No.32, Dec 2010 - Association of Surgeons of Great Britain and Ireland
Transcription
No.32, Dec 2010 - Association of Surgeons of Great Britain and Ireland
Association of Surgeons Great Britain•and Ireland32, DecemberNumber Association of Surgeons of Great Britainofand Ireland Number 2010 28, December 2009 EDITORIAL On the first day of Christmas, my true love sent to me A partridge in a pear tree. … and a merry Christmas and a Happy New Year from the Association of Surgeons of Great Britain and Ireland ….. or is it? We are in the process of great change to our long loved profession of Surgery. Our budgets are being cut, we are asked to produce more for less, our hours are restricted, but not as much as our pay, and we are being WATCHED. Yes, “Big Brother” is out there Ladies and Gentleman and he can take many shapes or forms. Take the week 22nd to 28th November 2010 as an example. On the Wednesday, the Guardian published an article entitled “NHS heart surgeons ‘lead Europe’ with a 25% lower mortality rate”. Hurray I hear you say, but wait! Heart surgeons results are collected, audited and published and are available for public scrutiny. “UK cardiac surgeons are very proud that they publish the most comprehensive cardiac surgery data in Europe” quotes David Taggart, President of the Society for Cardiothoracic Surgery. But, we are not cardiac surgeons and we are not publishing our results! The Guardian states that “other specialties are far behind heart surgeons in data collection” and that, my friends, includes us! Indeed, a separate Guardian investigation earlier in the year found that “data collection by vascular surgeons was variable around the UK, as were patient death rates”. In addition, they noted that “some disciplines collected little or no data”! How can we allow this to happen in 2010? The Guardian will return to look at the Vascular Surgeons (and you!) and will have access to all of our data, utilising the Freedom of Information Act. You are all exposed to external audit, and it is essential that your “house is in order”. Each one of us needs to contribute to National Specialty Databases and set up Quality Improvement Programmes (QUIP) within our disciplines before we are named and shamed! To this end, I have asked David Mitchell, Audit and Quality Improvement Lead for the Vascular Society to write in this Newsletter about the Society’s approach to this concern. That Sunday 28th November, the Observer published its leading article entitled “Exposed: Hospitals that shame the NHS”. I quote: “19 hospitals have high death rates; NHS failing patients’ on critical care”. The article refers, in fact, to the Dr Foster Hospital guide 2010 (http://www.drfosterhealth.co.uk/docs/hospitalguide-2010.pdf) which publishes Hospital Standardised Mortality Ratios (HSMRs) for NHS hospitals. Were you named and shamed? Was the guide accurate? If not, do you have your own data to support your practice? Remember, newspapers like headlines and most headlines are BAD! We need to collect data, audit our practice, adopt QUIPs and improve our service to patients urgently in 2011. Are you all QUIPing? Do you need to QUIP? Your views will, as usual, be gratefully received at: [email protected] On the second day of Christmas, my true love sent to me Two turtle doves, And a partridge in a pear tree. Turtle doves symbolise teenage deaths from knife crime over the Festive Season. Within the UK, teenage knife crime is rapidly rising. To this end, ASGBI and its charity, The Surgical Foundation, hosted the first joint surgical/police conference in London on Monday 15th November 2010. The aim was to improve cooperation and effectiveness of harm prevention and crime reduction associated with knives. This highly successful venture resulted in several areas of agreement which will form the basis of an ASGBI consensus document on knife injuries to be published in early 2011. The conclusions included the following statements of intent: • Surgeons should get involved in early years peer group education programmes. • Data sharing between emergency departments and community crime reduction partnerships must become standard practice in every hospital in the UK. • Restrictions in the access to alcohol are supported; evidence suggests that this would have a dramatic effect on violent behavior in the young. • The development of regional trauma networks, supported by accredited training programmes and courses that include the management of violent injuries, is encouraged. • ASGBI strongly recommends that all general surgeons involved in the treatment of trauma should attend one of these accredited training programmes. • Surgeons should be trained to appreciate the forensic requirements of the criminal justice system by preserving evidence. The conference was widely reported in the media, and we do hope that you will all become involved in local initiatives to reduce knife crime in your regions of the UK. On the third day of Christmas, my true love sent to me Three French hens, Two turtle doves, And a partridge in a pear tree. Finally, may I inform you that the Stage 2 Application for Specialty Status for Vascular Surgery has been submitted for approval. If successful, “National Selection” to ST3 training in the new specialty may begin as early as summer 2012, with the first tranche of CCTs being awarded in 2018. Clearly the separation of Vascular from General Surgery will have profound effect to the provision of emergency surgical services, and this will require significant forward planning in the years ahead. Vascular reviews are occurring in most regions already, but if you are not yet prepared for change, you will need to discuss your situation on a local basis. There is no one plan which will suit all centres, and the decision for networks or centralisation will be a local agreement. At the ASGBI 2011 International Surgical Congress to be held in Bournemouth from 11th to 13th May 2011, we have organised a symposium entitled: “Specialty Status for Vascular Surgery: Implications for the General Surgeon?” Please do come and participate. Tell us of your concerns and local problems with this radical change to the provision of Vascular Services within the UK. Also, please write to me at [email protected] with any local issues you may wish to share, and I will publish your letters in the March 2011 Newsletter. On the twelfth day of Christmas, my true love sent to me Twelve drummers drumming … And a partridge in a pear tree! I have no more gifts for you except of course the gift of succession. The advertisement for a new Honorary Editorial Secretary is within the pages of this Newsletter . I wish all of those interested good luck and much joy if successful; it is indeed a worthwhile and extremely rewarding job! Have a peaceful ‘Twelve days of Christmas’ and a happy and prosperous New Year. Mike Wyatt Honorary Editorial Secretary IS THE GENERAL SURGERY CCT FIT FOR PURPOSE? 2 Number 32, December 2010 NEWSLETTER Association of Surgeons of Great Britain and Ireland William Allum Chair, SAC in General Surgery Introduction The last ten years have seen a series of significant changes in surgical training. We now have a comprehensive, on-line, interactive curriculum, which has defined knowledge and clinical and technical skills. This has also carefully documented - for the first time - the professional attributes of a good surgeon as well as the appropriate approaches for clinical judgment in daily practice. The Junior Doctors New Deal and the European Working Time Regulations (EWTR) have radically modified working time. This has created considerable disquiet, but has also highlighted the need to consider novel approaches to training and learning with emphasis on work place based assessments, self-directed learning and simulation. The training environment has been modified by the changes in service culture with emphasis on targets and contracting of work to agencies outside the NHS. These have all challenged the traditional apprenticeship model of surgical training. Many are concerned that, on completion of surgical training, a trainee may not be fully equipped to meet the demands of the modern NHS. In such a debate, it is important to understand the current requirements and regulations for training, how these are provided and how they fit into the current service, as well as looking in to the future to identify how and where improvements can be made. Requirements for the General Surgery CCT The requirements and the regulations are defined in the ‘Gold Guide’ [1]. The Certificate of Completion of Training (CCT) qualifies the trainee for entry to the Specialist Register of the GMC and, hence, the ability to apply for a consultant or equivalent post in the NHS. Award of the CCT is subject to the successful attainment of the required competencies as defined in an approved curriculum. A CCT can only be awarded to a doctor who has been allocated a National Training Number (NTN) by competitive entry to an approved training programme. The programme should provide specialty training covering the entirety of the relevant curriculum. A trainee with a NTN is required to register with the relevant Deanery and is encouraged to enroll with the relevant College or Faculty for support in the process of application for award of the CCT. On completion of training the Surgical Royal Colleges recommend the trainee to the GMC for entry to the Specialist Register. The process of application is overseen by the Joint Committee on Surgical Training and, in practice, by the appropriate SAC. The application includes details of all training appointments since qualification with an up to date CV, confirmation from the Deanery that the training programme has been satisfactorily completed, a completed RITA G or ARCP 6 form, with reference to passing the Intercollegiate examination, and a final report from the Training Programme Director (TPD). Currently in general surgery, unlike some surgical specialties, a validated logbook is not required. It is expected that the logbook will have been continually and progressively reviewed throughout the RITA and ARCP processes. Content required for a CCT application General Surgery specialty training comprises core surgical training with competitive entry into higher surgical training. The programmes are designed to provide experience in the generality of general surgery and experience in a chosen subspecialty as defined in the ISCP curriculum [2]. Currently, there are two groups of trainees; those appointed before the introduction of the ISCP (Calman type), and those appointed after. The duration of higher surgical training for both groups is six years, although the Calman trainees have been eligible for recognition of one year of research as part of the six years. Exposure to emergency general surgery is expected throughout training, although emergency experience in the chosen subspecialty is accepted for the final year if appropriate. The curriculum has defined the Scope and Practice of General Surgery at CCT as competence to manage an unselected emergency surgical “take” and development of an interest in one of the subspecialties of general surgery. Progression through the programme is guided by the syllabus which describes the basic, intermediate and advanced aspects of knowledge, clinical skills and technical expertise. In order to complete a programme, satisfactory progress is assessed by either the RITA or the ARCP process. These processes take into account assessments undertaken in the work place of clinical and technical competences as well as of professional behaviour and clinical judgment. Such regular review allows identification of areas of deficiency and their correction by appropriate targeting of training and allocation to appropriate training posts and opportunities. Particular reference is made of logbook experience which is essential for a craft specialty. The preferred format for satisfactory progress is for the trainee to undertake as much surgery as possible in a supervised setting, rather than spending prolonged time assisting or operating unsupervised. The work place based assessments are complimented by the assessments in the Intercollegiate examination. This currently is undertaken after completion of a minimum of four years of higher surgical training and requires approval of satisfactory progress by the TPD. The exam comprises aspects of elective and emergency general surgery with critical care as well as special interests assessed in both written (multiple choice paper) and oral sections. The final report of the TPD should not identify any specific issues, as the nature of the annual or more frequent review process should have ensured satisfactory progress by the end of training. Does training deliver the content of a CCT application? The ISCP 2010 curriculum has evolved into its current comprehensive form based on previous iterations written by the SAC, which reflected the design of training from the time of primary FRCS and Clinical in Surgery in General FRCS to the development of the Intercollegiate exam. Most would accept that the current curriculum covers the required body of knowledge as well as describing the progression of skills and experience and the development of the professionalism and clinical judgment expected of a consultant. It is acknowledged that, in some specialised areas, it is not possible to achieve full competence. The development of fellowships, either before or after the award of the CCT, reflects the need for such specialist experience, The financial constraints of the service, together with the emphasis on productivity, have also affected training. The target culture has created a tension between completing operating lists for the service and allowing unpressurised time for training. The development of contractual arrangements with both Independent Treatment Centres and the private sector has limited opportunities, particularly for basic surgical procedures. A concern from Iain Anderson’s recent survey of Emergency General Surgery [5] was the relatively limited availability of CEPOD theatres for general surgery emergencies implying that the limited “productivity” of an The introduction and the implementation of the ISCP were dependent on new approaches to training, and this specifically required faculty development. Traditionally, the apprenticeship model was based on the ‘what and how’ of surgery and the ability to know how to and, equally, when not to, was experiential. The ISCP provides challenges to these approaches and the emphasis on work place based assessments has had some teething problems. Jonathon Beard’s well argued article in the July 2010 ASGBI Newsletter [7] identifies many areas where new approaches can overcome the changes in the learning environment. However, these and the developments implicit in the use of simulation require investment both in terms of human and financial resources and of time. Evolving attitudes to the definition of “work” within EWTR should allow appropriate time allowance and incentive for trainees to progress their experience by self-directed learning. Measurement of the effectiveness of training is difficult. The majority of trainees entering higher surgical training are eventually awarded a CCT. Some will have had periods of targeted training or had their time for training extended as a result of issues identified at the annual review. The only objective evidence is the success rate in the Intercollegiate examination, a test of knowledge. Figures for the 2009/2010 diets of the exam show that, for those trainees in recognised training programmes, 77% passed the first section (MCQ) of whom 85% were sitting for the first time and 83% passed the second section (orals and clinicals) of whom 91% were sitting for the first time. The forthcoming developments in sub-specialty recognition will allow identification of what is required as well as highlighting how these requirements can be achieved and in what environment. It is for these reasons that the planned changes to the Intercollegiate exam will ensure appropriate assessment both in the generality of general surgery including critical care and in the proffered sub-specialty. The timing of the general Number 32, December 2010 There have been significant changes, which have affected the ability of training units to meet these standards. These were highlighted in Professor Michael Eraut’s report [3] on the introduction of the ISCP. The EWTR and the Junior Doctors’ New Deal have reduced time available for training. It is no longer possible to train to a standard of competence across the spectrum of general surgery, as many of us did. However, the demands of the service actually no longer require such a breadth of skills. Nevertheless, there are many examples of comparisons of logbooks between current and previous cohorts of trainees showing significant reductions in practical operating experience. The PMETB survey [4] of the effect of EWTR implementation in 2009 highlighted that surgical specialties had the lowest rate of compliant rotas (66.7% compared to an overall of 78.5%), the lowest attitude rating of acceptability (52.1% compared to an overall of 70.7%) and the lowest level of agreement that trainee needs have been met (31.5% compared with 67.4%). These and other similar influences need to be resisted by engagement with our managerial colleagues to ensure training and service provision are on an equal level. The development of a training contract would allow the respective responsibilities of the training unit, the trainers and the trainees to be defined to ensure the necessary opportunities are readily available to the required standards. A review of the relationship between local providers of training and those responsible for the standards would be timely. The externality provided by the previous SAC visits process not only enabled advocacy of the standards, but also identified areas of good practice as well as areas where improvements were required. Modification and regeneration of this process by, for example, using existing trainer and trainee structured questionnaire information would facilitate qualitative improvements and consistency in training. In their recent report The Future of Surgical Training ASIT [6] have highlighted the limitations of training within the modern NHS and have stressed the responsibilities of all involved, identifying in particular the onus on Trusts, not only in terms of human resource but also financial, to ensure adequate and appropriate incentive for high quality training. NEWSLETTER The quality of specialty training programmes should reflect best practice and, indeed, there should be an appropriate link between good service provision and good training experience. The GMC is responsible for quality assessment with the Deaneries responsible for quality management of the provider units. This has been evolving as the Schools of Surgery have developed over the last five years. However, the standards expected of general surgical training are a professional issue and the responsibility of the SAC. In 2003, the SAC set objective standards against which a training unit should be assessed. This included staffing and firm structure, hospital facilities and working arrangements and an educational environment to support trainees both in terms of supervision and educational opportunities. These standards formed the basis of the previous approach to training unit evaluation including regular and triggered visits. Currently, the JCST is developing recommendations for a variety of quality measures which include both generic and specialty specific standards. In fact, in general surgery, much of what was documented in 2003 still pertains, although there have been reductions in caseload volumes. emergency theatre has led to its use for more costeffective elective work. Association of Surgeons of Great Britain and Ireland but also raises limitations within existing programmes to deliver the entirety of the syllabus. The popularity of these fellowships among trainees can be interpreted as a desire to develop a competitive CV, but may also reflect an appreciation that current training does not allow accumulation of the confidence to start consultant practice, which additional time will provide. Comparison with US and Australian residency programmes shows the benefits which fellowships can confer. 