook range, this slim textprovides a succinct bullet-pointed guide to liver andpancreatobiliary surgery, together with liver transplantation.At 293-pages, it provides a detailed description of thediseases and subsequent management encountered in thisspeciality. Interventional procedures are covered togetherwith operative techniques, all illustrated with explanatorydiagrams and black and white pictures. The quick referencestyle these OUP handbooks are known for is usefullydeployed in this book, which will make a useful guide tokeep in the pocket for trainees in this speciality.

Recent Advances in Surgery (number 32)Edited by Taylor & Johnson, ISBN 9781853158742Royal Society of Medicine PressThe ‘Recent Advances’ series is a well known and wellestablished offering from RSM Press. This latest editioncontinues the tradition of expert-authored chapters updatingtrainees on the latest trends, research and surgicaltechniques within the general surgical sub-specialities. Fromthe management of patients with breast cancer through torecent advances in laparoscopic surgery, the breadth andtopicality of this book continue to make it essential readingfor all those preparing to take their MRCS and especiallyFRCS exams.

Get Through Intercollegiate MRCS Parts 1 and 2:MCQs and EMQsOverstall, Cunnick & Mokbel, ISBN 1853155950Royal Society of Medicine PressDoes exactly what it says on the tin - this useful bookprovides MRCS-style questions for exam practice andpreparation. Although the nomenclature of the exam hasnow changed, with parts 1 and 2 now known as ‘Part A’, thisbook still provides extensive MRCS-style questionscovering the breadth of material encountered in the exam. Ifyou’re looking to get through as many practice questions aspossible beforehand, this book will help you on your way.

Get Through MRCS: Anatomy VivasSimon Overstall, ISBN 185315668XRoyal Society of Medicine PressAlthough the frequently encountered topics and questionsremain much the same over the years, this text is showing

its age slightly since the change of MRCS format in 2008.Nonetheless, if you’re looking to revise and practicequestions in preparation for the Part B OSCE then this stillprovides a valuable source of material. A range ofradiographs, colour specimens and surface anatomypictures and illustrations are partnered with relevantquestions assessing the breadth of clinical anatomy. Auseful revision adjunct.

Companion to Specialist Surgical Practice SeriesSaunders Elsevier PublishingThis popular range of 8 volumes gives in depth coverage ofthe general surgery sub-specialities at a level suitable forFRCS revision, and reference throughout a career in surgery.Newly revised, two of these texts are reviewed in more depthbelow. The full range of volumes is as follows:• Core Topics in General and Emergency Surgery• Oesophagogastric Surgery• Hepatobiliary and Pancreatic Surgery• Colorectal Surgery• Breast Surgery• Endocrine Surgery• Vascular and Endovascular Surgery• Transplantation Surgery

Vascular and Endovascular Surgery (4th Edn)A Companion to Specialist Surgical PracticeBeard & Gaines, ISBN 9780702030116Saunders Elsevier PublishingThe latest edition of this well-regarded series continues toprovide a reference source for higher surgical trainees, inparticular those preparing for their FRCS. The latestmanagement issues and operative procedures are covered,providing a comprehensive up-date. With a strong emphasison evidence-based practice, the text is fully referencedthroughout. This new edition also introduces colour text andpictures, with useful illustrations and diagrams providingclarity where needed. The Companion to Specialist SurgicalPractice series is now also available on-line as an ebook atwww.elsevier-surgicalcompanion.com

Endocrine Surgery (4th Edn) A Companion toSpecialist Surgical PracticeTom Lennard, ISBN 9780702030161Saunders Elsevier PublishingAnother revision of this well-regarded series, the fourthedition of Endocrine Surgery refreshes the text and providesup-to-date evidence to support management and treatmentdecisions across the breadth of this sub-speciality. At 231-pages this hard-back book is a heavyweight reference in itsfield. With contributing authors noted as experts in theirrespective fields, this provides in-depth coverage suitablefor FRCS and beyond. In-line with the other new editions inthis series, colour is now used throughout and extensive useof referencing is made to original research papers. The textis enhanced by numerous radiographs, illustrations andtables to display the relevant information. The Companion toSpecialist Surgical Practice series is now also available on-line as an ebook at www.elsevier-surgicalcompanion.com

Page 140-141 Book Reviews:Scientific Section 11/5/10 16:32 Page 99

frequently not diagnosed until operative exploration forobstruction, perforation or gastrointestinal bleeding4,8,9. Theobstruction is secondary to mesenteric lymph nodes andfibrosis leading to kinking of the bowel2,10. This extensivemesenteric stranding and fibrosis is thought to be secondaryto serotonin and growth factors released from tumour cells.This can also lead to encasement of mesenteric vessels withsubsequent ischemia of the bowel2.

Carcinoid tumours are the most common malignancy ofappendix and are usually diagnosed in the fourth and fifthdecade of life11. Less than 10 percent of patients withappendiceal carcinoids are symptomatic12. Over 95 percentof appendiceal carcinoids are less than 2cm in size and rarelymetastasise. These patients can be treated with simpleappendicectomy. Most tumours more than 2cm in size aretreated with right hemicolectomy12.

Colonic carcinoids most commonly present in the seventhdecade with symptoms of pain, anorexia and weight loss13.Most of these patients present with advanced disease with anaverage tumour size of 5cm and over two third of patientshave nodal or distant metastasis13,14. The majority of thesepatients need radical colectomy. Rectal carcinoids accountfor about 2 percent of rectal tumours. They differ from otherGICT in that these cells mainly contain glucagons andglicentin related peptides rather than serotonin15. Rectalbleeding, pain and constipation are common symptoms,although about 50 percent are asymptomatic at diagnosis andfound incidentally at routine endoscopy16. Tumours less than1cm in size, which account for two third of all rectalcarcinoids, can be treated with local excision16. Tumoursgreater than 2cm have traditionally been treated with anteriorresection or abdominoperineal resection although thispractice has been questioned recently as there does notappear to be much survival advantage over and above thatachieved by local excision17,18.