3 component is likely to be after four years of higher surgical training with the sub-specialty component two years later. It is still envisaged that clinical and technical competence to CCT level will only be achieved by a total of six years of higher surgical training, irrespective of sub-specialty or even general interest. Number 32, December 2010 What is the required end product of Training? There are currently approximately 1,800 Consultants in General Surgery in the UK. The actual numbers with sub-specialty interests is not known, although the membership numbers at consultant level for the sub-specialty associations suggests, as a rough guide, the proportions with respective interests: NEWSLETTER Association of Surgeons of Great Britain and Ireland The fact that the vast majority complete higher surgical training and are awarded a CCT, suggests that the selection process, the development of ISCP defined competences and the acquisition of required knowledge during the training programme are fit for purpose. However, is that the correct end product? ASGBI AUGIS ACP ALS ABS BAETS Transplant Vascular 2270 390 600 334 435 200 140 460 As part of the recent application to the GMC for sub-specialty recognition, Peter Lamont analysed the consultant posts advertised in the BMJ online in May 2009. There were 16 vacancies: General Surgeon General & Upper GI General & Colorectal General and Breast Colorectal (laparoscopic) Upper GI (intestinal failure) Vascular General and Oncology (sarcoma) Renal Transplant 0 2 2 4 2 1 2 1 2 All specified a sub-specialty interest and participation in emergency surgery was optional/not required for three of the four breast posts. Neither of the two vascular posts, nor the two transplant posts, included involvement in the emergency general surgery rota, as they would take part in a separate vascular or transplant rota. By contrast, the ASGBI survey of Emergency General Surgery [5] confirmed that 75% of respondents had a regular commitment to acute general surgery on-call. The recent White Paper Equity and Excellence: Liberating the NHS [8] has highlighted the provision of local care. It remains to be seen how this will affect service configuration, but the emphasis on commissioning by primary care is likely to focus on local hospital surgery. There will need to be a balance with sub-specialisation, as patient demand is an important driver for subspecialty treatment. It became apparent during the recent application to the GMC for sub-specialty recognition, that there is central concern that overemphasis on sub-specialisation could be to the detriment of the provision of emergency care. This was strongly countered by assurance that the evolving sub-specialty curricula will ensure the commitment to general surgery throughout higher 4 surgical training, particularly for acute and emergency patients, as well as defining the subspecialty skills. This will, however, have manpower implications. Once vascular surgery becomes a separate specialty and many consultants with a breast sub-specialty interest withdraw from the acute rota, the consultant workforce will need to be sufficient to provide the acute service and have acceptable and appropriate working conditions. Manpower numbers will need to be defined with regard to the sub-specialties to prevent trainees selecting areas of interest where there are likely to be very few vacancies. Although Peter Lamont’s survey showed little call for general surgery, the White Paper initiatives suggest a need for the general surgeon with a gastrointestinal interest. Indeed, this is consistent with the joint statement from AUGIS, ACPGBI and ALS in 2006 [9] in which the specialist gastrointestinal surgeon was defined, providing a general gastrointestinal portfolio having completed two years each of upper GI and colorectal surgery training. Conclusions The current CCT is awarded after successful completion of the training programme which provides the necessary skills defined in the ISCP curriculum. In keeping with other aspects of professional development, the CCT should be considered part of an evolving process, the evolution being defined by the demands of the modern NHS. It does provide a surgeon at the end of training with the skills upon which to build as their consultant career develops including both emergency general surgery and sub-specialty interest. However, training must be able to respond to changes in the NHS and must be carefully and continually reviewed. There is an imperative for all involved in training to ensure that the right environment is in place to enable us to provide the highest quality training opportunities to ensure that the CCT holder of the future is fit for purpose. References [1] A Reference Guide for Postgraduate Specialty Training in the UK - The Gold Guide Fourth edition, 2010 [2] Intercollegiate Surgical Curriculum Programme 2010 www.iscp.ac.uk [3] PMETB and the European Working Time Directive PMETB, September 2009 www.gmc-uk.org [4] Evaluation of the Introduction of the Intercollegiate Surgical Curriculum Programme Eraut M, 2009 [5] Emergency Surgery Survey Anderson I, Krysztopik R and Cripps N ASGBI Newsletter, No 31, September 2010: 12-15 [6] The Future of Surgical Training: A Position Statement Association of Surgeons in Training, 2010 [7] Can UK surgical trainees achieve competence in procedural skills within the current working time restrictions? Beard J D ASGBI Newsletter, No 30, July 2010: 2-5 [8] Equity and Excellence: Liberating the NHS Department of Health, 2010 [9] Specialist Gastrointestinal Surgical Training ACPGBI, AUGIS and ALS ASGBI Newsletter, No 14, June 2006: 8-10 Bill Allum is to be congratulated for this comprehensive and succinct analysis of where we currently stand with training in General Surgery. The problems faced in service delivery of upper gastrointestinal surgical practice are complex but not insurmountable and are summarised thus: • Upper GI has evolved further into three distinct service driven sub-specialties over the last decade: • Oesophago-gastric cancer surgery. • Complex (predominantly cancer and transplant) hepato-pancreato-biliary surgery. • Complex benign UGI surgery (largely driven by the demand for bariatric procedures). • These developments over the last ten years have not, until now, been matched by appropriate evolution of both the training curriculum and syllabus, nor by the final accreditation examination. • External pressures beyond the control of the profession that make calculations of future UGI consultant numbers difficult to predict in the years ahead: • Future role of the ISTCs and NHS reimbursement for routine procedures within the remit of the UGI surgeon (elective cholecystectomy, anti-reflux surgery, abdominal wall hernia surgery). • The impact of developments in chemotherapy on the role of the surgeon in the management of UGI cancer patients (the reduction in the use of surgery for oesophago-gastric cancers versus the increase in the use of surgery for patients with liver metastases). • The threat to bariatric practices from ‘Big Pharma’ where the magic pill to cure satiety is now the number one area of drug development globally (members of the Association will be relieved to know that male impotence remains the number two area of development, while cancer lags at number five!). Those of us of over a certain age will remember vividly the overnight impact of the introduction of H2 antagonists for peptic ulcer disease on the use of elective vagotomy in the mid nineteen seventies. AUGIS ( and its constituent groups: BOMSS, GBIHPBA and the OG surgical group) has, for some time now, recognised the challenges posed by these developments, particularly within the training requirements for often complex surgical procedures within all three areas of our practice. Even before the very welcome changes to subspecialty status within General Surgery now being taken through the GMC, we have been instrumental in establishing post-CCT fellowships in all three of our elective sub- The other perennial problem remains the delivery of emergency General Surgery. The separation of vascular (outside General Surgery) and transplant (remaining within General Surgery) surgery is welcome, and reflects the sophistication of twenty first century surgical practice. What remains is predominantly acute gastrointestinal disease and trauma. It is, therefore, appropriate that the demand to deliver such services, with ever increasing expectations on outcomes (especially with possible moves to centralise trauma services) should not fall on surgeons with a major interest in breast disease. This effectively means that this service will continue to be delivered, for the foreseeable future, by members of AUGIS and the Association of Coloproctology. This reality means that the new curricula and syllabus has to reflect necessary skills and competencies in both UGI and Coloproctology training programmes to reflect these demands. As Bill says above, much of this experience in emergency surgery can be achieved in years 1-4 of specialist surgical training before sub-specialty training, but will need to be reiterated by continuing exposure to emergency surgery in the subsequent subspecialist years of training through to CCT. The way ahead AUGIS is committed to the development of upper GI Surgery as a recognised sub-specialty within General Surgery. The changes currently being taken through the GMC by the remaining five (Upper GI, Coloproctology, Breast, Transplantation and Endocrine) sub-specialties of General Surgery (following the recent departure of Vascular Surgery) do not alter the fact that the CCT remains within General Surgery. What these changes do achieve is to enable trainees to focus their final years of training in dedicated and accredited training units within their chosen sub-specialty discipline, in the knowledge that this training will be intense and allow them to maximise their training opportunities within the restrictions of the EWTR and finite training programmes. Furthermore, it will finally offer future employers the opportunity to appoint consultants in the knowledge that the appointment actually does ‘what it says on the tin’. However, we will need to continue to refine the training programmes to reflect the realities of the further sub-specialisation that has already occurred, and horizon scan for the known challenges outlined above, while remaining vigilant for the unknown challenges that will inevitably confront the profession during the financially troubled times of the decade ahead. Number 32, December 2010 Graeme Poston President, Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland (AUGIS) NEWSLETTER COMMENTARY ONE specialty areas of interest (funded centrally, locally or externally from industry). These posts remain popular, competitive and over-subscribed, but I am concerned that, as we move into tighter fiscal times, such funding may become more difficult to achieve in the future. Indeed, AUGIS with the English Department of Health, has now produced a position paper (view at www.augis.org) on the structure, centre volume and surgeon volume necessary for the delivery of upper GI cancer surgery services, which we hope will give better guidance to future manpower demand in our sub-specialty. Association of Surgeons of Great Britain and Ireland COMMENTARIES 5 COMMENTARY TWO Mark Lansdown SAC member with specialist interests in Endocrine and Breast Surgery Number 32, December 2010 NEWSLETTER Association of Surgeons of Great Britain and Ireland Yes, the CCT in General Surgery is fit for purpose, but the processes for ensuring that trainees holding a CCT are fit for purpose is another matter. This may seem contradictory, but developing a curriculum and standards for the competencies required to take a place on the specialist register is a lot easier than putting in place a comprehensive training programme which ensures that a trainee only progresses when those competencies have been achieved. We have developed a competency-based curriculum which has been shoe-horned into the constraints of the EWTR and an expectation that the CCT will be achieved in six years of higher surgical training. Many have voiced their concerns about the massive reduction in hands-on experience that trainees now get in the operating theatre compared with 10 or 20 years ago. But this is not just because of the EWTR. Other factors include pressure from managers to get as many patients through a list as possible, and the need to achieve the highest possible operative success rates in an increasingly transparent and competitive world. Nevertheless, I believe it is possible to train the majority of our trainees in six years if they have access to training of sufficient quality. As a trainee and newly appointed consultant I was often struck by how much longer operations took in North America compared with my experience of surgery here in the UK (just look at the literature on laparoscopic procedures to see how long cholecystectomy usually takes there); and how few procedures an American trainee performed before being “licensed”. Later, I had the opportunity of observing surgical training at a specialist centre in New York. As far as I could tell, every case was a training case and the trainer took time to help the trainee with every step of the procedure, ensuring that the operation was performed to the same standard as if they had done it themselves. Now I understood how an American trainee could become proficient at an operation with exposure to so few cases. I recently heard of a trainee whose RITA form stated that they needed more operative experience. During that attachment the trainee had assisted at more than 30 cases of a particular procedure, but had only been allowed to perform the procedure twice under supervision! They were signed off ready for the next stage of training. You cannot have it both ways – either provide training, or tackle in the appropriate way the issue of a trainee who should not be allowed to progress. Perhaps the trainer was worried about outcomes. It appears (in cardiovascular surgery at least) that publication of surgeon-specific data leads to a reduction in the COMMENTARY THREE Wyn Lewis The traditional British Surgical apprenticeship, which had evolved over more than 200 years, and was arguably once the envy of the world, has 6 number of cases deemed suitable for trainees to perform. In fact, evidence that outcomes are as good in training cases as those performed by consultants is accumulating. High-quality training takes time, and much of that time is the trainer’s time whether in theatre, helping with simulated training or giving feedback. It also conflicts with the target-driven environment that most of us have to work in and the lack of a surgical assistant to hold the retractors while we hold the trainee’s hand. When will managers recognise that we must be allowed this time and resource? Perhaps they would listen if there was a sufficient uplift to the HRG (Healthcare Resource Groups) paid for a procedure during which training took place. I do not think they are listening to the Deaneries or the SAC. I contend that there has been insufficient pressure on our employers to allow us to train, and too little re-education and training of trainers to ensure that trainees are thoroughly scrutinised as they progress towards their place on the specialist register and their ticket to applying for consultant posts. Within each Deanery there are some training posts that are more fit for purpose than others, and there are hawks and doves when it comes to filling in trainees’ assessment forms. Comparing the situation now with my experiences of sitting on training committees 10 years ago, I would say this has not changed and a minority of trainees are being signed off ready for the next stage of training when they should not be. The difference now with shortened training is how little time there is to get the trainee back on track when the deficiencies are recognised – assuming they are. When deficiencies (perhaps a better term is “lack of progress”) are recognised, I am surprised at how many trainees contest a decision that they would benefit from targeted training or perhaps an extra six months or a year before being signed off for independent practice. Perhaps they are mindful of all those cases spent holding a retractor when they could have been performing the procedure under supervision! In conclusion, I believe the solutions to ensuring that trainees with a CCT are fit for purpose are threefold: 1 Trainers need more support to understand the modern curriculum and how to ensure that an individual trainee has reached the required standard to progress to the next stage of training. 2 Trainers must be given the time and resources to train properly. 3 The SAC and schools of surgery must be allowed by PMETB/GMC and our employers to re-invigorate training and quality assurance. Then I think we will produce CCT holders to be proud of. during the course of the last fifteen years been systematically dismantled. The culprits and usual suspects are well known and stem from a workplace target driven culture allied to health and safety legislative dogma. The contemporary Certificate of Completion of Training has adapted The purpose of a generic Certificate of Completion of Training (CCT) is to comfirm satisfactory completion of a United Kingdom training programme, which has commenced from the start of the prospectively approved programme or equivalent, and makes a doctor eligible for inclusion on the General Medical Council’s Specialist or General Practitioner Register. To deliver an assessment of this competency within a limited time frame inevitably means a degree of counting of index procedures performed, together with an assessment of an individual’s position on the global general surgical learning curve. Nevertheless, this should be limited to certain specific, agreed and proven key outcomes. With regard to General Surgery the counting of competencies begins at an early stage, with the requirements for competitive entry into higher surgical training, and then continues with the aid of log books, regional RITA and ARCP processes, culminating in an Intercollegiate FRCS examination, both in general surgery and a subspecialty. More recently, sub-specialist fellowships have been developed in addition to the above to increase logbook numbers of specialist operative procedures and further enhance trainees’ multi disciplinary experience. This is of particular In conclusion, with the contemporary trend for increasing sub-specialisation, general surgery has perhaps foregone much of its traditional romance, glory and breadth. Nevertheless, it remains a very competitive, demanding but rewarding specialty in which to practice. The contemporary CCT is indeed evolving and the planned modifications to the intercollegiate exit examination are moving in tandem. Plans to assess general surgery and critical care competencies at ST 5/6 level, with the option to proceed to a subsequent specialist qualification after a further two years experience, seem both sensible and workable. Finally, large professional organisations such as the NHS are, by their very nature, continually in a state of flux and continuous change. The most recent Government white paper relating to the NHS in England; Equity and Excellence: Liberating the NHS; is explicit in its aims to provide local care with an emphasis on commissioning of services by primary care. Such change is not, obviously, in keeping with increasing surgical subspecialisation which risks being at odds with locally delivered emergency care, and will undoubtedly drive local manpower planning. The CCT of the future decade will, as ever, need to adapt if it is to remain fit for purpose. COMMENTARY FOUR by Bill Allum in his leading article. All of the uncertainties and difficulties implied by the curse are certainly present. Neville Jamieson Head of School of Surgery, East of England Deanery “May you live in interesting times” usually described as a Chinese curse/blessing and attributed to Confucius is, in fact, more likely to have been first coined in the USA in the early part of the 20th century. Nonetheless, it does accurately describe the present situation outlined Number 32, December 2010 “Not everything that counts can be counted and not everything that can be counted counts.” The potential weaknesses of the system currently evolving lie in the local or regional assessments of on the job practical competencies, and it will be the remit of the regional Schools of Surgery to address this potential pit fall. Moreover, the forthcoming developments in sub-specialty recognition, with a separate vascular SAC high on the agenda, must to some extent be viewed as experimental. While the advantages are clear in terms of large multidisciplinary teams, high quality outcomes and enhanced training opportunities in large regional centres of excellence; this scenario may not be in the interest of rural and other relatively smaller district general hospitals, proving local care and services to populations of circa 120,000, and often seeking to attract general surgeons with diverse skills and abilities. NEWSLETTER In the greater context, western general surgical pos graduate training (Australia, New Zealand, Canada, United States) consists of a five to seven year residency leading to eligibility for a Professional College Fellowship or American Board of Surgery Certification respectively, which is also required for hospital operating privileges in the USA. In the United Kingdom, there are clear similarities, with the caveat that the last decade has witnessed the emergence of multiple workplace targets, which has had a particular affect on the way that medical care and training is delivered. The above has also been heavily influenced by European Working Time legislation, which may, at first glance, seem to have theoretical advantages, but nevertheless also carries inherent risks. It is said that Albert Einstein had the following quote hung high on the wall behind his office desk at Princeton University, which is a poignant summation of the present state of target culture: importance within focused areas such as oncoplastic and laparoscopic surgery, where indepth experience is more challenging, associated with longer and, by definition, shallower learning curves, and therefore more challenging to achieve. While this latter development may be a reflection of the beneficial experience reported from Australian and the United States, it may also simply reflect a practical manifestation of competition for Consultant appointments. Association of Surgeons of Great Britain and Ireland and evolved in tandem with the above, and William Allum’s article is a well-timed and erudite summary of the present position. Bill has described well the current situation and the difficulties seen with the impact of the EWTR and New Deal on delivery of training using the traditional apprenticeship system which was the mainstay of surgical training. The old, broad based, general surgical training is disappearing and being replaced by more focussed sets of skills 7 8 Number 32, December 2010 NEWSLETTER Association of Surgeons of Great Britain and Ireland aimed at specialty specific skills. Overall experience in the trainees log book can be inspected by RITA and ARCP panels and has certainly decreased with shorter hours, although this can be mitigated by focussed training and emphasis on achieving relevant competencies without excessive commitment to repetitive routine service tasks. Although we do emphasise that training is competency based, it is interesting to see that some specialties where a wide range of operative skills are required are using indicative log books reflecting the experience gained in training by a cohort of newly appointed consultants to gauge the progress of trainees currently in training. General surgery still exists as a title which we all recognise and even as a sub-specialty in the existing Intercollegiate exam in general surgery – but not in the adverts section of the BMJ as pointed out by Peter Lamont. Trainees now aspire to be colorectal surgeons, breast surgeons, oesophago-gastric surgeons, endocrine surgeons, etc and seek training and experience to match the jobs which do exist. These various subspecialties are likely shortly to be accepted formally as separate sub-specialties and vascular is close to separating completely with a separate SAC, separate training programme and a new career structure of its own. These changes have come rapidly and we have adapted training to match, although new changes are constantly appearing and, as Bill points out, it is essential that the training system remains under constant review to allow it to adapt and evolve in response to the rapidly changing requirements of the health service. We have an online curriculum, which has been recently updated, and have changed the emphasis of the training programmes to give more sub-specialty training. COMMENTARY FIVE Mike Bradburn Head of School of Surgery, Northern Deanery Bill Allum has comprehensively outlined the external influences on surgical training and the changes these have caused over the last 15 years or so. The restriction of hours, the introduction of targets and the tension between service and training have all conspired to affect the training opportunities available to a trainee. He rightly points out that the newly qualified surgeon is a different animal to that of 20 years ago, but the job itself has changed, and most of us are now subspecialists to a greater or lesser degree. The most telling figure is Peter Lamont’s analysis of consultant vacancies in May 2009. There were no adverts for pure general surgeons, and the adverts for three of the four breast surgeons allowed an opt-out from the on-call (general surgery); the vascular and transplant posts had no on-call component at all. General surgery is coming to mean participation in the emergency on-call rota, and this is increasingly becoming the province of the upper and lower GI surgeons. Despite this, we make all trainees sit examinations and achieve a The Intercollegiate Board Examination is undergoing huge changes to reflect the need to provide and test a training in general emergency surgery followed by a defined sub-specialty specific exam. Fellowships have developed in all areas of surgery, and many trainees who have completed their CCT will now add a further period of fellowship to their training. Many of these fellowship posts were designed to meet specific training needs not available at the time in conventional training programmes such as oncoplastic fellowships for breast trainees, laparoscopic fellowships for colorectal trainees and endovascular fellowships for vascular trainees. The need for some of these will become less as these techniques are more widely adopted and applied in all units in the standard training programmes. However, they also serve a second purpose, allowing further experience, polish and competitive edge to advanced trainees in an increasingly difficult job market. In some cases, they exist in the first instance primarily to allow units to function within the EWTR with their educational role being secondary and, indeed, by diluting experience for the standard NTN bearing trainees may be counter-productive in this regard. Meanwhile, there is an increasing emphasis on consultant delivered services which will see further changes in the jobs on offer to the new CCT holder and the prospect of reductions in training budgets and numbers of trainees with increasing emphasis on their training requirements and less on their availability to help with service. The health service has changed enormously in recent years but more change is on the way – interesting times indeed! CCT in general surgery, an experience it is unlikely the breast, vascular and transplant surgeons will ever use. These changes are now upon us, but the examination and certification system is still catching up. Vascular surgery is likely to split as a separate subspecialty in the near future. Trainees will be awarded a CCT, but not with general surgical competencies, and their exposure to upper and lower GI surgery - “general surgery” - will be much reduced from current requirements. Transplant and breast surgery have not yet taken this step, but may do so in the future and would, consequently, seek their own CCTs. The current CCT is an adequate level of certification; it confirms that new consultants have the necessary skills to develop their future practice. Medical indemnity malpractice claims for newly appointed consultants would not suggest that we are training unsafe surgeons. We should, however, award this to trainees who will practice in the generality of emergency surgery and allow more tailored training and certification to those subspecialties already breaking away from the fold. This is a difficult question to answer, as there are inevitably two sides to any story. However, we are all aware of patients subjected to surgery when they may well have been better off without an operation. Getting the best results for our patients requires careful consideration of the risks and benefits of any procedure and a careful discussion with the patient, their families and carers. It is also important to recognise that it takes a team of surgeons, anaesthetists and nurses to perform an operation and the agreement of the patient to go forward to surgery. Avoiding poor outcomes requires a team practised and skilled in the procedure required. In higher volume hospitals with good outcomes, patient factors are most important in determining outcomes. Teams need to be able to recognise the high risk patient and have time to explain those risks, finding out what the patient wants. This forms the core of the new government strategy “no decision about me, without me” [1]. The time spent on assessment and consultation may avoid the distress of complications and death that could have been avoided by deferring risky surgery. It is no longer acceptable to say that the patient had to have any given operation, as many elderly patients will elect for conservative management once the risks and benefits of major surgery are fully discussed. Improving quality requires recognition that there is a problem, or that outcomes or service quality could be improved. If accompanied by a change in behaviour to ensure that all members of the team and the patient are fully involved in decision making, then improvement is much easier to achieve. One of the major issues facing vascular surgeons in the UK in 2008 was that our reported mortality for open Abdominal Aortic Aneurysm (AAA) repair compared badly to the rest of Europe [2]. These poor outcomes mirrored those reported from NCEPOD [3] and The Vascular Anaesthesia Society of Great Britain and Ireland [4], suggesting that there were problems with the quality of care we offer our patients. Our response has been to approve a quality One of the key features of any QIP is robust measurement to ensure that the programme is heading in the right direction. QI methodology is somewhat different from standard clinical research methodology in employing small tests of change to determine progress. The randomised clinical trial is not a traditional feature of QI programmes, as the time taken to implement change by this route is often lengthy. Another central focus of QIPs is implementation and embedding of change in clinical culture. A good example of this is hand washing after patient contact in the NHS. This was combined with a focus on “naked below the elbow”. It was this latter part of the programme that irritated many clinicians who complained of a lack of evidence base. This, in part, missed the point of the QIP which was to change attitudes to hand hygiene. Changing the dress code focussed minds on washing and clean hands around patient contact. Combined with regular audits of hand washing behaviour (measurement), the culture in the NHS has been shifted to one that focuses on clean hands for patient contact. Similar approaches questioning the use of central venous catheters has seen MRSA rates fall in many NHS hospitals. This was achieved without the use of RCTs. The data collection method was to provide running totals of MRSA rates within hospitals, the so-called “run chart”. This allowed all clinicians to see how they were progressing from month to month. The effect was to heighten awareness of the MRSA problem and to see steady and sustained falls in bacteraemia rates. Number 32, December 2010 Introduction At the first patient focus group meeting I attended, one of the patients told the story of his uncle George. George had heart failure and was in hospital being treated for it. He had very limited exercise tolerance. Whilst in the ward, he had a number of tests and was found to have a large abdominal aortic aneurysm. He was referred to, and seen by, a vascular surgeon who told him he needed an operation to fix it. His family was not involved in this discussion, and were of the view that George was not fit enough to survive major surgery. Following the operation, he had a stormy course with repeated lapses into heart failure. About a week after the operation he died on the ward. The question that the patient in the group wanted answered was “How do we stop surgeons operating on patients like Uncle George?” Aims of quality improvement programmes (general) Vascular surgery is not alone in facing challenges provided by better audit and greater scrutiny of clinical outcomes. The desire to improve outcomes is common throughout medicine, and any committed clinician will agree that quality improvement is a worthwhile activity. The Vascular Society submitted, and was awarded a grant by the Health Foundation to undertake a quality improvement programme (QIP) for AAA surgery. There were many applicants for these grants with varied aims from reducing needle sharing in drug addicts to improving neonatal care. The common theme was a desire to improve the care offered to patients. The funding enabled us to appoint a project management team to co-ordinate and deliver our QIP [6]. NEWSLETTER David Mitchell, Audit and Quality Improvement Lead for the Vascular Society improvement framework as a Society, in 2009, with the aim of halving the 30 day mortality rate following elective AAA repair [5]. Association of Surgeons of Great Britain and Ireland QUALITY IMPROVEMENT PROGRAMMES IN VASCULAR SURGERY: WHAT, WHY AND HOW? Such techniques have been subjected to formal assessment showing that providing regular data feedback can drive quality improvement on its own [7]. What is important is that there are clear, achievable, goals for each QIP and that the clinicians involved understand the steps required to reach those goals. Regular monitoring will allow the direction of the programme to be varied, if needed, to maintain progress towards the QI goal. Why do this in Vascular Surgery? A significant part of vascular surgery deals with sick elderly patients presenting with arterial disease. The presentations of severe limb ischemia, cerebro-vascular ischemia and abdominal aortic 9 Number 32, December 2010 NEWSLETTER Association of Surgeons of Great Britain and Ireland pathologies are often accompanied by underling arteriopathy in the heart, kidney and intestine. Such patients face high risks of death and complications from surgery. Discussion with older patients often focuses on a fear of disability and death from interventions. The role of a QIP is to identify areas where change in process or outcome (or both) is desirable. The programme brings together the evidence available and fashions a pathway of care that will minimise the risks associated with surgery. Once a pathway of care is agreed, the next step is to implement it and to monitor the effects of implementation on outcomes. This requires a period of measurement before, during and after introducing changes. For vascular surgery in the UK, the most obvious need for change is to improve mortality rates after elective AAA repair. The introduction of the National Abdominal Aortic Aneurysm Screening Programme (NAAASP) is another important stimulus to change, as the benefits of screening are only seen if surgery for AAA can be delivered with a low mortality [8]. Our first step was to articulate a quality improvement framework (QIF). This set out a clear goal of reducing the death rate by 50%, from the current level to 3.5% by 2013. The QIF then described the processes by which this would be achieved and the necessary organisational structures to underpin it. Once designed, it was published and circulated to the membership of the Vascular Society of Great Britain and Ireland (VSGBI) with a questionnaire asking for feedback. There was strong support from within the VSGBI, and the QIF was formally adopted at our annual meeting in November 2009. The VSGBI also had strong support from our sister organisations, the Vascular Anaesthesia Society of GB & I, the British Society for Interventional Radiology and the Society of Vascular Nurses. It is this support that forms one of the cornerstones of our programme. The other is having significant patient input to the project. Finally, the grant we received provided us with access to healthcare consultants and experts in QI methodology. Their input has proven very important to maintaining focus and momentum in the project. How the QI programme works * Organisation of teams There are a number of key steps that follow agreement to embark upon a QIP. Firstly, the programme requires significant time input from the core team and a wider team of healthcare professionals. To deliver change, everyone involved in providing care to the patient has to become involved. The QIP has to become part of the “how” for all team members and also for all clinicians delivering care to patients. Funding to support the work is important as it allows the core team to devote time to the project. Our first steps involved securing grant monies. Once achieved, we appointed a team to run the programme. We have a full-time project manager, an audit assistant and part-time PA support. The next task was to produce a project plan that described how our quality improvement framework (our aspirations) would be translated into clinical practice. This was organised through a stakeholder day at the Royal College of Surgeons of England. We had input from surgeons, anaesthetists, radiologists, nurses, cardiovascular networks, 10 public health and patients. This ensured that the plan was focussed on all aspects of care delivery. The project plan is a living document and has needed updating as we progress. The plan allows us to focus on a number of workstreams that drive the programme. The two initial workstreams focus on patient involvement and data collection. A project that covers the whole UK cannot be delivered centrally, so our first step was to create a regional network to allow us to spread information. Significant time was also spent ensuring that we can contact clinicians and clinical governance leads in all UK NHS Trusts, both to provide data and information and to receive feedback on the project. We continue to work on developing contacts with commissioners and cardio-vascular network leads. * Patient involvement Setting up patient groups was also organised on a regional basis, using local leadership. This has proved to be a very empowering process for both patients and clinicians. Under the guidance of the focus groups, we have improved our patient information sheets and provided (for the first time) written information about what to expect in the recovery phase after discharge from hospital. Our original (evidence based) information sheets were heavily criticised for being too defensive and focussing excessively on what could go wrong. We were concerned that we might fail to warn of the risks of surgery, but were encouraged to produce leaflets that provide information on assessment and care delivery in a more positive tone. These are now available for surgeons to use. The patient groups are focussed on ensuring consistency in clinical behaviour and have strongly supported the introduction of a “safe for surgery” checklist, formal anaesthetic assessment prior to admission and more detailed discussion with the patient about their concerns prior to deciding on intervention. They also supported our view that all centres offering AAA intervention must be able to provide both open and endovascular repair, and must offer patients a choice when they are suitable for either method of intervention. The patient groups are now established in England, Scotland and Wales and we see them as powerful influencing groups for developing QIPs in other areas of vascular surgery in the future. They provide a regular reality check on our plans and the progress of the project. * Data collection and reporting Data on AAA repair is collected by vascular surgeons on our national vascular database (NVD). This is a web-based tool located on the secure NHS server. It collects data about indications for surgery, pre-operative fitness, the conduct of the operation (both open and endovascular) and about anaesthesia. Data on post-operative care, complications and outcomes are also routinely collected. The database contains a search facility that can highlight incomplete records. It also provides a reporting tool giving outcome analysis by unit, and surgeon for all of our national index procedures (AAA, carotid intervention, lower limb bypass and amputation). Data entry is voluntary, and has been inconsistent with wide variation in data entry rates between * Measurement of process and outcome Part of any QIP is to describe the processes that are needed to bring about change. For our QIP the focus is on three key areas involved in delivering high quality care. The first is to describe the process of pre-operative care. We believe that improving pre-operative optimisation of patient fitness and improving selection will enhance patient safety. To enable measurement of the processes involved in delivering care, we have created care bundles. These are a group of practices which, when performed together, make a process consistent. Consistency of performance can be measured against the number of times that the full care bundle is implemented. The preoperative care bundle states that: • Elective anaesthesia to be provided by an anaesthetist with a regular elective practice in vascular anaesthesia. • All patients to be operated upon by vascular surgeons and, for EVAR, by interventional specialists experienced in the techniques involved. • The operating theatre must be properly equipped for AAA procedures including cell salvage auto re-transfusion. • There must be rapid access to transfusion & haemostatic agents EVAR must be performed in a sterile environment. Challenges * Clinician Engagement A plan can only succeed if implemented in clinical practice. This requires clinicians involved in care delivery to adopt it. We all lead busy lives and face many challenges in daily practice with continual change being pushed at us. The AAA QIP is just one of many such challenges. Seeking engagement from clinicians requires the core team to have a clear message and a plan that can be understood and embedded into everyday practice. Clinicians need to feel that the plan and care pathway will work for them on a personal level. It requires time and effort to spread the word about our project. Seeking engagement works best if done at a personal face-to-face level. Although we have created a website for the project, this serves mainly as a repository of information and evidence that can be accessed by all clinicians and patients. * Measurement and feedback To engage clinicians, we have visited both regional and national meetings of surgeons, anaesthetists and radiologists. Part of the process is to provide feedback on the progress of the project and part to seek engagement through encouraging regional action planning days. The core team works with a local organiser to arrange the meeting and provides some essential funding through our grant monies. The day focuses on developing a local plan and the core team then provide significant input in translating those plans into useable documents. We also provide assistance to those clinicians involved from the outset to help to cascade the regional plan throughout all hospitals in each region. Number 32, December 2010 * Patient pathway It is difficult to bring about