The liver is the commonest site of distant metastasis fromGICT; rarely, they can metastasise to extra-abdominal organsincluding bone, lung, central nervous system, mediastinal andcervical lymph nodes. Carcinoid liver metastases tend to behypervascular and may appear isodense on conventionalpost contrast CT scans19,20. The clinical course of patientswith metastatic carcinoid tumour is highly variable and somepatients remain symptom free for years21. Carcinoidsyndrome is typically seen in patients with liver and lungmetastases. It occurs in 10% of all patients with carcinoidstumours and in about 20% of patients with jejuno-ilealcarcinoids3,4. The symptoms of carcinoid syndrome includeflushing, diarrhoea, tachycardia, hypotension, bronchospasm,telangectasia and right heart failure. Carcinoid heart disease isa late and potentially fatal complication in patients withcarcinoid syndrome and is thought to be secondary toendocardial fibrosis of right side heart valves leading topulmonary valve stenosis and tricuspid insufficiency. Althoughthe exact substance responsible for symptoms of carcinoidsyndrome is not clear, the diarrhoea is thought to besecondary to excessive circulating levels of serotonin,bronchospasm is thought to be due to serotonin andbradykinin and prolonged high serum levels of serotonin isthought to be the cause of carcinoids heart disease22. Leftside heart valves are less affected because of the metabolismof serotonin with in the lungs.

Scientific - Management of Gastrointestinal Carcinoid Tumours

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Management ofGastrointestinalCarcinoid TumoursShridhar Dronamraju, Specialty Trainee,General Surgery, Northern Deanery

Gastrointestinal carcinoids tumours (GICT) are neuroendocrinetumours arising from the serotonin producing endocrine cellswithin the gastrointestinal tract. Depending on the site of theirorigin they can be classified as foregut, midgut and hindgutcarcinoids. The common sites of carcinoid tumours includeappendix, rectum, ileum, lung, bronchi and stomach1-3. Theoverall incidence of carcinoid tumours has been steadilyincreasing and they are considered to be more aggressive witha poorer prognosis than thought previously4,5.

Diagnosis of carcinoid tumours can be challenging as mostare asymptomatic and advanced by the time of clinicalpresentation. The diagnosis of carcinoid tumour is often notmade until after operative exploration for acute presentation withbowel obstruction, perforation, or gastro-intestinal bleeding.Although staging systems for carcinoids tumours have beenpublished more recently6, the long term prognosis is still notclear. There are no clear guidelines for management, referral andfollow up of these patients.

Clinical PresentationGICT grow very slowly and patients usually present with non-specific abdominal pains progressing to symptoms of smallbowel obstruction2. Rarely, they can present withgastrointestinal bleeding. In nearly half of GICT patients, thediagnosis is not revealed until after an emergency surgery forsmall bowel obstruction, undertaken without awareness of thediagnosis. Gastric carcinoids can be associated with eitherchronic atropic gastritis type A (usually multifocal and accountto up to 75 percent of cases) or Zollinger-Ellison syndrome(5-10 percent cases, seen exclusively in patients with MENtype I)7. Sporadic gastric carcinoids, which account for 15 to25 percent cases, are usually solitary, more aggressive andhave systemic metastasis at time of presentation7.

Midgut carcinoids (MC) constitute around 30% ofcarcinoids and are the most common cause of carcinoidsyndrome4. They are commonly diagnosed in the 6th and 7thdecade, predominant in males and account for 25% of allsmall bowel tumours. They are often multicentric and thoughtto arise from serotonin producing intraepithelial endocrinecells. They usually present with long standing abdominal painand obstruction. MCs have significant malignant potentialwith about 50 to 60% having metastatic disease at time ofdiagnosis4. In most patients, MC is incidentally diagnosedfollowing a laparotomy for small bowel obstruction and thefindings at laparotomy in these patients include small primarytumour in ileum and large mesenteric nodes with adjacentmesenteric fibrosis8. The primary lesion in MCs is often small(<1cm), flat and fibrotic in submucosal plane and are


DiagnosisBiochemical Tests: Carcinoid tumour cells originate fromneuroendocrine cells and are capable of synthesis, storage andrelease of serotonin, histamine, prostaglandin, kallikrenin,bradykinin, substance P, gastrin, and corticotrophin and neuronspecific enolase. The most abundant of these is serotonin(5-hydroxytryptamine) which, after metabolizing, is converted to5-hydroxyindolacetic acid (5-HIAA), Determination of raised5-HIAA levels in 24-hr urine samples is routinely used fordiagnosis of carcinoids but it is neither specific nor sensitive asit may not be elevated in some carcinoids and may be elevatedin conditions such as tropical sprue, celiac disease, Whipple’sdisease and small bowel obstruction5. Serum Chromogranin Alevels are shown to reflect tumour load and provide evidence ofpersistent or recurrent carcinoid disease and is a usefulparameter to monitor disease spread and recurrence23.Presence of carcinoembryonic antigen is a poor prognosticindicator and these tumours are often classified as adeno-carcinoids and treated as adenocarcinomas rather thancarcinoids24,25.

Radiology: Plain abdominal radiographs may show dilatedbowel with thickened walls consistent with chronic obstruction.CT scans rarely demonstrate the primary GICT lesion but thepresence of a circumscribed mesenteric mass with radiatingmesenteric stranding is pathgnomonic of a GICT. CT can alsoshow liver metastases but as these lesions are hypervascular aporto-venous phase scan will be more sensitive to diagnosesmaller lesions19,20. GICT cells are rich in somatostatinreceptors which have high affinity for somatostatin analogueOctreotide. A radio labelled octreotide scintigraphy, Octreo-scan, has more than 90% sensitivity to detect metastasis andrecurrent disease26. Positron emission tomography (PET) with

serotonin precursor 5-hydroxytrytophan, labelled with 11C(5HTP-PET) has been shown to have high specificity and isused to monitor effects of therapy27,28.

Histology: Depending on the histological appearance,mitotic index and proliferation index using Ki67 antibody,GICT may be classified as well differentiated neuroendocrinetumours, well-differentiated endocrine carcinoma, poorlydifferentiated endocrine carcinoma and mixed exocrine andendocrine tumours29,30. About 85% of MCs and theirmetastasis show reactivity to Chromogranin A andsynaptophysin immunostaining. Serotonin reactivity impliesthat primary tumour originates in the midgut3,31. Proliferationindex is assessed using immunostaining with Ki67 antibodyand is usually low (<2%) in classical MCs.

TreatmentSurgery: Surgery continues to be the main modality oftreatment for GICT with a potential to cure in early stagedisease and provide best palliation in those with advanceddisease. The type and nature of surgery mainly depends on thesite and extent of the primary lesion. Asmentioned earlier, manypatients with MC are subjected to laparotomy without anawareness of diagnosis of carcinoid tumour. A wedge resectionincluding the bowel segment containing the primary tumourand the involved lymph nodes need to be excised. Thisprocedure is also indicated in patients with synchronous livermetastasis, as local disease if left alone can lead to significantmorbidity3. In spite of curative primary surgery, about 80% ofpatients with MCs develop recurrence and liver metastasis onlong term follow up32. These recurrences can be clinically overtafter a median 5-10 years of follow-up. Early diagnosis ofrecurrence may be accomplished by serum chromogranin A

Table 1 - Characteristics of Gastrointestinal Carcinoid Tumours by location*

*Data adapted from Robertson et al [5] and Modlin et al4

#Pooled data from End Results group, Third National Cancer Survey and Surveillance, Epidemiology and End Results programme registries ofNational Cancer Institute

99


100

develop new metastasis, which typically show slowprogression. Carcinoid tumours are unusually tenacious andimaging even with specific methods as octretide scan and5-HTP PET may fail to detect disease spread.

Medical TreatmentSomatostatin is a 14-amino acid peptide that inhibits thesecretion of broad range of hormones including growthhormone, insulin, glucagons and gastrin36,37. Over 80 percentof carcinoid tumours express somatostatin receptors.Somatostatin analogues (Octreotide, Lanreotide) andinterferons can effectively palliate symptoms associated withcarcinoid syndrome in up to 70% of patients, moderate tumourreduction in around 5% and stabilise the disease for an averageof three years in approximately half of the patients22,38,39. Theanalogues are self-administered by 3 daily subcutaneousinjections of 50-150µg and long acting formulations with theconvenience of once monthly injections are currentlyavailable38. Side effects of somatostatin analogues include gallstone formation and pancreatic insufficiency. Interferons havemore adverse effects than somatostatin analogues and includeflu-like symptoms, chronic fatigue and autoimmune reactions.Cytotoxic chemotherapy has shown limited success in thetreatment of carcinoid tumours. Systemic chemotherapy maybe more effective in patients with aggressive variants ofcarcinoid tumours like neuroendocrine carcinomas in which aregimen containing cisplatin and etoposide has shown over 60percent response rates40. External bean radiotherapy has beenshown to be effective in palliation of bone and central nervoussystem metastases41.

Prognosis and Follow upPrognosis of patients with GICT is largely determined by siteand size of primary lesion and extent of the disease (table 2).Large patient series from Sweden (1960-2000) and from US(1973-1999) have reported an age adjusted 5-year survivalrates of 67% for midgut carcinoids4,42. In a series of over

Table 2 - Prognosis of gastrointestinal carcinoids based on the site of origin

estimates2. Recurrent disease and mesenteric fibrosis can leadto chronic abdominal pain, intestinal obstruction and bowelischemia which may necessitate further surgical inter-vention33,34. Recent studies advocate prophylactic surgery toremove mesentrico-intestinal tumour in asymptomatic patientsconsidered for medical treatment. A pre-operative mapping ofthe extent of disease within the mesentery and involvement ofthe root of the major mesenteric vessels with a dynamic CTscan is essential. This is because patients who survivemedical treatment can present with major intra-abdominalcomplications from the mesentric disease3. Mesentric tumourdebulking in patients with advanced mesentric metastasis inabsence of liver metastasis is shown to improve survival. In onesuch series with 300 patients who had radical resection ofmesentric metastasis, median survival was 12.4 years and 5-year survival was 91%35. Operating on a patient with carcinoidsyndrome may induce carcinoid crisis with hyperthermia,shock, arrhythmia, excessive flush and bronchial spasm. Asprophylaxis, these patients are treated with intravenousoctreotide (500g in 500ml saline, 50g/hour) during surgery.

Liver MetastasisMajority of carcinoid patients with liver metastasis havemultiplelesions widely spread in both lobes and need medicaltreatments, including somatostatin and interferon, which areeffective in symptom control and increasing the lifeexpectancy23. Less than 10% of patients have solitary ordominant lesions which are amenable for surgical resection3.Other modalities used to treat liver metastasis includeradiofrequency ablation, liver embolisation, transplantation,radioactively labelled octreotide and MIBG. Radiofrequencyablation is being used increasingly and can induce necrosis oflesions up to 3-4cm in size. However, it is not very effective forlesions close to major vessels. Significant and sustainedsymptom relief and reduction in tumour markers can beachieved if ~90% of tumour volume has been excised orablated. Almost all patients who had curative liver resection


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300 patients median survival was 12.4 years and 5-yearsurvival was 91% in absence of liver metastasis and 50% inpatients with inoperable liver metastasis35.

Significant symptom relief and long disease free survivalhave consistently been reported following liver surgery inpatients with carcinoid syndrome2,3,26. Five year survival ofover 70% has been reported following radical curative liverresection. Virtually every patient will present with newmetastasis after liver resection or ablation, but often withslow progression. Long term follow-up studies haveidentified presence of liver metastasis and carcinoid heartdisease as two most significant adverse prognosticindicators35,42.

With increasing evidence to suggest that recurrencescan be clinically overt after median 5-10 years of follow-up,all patients need to have prolonged follow up. Currentlythere is lack of clear guidelines for referral and follow up ofpatients diagnosed with GICT particularly in the setting ofdistrict general hospitals within the UK. With the recentpublished evidence about staging, treatment options andprognosis of carcinoid tumours, it should be feasible toformulate management guidelines for patients with GICTs.