change by data reporting alone. We believe that it is important to describe how improved care will be achieved. The method we have chosen is to develop a pathway of care for a patient that describes the journey from the out-patient consultation, through admission and surgery to return home. The approach adopted has been to develop this in one region using a multidisciplinary team. We are using the North East of England to initiate the process and develop a pathway. This forms a core part of our regional approach, using what we term “Regional Action Plans”. The idea is that the pathway will be developed and publicised. It will describe the key steps in assessment and care delivery and contain documentation relevant to the pathway. This can then be taken and adapted to local needs by other regions in the country ensuring a consistent approach to care delivery. We anticipate that the pathway will be ready for dissemination in the spring of 2011 when we have a number of regional action planning days arranged. This approach avoids the need to start from scratch in each region, and helps to clarify the steps required from each unit to meet national standards for care delivery. We have also created a bundle for the facilities that need to be provided in order to undertake surgery safely. The components of this bundle are: NEWSLETTER Figure 1. Regional data comparison of Hospital Episode Statistics (HES) contribution and National Vascular Database (NVD) contribution for April to June 2010 • All patients will undergo formal pre-admission anaesthetic assessment. • All patients being considered for intervention will be assess by CT angiography for suitability for open and endovascular repair. • Patients will be assessed through a multidisciplinary team that will comprise a surgeon, radiologist and anaesthetist as a minimum. • All patients will be offered a choice of Open Repair or EVAR if suitable. Association of Surgeons of Great Britain and Ireland surgeons and NHS Trusts. Part of our QIP has been to provide feedback to surgeons and Trusts about data entry (see Figure 1). To provide a stronger focus, the VSGBI is now setting quality standards for data entry to try and achieve a consistently high quality of data. This will allow us to monitor progress against our mortality goals with greater confidence. There is interest from commissioners in using these standards as part of the commissioning process for vascular surgery. Current evidence suggests that providing data feedback has stimulated a fall in the mortality rates following elective AAA repair in the UK in the last two years. A second challenge is to provide enough feedback to show that the project is progressing and that the efforts being made to change practice are achieving their aims. Measurement can take many forms, and having national data returns provides a significant part of this. Delivering local measurement against care bundles may require a varied approach. One method that can help to keep 11 12 * Embedding change Changing processes is not accomplished until those processes are embedded in the culture of care. At that point, the new (better) process replaces the old process. Providing the tools to do this and support for change is important as is demonstrating that change is working and producing the improvement sought by the project. However, embedding those changes may require more push than laying these things in front of clinicians. Using the influence of commissioners to commission clear national quality standards can be a vital step in getting change to take hold. This is why an important part of the project team activity is to seek the support of key figures in local cardiovascular networks, commissioning bodies, Royal Colleges and the Department of Health. Number 32, December 2010 NEWSLETTER Association of Surgeons of Great Britain and Ireland measurement active is to perform short repeated snapshot audits of defined steps in the pathway. This allows sampling of activity at regular intervals and plotting of trends. This may help to both demonstrate progress and to embed change within the culture of an organisation. The future Delivering a quality improvement programme is a learning process for the whole Vascular Society and its partner organisations. We intend to use this experience to drive quality improvement throughout our speciality. We already run a carotid intervention audit with the Royal College of Physicians and we are focussing more and more on trying to deliver against national targets for intervention after stroke or transient ischemic attack. Through two rounds of the audit we have seen improvement in reducing delays to treatment. Lower limb amputation for vascular disease is associated with poor outcomes and a high mortality rate in the UK. We have developed a QIF for amputation which should be approved by the VSGBI by the time this Newsletter is published. This will inform our national pathway for amputation, seeking to raise the standards of care that we offer to some of our most vulnerable patients. Conclusions Quality improvement is a worthwhile activity for all clinicians to engage in. Self reflection and redesigning processes of care to improve patient safety in surgery should be part of everyday clinical practice. When combined with robust measurement and audit, it can empower healthcare providers to embed new standards of care into routine clinical practice. Whilst it is challenging to individuals to admit that a service could be improved, the process of delivering improved quality can provide a focus and stimulus to daily practice that re-invigorates clinical teams. Coupled with improving outcomes for our patients this can generate high levels of professional satisfaction. References [1] Equity and excellence: Liberating the NHS. The Stationery Office 2010 http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalas sets/@dh/@en/@ps/documents/digitalasset/dh_117794.pdf [2] Gibbons C et al: 2008. http://www.esvs.org/files/About_the_Society/ESVS_VAS CUNET_REPORT_2008_BW.pdf [3] Abdominal Aortic Aneurysm: A service in need of surgery? http://www.ncepod.org.uk/2005report2/index.html [4] In-hospital mortality from abdominal aortic surgery in Great Britain and Ireland: Vascular Anaesthesia Society audit. Bayly PJ, Matthews JN, Dobson PM, Price ML, Thomas DG. Br J Surg 2001, 88(5): 687 – 692 [5] Framework for improving the results of elective AAA repair, Dec 2009 http://www.vascularsociety.org.uk/library/qualityimprovement.html [6] Abdominal Aortic Aneurysm Quality Improvement Programme. www.aaaqip.com [7] Campbell D A, Englesbe M J, Kubus J J, Phillips L R, Shanley C J, Velanovich V, Lloyd L R and Hutton M C Accelerating the pace of surgical quality improvement: the power of hospital collaboration. Arch Surg 2010 Oct;145(10):985-91. [8] Ashton H A, Buxton M J, Day N E, Kim L G, Marteau T M, Scott R A, Thompson S G and Walker N M. The Multicentre Aneurysm Screening Study (MASS) into the effect of abdominal aortic aneurysm screening on mortality in men: a randomised controlled trial. Lancet 2002 Nov 16; 360(9345):1531-9. GENERAL SURGERY: ST3 NATIONAL SELECTION ENGLAND AND WALES Number 32, December 2010 History Prior to 2007, Deaneries advertised vacancies on their training programmes as they arose. Applicants were shortlisted, based on their CV or application forms, and generally underwent a single panel interview lasting 15 to 20 minutes. There was little or no standardisation of eligibility requirements, and interview design and technique varied widely. Applicants’ interview performances were discussed by the panel before a ranking was agreed introducing the risk that dominant panel members could sway others’ opinions. NEWSLETTER Association of Surgeons of Great Britain and Ireland Gareth Griffiths, Chair of Selection Group Bill Allum, Chair SAC in General Surgery Peter Lamont, Past Chair SAC The widely derided Medical Training Application Service (MTAS) was introduced in 2007 as part of the Modernising Medical Careers (MMC) reforms. These changes included the introduction of run-through training in which trainees were required to select their specialty/ies of choice during their 2nd Foundation Year and compete for entry into training in those specialties. Trainees who had already received some training/experience at the old Senior House Officer level also applied, but for higher levels of training. The application and interview process was the same, however, for all levels. Difficulties arose from the application form which had many questions requiring free text answers and from the interview process which, in being formulaic and highly structured, prevented in-depth questioning. These issues were then compounded by capacity and security issues with the computer system. Following the collapse of MTAS, selection reverted back to the Deaneries with each developing their own process, guided by what by then had become the national person specifications. Rationale Selection processes are better now than before MTAS in that they are based on a standardised person specification and many include a selection centre approach in which a longer interview (often 30 minutes) involves interaction with two or three different pairs of interviewers. Selection centres give a more reliable outcome than a single panel and a greater number of stations gives even greater reliability. However, there are still drawbacks to the current system. Standards are inevitably applied differently around the country. Popular programmes attract the best applicants, but may not have sufficient posts to accommodate them all leaving the possibility that good trainees may not be accepted onto any training programme. There is the risk that local applicants may be favoured over others, leading to potential unfairness. Applicants correctly apply to a number of Deaneries (728 applicants made over 4,000 applications for general surgery at ST3 in 2010), but this increases the cost of the process, both in financial terms and in lost time for patient care, as 14 trainees attend several interviews and Consultants spend more time interviewing than is strictly necessary. Trainees and Deaneries face difficulties when offers are made, as trainees may prefer to wait to see if they get a better offer. This can lead to offers being declined or trainees withdrawing from posts they previously accepted. In addition to the administrative difficulties this causes, it can result in poorer applicants being offered a post in one Deanery while better applicants get no offers from other Deaneries. Clearly, improvements can be made. National Selection Pilot Studies Against this background, the Specialty Advisory Committee (SAC) in General Surgery was asked, in 2008, to recommend how best to select trainees for specialty training at ST3 level. A pilot study was funded by the Department of Health and led by Mr Peter Lamont, then Chair of the SAC. The principle aims were to establish how best to ensure fairness for all applicants and to develop a process which selected the best trainees and placed them in their highest possible preferred Deanery. While a single selection centre panel interviewing all applicants might achieve this, such a process would clearly be impossible to organise given the numbers involved. The aims of the study were, therefore, to establish whether multiple panels could reliably select the best applicants and to develop a robust selection methodology which assessed the characteristics considered important for general surgery training, as based on the person specification. The results of the first year of this pilot were presented at the ASGBI International Surgical Congress in April 2010, and published in the Association’s Newsletter. A paper describing the outcome of the full pilot is soon to be submitted for publication. In the first year of the pilot, two separate teams of assessors each assessed the same cohort of volunteer applicants to see if similar interview scores would be obtained. In the second year, the selection methodology was used “live” in three Deaneries for their ST3 selection to see if the results from the first year were repeatable on a larger scale. Station 1 Portfolio Station 2 Clinical and Managerial Scenarios and Academic Station 3 Leadership and Teamworking Scenarios Station 4 Technical Skills and Audit Presentation Station 5 Communication Skills Table 1: Description of the domains assessed at each of five stations Stations were designed to each specifically assess different characteristics (see Table1) and a global rating score format was used to assign scores (see Figure 1). In this system, which has been shown to be reliable and valid in a number of different assessment settings, the important components of the characteristic under question are separated into four or five fields each of which has a five point descriptive scale guiding which score (from 1 to 5) should be applied. 4 5 Safety features no safety features beyond standard seat belts driver and passenger air bags only, anti lock brakes, pre-tensioned seat belts with antisubmarining multiple front and side air bags, ABS with power assist brakes, pre-tensioned seat belts with anti-submarining, electronic stability control, speed/lane wandering alerts Economy known poor resale value, high fuel consumption/CO2 output, high servicing costs (all quantified) moderate resale value, moderate fuel consumption/CO2 output, moderate servicing costs (all quantified) good resale value, good fuel consumption/CO2 output, good servicing costs (all quantified) documented history of poor reliability, warranty limited to 1 year and mileage and does cover important features average reliability, warranty period 1-3 years covering most features documented good reliability, warranty period over 3 years covering all important features 0-60 in <20 seconds 30-60 in <15 seconds 0-60 in <15 seconds 30-60 in <10 seconds 0-60 in <10 seconds 30-60 in <7 seconds Reliability/ warranty Performance Figure 1: Example Global Rating Score scheme as applied to assessing the quality of a new car In brief, inter- and intra-team reliability was good to excellent when two different teams of interviewers assessed the same applicants, even though there was a learning effect for the second of these two interviews. This reliability was confirmed in the second year of the study. Internal consistency was appropriate in both years and was consistent with the fact that the selection centre was designed to assess different characteristics. By far the greatest variability in scores arose from applicant related factors in both years of the pilot. A statistical tool known as Rasch analysis was also assessed. This assumes there is bias in all the factors which influence a score except one – the applicant. Through an extension of linear regression, the bias is then removed and a “fair” score calculated from the “observed” score. In the second year of the pilot, had this technique been used, then very few successful applicants (as selected on the observed score) would have fallen below the appointable score, although more (as selected on the fair score) would have had their scores increased so bringing them into the appointable range. Plan for 2011 The Training Programme Directors and the Heads of School have agreed that a national selection process should be recommended to the Department of Health adopting the same format as the Selection Pilot. Arrangements are now being made to implement this, and a core group comprising Programme Directors and members of the SAC has been established to oversee the process. It has been decided that no short-listing will be used for the first year of this process for two reasons. First, there is evidence from the 2010 selection process across the UK that short-listing scoring is unreliable. Secondly, the pilot study did not assess short-listing and further work is required before it can be relied upon. It is intended to carry out a study to examine how short-listing may be improved as part of the 2011 selection, although it will not contribute to the actual selection process. The question of how to enable fair competition between those who just meet the essential entry criteria (ie, those completing Core Training) and those with more experience, has exercised a number of specialties over the last few years. A variety of methods have been devised in an attempt to address this issue and active consideration is currently being given as to how this will be handled for general surgery for 2011. More information on this will be available in the near future. Rather than attempting to run several selection centre panels in each of three or four different geographical locations, as was the original intention, it has been decided for ease of administration to hold all interviews in London. The London Deanery is the Lead Deanery for General Surgery and would be responsible for administering national selection however it was designed. Although all interviews will take place in London, the membership of the panels of assessors will be representative of the whole country. The selection methodology will be the same as that developed in the Pilot Study, and the whole process will be subject to quality assurance and statistical analysis. Rasch analysis will not be used to assign scores for actual selection, but will be studied further to see what effect it would have if it were used. Number 32, December 2010 3 NEWSLETTER 2 Association of Surgeons of Great Britain and Ireland 1 The basic process will run as follows: • Advert placed by London Deanery in February on behalf of all Deaneries. • London Deanery host national on line portal of application. • Applicants complete the national application form. 15 Number 32, December 2010 NEWSLETTER Association of Surgeons of Great Britain and Ireland • Applicant preferences for deaneries captured at application stage. Applicants will be able to rank their choice of all participating deaneries and indicate if they do not wish to be considered for any regions. There will not be an opportunity for applicants to change this after submission of their application. • Preferences will be blinded from interviewers. • Long-listing will be based on immigration status, Fitness to Practice, language and the essential criteria from the person specifications. • Any candidates who do not meet basic eligibility requirements or essential criteria will be removed from the process at this stage. • All eligible applicants invited to a national selection centre hosted in London. • Interviews will take place between 4th and 15th April 2011 using the nationally agreed scoring methodology. • Panel made up of members from all deaneries to ensure equitable representation across regions. • There will be a national minimum score required for appointment. • Scores will be collated at the end of the interviews to form a national ranking. • Offers will be managed by London Deanery. • In rank order, successful applicants will be offered a deanery programme based on applicant preferences collected at the application stage (eg, top candidate gets first choice and so on). • If a first choice deanery is unavailable as all the slots have been taken by higher ranked candidates, applicants will be allocated to their second choice deanery and so on until all slots are filled or the limit of appointable candidates is reached (whichever comes first). • If an applicant does not score high enough to be allocated to any of the deaneries they have preferenced (eg, all the slots have been taken by higher ranking candidates) then no offer will be made. • If there are sufficient posts to be filled later on in the year, a second recruitment round will be held in the autumn. Summary National selection for general surgery at ST3 level is being introduced after a careful pilot study of interview methodology and process design. It is being introduced so that applicants are assessed by a fairer and more standardised process. It is aimed at ensuring that the best applicants are selected from all over the country and that they get their highest possible choice of Deanery location based on their ranking. It should make the offers and acceptance process clearer and easier for both applicants and Deaneries and will be more efficient in terms of overall time taken and cost over a regional model. Timetable Applications open Closing date Interviews 7th February 2011 4th March 2011 4th to 15th April 2011 SIR BERNARD RIBEIRO APPOINTED AS A LIFE PEER The Association is delighted to report that Sir Bernard Ribeiro has been appointed a Life Peer. Lord Ribeiro was the Honorary Secretary of ASGBI from 1991 to 1996 and President of the Association in 1999-2000, when he held the ‘Millennium’ Annual Scientific Meeting in Cardiff. Amongst Bernie’s many achievements for the Association were the evolution of the Link Surgeon network, the development of the Overseas Surgical Fellowship Group (now the ASGBI International Committee) and the inauguration of the annual Helen Rollason Memorial Lecture at the International Surgical Congress. Bernie was appointed as a Consultant Surgeon at the Basildon Hospital in 1979 where he served until his retirement in 2008. During a distinguished career, Bernie has made many major contributions to surgery at a local, regional and national level, and was President of the Royal College of Surgeons of England from 2005 to 2008. 16 This raises the question of whether academic pathways should be ‘decoupled’, as has been the case for most surgical specialties with some exceptions (for example neurosurgery). This would limit potential complacency amongst academic trainees and allow for appropriate competition for academic ST3 at the core-to-specialty training transition point. Furthermore, should clinical lectureships remain open to all NTN holders who hold a higher degree and the other essential and desirable attributes, or should they be offered exclusively to those who are ACFs with an NTN(A)? Similar considerations, as regards how well the ACFs have used the opportunities afforded to them by the academic pathway, need to be made and compare this with how productive a nonacademic NTN holder would be in a clinical lecturer post. Predicting productivity in a post, and hence the selection to academic surgical training in general, is fraught with difficulty. This difficulty with standardising academic success is magnified when one considers that academia has a number of guises including science, education, management and leadership. Factors such as publications, grant generation, collaborations, presentations, departmental cost-savings and student achievement of learning outcomes may not be equally applicable to each of these ‘academic’ disciplines. It is likely that each such discipline will require its own entry criteria and competencies/performance indicators. An additional consideration is whether selection should be local or national. National selection would facilitate the appointment of the best candidates to posts, particularly at a time when NTNs and NTN(A)s are limited. Also to be addressed is the mechanism by which surgical trainees are attracted to academic training. This may be achieved by confronting some of what are currently considered to be deterrents to academic surgical life and why 9% of clinical academics are surgeons, compared to 37% being physicians [1]. Unfortunately, at present less than 2% of the UK’s medical research funding is applied to surgically-based research projects – the Royal College of Surgeons of England has stated “a desperate need to redress this balance” [2]. Junior academic surgical trainees may be deterred by ‘unbanded’ academic blocks in their training, coupled with a requirement to attain their clinical competencies in less time than non-academic colleagues. As surgery is, arguably, more experience-dependent than other medical specialties, some say that research comes at the cost of clinical development, with academic surgical trainees ‘deskilling’ whist in research posts. More senior surgical academics may experience job vulnerability, with pressure from the employing universities to publish papers in high impact factor journals and generate research grant income. During challenging economic times, there are often redundancies among academic staff. Furthermore, surgical academics may have less time for private practice and other activities which generate additional income (such as medico-legal work). This may be offset in some instances by commercial consultancy work and, although less commonly, lucrative patents and intellectual property. Number 32, December 2010 There are a number of challenges relating to the recruitment of surgical trainees to an academic ST3 appointment. A good starting point would be overall number of these posts, particularly outside London. This is confounded by the fact that a proportion of these posts are earmarked for surgical academic core trainees/fellows (ACF), who are still appointed to run-through programmes. These trainees, upon completing their clinical and academic competencies and successfully negotiating their annual review of competence progression (ARCP), would pass into these ACF posts at ST3 level. The opportunity, therefore, for non-ACF core trainees to obtain ST3 ACFs is attenuated. NEWSLETTER Alun H Davies However, clinical lecturer posts may be better suited to a particular individual: perhaps s/he has worked in the department, set up a project, is already undertaking or supervising work in a department, has expertise in a technique which is desired by the department. Such may not be addressed by national selection process where the ‘best’ candidates are chosen centrally and then ‘distributed’ to units according to selection rank and candidate choice rank, i.e. national selection may lead to a ‘mismatch’ of candidates to posts. Association of Surgeons of Great Britain and Ireland THE PROBLEMS OF RECRUITING TO ACADEMIC ST3 References [1]. Margerison, C.M., Clinical Academic Staffing Levels in UK Medical and Dental Schools 2007, Medical Schools Council (previously The Council of Heads of Medical Schools) and the Council of Heads and Deans of Dental Schools. [2]. Research Department, RCS England Surgical Research Report 2010-2011. Investing in research to improve patient welfare,. J. Hackett, Editor. 2009. 17 LAPAROSCOPIC SURGERY: A TRIUMPH OF TECHNOLOGY OVER COMMON SENSE? John MacFie 18 Number 32, December 2010 NEWSLETTER Association of Surgeons of Great Britain and Ireland “Every age has its sources of wisdom, those to whom we turn for a little light in the abiding darkness: the oracle at Delphi intoxicated by volcanic gases; shadowy priests whispering behind the grille; or ascetics and gurus in their mountain fastnesses.” So wrote Julian Sheather recently in the British Medical Journal [1]. This was a preface to a comment on a recently published book entitled Wrong: Why experts keep failing us and how to know when not to trust them by David Freedman [2]. I would strongly recommend this text to all who claim to practice evidence-based medicine. It turns out that, even when focusing on research published in the most prestigious of medical journals, two out of three studies are likely to be unreliable. Freedman states that the rate could be higher, but no one has tried to refute more than half the rest and yet the findings of many of these studies appear daily in the media as the nearest thing we have to health gospel. As we are all well aware, career researchers are under enormous pressure to get their research published. These journals are more interested in positive than negative findings. There is undoubtedly pressure on researchers to come up with findings that support a study’s hypothesis rather than refute it, resulting in so-called publication bias. And there are, of course, many other sources of contemporary scientific error. These include the effect of commercial sponsors, the perils of peer review, the habit of assuming causes when there are only correlations and the failure to publish negative findings. Could this have happened with laparoscopic surgery and particularly laparoscopic colorectal surgery? The last decade or so has seen an explosion in publications related to laparoscopic surgery. Invariably, these papers purport to show that laparoscopic surgery is associated with enormous benefits. of hospital stay for these studies, it is rapidly apparent that laparoscopic surgery was associated with shorter durations of hospital stay, but these are far in excess of what we would now consider the norm after open surgery conducted using the principles of enhanced recovery. We have previously suggested that, if ERAS principles are adopted and rigorously applied, it is difficult to demonstrate additional advantages for the use of the laparoscope [3]. Admittedly, there is relatively little controlled data comparing laparoscopic vs. open colorectal surgery within an ERAS setting (see Table 1). A recent meta analysis reported two randomised controlled studies and three controlled trials which suggested a more favourable, but non-significant, benefit for laparoscopic procedures in terms of length of stay, re-admission rates and morbidity [4 to 9]. However, these studies have several methodological limitations: the sample size was small, different colonic surgical procedures were carried out in the same data analysis and outcome parameters varied between the studies. There are recent reports of laparoscopic surgery conducted within an ERAS setting, but these are largely case series conducted without a control group. Table 1 Studies included in this review: Considering that laparoscopic colorectal surgery has been practised for over twenty years, is routine in many units and has recently been endorsed by NICE, it really is surprising that there is so little robust data supporting its use. This is not to doubt that laparoscopic colonic surgery is safe, feasible in the majority of patients and oncologically sound when performed in expert hands. Further, there is no doubt that it is aesthetically satisfying, and all of us will be aware of anecdotal reports of patients undergoing extensive surgery with the laparoscope who return to work within hours of their surgery apparently completely well. But, as they say, anecdote is the lowest form of science. I know lots of anaesthetists who rely upon anecdote to judge us surgeons. Almost to a man (or woman) they regard laparoscopic surgery as a means by which straightforward operations that used to be done quickly now take hours and inevitably involve vast quantities of disposable kit. This table originally appeared in: S Khan, M Gatt and J MacFie Enhanced recovery programmes and colorectal surgery: Does the laparoscope confer additional advantages? Colorectal Disease 2009; 11; 902-908 and is reproduced here with the kind permission of Blackwell Publishing. The definitive version of the paper is available at: http://onlinelibrary.wiley.com The main pillar upon which laparoscopic surgery is based (assuming equivalence in oncological safety, etc) is that it is associated with improved outcomes inferring more rapid recovery and reduced lengths of hospital stay. Many of the early trials did suggest this but, arguably, are open to the criticism that their comparator was open surgery using old-fashioned perioperative care. If one looks at average durations Notwithstanding any benefits for the laparoscopic over the conventional approach, no one would dispute that there are some drawbacks to the laparoscopic approach. These include a prolonged learning curve, prolonged operating times and higher initial costs. No one would doubt the learning curve issue. Few would challenge the prolonged operating times, at least for complex There is no question that we need to encourage Lapco and other training modalities to ensure that surgeons are comfortable with these new techniques. It is, however, debatable whether or not we should support recent NICE guidelines which recommend that patients who require elective left or right hemicolectomy should be offered laparoscopic resections and that failure to be able to provide this service should necessitate the patient being transferred elsewhere. No wonder surgeons feel anxious to adopt these techniques. There is no doubt in my mind that one consequence of NICE’s recommendations is that surgeons feel under pressure to complete procedures laparoscopically. This, in my view, is not justified on the basis of available evidence. This, I would emphasise, is not saying that those who are competent to perform laparoscopic procedures safely and expeditiously should not do so, We need more information before deciding that the laparoscope is an essential component of every abdominal operation rather than a valuable part of the colorectal surgeon’s armamentarium. Many colorectal surgeons will be aware of the La-FA study which is an on-going multicentre randomised, controlled trial comparing laparoscopic with open surgery using ERAS principles [11]. This study will be adequately powered and may provide definitive results. Until then, or until other good prospective data is published, we should be cautious about adopting surgical techniques which are not evidence-based. Footnote I am grateful to Mr Nick Markham for the title. References [1] Sheather J The sybil is faulty BMJ 2010; 341: c4471 [2] Freedman D Wrong: why experts keep failing us and how to know when not to trust them Little Brown and Company, London, New York 2010 [3] Khan S, Gatt M and MacFie J Enhanced recovery programmes and colorectal surgery: does the laparoscope confer additional advantages? Colorectal Dis 2009; 11: 902-8 [4] Vlug M S, Wind J, van der Zaag E, Ubbink D T, Cense H A and Bemelman W A Systematic review of laparoscopic vs open colonic surgery within an enhanced recovery programme Colorectal Dis 209: 11(4): 335-43 [5] Basse L, Jakobsen D H, Bardram L, Billesbolle P, Lund C, Mogensen T, et al. Functional recovery after open versus laparoscopic colonic resection: A randomised, blinded study Ann Surg 205; 241(3): 416-23 [6] King P M, Blazeby J M, Ewings P, Franks P J, Longman R J, Kendrick A H, et al. Randomised clinical trial comparing laparoscopic and open surgery for colorectal cancer within an enhanced recovery programme Br J Surg 2006: 93(3): 300-8 [7] Polle S W, Wind J, Fuhring J W, Hofland J, Gouma D J and Bemelman W A Implementation of a fast-track perioperative care program: What are the difficulties? Dig Surg 2007; 24(6): 441-9 [8] MacKay G, Ihedioha U, McConnachie A, Serpell M, Molloy R G and O’Dwyer P J Laparoscopic colonic resection in fast-track patients does not enhance short-term recovery after elective surgery Colorectal Dis 2007; 9(4): 368-72 [9] Junghans T, Raue W, Haase O, Neudecker J, Schwenk W Value of laparoscopic surgery in elective colorectal surgery with ‘fast-track’-rehabilitation Zentralbl Chir 2006; 131(4): 298-303 Number 32, December 2010 The survey is published in this Newsletter. The findings are disturbing: of over 500 surgeons who responded no less than 78% were aware of a case of serious iatrogenic injury in the previous 12 months (note, the survey asked for information about all laparoscopic procedures, not just colorectal). I am well aware of the fact that many have criticised this survey on the grounds that it is not a prospective randomised trial, that it is not evidence-based, that it does not compare results to a controlled group using open surgery and that it is prone to the criticism of double reporting. I would remind these critics, however, that a survey is a survey and does not claim to be anything else. Its purpose is simply to raise awareness of a potentially important problem and thereby encourage appropriate investigation. This survey should be seen as a wake-up call to those that inappropriately pursue laparoscopic procedures or slavishly persist with the laparoscopic approach for hours in the mistaken belief that this is in the patients’ best interests. I do recognise that some surgeons are capable of performing all their colorectal resections without significant morbidity and that clearly these surgeons are masters of the laparoscopic art. This, however, is not a reason to coerce other surgeons to adopt these techniques, particularly when the evidence of benefit remains inconclusive. NEWSLETTER More important than these drawbacks to laparoscopic colorectal surgery is the recognition that iatrogenic complications may occur. Some months ago, the NPSA issued a patient safety notice appertaining to iatrogenic injury occurring in association with laparoscopic surgery (all laparoscopic injury, not just colorectal procedures) [10]. The NPSA, as part of their investigation into this topic, invited a number of surgeons to a meeting to discuss the issue. These surgeons included myself, representing ASGBI, Derek Fawcett, President of the FSSA and the then President of BAUS, and Mike Parker, Council Member of RCS England and President, at the time, of ALS. All were agreed that adequate training was essential to minimise risks of iatrogenic injury and that the true incidence of such injuries was not known. This was the catalyst to embark upon a survey, which was an attempt to determine the magnitude, if any, of the problem. simply that the jury is still out as to whether this provides tangible benefits to patient outcomes if compared to open surgery conducted using modern perioperative care. Association of Surgeons of Great Britain and Ireland cases. It is remarkable, however, how little discussion there has been in the literature about the cost-effectiveness of laparoscopic colorectal surgery. The difference in the comparative costs of disposals is enormous. Yet these differences are justified by surgeons on the grounds that they are offset by reduced lengths of stay or morbidity. Our political and managerial masters and mistresses have, so far, accepted this without challenge. Hence, the laparoscopic bandwagon rolls on unimpeded much to the delight of industry. [10] Laparoscopic surgery: Failure to recognise post-operative deterioration NPSA Rapid Response Report NPSA/2010/RRR016 [11] Wind J, Hofland J, Preckel B, Hollmann M W, Bossuyt P M M, Gouma DJ et al. Perioperative strategy in colonic surgery: LAparoscopy and/or FAst track multimodal management versus standard care (LAFA trial) BMC Surg 2006; 6: 16 19 ASGBI SURVEY: INJURIES ASSOCIATED WITH LAPAROSCOPIC SURGERY Nicholas Markham ASGBI Director of Informatics Number 32, December 2010 NEWSLETTER Association of Surgeons of Great Britain and Ireland Introduction The veritable explosion in laparoscopic surgery has, arguably, been one of the most significant developments in surgery over the last 50 years. From the early nineties, it mushroomed to become almost as commonplace in an operating theatre complex as are sutures and blades. Like all surgery, there are potential complications, risks and traps for the unwary. Long thin instruments, often attached to diathermy, have a huge potential for causing inadvertent damage, especially when one considers that about 80% of the instrument’s length is out sight of the operator as it is being used. Added to that, an even more difficult and potentially disastrous scenario can unfold as the operator tries to gain first entry into the abdominal cavity, whether that be by an ultrathin Verres needle, completely blindly, or by using an optical port with tissue-separating blades. Even ‘open’ insertion of the first port can be difficult and hazardous at times. Many have expressed concerns about reports of inadvertent injuries sustained either at first-entry or during the procedure itself. An analysis of the true incidence of such adverse events, taken across the country, would be a difficult exercise; however, a survey of surgeons should give us an idea of just how significant, or not, the issue might be. As a result, the National Patient Safety Association, through ASGBI, conducted an on-line survey, in which surgeons were asked to state how many serious injuries they had seen in the previous year (whether or not they had actually been personally involved) and to say what were the outcomes in terms of morbidity and mortality. Serious injury, as defined by the survey, would not include, for instance, the troublesome bleeding that can beset all surgeons from time to time, but incidences where serious inadvertent damage, however produced, had occurred. We present the results below. Summary • Over 500 surgeons from the UK and Ireland responded to the survey. • 95% were either Consultants or SpRs, over half of whom had been qualified for more than 10 years. • Furthermore, 93% had themselves undergone formal laparoscopic training and ? were performing more than 5 laparoscopic procedures a week. On the whole, therefore, the respondents were experienced surgeons. • 75% had witnessed a serious injury at some time in their career. • 3 people said they had seen two such events in the previous week. • 22% had seen a vascular injury in the previous year. 20 • 50% had seen a visceral injury in the previous year. • Most injuries (about 2/3) were seen in either biliary or colonic surgery, with over 20% in what was classified as ‘other’ surgery. One suspects this referred to gynaecological procedures. • In nearly half the incidents, no adverse harm resulted as the injury was recognised and dealt with immediately and appropriately. • In about 20% the result was ‘nothing more’ than a delayed discharge. • Death was the ultimate outcome of serious injury in 7.5% (although the figures for ‘death’ are different in Figures 16 and 17, as in the latter the number is only 5%). Comment These are not reports from those who one might imagine have a natural opposition to laparoscopic surgery, but rather from self-evident enthusiasts. That said, there was one person who reported having seen between 6-10 serious vascular injuries over the preceding year and another one (perhaps the same?) who said they had seen between 16-20 visceral injuries in the same period. One is tempted to surmise that this was either a tertiary referral surgeon to whom all these injuries would have been referred, or else that the department of surgery in that hospital needs an urgent visit. So what should we conclude? How reliable or representative are the results? Could it be, for instance, that more than one surgeon is reporting the same incidents? Whatever else, the outcome of the survey needs to be viewed in the light of the fact that I would estimate that well over a hundred thousand laparoscopic procedures would be performed each year in the UK and Ireland. Some serious injuries (about half in this survey) are recognised immediately, dealt with appropriately and little deficit accrues. However, that does not lessen the importance of the message that we must strive rigorously to reduce the incidence of serious injury. Others (20% in this survey) are dealt with and a delay in discharge results, but probably nothing worse. There is a group (5% here) where the consequent morbidity is highly significant and where the patient ultimately dies. Every surgical operation caries risks – no matter who does it, where it is done or how carefully it is performed. We all need constant reminders of the fact that all surgery has the potential to be dangerous for all