References1 Godwin JD, 2nd. Carcinoid tumors. An analysis of 2,837 cases. Cancer

1975 Aug; 36(2): 560-92 Akerstrom G, Hessman O, Hellman P, Skogseid B. Pancreatic tumours

as part of the MEN-1 syndrome. Best practice & research 2005 Oct;19(5): 819-30

3 Akerstrom G, Hellman P, Hessman O, Osmak L. Management of midgutcarcinoids. Journal of surgical oncology 2005 Mar 1; 89(3): 161-9

4 Modlin IM, Lye KD, Kidd M. A 5-decade analysis of 13,715 carcinoidtumors. Cancer 2003 Feb 15; 97(4): 934-59

5 Robertson RG, Geiger WJ, Davis NB. Carcinoid tumors. Americanfamily physician. 2006 Aug 1; 74(3): 429-34

6 Landry CS, Brock G, Scoggins CR, McMasters KM, Martin RC, 2nd.A proposed staging system for small bowel carcinoid tumors based onan analysis of 6,380 patients. American journal of surgery 2008 Dec;196(6): 896-903; discussion

7 Rindi G, Bordi C, Rappel S, La Rosa S, Stolte M, Solcia E. Gastriccarcinoids and neuroendocrine carcinomas: pathogenesis, pathology,and behavior. World journal of surgery 1996 Feb; 20(2): 168-72

8 Akerstrom G. Companion to specialist surgical practice: endocrinesurgery: Elsevier Saunders 2005

9 Modlin IM, Kidd M, Latich I, Zikusoka MN, Shapiro MD. Current statusof gastrointestinal carcinoids. Gastroenterology 2005 May; 128(6):1717-51

10 Moertel CG, Dockerty MB, Judd ES. Carcinoid tumors of the vermiformappendix. Cancer 1968 Feb; 21(2): 270-8

11 Modlin IM, Sandor A. An analysis of 8305 cases of carcinoid tumors.Cancer 1997 Feb 15; 79(4): 813-29

12 Moertel CG, Weiland LH, Nagorney DM, Dockerty MB. Carcinoid tumorof the appendix: treatment and prognosis. The New England journal ofmedicine 1987 Dec 31; 317(27): 1699-701

13 Rosenberg JM, Welch JP. Carcinoid tumors of the colon. A study of 72patients. American journal of surgery 1985 Jun; 149(6): 775-9

14 Ballantyne GH, Savoca PE, Flannery JT, Ahlman MH, Modlin IM.Incidence and mortality of carcinoids of the colon. Data from theConnecticut Tumor Registry. Cancer 1992 May 15; 69(10): 2400-5

15 Capella C, Heitz PU, Hofler H, Solcia E, Kloppel G. Revisedclassification of neuroendocrine tumours of the lung, pancreas and gut.Virchows Arch 1995; 425(6): 547-60

16 Jetmore AB, Ray JE, Gathright JB Jr, McMullen KM, Hicks TC,Timmcke AE. Rectal carcinoids: the most frequent carcinoid tumor.Diseases of the colon and rectum 1992 Aug; 35(8): 717-25

17 Sauven P, Ridge JA, Quan SH, Sigurdson ER. Anorectal carcinoidtumors. Is aggressive surgery warranted? Annals of surgery 1990 Jan;211(1): 67-71

18 Koura AN, Giacco GG, Curley SA, Skibber JM, Feig BW, Ellis LM.Carcinoid tumors of the rectum: effect of size, histopathology, andsurgical treatment on metastasis free survival. Cancer 1997 Apr 1;79(7): 1294-8

19 Woodard PK, Feldman JM, Paine SS, Baker ME. Midgut carcinoidtumors: CT findings and biochemical profiles. Journal of computerassisted tomography 1995 May-Jun; 19(3): 400-5

20 Sugimoto E, Lorelius LE, Eriksson B, Oberg K. Midgut carcinoidtumours. CT appearance. Acta Radiol 1995 Jul; 36(4): 367-71

21 Kulke MH, Mayer RJ. Carcinoid tumors. The New England journal ofmedicine 1999 Mar 18; 340(11): 858-68

22 de Vries H, Verschueren RC, Willemse PH, Kema IP, de Vries EG.Diagnostic, surgical and medical aspect of the midgut carcinoids.Cancer treatment reviews 2002 Feb; 28(1): 11-25

23 Oberg K. Carcinoid Tumors: Current Concepts in Diagnosis andTreatment. The oncologist 1998; 3(5): 339-45Bishopric GA, Jr, OrdonezNG. Carcinoembryonic antigen in primary carcinoid tumors of the lung.Cancer 1986 Sep 15; 58(6): 1316-20

24 Federspiel BH, Burke AP, Shekitka KM, Sobin LH. Carcinoembryonicantigen and carcinoids of the gastrointestinal tract. Mod Pathol 1990Sep; 3(5): 586-90

25 Ganim RB, Norton JA. Recent advances in carcinoid pathogenesis,diagnosis and management. Surgical oncology 2000 Dec; 9(4): 173-9

26 Orlefors H, Sundin A, Ahlstrom H, Bjurling P, Bergstrom M, Lilja A, et al.Positron emission tomography with 5-hydroxytryprophan in neuro-endocrine tumors. J Clin Oncol 1998 Jul; 16(7): 2534-41

27 Oberg K, Eriksson B. Nuclear medicine in the detection, staging andtreatment of gastrointestinal carcinoid tumours. Best Pract Res ClinEndocrinol Metab 2005 Jun; 19(2): 265-76

28 Solcia E, Capella C, Buffa R, Fiocca R, Frigerio B, Usellini L.Identification, ultrastructure and classification of gut endocrine cellsand related growths. Investigative & cell pathology 1980 Jan-Mar; 3(1):37-49

29 Solcia E, Rindi G, Paolotti D, La Rosa S, Capella C, Fiocca R.Clinicopathological profile as a basis for classification of the endocrinetumours of the gastroenteropancreatic tract. Ann Oncol 1999; 10 Suppl2: S9-15

30 Van Eeden S, Quaedvlieg PF, Taal BG, Offerhaus GJ, Lamers CB,Van Velthuysen ML. Classification of low-grade neuroendocrine tumorsof midgut and unknown origin. Human pathology 2002 Nov; 33(11):1126-32

31 Akerstorm G. Companion to specialist surgical practice: endocrinesurgery 3 ed: Elsevier Saunders 2005

32 Soreide JA, van Heerden JA, Thompson GB, Schleck C, Ilstrup DM,Churchward M. Gastrointestinal carcinoid tumors: long-term prognosisfor surgically treated patients. World journal of surgery 2000 Nov;24(11): 1431-6

33 Gulec SA, Mountcastle TS, Frey D, Cundiff JD, Mathews E, Anthony L,et al. Cytoreductive surgery in patients with advanced-stagecarcinoid tumors. The American surgeon 2002 Aug; 68(8): 667-71;discussion 71-2

34 Hellman P, Lundstrom T, Ohrvall U, Eriksson B, Skogseid B, Oberg K,et al. Effect of surgery on the outcome of midgut carcinoid disease withlymph node and liver metastases. World journal of surgery 2002 Aug;26(8): 991-7

35 Reichlin S. Somatostatin (second of two parts). The New Englandjournal of medicine 1983 Dec 22; 309(25): 1556-63

36 Reichlin S. Somatostatin. The New England journal of medicine 1983Dec 15; 309(24): 1495-501

37 Oberg K. Carcinoid tumors: molecular genetics, tumor biology, andupdate of diagnosis and treatment. Current opinion in oncology 2002Jan; 14(1): 38-45

38 Bousquet C, Puente E, Buscail L, Vaysse N, Susini C. Antiproliferativeeffect of somatostatin and analogs. Chemotherapy 2001; 47 Suppl 2:30-9

39 Moertel CG, Kvols LK, O'Connell MJ, Rubin J. Treatment ofneuroendocrine carcinomas with combined etoposide and cisplatin.Evidence of major therapeutic activity in the anaplastic variants of theseneoplasms. Cancer 1991 Jul 15; 68(2): 227-32

40 Schupak KD, Wallner KE. The role of radiation therapy in the treatmentof locally unresectable or metastatic carcinoid tumors. Internationaljournal of radiation oncology, biology, physics 1991 Mar; 20(3): 489-95

41 Zar N, Garmo H, Holmberg L, Rastad J, Hellman P. Long-term survivalof patients with small intestinal carcinoid tumors. World journal ofsurgery 2004 Nov; 28(11): 1163-8

females and rectal cancers are almost twice as common inmales, especially in high incidence areas2,3.

During the last three decades numerous studies havefocussed on the aetiology of CRCs. They have providedevidence that the aetiology is frequently multifactorial and is aninteraction between the genetic, dietary, environmental, lifestyleand hormonal factors. Rarely other ‘miscellaneous’ factors givean insight into pathogenic mechanisms.

AimThe aim of this article is to review the currently availableliterature pertinent to the aetiology of CRC. Brief mention ofpathogenesis is made because aetiology with a demonstrablemechanism is essential as evidence of causation. It is intendedthat at the end, the reader better understands the factorsleading to the development of CRCs and can relate to themechanisms behind them.

MethodsA Pubmed search was undertaken to identify and selectrelevant articles for this review. This included articles in theEnglish language from 1995 to 2007 using the key words‘colorectal cancers’, ‘rectal cancers’ and ‘colon cancers’combined with ‘aetiology of’, ‘epidemiology of’, ‘age &’, ‘sex &’,‘race &’, ‘diet &’, ‘dietary factors &’, ‘infections &’, ‘hormones &’,‘occupation &’, ‘smoking &’, ‘alcohol &’, ‘chronic diseases &’,‘genes &’, ‘genetics &’ and key articles were selected from this.

Scientific - Aetiology and Pathogenesis of Colorectal Cancer

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Aetiology andPathogenesis ofColorectal CancerMuhammad Kabeer1, Research Fellow,Adam Widdison2, Consultant Surgeon,Prof Andrew Demaine1, Professor of BiomedicalSciences and Joseph Mathew2, ConsultantPathologist1Peninsula College of Medicine and Dentistry,Graduate School, Research Way, Tamar SciencePark, Plymouth2Royal Cornwall Hospital, NHS Trust, Truro

AbstractIntroduction: Colorectal cancer (CRC) is a leading andincreasing cause of death from malignant disease worldwide.An estimated 102,3152 cases occurred in 2002 worldwide,which accounted for 9.42% of all new cases of cancer. Duringthe last three decades numerous studies have focussed on theaetiology of CRCs. They have provided evidence that theaetiology is frequently multifactorial and is an interactionbetween the genetic, dietary, environmental, lifestyle factorsand/or hormonal factors. Rarely other ‘miscellaneous’ factorsgive an insight into pathogenic mechanisms.Aim: The aim of this article is to review the currently availableliterature pertinent to the aetiology of CRC.Methods: A Pubmed search was undertaken to identify andselect relevant articles for this review. The evidence for differentaetiological factors was weighted depending on the strength ofthe studies.Results: There is enough circumstantial evidence to link theenvironmental factors to genetic events, but no single clearlydefined event in the development of CRCs represents the pointof interaction between environmental and genetic sequences.Conclusion: The aetiology of colorectal cancers ismultifactorial. An interaction between these factors leads to asequence of well defined genetic events and the developmentof colorectal cancers.Key Words: Colorectal cancer, colon cancer, rectal cancer,neoplasia.

IntroductionColorectal cancer (CRC) is a leading, and increasing cause ofdeath from malignant disease worldwide. According to theGLOBOCAN 2002 database of the IARC, there were anestimated 102,3152 cases worldwide, which accounted for9.42% of all new cases of cancer (excluding skin)1. The agestandardised incidence rate (ASR) of colorectal cancerworldwide are given in figures 1 and 2 (GLOBOCAN 2002).There is a 20-30 fold variation in the incidence rates around theworld, with highest rates seen in the developed world and thelowest in India, South America and Africa2-4. The overallfrequency of colorectal cancers is almost equal in either sexes,however right sided colon cancers are slightly more common in

Figure 1 - Age standardised incidence rate for CRC in males(GLOBOCAN 2002)

Figure 2 - Age standardised incidence rate for CRC in females(GLOBOCAN 2002)

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Additional search was done for key references cited in thesearticles. Standard Pathology and Surgical textbooks were alsoconsulted, which included The Pathologic Basis of Disease,Basic Pathology, Essential Surgical Practice, Short Practice ofSurgery and Current Surgical Diagnosis and Treatment. Keyarticles in the area dating before and after the specified searchdated were also included. Conference proceedings andabstracts were however not included as part of the review.

The evidence for different aetiological factors wasweighted depending on the strength of the studies. A doubleblind randomised controlled trial (RCT) was considered thegold standard; however individual studies do provide anoccasional insight into the aetiology of CRCs and these havealso been included in the review. In this paper, the aetiologyand pathogenesis of CRCs are described together for ease ofunderstanding.

Aetiology of CRCThe aetiology of CRC appears to be multifactorial and there isconsiderable interaction between these factors which ultimatelyleads to CRC. Many different theories and pathways have beensuggested, some focussing more on genetic basis and somegiving more importance to environmental factors. For exampleStubbs considers environmental factors to have a moresignificant role in CRC pathogenesis and proposes threehypotheses leading to this: the fibre hypothesis, the vegetablehypothesis and the animal fats hypothesis5. Potter proposedfour pathologically distinct pathways leading the transformationof normal colonic cells to a carcinoma: the adenoma-carcinomasequence, failure of mismatch repair genes in the growth-controlling pathway, ulcerative colitis leading to CRC in thedysplasia-carcinoma sequence and lastly, the loss of oestrogenreceptor (ER) gene2.