patients. There is ample evidence to support the belief that laparoscopic surgery ‘ups the ante’ in this regard, although equally, many having laparoscopic procedures fare considerably better as a result of having them performed in this way. What I believe this survey should do, is remind us of our responsibility to ensure that we are as well trained and as careful and meticulous in our surgery as we possibly can be. Each and every case where serious injury occurs should be reported to a central database so that surgeons can gauge their performance against their peers and those who are ‘outliers’ can be identified and the correct course of action (whatever that may be – it is outside the scope of this report) taken. Number 32, December 2010 NEWSLETTER Association of Surgeons of Great Britain and Ireland ASGBI SURVEY: SUMMARY OF RESULTS 21 Number 32, December 2010 NEWSLETTER Association of Surgeons of Great Britain and Ireland COMMENTARIES COMMENTARY ONE Mark Coleman, National Clinical Lead, Lapco Mike Parker, President ACPGBI “Cnut set his throne by the sea shore and commanded the tide to halt and not wet his feet and robes; but the tide failed to stop”. According to Henry, Cnut leapt backwards and said “Let all men know how empty and worthless is the power of kings, for there is none worthy of the name, but He whom heaven, earth, and sea obey by eternal laws.” He then hung his gold crown on a crucifix, and never wore it again. Laparoscopic surgery is here to stay for the simple reason that it has been shown to be as safe, and, moreover, preferred by patients compared to the standard open approach [1, 2, 3, 4, 5]. The reduction in length of hospital stay after laparoscopic colorectal surgery is more than mere anecdote, and with the dissemination of enhanced recovery programmes across the UK, this will undoubtedly become more widespread [6, 7]. All surgeons would do well to remember that it is our responsibility to offer, as part of the process of obtaining informed consent, all approaches to a procedure that have been demonstrated to be safe and effective by appropriate scientific study within our health care system [8]. Therefore, both 22 open and laparoscopic surgery should be mentioned, regardless of the surgeon’s preferred approach. This is the assessment made by NICE and we should stand by that decision. If a procedure, such as laparoscopic colorectal surgery, represents a challenge to surgeons without laparoscopic skills, it is necessary to offer them a safe and effective means to obtain the required skills. Lapco, the Department of Health’s National Training Programme in laparoscopic colorectal surgery for England offers such an opportunity [9]. Within Lapco, the proficiency gain curve, with direct mentoring by expert laparoscopic colorectal surgeons, is as little as 2425 colectomies, which can be achieved in less than six months and, therefore, refutes the suggestion of a ‘prolonged learning curve’ [10]. The Survey mentioned in Professor MacFie’s article related to all types of laparoscopic surgery and, therefore, includes non-general surgical specialities such as urology and gynaecology. Several major scientific flaws were apparent including: double reporting; retrospective; no denominator; and no attempt to determine the risks of open surgery. It is not acceptable for Professor MacFie to simply acknowledge in his article that the survey was badly flawed but then go on to refer to it as a “wake up call”. A survey, if correctly designed Professor MacFie is correct; more data are always required. Perhaps he would accept that no new surgical techniques have been more rigorously studied than laparoscopic colorectal surgery. We now have long-term data from a number of international multicentre prospective RCTs which prove the improved outcomes without the sacrifice of safety or oncological outcome. We have no need to fall back on anecdote; we have the evidence [1, 2, 3, 4, 5]. Even now, there is evidence that points to major variation in outcomes from open surgery – hernia recurrence rates, permanent stoma rates for colorectal surgery and, perhaps worst of all, wide variation on cancer outcomes [11]. Where is the evidence that TME was introduced on the back of a RCT? The current move towards prone extralevator APER has no RCT. Should Professor MacFie not consider that these matters are considered as well as laparoscopic surgery? It is worth dwelling on the LAFA trial, work presented at ESCP, Sorrento, September 2010 [12, 13]. In this RCT, four hundred and twenty seven patients were randomised into four groups: laparoscopic surgery and fast track (enhanced recovery) post op care, laparoscopic and standard care, open and fast track, and open and standard. Those patients undergoing laparoscopic surgery within fast track performed significantly better than those who underwent open surgery with fast track (5 days vs 7 days, p=0.001). This counters Professor MacFie’s suggestion that the rigorous application of ERAS principles to open surgery would be as good. Furthermore, the study assessed cost in the broader context of operative, hospital stay, out-patient attendance, operation time and complications, and no difference in cost between the patients who underwent either operative approach was found. It is not the only evidence References [1] Guillou P J, Quirke P, Thorpe H, et al. Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial): multicentre, randomised controlled trial. Lancet 2005; 365(9472):1718-26 [2] Nelson H, Sargent D, Wieand H S, et al for the Clinical Outcomes of Surgical Therapy Study Group. A comparison of laparoscopically assisted and open colectomy for colon cancer. N Engl J Med 2004;350(20):2050-9 [3] Buunen M, Veldkamp R, Hop W C, et al. Survival after laparoscopic surgery versus open surgery for colon cancer: long-term outcome of a randomised clinical trial. Lancet Oncol 2009; 10(1):44-52 [4] Veldkamp R, Kuhry E, Hop W C, et al. Laparoscopic surgery versus open surgery for colon cancer: short-term outcomes of a randomised trial. Lancet Oncol 2005;6(7):477-84 [5] Dunker M, Bemelman W, Slors J, et al. Functional outcome, quality of life, body image, and cosmesis in patients after laparoscopic-assisted and conventional restorative proctocolectomy. Dis Colon Rectum 2001;44 (12):1800-7 [6] Levy B F, Scott M J, Fawcett W J and Rockall T A. 23-hour-stay laparoscopic colectomy. Dis Colon Rectum 2009;52(7):1239-43 [7] Delaney C P. Outcome of discharge within 24 to 72 hours after laparoscopic colorectal surgery. Dis Colon Rectum 2008;51(2):181-5 [8] www.gmcuk.org/static/documents/content/ Consent_0510.pdf [9] www.lapco.nhs.uk Number 32, December 2010 There is substantial good quality peer-reviewed evidence that suggests laparoscopic surgery is as safe as open surgery and consistently offers patients advantages, particularly in terms of post operative outcome. The trauma and sequelae of open surgery should not be underestimated: the increase in short-term complications such as infection and dehiscence; the increased incidence of incisional hernia formation; the long-term additional morbidity and cost of adhesions including reduced fertility. Cnut saw the inevitable coming, and was wise enough to relent. It is high time that Professor MacFie saw the world from a patient’s perspective - not through the eyes of surgeons entrenched in the world of the open surgery of the last century. The Oracle at Delphi was known to enter a trance-like state, produced by the gaseous effluent from a volcanic hole in the ground, prior to the issuance of her prophesies. Perhaps those stuck in the ways of open surgery should wake up and smell the freshly brewed coffee of key hole surgery. They might find that it is actually quite tasty! NEWSLETTER We now have good evidence that laparoscopic colorectal surgery is being introduced safely through the Lapco programme. The conversion rate within the mentorship programme is 4.2%, the hospital stay is a median of 5 days, and the anastomotic leak rate is 1.8% [11]. There is a challenge to make sure clinical quality is maintained post sign-off from the programme which we are addressing. confirming that laparoscopic surgery is no more expensive than open surgery, which again is contrary to Professor MacFie’s commentary [14, 15]. Association of Surgeons of Great Britain and Ireland and carefully constructed, can determine trends and provide useful and pertinent data. This survey, however, does none of these things and remains a poor representation of the current state of knowledge regarding laparoscopic surgery and should be interpreted with great caution for fear of making erroneous claims. [10] Miskovic D, Wyles S M, Parvaiz A, et al. Outcomes of the National Training Programme in laparoscopic colorectal surgery. Presented as free paper, ALSGBI, Nottingham, Nov 2010 [11] NBOCAP 2009 [12] Wind J, Hofland J, Preckel B, et al. Perioperative strategy in colonic surgery; Laparoscopy and/or Fast track multimodal management versus standard care (LAFA trial). BMC Surg 2006;6:16 [13] Bartels Colorectal Dis 2010;12(S3): [14] Norwood M G, Stephens J H and Hewett P J. The nursing and financial implications of laparoscopic colorectal surgery: data from a randomised controlled trial. Colorectal Dis 2010 Oct. Epub [15] Dobson M W, Geisler D, Fazio V, et al. Minimially invasive surgical wound infections: laparoscopic surgery decreases morbidity of surgical site infections and decreases the cost of wound care. Colorectal Dis 2010 Apr. Epub 23 COMMENTARY TWO Number 32, December 2010 Professor MacFie raises some controversial yet valid concerns regarding the safety of universal adoption of laparoscopic colorectal surgery in the UK. Despite the many years of evaluation (more than any other laparoscopic procedure) prior to its introduction, it remained the technique of choice in less than 25% of all major colorectal procedures performed during 2009 in the UK. As John points out, few would argue that laparoscopic colorectal surgery is safe and effective in expert hands, the difficulty faced in the UK has been the relative lack of surgeons experienced in these techniques. This may be due, in some part, to the guidance issued by NICE in December 2000 recommending laparoscopic colorectal surgery only within the confines of an RCT. It was suggested that the remainder of patients should undergo “ordinary” surgery! NEWSLETTER Association of Surgeons of Great Britain and Ireland Alan Horgan National Clinical Lead, Enhanced Recovery Partnership Programme We were then faced with the dilemma that the major trials in the US and UK showed a favourable short-term outcome (admittedly minor) in those patients who had undergone laparoscopic procedures. It should be remembered that the surgical procedures undertaken in both of these trials were carried out by surgeons, the majority of whom were in the relatively early phase of their laparoscopic colorectal surgical experience. Indeed, some had done as few as 20 laparoscopic colorectal procedures. Despite this, no increase in postoperative complications was identified and no long-term adverse oncological issues were demonstrated. This would suggest that laparoscopic colorectal surgery can be performed safely by surgeons even when they are at the relatively early stages of their experience. In support, a study from The Cleveland Clinic looked at their laparoscopic colorectal experience over 12 years and 900 patients between 1991 and 2003. The group showed a reduction in operative time and conversion rates with increasing experience. More importantly, postoperative complications and readmission rates remained unchanged throughout the series, and were not dependent on operator experience. I accept that the recent NPSA survey uncovered 78% of respondents who could recall an iatrogenic COMMENTARY THREE Graham Layer I suspect the Editor asked me to write a brief commentary on John MacFie’s controversial article because I have written a little about laparoscopy in the past and now work in a Department of Surgery which must be one of the leading centres of laparoscopic surgery in the United Kingdom and, indeed, abroad – but these days, of course, I confine myself to the breast and have not even seen the new operation of endoscopic mastectomy and endoscopic breast reconstruction. However, I was one of the founder members of the British Surgical Stapling Group and the Society for Minimally Invasive General Surgery way back in the 1990’s, so I have seen this extraordinary evolution of surgery occur in parallel with extremely impressive technological advances in instrumentation, digital imaging and optics. 24 surgical injury associated with laparoscopic surgery over the previous 12 months; I strongly suspect that if asked the same question regarding open surgical procedures, the figure would be similar (or higher). Never before has any laparoscopic procedure been subject to such rigorous scrutiny before gaining acceptance. Certainly the same cannot be said for laparoscopic Cholecystectomy which was, as most Hepatobiliary Surgeons will attest, associated with unacceptable levels of iatrogenic injury. None of us would wish to repeat the same lessons learned during that particular learning curve, but few would argue that the end product was a major step forward in surgical innovation and technology. The formation of LapCo, with the on-going support of the Cancer Action Team, has gone a long way to ensuring that these lessons are not revisited. The lifting of the NICE Guidance (TAG105) waiver has certainly caused concern that surgeons throughout the UK will subject their patients to laparoscopic surgery for treatment of colorectal cancer without the requisite experience and expertise. It is likely, however, that it will be recommended that surgeons have achieved a certain level of experience prior to 2006 or have been “signed off ” by the National Training Programme before they can proceed independently. My enthusiasm for “Enhanced Recovery” Programmes approaches that of Prof MacFie (although not for as many years). I entirely agree with his sentiment that successful Programmes can be achieved without the use of laparoscopic colorectal surgery. It is also true that the large National and International randomised trials looking at laparoscopic colorectal surgery were conducted outside the confines of an Enhanced Recovery Programme. The same can be said, however, about most, if not all, other elements of the Enhanced Recovery Programme. This does not mean that each individual component does not have a valid contribution to make to the complete “package”. I remain confident that the LaFa Trial will show a benefit associated with the use of laparoscopic surgery compared with open surgery even within the confines of an Enhanced Recovery Programme. Until then, when asked, I will continue to respond that laparoscopic colorectal surgery is a desirable, but not essential, component of a successful Enhanced Recovery Programme for patients undergoing Colorectal Surgery. I came in to general surgery from gynaecology, where I was familiar with the rigid laparoscope for both diagnostic and therapeutic pelvic procedures – without television cameras and screens. I was also involved in the early birth of laparoscopic cholecystectomy and, indeed, remember trying to use a flexible choledochoscope through a port to image the interior of the common bile duct. So times have moved on and, although John’s leader is contentious, I have been incredibly impressed with the results of complex laparoscopic general and gynaecological surgery over the years and are fortunate enough to see, walking around our short stay wards, those patients who have had colorectal resections and are up and running to go home comfortably and safely very soon after their surgery. My colleagues are very skilled at performing these procedures and clearly that is one of the secrets of successful laparoscopic surgery. Michael Rhodes President, Association of Laparoscopic Surgeons It is a great pleasure to be invited to comment upon the article “Laparoscopic Surgery: a triumph of technology over common sense” by John MacFie. John refreshingly reiterates our need to have evidence for what we do, and also highlights the speed with which the landscape in which we operate changes. The rapid accumulation of evidence about Enhanced Recovery has been generated in parallel with the randomised trials on laparoscopic colorectal surgery. These sorts of parallel developments are not infrequent. It is hardly surprising that trials of laparoscopic verses open colorectal surgery, within the enhanced recovery environment, are few and relatively underpowered. It seems a trifle harsh, therefore, to label laparoscopic surgery as “a triumph of technology over common sense”!! First, let us lay one myth to rest, the lack of an evidence base for laparoscopic surgery. A cursory search on the international Medline databases reveals 451 prospective randomised trials comparing laparoscopic surgery with older open techniques. I would venture to suggest that there are very few other aspects of surgery that have been subject to such rigorous examination. In my own area, as an Upper GI surgeon, could somebody tell me the evidence base for Whipples resection in pancreatic cancer? Or, perhaps, the evidence for total oesophagectomy in Barrett’s oesophagus with severe dysplasia? Where is the evidence to say that surgery is superior to radical radio/chemotherapy in carcinoma of the pancreas, or newer endoscopic techniques for severe dysplasia in Barrett’s? There is none. Yet, for most laparoscopic therapies, there have been several reasonable randomised trials. Then, of course, we come to the ASGBI questionnaire about iatrogenic injuries from laparoscopic trocars and the related report from the NPSA on failure to recognise deterioration after laparoscopic surgery. I am sure the findings that 78% of 500 surgeons were “aware of serious iatrogenic injury after laparoscopic surgery in the last 12 months” is accurate. But STOP!!! First, if there is a serious iatrogenic injury in the average hospital with 6-8 general surgeons, is nobody “aware” of it, or everybody. I would venture to suggest, after over 15 years as a consultant in a hospital which now has 20 general surgeons, that EVERYBODY is eventually “aware” of it, thus the case for serious over-reporting is clear for the ASGBI questionnaire. Second, a very amateur academic like myself must ask, what is the denominator? There are over 100,000 laparoscopic procedures per annum in the UK according to HESS data. Thus, if we assume that 78% of 500 surgeons were “aware” of an iatrogenic injury in the previous 12 months, and that very few hospitals have less than 6 general surgeons, then there are 390 surgeons aware and being generous this may represent 65 incidents (the NPSA had somewhat less than this reported for the equivalent year I seem to recall). Thus, we have 65/100,000 injuries, 0.065%. That seems fair. Yes, we all wish that surgery was without complications, but this seems about right. Number 32, December 2010 COMMENTARY FOUR So, overall, I am an enthusiast for Surgical Darwinism and enjoy the evolution of surgical innovation and techniques which benefit our patients in a plethora of ways: be they enhanced recovery, cosmesis, oncologic safety and an overall better outcome. I have yet to be convinced that trying to perform these complex procedures through single operating ports is a correct way forward, and have fears that this simply might give rise to longer procedures and iatrogenic disasters, but cannot support that with fact. I am reliably informed that three dimensional laparoscopic surgery is the next thing for the future and is here to stay and I can certainly see the argument that, for some surgeons, this will help and improve their laparoscopic skills with which some fortunate surgeons have been born and others struggle to make the mark. What must be recognised is that those surgeons who themselves have insight into realising that they do not have the appropriate and necessary neural connections to perform safe laparoscopic surgery, or do not improve with further education and training, that they should recognise these facts and contribute to all the other facets there are of our fascinating profession. More festive food for thought! NEWSLETTER There is a parallel in the breast field when, after the successful ALMANAC Trial was performed, a proctored programme of instruction, validation and audit of the technique of sentinel lymph node biopsy in breast cancer was introduced. This was known as NEW START and was a joint venture of the Royal College of Surgeons of England, Cardiff University and The Department of Health and, for the first time, educated surgeons both systematically in the theoretical principles and in the practical tasks and skills that were required to perform the safe oncological procedure of sentinel lymph node biopsy which would be of benefit to the patient and not put them at risk of inappropriate axillary staging which would lead to the incorrect clinical management. NEW START has been a huge success, and it is my experience as a founder instructor with this scheme that influences my views on the uptake of laparoscopic surgery and I, therefore, mirror John MacFie’s thoughts on these aspects of the introduction of new techniques. Patients’ safety has to come first and then financial benefits can be considered, be it shorter length of stay despite more expensive equipment, etc. Association of Surgeons of Great Britain and Ireland The exponential take up of laparoscopic cholecystectomy without a formal training programme ended up with damaged biliary anatomy and hence the importance of particular mentoring in the advent of laparoscopic colorectal surgery and in training our new generations of surgeons. I am somewhat alarmed, on occasions, by very junior surgeons insisting on performing laparoscopic appendicectomy and this rings clinical governance alarm bells as consultants, when working with, or covering more junior surgeons. It is essential to know the capabilities of the operating surgeon to be certain of safe surgery. Now, before concluding, I must ask a somewhat mischievous question about the ASGBI and NPSA 25 reports. What if we substituted in the question about surgeons being “aware” the following possibilities: 1. Retraction of a colostomy needing revision. 