Later, Ponz de Leon noted that there are only 5 clearlyidentified causes with established direct link to CRC; hereditarynon-polyposis colorectal cancer (HNPCC), familial adeno-matous polyposis coli (FAP), inflammatory bowel disease (IBD),human papilloma virus (HPV) and acquired immunodeficiencysyndrome (AIDS)6.

Although a pattern can be identified in the occurrence andprogression of genetic mutations that ultimately lead to thedevelopment of cancer, some of the events are overlapping andindeed both genes and environment have their effect inmodifying the normal cell to form a cancerous one. For ease,we have divided our discussion into genetic factors, dietary,environmental & lifestyle factors, hormonal factors andmiscellaneous factors.

Genetic FactorsThe evidence for genetic factors predisposing to thedevelopment of CRCs is relatively new. It is now known thatcolorectal cancers occur through a gradual series ofhistological changes which are accompanied by genetic eventsinvolving tumour suppressor genes and oncogenes (figure 3).

Knudson proposed the ‘two hit’ hypothesis in an attempt toexplain the possible chain of genetic events leading to thedevelopment of CRC7. To understand this, consider the APCgene; it is suggested that one defective allele of the APC genemay be inherited by individuals or may mutate early indevelopment of adenomas, this forms the classic example ofthe ‘first hit’ of Knudson’s two hit hypothesis for the

development of CRC8. The ‘second hit’ being the loss of theother normal allele resulting in the complete loss of APCfunction. Mutations in other genes occur next as in K-ras, p-53and SMAD2 & SMAD4, leading to the formation of carcinomas.Further mutations may occur down the line or may accumulateindividually as in those of telomerases, caspases and the genesinvolved in Hereditary Non-polyposis Colorectal CancerSyndrome (HNPCC)4. How much effect these later mutationshave on the development of CRC is a subject of ongoingresearch, although some possible relationships have beenproposed and a brief discussion of these will follow later.

Whereas the effect of environmental factors leading to CRChas been studied in some detail, virtually all research on geneticfactors has focussed on western populations and no data isavailable even from migrant studies in this regard. Hence it isdebatable whether these genetic events occur across all racesand populations and further research in this direction is stillrequired.

The Adenoma-Carcinoma Sequence & Mutation of theAPC GeneThis model was first put forward by Marson and Hill in the1970s2 and proposes that carcinomas in the colon arise frompre-existing polyps (adenomas). Fearon and Vogelstein9considered the Adenomatous polyposis coli (APC) gene centralto this sequence. The APC gene is a tumour suppressor genelocated on chromosome 5q21 and was first mapped in198710-12. Since then, a lot of research has focussed on definingthe mechanisms involved in the development of adenomatous

Figure 3 - Molecular model for the evolution of colorectal cancers throughthe adenoma-carcinoma sequence, showing the genetic events and themorphologic changes associated with them.(Modified from: Neoplasia - Pathologic Basis of Disease, 7th edn 2004)



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polyps. Mutations of APC gene were first identified in patientswith familial adenomatous polyposis (FAP) and account forabout 80% of sporadic colorectal cancers and displays anautosomal dominant mode of inheritance8,13. Mutations in theAPC gene are detected early in the adenoma-carcinomasequence8 and lead to alterations in the β-catenin component ofthe Wnt signalling pathway, which is involved in the proliferation,differentiation, intercellular adhesion, cytoskeleton stabilisationand apoptosis of cells. APC enhances the phosphorylation of β-catenin within cells, leading to its degradation. In the absence ofAPC, there is an accumulation of β-catenin which results inincreased transcription of growth promoting factors and alsoinduces the expression of genes involved in cell proliferation,including among others, c-myc and cyclin-D114. Thus, loss ofAPC function leads to increased cell proliferation and decreasedcell adhesion4 and progression of cells along the adenoma-carcinoma sequence. This however can occur in the absence ofAPC mutations, and indeed 50% of cancers without APCmutations have β-catenin mutations14.

Conlin et al conducted a study to find whether the presenceor absence of K-ras, p-53 and APC mutations made anydifference in the prognosis and survival of patients. Theystudied a cohort of 107 patients and reported that 56% ofpatients had APC mutations. Most of these were frame shiftmutations and introduced a premature stop codon. Thishowever had no effect on the overall prognosis of thepatients15.

The molecular mechanics of this process have beenidentified to some extent and further research is ongoing. Thereader is referred to the appropriate references for a moredetailed account of the processes involved8,14,16-19.

Several different phenotypes of FAP occur as Gardner’sSyndrome, Turcot’s Syndrome and the attenuated form of FAPin which very few polyps occur. This variation in the phenotypesas well as evidence from transgenic studies showing a possiblerole of folate and NSAIDs in reducing CRC, indicates that thepenetration of APC mutations is dependent on both geneticand environmental factors2.

Mutation of the K-ras (Kirsten-ras) GeneK-ras is an oncogene located on chromosome 12p12. It isfound in about 20% of all human tumours and 50% ofcolorectal carcinomas20 and occur early in colorectaltumorigenesis21. This gene codes for signal transductionproteins located on cell membranes. When stimulated bygrowth factors they lead to activation of intracellular kinases,which target nuclear transcription factors to promotemutagenesis. Normal K-ras is degraded instantly by intrinsicGTPase activity, and so this process is auto-regulated.Mutations in K-ras lead to loss of this degradation and thus tounregulated cell proliferation15. In the cohort study by Conlin15,K-ras mutations were present in 27% of patients, with 79% ofthe mutations occurring in codon 12 and 21% in codon 13. Thestudy demonstrated that the K-ras mutation was anindependent prognostic variable and was associated with poorprognosis at all disease stages. It was also noted that most ofthese mutations were present in later stages of the disease15.Apart from the direct activation of Ras, there has been evidencethat inactivation of tumour suppressor or negative Ras effectorsas RASSF1 may also play an important role in tumorigenesis21.

Loss of p53This tumour suppressor gene is located on chromosome17p1320 and encodes a phosphoprotein, which is a DNAbinding protein. Whenever there is DNA damage, the p-53system comes into play leading to cell cycle arrest and inducesDNA repair genes. If the DNA is not repairable, it is directed toapoptosis15,20. Mutations of this gene occur in varyingproportions in virtually any type of cancer and are noted in upto 80% of colorectal cancers4. Most commonly, mutations inboth alleles occur as acquired somatic mutations. One mutantallele can sometimes be inherited as well and forms the ‘first hit’(Li-Fraumeni syndrome) in transformation to cancerous cell.Loss of this gene leads to the DNA damage being unrepairedand mutations becoming fixed in dividing cells, thus leading tomalignant transformation20.

Mutations in p53 are known to be associated with previousexposure to a number of environmental factors such ascigarette smoking (lung, bladder, oesophageal, head & neck),ageing (prostate), UV light (skin), aflatoxins and hepatitis-B virus(hepatocellular)22, but whether these factors play a similar rolein CRC carcinogenesis is not clear. The attempts at defining alink between environmental factors and the occurrence of p53mutations have been limited by technique and sample sizes,although one study by Zhang has shown an associationbetween family history and p53 over expression in CRC22. Thisstudy reported that patients with two or more first degreerelatives with cancer had an increased chance of p53 overexpression (OR=2.9) in CRC tissue than those with a negativefamily history.

Conlin15 in his study found p-53 mutations in 61% ofpatients andmost of these occurred in exons 5-8. There was noeffect of these mutations on the overall prognosis of patientswith CRC. The presence of normal p53 function does haveimportant therapeutic implications. It has been seen that thosehuman tumours which retain normal p53 tend to respond moreto chemotherapy and radiotherapy than those who have themutated forms, as colorectal cancers20.

Hereditary Non-Polyposis Colorectal Cancer (HNPCC)Hereditary Non-Polyposis Colorectal Cancer (HNPCC) is alsoreferred to as Lynch Syndrome, after Henry Lynch whoextensively described the condition4. It is an autosomaldominant familial syndrome and is characterised by a lack ofextensive colonic polyps. It can also be associated with extra-intestinal cancers, particularly endometrial, stomach, biliary andurinary tract4. HNPCC accounts for about 5% of CRCs23.

In 1913, Warthin described different family cancersyndromes. One of the family cohorts, the family ‘G’ initially hadonly gastric and uterine cancers. In recent generations, thisfamily has very high incidence of CRCs and is typical ofHereditary Non-Polyposis CRC (HNPCC). However, the risk ofsomeone with HNPCC developing CRC is not different from thegeneral population2 although these tend to occur earlier4,6.Indeed, when Lynch studied the disease pattern in thesefamilies in the third and forth generations, he found adecreasing incidence of stomach and uterine cancers and anincreasing incidence of CRC. This however only reflects thegeneral trend in the increase of incidence in CRCs in the generalpopulation over this century2 and can be attributed to betterunderstanding of the disease diagnostic facilities.



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The primary cause of HNPCC is now thought to be adefective DNA mismatch repair (MMR) system. The MMRsystem mainly functions in the post-replicative phase of DNAsynthesis and detects and repairs errors made by DNApolymerases and promotes genetic stability23. The MMR genesthemselves are not oncogenic, but their defects allowmutations in other genes23. The MMR genes were first studiedin bacterial models and nowmost of the genetic homologues inhumans have been mapped2,23. Mutations in five mismatchrepair genes have so far been identified and include MSH2(chromosome 2p22)24, MSH6 (chromosome 2p21), MLH1(chromosome 3p21)25, PMS1 (chromosome 2q31) and PMS2(chromosome 7p22)6,23. Microsatellite instability (MSI) is thehallmark of mismatched repair. Microsatellites are small repeatsequences of DNA with one to six base pairs which are foundthroughout the genome and are the same in all tissues20. InMMR mutations, these microsatellite become unstable andeither increase or decrease in length26. These unstablemicrosatellites accumulate in tumour cells and are differentfrom the microsatellites found in normal cells23. MSI has beenreported in 10% to 15% of sporadic CRCs26. Many of thegenes that are altered in MSI encode for proteins involved insignal transduction, transcription, apoptosis and DNA repair23.This results in unhindered cell growth and malignanttransformation. Further research is still required to map out theexact mechanisms involved in this as well as the specifictargets of unstable microsatellites.

Miscellaneous Genetic Changes Associated with CRCThe 18q21 deletion: Three genes have been mapped to thislocus, the DCC (deleted in colon carcinoma), DPC4/SMAD4(deleted in pancreatic carcinoma) and SMAD2. Loss of thesegenes is thought to allow uninhibited cell growth by loss ofcoding for TGF-β which normally inhibits cell cycle4,27. Theexact molecular mechanics of this are still unclear27. In fact ithas been seen in experimental mouse models that even in theabsence of both alleles of DCC, the mice show noabnormalities4.The telomerases: Telomerase is a ribonucleoprotien complexwith telomeric reverse transcriptase (TERT) as one of its sub-units. Its activity maintains telomere stability in thechromosomes and get shorter with each cell division until cellsenescence develops and the cell dies. In colorectal cancerstelomerase remains in the activated state and does not shorten,leading to loss of cell senescence and loss of apoptosis28.Caspases: Caspases are proteolytic enzymes involved in thecleavage and subsequent deactivation of a number of growthpromoting proteins including the retinoblastoma protein (Rb)which leads to apoptosis29. A number of studies have focussedon the precise role of capases in tumour genesis and havesuggested that a mutation in the caspase gene leads tocessation of apoptosis and tumour formation26,30,31.

Dietary, Environmental and Lifestyle FactorsSharp contrasts in the geographical distribution betweendeveloped and developing countries and between higher andlower socio-economic classes within countries are seen,suggesting that environmental factors, lifestyle and dietarypractices are important in CRC aetiology. Lifestyle and dietaryhabits are closely linked. A sedentary lifestyle, obesity, andconsuming more refined foods high in energy, saturated fats

and refined carbohydrates and low in fibre and micronutrients,are associated with an increase in the incidence of CRC3,32,33.Diet is also a major source of the body’s exposure toenvironmental factors and hence plays a major role in bothincreasing and reducing cancer risk32.

In 1983, Stubbs published a review of the aetiology of CRC.Based largely on epidemiological evidence, he postulated threetheories of the aetiology of CRC: Fibre hypothesis, animal fathypothesis, vegetable hypothesis5. Since then numerousstudies have focussed on the relationship between dietaryhabits & lifestyle and CRC.