2. Dehiscence of a laparotomy. 3. Leak from a routine right hemicolectomy. COMMENTARY FIVE Number 32, December 2010 Bruce Campbell NEWSLETTER Association of Surgeons of Great Britain and Ireland Dare I suggest the 78% affirmative response from the ASGBI survey is likely to be the same for these questions? Does this mean that Hartman’s procedures, laparotomies and open right hemicolectomies should be highlighted as no longer safe - of course not! All surgery has complications, which we strive to keep to an absolute minimum. To do so, we need rigorous and John McFie rightly suggests that the plural of anecdote is not evidence, but then uses the results of a survey to suggest that serious iatrogenic injury after laparoscopic colorectal is common. Serious events often become well known in the specialist community, and so there must be quite some uncertainty about how many of these were duplicated in the survey. It is true that observational data are particularly powerful for flagging up adverse events, but their validity does depend on some certainty that events are reported only once. COMMENTARY SIX Iain Anderson Professor MacFie’s challenging article brings to the fore several issues of current debate around laparoscopic surgery, colorectal in particular. For the questions of learning curve, longer surgery and doubt about benefit, we have been here before, most notably with laparoscopic cholecystectomy. Are there lessons learned that can be transferred, and where might the common sense come in? Whatever the initial problems and lack of randomised evidence, there is no doubt now that lap chole is better - better view, better recovery - a great success story. I doubt any of us would opt for an open cholecystectomy now. Some pressure to change and improve is healthy but if ill judged it can put patients at risk. Is Professor MacFie’s article undue provocation or a timely reminder? Mini-lap cholecystectomy was briefly touted as an equivalent, but was characterised by a poor view and lots of pulling. Some of the same arguments can apply to inexpert laparoscopic colorectal surgery. Is a lap-assisted right hemicolectomy any advantage? Non-believers argue that the operation can be done through a short transverse cut anyway – but either type of procedure can risk the surgeon resorting to excessive pulling or other poor techniques in order to prove a point. Pulling viscera and mesenteric pedicles out through slightly too small holes with a cry of “Voila!” by either technique will come unstuck for the individual patient at some point. Left hemicolectomy and rectal resection pose different questions, some technical, which probably need to be addressed separately. 26 comprehensive training which needs considerably more hours actually performing surgery than our current shortened training allows for. We also need accurate and dispassionate data collection. The ALS, along with its fellow associations AUGIS and BOMSS, has established the National Bariatric Surgery Database for just this reason, and is also seeking to establish clear data about other laparoscopic procedures. The job of the Associations is to make it clear that surgeons wish to do all they can to reduce complications, but also to inform the public that ALL surgery carries complications. I suspect, on the basis of evidence, those from many laparoscopic procedures may well be less than those from the equivalent open surgery. The future of laparoscopic surgery will be driven by a balance between the demands and expectations of patients, and how much society is prepared to pay for the increased costs of equipment, operating time and surgeons. The demand for decreasingly invasive surgery, done to a very high standard, is universal in developed countries. It is hard to imagine that the period from the late 1800s to the early 2000s will not be seen in medical history books as the age of open surgery. The appeal of tiny and less painful incisions is just too attractive for the march of laparoscopic surgery to be halted. What is needed is a very high standard of training and practice, together with the maturation of really effective and safe techniques. When the advocates and detractors of laparoscopic colorectal surgery are closely matched and hence each at risk of stating their case slightly too stridently, where can we turn in the current definitive evidence dearth? Our specialist nurse colleagues are often a good source of objective comment and common sense - certainly mine are, and maybe they have it right. They tell me that some cases seem to do very well with laparoscopic, others are no different to open. Maybe we don’t understand all the factors, but some lap patients recover far better than open patients ever will. Whether that difference is cost-effective is another question. What about injuries then? Professor MacFie is right in that most of us have seen them, but maybe there are different subgroups being lumped together here. The initial years of lap chole were troubled by a high rate of biliary injury, some of which may have been contributed to by marked inexperience or by surgeons’ persevering with difficult cases. Lapco is a laudable attempt to prevent a repetition of the former, but common sense is needed to avoid the latter. Pressure to succeed can influence decision making and we need to guard against a repeat. Other injuries, especially vascular, still come from port entry and may be almost totally avoidable by a cut down technique as has been long-known. Unfortunately, it can be very difficult in the larger patient. Should sharp entry be banned, or is a tiny incidence of catastrophic injury acceptable? If the latter, should it be on the consent form given the consequences? Is optically guided port entry the happy medium or neither one thing or the other? Objective data or guidelines may be overdue. more than offset by the reduced length of stay and reduced need for blood and medications. Other benefits are also becoming apparent: reduced fluid and electrolyte disturbances, reduced blood loss, earlier mobilisation and reduced need for analgesics. These are all likely to account for the reduced complications and mortality after laparoscopic surgery. Just as laparoscopic cholecystectomy was originally considered by some to be an expensive waste of time, so it is with laparoscopic colorectal surgery. Adam Widdison There is no doubt that Professor John MacFie, Vice President of ASGBI and an eminent colorectal surgeon, eloquently voices the opinions of many in his thought-provoking article. In the interests of promoting a healthy debate, I would contend that laparoscopic surgery is not a triumph of technology over common sense, rather, the triumph of common sense over the straightjacket of the doctrine of evidence based medicine. There is no doubt that laparoscopic surgery has been widely adopted despite the absence of robust evidence to prove its efficacy. However, if the rules of evidence-based medicine had been applied to laparoscopic surgery, then surgery would have been set back 10 years. The growth in the application of laparoscopic techniques to surgery has occurred because the benefits are so obvious that patients want it. It has nothing to do with commercial interests or hiding trials with negative results. It is a clear example of common sense prevailing; evidence has to catch up. Laparoscopic surgery has led to a different spectrum of complications compared with open surgery. Furthermore, they present in different ways and at different times after the surgery. Iatrogenic injury occurs with all types of surgery and is more likely during the learning curve, when a new technique is introduced or when an operation is performed infrequently. However, the complications are the same whether the operation is performed open or laparoscopically. There is, however, increasing evidence that the rate of complications is reduced after laparoscopic surgery and it is likely that late complications such as adhesions and incisional herniae are also going to be reduced. Indeed, one of the successes of laparoscopic surgery is that it is memorable when a complication occurs! Within 10 years of Phillipe Mouret (1987) reporting the first video laparoscopic cholecystectomy, most general surgeons were routinely doing the operation. The widespread uptake of laparoscopic cholecystectomy heralded an era of rampant innovation. Laparoscopic techniques were tried everywhere, and sometimes with disastrous results. In the early years, the UK colorectal fraternity was concerned that laparoscopic surgery would compromise cancer resection margins and cause port site metastases. It is of note that the evidence for this was confined to animal studies, case reports and anecdotes. Another 10 years were to pass before this fear was disproved and the safety of laparoscopic colorectal surgery accepted. As a consequence, laparoscopic colorectal surgery only really started outside clinical trials in the UK about 5 years ago. This was a tipping point similar in importance to the laparoscopic cholecystectomy revolution. Technology allowed the change, but did not drive it. Technological advances in high-energy devices and staplers have made laparoscopic colorectal surgery easier, but have not caused the phenomenal growth. In reality, the converse is true: progress in laparoscopic surgery has been handicapped by the lack of technological advances. For example, there is a long overdue need for laparoscopic stapling devices to be improved. Laparoscopic surgery has now come of age. It is no longer just the domain of benign upper GI surgeons but also of colorectal surgeons, gynaecologists and urologists. In recent years, the balance between open and laparoscopic surgery has shifted. Elective abdominal operations are increasingly being undertaken laparoscopically. Elective open abdominal surgery is in the minority in many centres. In the last decade, more and more laparoscopic surgeons have gained the confidence and experience to train others. Trainees are increasingly exposed to laparoscopic surgery and are being trained in laparoscopic techniques, often to the exclusion of their open surgical experience. Many laparoscopic techniques are transferrable so trainees are developing generic skills. Teaching is easier to undertake laparoscopically compared to open surgery because, not only is the operating site visible to all, but it is easier to demonstrate how to use the equipment and to show subtleties of technique. Video’s can be reviewed to learn method and technique and to assess progress. Current surgical trainees must become excellent laparoscopic surgeons to prepare themselves for the future. At the present time, laparoscopic colorectal operations take slightly longer than the equivalent open operation. However, the anaesthetic time is reduced so that the overall theatre time is now less for some laparoscopic colectomies than it takes to do an equivalent open operation. It is likely the procedure time will continue to improve in the same way it did with cholecystectomies. There is little data comparing cost, and it is widely assumed that laparoscopic surgery is more expensive than open surgery. However, with similar theatre utilisation times, the extra cost in disposables is All these changes have occurred because improvements in the patients’ experience have been so great that they are apparent to patients, relatives, friends, healthcare professionals and surgeons alike. Patients do talk to one another, and word of mouth is driving patient expectations irrespective of the evidence base. There remains a serious ethical issue about whether a development such as the introduction of laparoscopic surgery with manifest advantages to patients should be withheld until unequivocal evidence is available. Common sense says it should not. Number 32, December 2010 COMMENTARY SEVEN NEWSLETTER With that, I would agree. Standards, yes but recognise excessive pressure may be counterproductive. Let’s take the good bits and develop steadily. Association of Surgeons of Great Britain and Ireland The learning curve remains a weakness of complex laparoscopic surgery. I think Professor MacFie is calling for stepwise advancement of technique but without undue pressure applied to those learning. 27 Number 32, December 2010 TRAINEE FOCUS Association of Surgeons of Great Britain and Ireland 90th Anniversary Bursaries In partnership with ASiT, and generously sponsored by STRYKER, the Association has been able to is award six 90th Anniversary Trainee Bursaries during 2010. These Bursaries are to the value of approximately £1,000 each, and the purpose is to enable aspiring young consultants (within two years of appointment) and senior registrars (within three years of CCT) to extend their training by attending a course of their choice held at The Royal College of Surgeons of England in the prestigious Raven Department of Education. To be considered for one of the 90th Anniversary Bursaries, candidates were invited to write a short paper (maximum 1,000 words) on “The future of laparoscopic surgery single incision versus less traumatic instrumentation” One of the winning entries is reproduced below. THE FUTURE OF LAPAROSCOPIC SURGERY: SINGLE INCISION VERSUS LESS TRAUMATIC INSTRUMENTATION Martyn Evans Year 6 Specialist Registrar, All Wales Higher Surgical Training Scheme The explosion in the use of laparoscopic surgery in the last twenty years must be viewed as one of the major developments in the art of surgery. In my short career in surgery, spanning only ten years, I have observed first hand how the number of procedures performed laparoscopically has mushroomed, with minimally invasive approaches now considered the standard of care for many conditions. The impetus for this growth has been the enhanced recovery observed, with twenty-four hour stay for laparoscopic cholecystectomy and three-day 28 stays for laparoscopic colectomy now the norm, rather than the exception. Whilst hospital stay is important, for patients it is the impressive reduction in post-operative pain and early comfortable ambulation that must be viewed as the greatest success of laparoscopic surgery. In the last five years, single port laparoscopic surgical (SPLS) procedures are being reported with an ever-increasing regularity. Are we therefore about to embark on another chapter in surgical history, whereby SPLS makes as bigger contribution as the introduction of conventional less traumatic laparoscopic surgery twenty years ago? SPLS was developed in an effort to further reduce the surgical trauma compared to “traditional” laparoscopic surgery (TLS). There are many commercially available systems, but all share a single port which is larger than “traditional” laparoscopic ports. The fundamental idea of SPLS is to have all Number 32, December 2010 The safety of SPLS for cholecystectomy has never been addressed in a randomised trial, however, a recent review analysed the published data to date [1]. They showed that, although feasible, data on safety was lacking. It was noted that it was more difficult to achieve the “critical view of safety” of Calot’s triangle with SPLS than TLS. The overall biliary complication rate was 0.7%, although what these injuries were was poorly documented. Currently SPLS is generally being attempted by surgeons who are “good” laparoscopic surgeons, who are likely to have a lower than average biliary complication rate with TLS. A concern with the widespread adoption of SPLS must be as surgeons with less laparoscopic skill attempt the technique it is likely that complications will increase. This, of course, was one of the major concerns when TLS cholecystectomy was popularised and one must be careful not to let skepticism halt surgical development. Another concern about SPLS is that the larger incision necessary may increase risk of incisional hernia compared to TLS port incision. At present, there are insufficient data to confirm or refute this concern but there are several reported cases [2, 3]. Thus, early data suggest that SPLS is feasible, but that more data is required to confirm its safety. SPLS therefore appears feasible and maybe associated with improved cosmesis when compared to TLS, but at present is significantly more expensive. However, questions remain about its safety. When considering the present data on SPLS, there are some other factors that should be considered: the data maybe skewed by early adopters being more technically able than the average surgeon, consequently as more surgeons perform SPLS the complication rate may increase. Alternatively, it may be that currently available data underplays the benefits of SPLS, as it is representative of surgeons on their “learning curve”; with technical refinement greater benefits maybe realised. For the patient, a choice exists between possible improved cosmesis and greater risk of complication, the importance of each which will vary between individuals. For healthcare providers, at the present time, the benefits do not appear great enough to justify the risk. Then again, this is what was said about laparoscopic cholecystectomy twenty years ago. It may be that, in twenty years, SPLS is as commonplace as conventional less traumatic laparoscopic surgery is today. Ultimately, is SPLS the future at present the jury is still out. TRAINEE FOCUS Safety and Feasibility of SPLS The successful use of SPLS has been reported for a myriad of different operations across specialties. In General Surgery, large numbers cholecystectomies, and appendicentomies are reported. The largest amount of published data using SPLS pertains to cholecystectomy, which interestingly was the procedure that is credited with popularisation of TLS. A recent review reported accumulated data on 895 patients that established the feasibility of SPLS cholecystectomy, with a conversion rate of 2% [1]. It is probably reasonable to assume that, if cholecystectomy is feasible, then other intermediate level surgical procedures are also achievable. More complex TLS for upper and lower GI procedures are now common place, whilst the number of reported SPLS complex procedures are fewer early reports suggest they are also feasible. Outcomes and cost effectiveness of SPLS Length of stay (LOS) is one surgical outcome that interests patients, surgeons and healthcare managers alike. The biggest success of TLS was the dramatic improvement in LOS. At present, LOS after SPLS is equivalent to that after TLS. It is difficult to envisage that this situation will change even as SPLS is used for complex surgical procedures. This is because, generally, it is not the trauma related to abdominal access that limits LOS following TLS, but the patients’ response to the actual intra-abdominal procedure. When considering surgery for malignancy, there are insufficient data to draw any conclusion about the oncologogical adequacy of SPLS. One area where SPLS may be beneficial is in postoperative cosmesis; SPLS is usually performed through the umbilicus, meaning that the mature scar often can shrink to a point that the scar is almost invisible. When cost is considered, at present SPLS is unequivocally more expensive [1]. Association of Surgeons of Great Britain and Ireland laparoscopic working ports entering the abdominal wall through the same incision, allowing a camera and two operating instruments. The challenges for the surgeon performing SPLS surgery are those of loss of triangulation and available ports with which to create tension to facilitate dissection. Consequently, at present SPLS remains a procedure being performed by the minimally invasive enthusiast. Should SPLS be adopted into the mainstream surgical armamentarium? When assessing any new surgical intervention or technique, the important questions that must be answered concern whether it is safe, feasible, with acceptable outcomes of surgery and is it cost-effective? References [1] Allemann P, Schafer M and Demartines N Critical appraisal of single port access cholecystectomy Br J Surg. 2010 Oct;97 (10): 1476-81 [2] Romanelli J R, Roshek T B, Lynn D C and Earle D B Single-port laparoscopic cholecystectomy: initial experience Surg Endosc. 2010 Jun; 24(6): 1374-9 [3] O’Gorman T, MacDonald N, Mould T, Cutner A, Hurley R and Olaitan A Total laparoscopic hysterectomy in morbidly obese women with endometrial cancer anaesthetic and surgical complications Eur J Gynaecol Oncol. 