These include randomised controlled trials (RCTs), twin andmigrant studies, case-control studies as well as animal modelsand have verified Stubbs’ observations. These are discussed inthe subsequent sections.

However, many conclusions drawn from animal studiesmay not be valid in humans. For example the gut flora in rats isdifferent from that in man and may possess different metabolicpathways, eg rats have the ability to 6-β-hydroxylate bile acidsto reduce their hydrophobicity, thus reducing the feedbackinhibition in bile acid biosynthesis and an increased bile acidexcretion into the bowel lumen34. This however may not applyto humans.

Dietary FibreIn vitro studies have shown that low fibre intake can lead toincreased risk of colorectal cancer35. This depends on the typeof fibre ingested with wheat bran and other insoluble dietaryfibres appearing to be more consistently protective thanothers33,36. Low dietary fibre increases the transit time of stoolin the large bowel37-41. This results in increased bacterial floraand potentially toxic degradation products of carbohydratesremaining in contact with the colonic mucosa for a longer time,which is potentially carcinogenic35. Another mechanism ischelation of dietary iron by the phytate content in fibre. Ironcatalyses the oxidation of lipids to substances that arecarcinogenic and this is prevented by fibre42. It has also beenshown that low fibre in the diet results in decreased adsorptionof heterocyclic aromatic amines which are present in humandiet and are known carcinogens43.

Refined CarbohydratesA number of case control and cohort studies as well as in vitrostudies have shown a direct relationship to high intake ofrefined carbohydrates, high glycaemic load and glycaemicindex, insulin resistance and increased BMI to colorectalcancers32,33,44,45. But till now, the exact mechanism remainsobscure.

Saturated FatsHigh dietary saturated fat content, especially from meat,increases the risk of colorectal cancers. This effect could besimilar to increased carbohydrate intake as it also increasesthe BMI which has a direct relationship with the risk ofcolorectal cancers32-34,44,46. It also enhances the synthesisof cholesterol and bile acids by the liver which can beconverted to potential carcinogens by intestinal bacteria47.

MicronutrientsDecreased intake of micronutrients as vitamins A, C, D, E,selenium and other trace elements which are needed to



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metabolize oxygen radicals and are also mucoprotective,can lead to carcinogenesis33,42,48-50. Increased alcoholconsumption reduces the availability of micronutrients andthus works in a similar way51.

CalciumDietary calcium is known to reduce colonic epithelial cellturnover both topically and after absorption. It also bindsbile acids, the metabolites of which are known to becarcinogenic33,52,53.

Miscellaneous FactorsHormonesAutocrine, paracrine and endocrine effects of differentfactors and hormones have been studied and indicate thatthey play important roles in the sustenance, growth andmetastasis of cancers.

The effects of gastrin54, androgens55-60, growth hormone(through IGF-1)61, insulin62-66, nor-adrenaline67-69, thyroidhormone70, and glucocorticoids71 have all been evaluatedand mainly lead to the activation of growth factors and theirpathways which can lead to the formation of tumours. Theeffects of oestrogens however are thought to be protectiveand play a role in the maintenance of Vit-D and calciumhomeostasis, particularly in post menopausal women72,73.

Stimulation of the epidermal growth factor receptor(EGFR) and vascular endothelium growth factor receptor(VEGFR) serve as a common pathway for the effects of manyof these hormones74-77 which leads to growth andsustenance of the neoplastic tissue.

Infectious AgentsThe presence of certain bacteria and viruses has also beenlinked to the increased risk of developing colorectal cancer.Among these, intraepithelial E.coli and CitrobacterRodentium have been found to be strongly related tocolorectal polyps78,79 as well as Human Papilloma Virus 16and 1840. H pylori has also been indirectly linked to color-ectal cancers and it is postulated that hypergastrenaemiaassociated with H pylori infection acts as a growth factor forCRCs56,80.

Cigarette SmokingCigarette smoking has been shown to increase the risk ofcolorectal adenomas and carcinomas in both men andwomen33,43.

NSAIDS (non steroidal anti-inflammatory drugs)Some recent studies have proposed a carcinogenic role forcyclo-oxygenase-2 (Cox-2), which is an enzyme thatmetabolizes Arachidonic acid and results in the productionof Prostaglandins E2, D2, F2, I2 and Thromboxane A281,82.These metabolites in turn favour the production of variousgrowth factors including vascular endothelium growth factor(VEGF) which promotes angiogenesis56,79 and epidermalgrowth factor (EGF) which is thought to play important rolein metastasis83,84.

Anti-prostaglandin effects of NSAIDS have been shownto reduce the risk of colorectal cancers. Inhibiting Cox-2selectively has been shown to prevent colorectal cancers81.It is also suggested that dietary fish oils rich in unsaturated

fatty acids of the n-3 type work in a similar way, thus beingprotective in colorectal cancer43,82,85. Some clinicians favourthe use of NSAIDS as chemopreventive agents in patientswith Familial Adenomatous Polyposis Syndrome (FAP)42,86.

Chronic IllnessesCertain conditions are known to predispose to colorectalcancer, although the exact mechanisms are not properlyunderstood. These include long standing inflammatory boweldisease, schistosomal colitis, exposure to radiation, asbestos,previous gastrectomy, cholecystectomy, vagotomy andureterosigmoidostomy and ileosigmoidostomy. Infections withHIV and HPV (types 16 & 18 in anal cancers only) also increasethe risk of colorectal cancers37-40,43,46,79,87-94.

ResultsIt is evident from the above that there is enough circumstantialevidence to link the environmental factors to genetic events butno single clearly defined event in the development of CRCsrepresents the point of interaction between environmental andgenetic sequences. However, mutation of APC gene or MSIseems to be the initial event in most cases. Other geneticmutations as K-ras, p-53, 18q21 etc also occur in somesporadic cases and could be the point of interaction betweenenvironmental and genetic factors leading to the developmentof CRCs.

This review however, was not a commissioned systematicreview and did not analyse these studies in that context.

ConclusionThe aetiology of colorectal cancers is multifactorial. Aninteraction between these factors leads to a sequence of welldefined genetic events and the development of colorectalcancers. It is clear from the above discussion that the exact linkbetween these and the development of CRCs is not welldefined and further research in this direction still needs to beperformed. This review however, gives the reader anopportunity to grasp the aetiology of CRCs and would behelpful clinically in managing the risk factors in patients.

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