2009; 30 (2): 171-3 29 PUBLICATION MALPRACTICE AND FRAUD FOR SURGEONS Number 32, December 2010 Introduction Publication malpractice and publication fraud are major challenges to the integrity of the world’s professional and scientific literature. Regrettably, some of those who perpetrate it are members of the medical profession. From time to time, a journal editor is faced with quite outrageous examples of deceit and fraud. Some examples are headed off at the pass, but others undoubtedly slip through an imperfect professional net, sometimes to be detected many years later. NEWSLETTER Association of Surgeons of Great Britain and Ireland David A Rew Medical Chair, SCOPUS Content Selection Advisory Board Council Member, Committee on Publication Ethics (COPE) In this article, I consider the range of publication fraud; the reasons why it is not a victimless crime; the means by which it is increasingly being detected; and the consequences for the perpetrators, from the perspectives of the Editor of a peer reviewed surgical journal with a broad international authorship. The motives for publication fraud Publication fraud may be viewed as the deliberate misrepresentation of research accomplishments and findings to advance a research programme, to secure sources of funding, or quite simply for personal professional advancement at least effort and to disguise personal inadequacies. Professional career success and public recognition are significantly influenced by publication records and published work. Academic institutions place great store on the publication productivity of their staff, and a whole industry of citation metrics exists to measure and quantity academic output. There is, thus, great pressure on individuals to publish. The damaging professional myth of “publish or perish” is bandied about, where volume of publications is perceived to equate with intellectual energy and professional effectiveness. In truth, publication quantity is no substitute for quality. The double Biochemistry Nobel Prize laureate Fred Sanger at the University of Cambridge was quoted as saying that he rarely published, and then only every eight years or so. His infrequent publications each had considerable impact. The international medical scientific literature has been accumulating over many centuries, and at an increasing rate as the technologies of print and information distribution change. It contains a small number of world and life changing papers and books; many very good and important papers and books; and a mass of papers and books of lesser interest which are rarely, if ever. cited. In order to get noticed, it becomes more and more difficult to find original angles and to make an impact. For the gifted few, publication success 30 flows easily. For the grafting many, small and original contributions come with time and effort. For a number of individuals without such talent or commitment, plagiarism (copying) of the work of others may appear as an easier route to recognition than personal graft. Why does dishonesty in publication really matter? Medical science flourishes on trust. The world’s journal repository is vast, and there are many places in which to lodge and lose suspect science. However, if plagiarism and malpractice are allowed to flourish, the scientific literature becomes progressively contaminated and overburdened with unreliable and untrustworthy work, and the public reputation of the profession sinks and stinks. Misleading, unvalidated and dishonest work can lead to inappropriate actions in medical practice which can misdirect huge resources and, at worst, can lead to death. At best, they waste professional effort, time and resources in unravelling and cross-checking the work of others. Your colleagues and collaborators, your unit, your hospital, your university, your corporation or even your country may suffer serious professional and reputational damage which may take years of restoration. For example, the reputation of the South Korean scientific community was seriously undermined in late 2005 by the revelation than an entire stem cell research programme, under the direction of Professor Hwang Woo-Suk at the Korean National University, was built on wholly fictional and dishonest data. Woo-Suk had become a national hero on the basis of fraudulent work which had given him two papers in Science in 2004 and 2005 on the creation of human embryonic stem cells by cloning. Definitions and the scope of Malpractice Publication malpractice can range from minor, inadvertent and forgivable errors to wilful fraud which might be judged as criminal intent. At the heart of malpractice is plagiarism, which is the copying and passing off of the work of others as one’s own without recognition or attribution. The act of copying in itself is not wrong. Indeed, the entire basis of citation would be undermined if selective quotation were outlawed. The key moral obligation is to make appropriate reference to the work of others, rather than to conceal the origins. High standards of study design, departmental, institutional and Ethical Oversight of all work coming out of a department often help eliminate publication misconduct at source, and help eliminate the following forms of mild to serious publication malpractice: Deliberate deception: The World Association of Medical Editors, WAME, sets out the following definition on its website: “Deception may be deliberate, by reckless disregard of possible consequences, or by ignorance. Since the underlying goal of misconduct is to deliberately deceive others as to the truth, the journal’s preliminary investigation of potential misconduct must take into account not only the particular act or omission, but also the apparent intention (as best it can be determined) of the person involved”. Salami Slicing: This is another form of multiple publication, which unnecessarily inflates the literature. It takes a body of work which could be covered in a single paper, and divides it up into as many component parts as possible. It is difficult to address if the components are sent to different journals, but the practice becomes very evident over time on the citation indices. The most outrageously entertaining example of this practice which I have seen was when we received a seemingly well written paper some years ago at the EJSO on the expression of a particular protein in a modest cohort of lung cancers which was accepted. We then received eight further papers in short order from the same group reporting the same series of tumours, in each case with a different protein. It became obvious that they were simply working through the results of a single micro-array analysis which could, and should, have been written up in one paper. We rejected the entire cohort of papers with a recommendation that they should be rewritten into one paper. Near-duplicate publication: This is a variant on salami slicing, in which the same material or series is used repeatedly with minor changes. For example, through republishing, on an annual basis, the same case series with marginal additional short-term follow up information. The repeat publication of the same or related results artificially inflates both the author’s publication record and the general literature. Reverse salami slicing or jigsaw reconstruction: I have recently adjudicated on three papers submitted to the EJSO which fraud detection software demonstrated to be re-assemblies of Misappropriation of the ideas of others: An important aspect of scholarly activity is the exchange of ideas among colleagues. Authors can acquire novel ideas from others during the process of reviewing grant applications and manuscripts. Violation of accepted research practices: Serious deviation from accepted practices in proposing or carrying out research, improper manipulation of experiments to obtain biased results, deceptive statistical or analytical manipulations, or improper reporting of results. Material failure to comply with legislative and regulatory requirements affecting research: Including, but not limited to, violations of applicable local regulations and law involving the use of funds, care of animals, human subjects, investigational drugs, recombinant products, new devices, or radioactive, biologic, or chemical materials. Inappropriate behaviour in relation to misconduct: This includes unfounded or knowingly false accusations of misconduct, failure to report known or suspected misconduct, withholding or destruction of information relevant to a claim of misconduct and retaliation against persons involved in the allegation or investigation. Data fabrication: This is the act of creating data to fit the purposes of the paper and its authors. This may range from small quantities of data to complete a series, to the fraudulent creation of entire papers from scratch. Forensic statistical analysis will often reveal such frauds, as the intricacies and variability of true raw data can be difficult to replicate in synthetic data. Number 32, December 2010 Duplicate publication: This practice is widespread and sometimes unintentional. It commonly arises where work in a local language paper is resubmitted to an English language journal to reach a wider audience. Moves towards the English language as the standard medium of international scientific communication, combined with the much greater transparency for all papers on the Internet, should reduce the need for dual publication on language grounds alone. A variant on this process is simultaneous submission, which is the concurrent submission of the same manuscript to multiple journals. This wastes the time of editors and publishers who may invest considerable resources in assessing the manuscript, and it may lead to duplicate publication. Improprieties of authorship: Improper assignment of credit, such as excluding others, misrepresentation of the same material as original in more than one publication, inclusion of individuals as authors who have not made a definite contribution to the work published; or submission of multi-authored publications without the concurrence of all authors. NEWSLETTER Self-plagiarism: This refers the practice of an author using portions of their previous writings on the same topic in another of their publications, without specifically citing it formally in quotes. component papers. This would be a seemingly clever and putatively undetectable fraud but for the power of text comparison systems. Association of Surgeons of Great Britain and Ireland One example of such deliberate fraud which came to our notice at the EJSO involved the precise replication and re-submission of a paper on nasojejunal feeding under new surgical authorship which had appeared 10 years previously in a journal which had subsequently folded. The perpetrators, who clearly thought that their fraud would have no chance of detection, had not reckoned with the powers of observation and memory of one astute reviewer. Responsibilities in countering malpractice These lie squarely with those perpetrating the fraud. Nevertheless, education about those marginal aspects of misconduct where genuine confusion might arise, combined with awareness of the power of modern fraud detection systems, should help reduce fraud to a minimum. Notwithstanding protestations of innocence and ignorance from the perpetrators, major fraud is as obvious as the elephant in the room when you see it. WAME states that “Journals should have a clear policy on handling concerns or allegations about misconduct, which can arise regarding authors, reviewers, editors, and others. Journals do not have the resources or the authority to conduct a formal judicial inquiry or arrive at a formal conclusion regarding misconduct. That process is the role of the individual’s employer, university, 31 Number 32, December 2010 Publication fraud detection systems Editors, reviewers and readers cannot be expected to spot wilful and devious misdemeanours in the publication process, and examples in my own experience have usually come to light by extraordinary coincidence. In one of our cases, a reviewer spotted his own work in a manuscript submitted for review. This role of luck suggests that many more examples go undetected. Some malpractice can be detected in advance of publication by simple checks on the authors and on the related literature using PubMed or other citation systems. This can be very helpful in identifying duplicate and near-duplicate publication and salami slicing. NEWSLETTER Association of Surgeons of Great Britain and Ireland granting agency, or regulatory body. However, journals do have a responsibility to help protect the integrity of the public scientific record by sharing reasonable concerns with authorities who can conduct such an investigation.” Automated plagiarism detection systems Sophisticated software and text comparison systems are now under development for the detection of publication fraud. One only needs to consider the functionality of search engines such as Google, which can trawl and compare huge quantities of data almost instantaneously, to realise the potential of computer systems in this role. Some of these systems have evolved from academic plagiarism detection systems. For example: Turnitin ™ is a plagiarism detection service which was originally developed for academic and undergraduate use. Students submit their papers electronically to the system, which compares the content of those papers to over a billion other papers and documents. Turnitin highlights any similarities and supplies an annotated document showing both the student’s paper and the original source. This document is called the Originality Report. Turnitin uses three continually updated content bases, which trawl billions of pages of web content; hundreds of millions of pages of proprietary content from subscription-based publications, books, newspapers, magazines and scholarly journals; and 100 million+ student papers previously submitted to Turnitin in over 30 languages. CrossRef TM is the official Digital Object Identifier (DOI) registration agency for scholarly and professional publications. It was established in 2000 as an independent, non-profit membership association and the citation-linking backbone for online publications and the navigation of electronic journals across digital internet platforms provided by individual publishers, using open-standards technology. CrossCheck TM is a database system which has grown from work between CrossRef and iParadigms, a developer of plagiarism screening systems, using the iThenticate TM tool for checking documents against the database. Publishers’ content is trawled in much the same way that a search engine indexes full text. The system then produces a “similarity report” which 32 shows the percentage of the document that matches other content in the database, where that content comes from, and the matching content itself. Publishers can then check new manuscripts against the database and, optionally, the wider internet. By integrating systems such as CrossCheck with electronic submission systems for manuscripts, it will be possible in due course to undertake “up front” plagiarism checking very early in the manuscript acceptance process. The Déjà vu TM Plagiarism Detection System is an academic project developed at the University of Texas Southwestern Medical Center for the detection of plagiarism and covert multiple publications of the same data. The developers report that, in 2002, an anonymous survey of 3,247 US biomedical researchers asking them to admit to questionable behaviour revealed that 4.7% admitted to repeated publication of the same results and 1.4% to plagiarism. In general, the problem of duplication of scientific articles has largely been ignored by the publishers and database curators. Extrapolation of the results of an anonymous survey to the Medline database of more than 17 million citations predicts some 800,000 such cases on Medline. In recent work, Deja Vu searched a subset of 62,000+ Medline abstracts. 421 potential duplicates were found and further investigated. Three of these papers which were referred to us at the EJSO were found to be almost identical “jigsaw” reconstructs of related papers by other authors, which we subsequently decided to retract formally from the literature. Extrapolating to the subset of Medline records that have abstracts (8.7 million), this would correspond to roughly 117,500 duplicates with the same authors. Simultaneous submission: The Déjà vu database also contains many pairs of highly similar abstracts with overlapping authors that appear in the same month, all apparently acts of simultaneous submission to multiple journals. In general, duplicates are often published in less prominent journals with lower impact factors to minimise the odds of detection. As increasing numbers of journals and publishers put their back catalogues on line and up for checking by tools such as déjà vu, so it is both possible and likely that more such cases will come to light. The Déjà vu team cite various contributing factors to such publication fraud, in that: a. There is considerable international confusion over acceptable publishing behavior. b. There is a perception that there is a high likelihood of escaping detection. c. There is a lack of clear standards for what level of text and figure re-use is appropriate. Automated text-matching systems must, and will, ultimately become a ubiquitous aspect of the publication process. There will be automatic crosschecking of submitted manuscripts against all published work. The costs of detection arising from participation in unethical duplication practices will progressively become such as to be unacceptable to all but the most desperate (or most skillfully fraudulent) practitioners. • Acknowledge their error and offer to correct it by withdrawing the paper, introducing appropriate references, or issuing a letter or note of formal clarification if their manuscript is already in print. • Deny all knowledge of the source papers. • Become agitated and abusive in communications or threaten legal action, which responses are often an indication of guilt. Sanctions against publication fraud 1. Notifying the fraudster’s institution Where the institution of affiliation of the fraudsters is known, the notice of concern and the evidence for it should be directed to the Head of the institution. At this point, things become murky, because many institutions do not want such problems brought to public attention. They may fail to reply and/or decide to bury the matter locally. The response varies considerably from institution to institution and from country to country in the absence of clear guidance, recognised international law and directives on publication fraud. A reputable institution or university will generally take such allegations seriously, request the evidence and take public and visible action to address the issue and deal with the problem, or refer the fraudster to an appropriate regulatory body for further action. There are, as yet, no explicit obligations or powers for Editors and publishers to take the matter to professional regulatory bodies; to take the case to advisory bodies such as the Committee on Publication Ethics (COPE); or to take matters to the Police and Criminal investigation authorities in the relevant jurisdiction (although the police may subsequently become involved). Publicity in the media may force public attention to the matter, as has ultimately been the case in all of the documented major scientific frauds. In going public, the complainants must be confident in their grounds, and have taken sound legal advice in advance. 2. The formal retraction notice If the responses from the perpetrators and the relevant institutions are unsatisfactory; if there is evidence of plagiarism beyond reasonable doubt and coincidence, and if informal approaches have failed to resolve the issue, then a formal retraction notice can be issued by the recipient journal. Retraction is a formal process which places the Future developments in dealing with publication fraud The work of well intentioned editors and publishers in combating publication fraud in all of its forms is currently constrained by the lack of a consistent international approach to the issues, and even recognition of the problem from one jurisdiction to another. The work of institutions such as COPE, WAME and the Déjà vu team have done much to develop the evidence base, from which further developments will come. We can look forward to the creation of a body of law; a common regulatory approach across international boundaries; a formal and objective classification of publication fraud, and an Internet “hall of shame” database of publication misdemeanors and their perpetrators which is accessible to all editors, publishers, reviewers and readers. Now that so many publishers have recognised the problem, and that the subject is under discussion at a high level in various organisations and bodies, it is likely that such a formal international framework will ultimately be put in place. In conclusion, case experience demonstrates that publication malpractice in its various forms is commonplace, and that surgeons are, from time to time, involved in serious forms of publication fraud. Awareness of the problem and of the potent systems now available for the detection and notification of such transgressions should reduce inadvertent misconduct. It should help banish thoughts of publication misconduct from the minds of all but those most willfully set upon such foolhardy actions, and in full knowledge of their potential consequences. Number 32, December 2010 • Refuse to respond. 3. The personal consequences of fraud detection Publication fraudsters can, and do, escape detection and sanction. However, the personal consequences of being named and shamed as a publication fraudster can be profound, with loss of professional license, status and reputation, and even criminal sanctions in the most rigorous jurisdictions, such as the UK. The General Medical Council takes matters of plagiarism very seriously, and has recently set severe precedents in proven cases. NEWSLETTER Once the editors, publishers and their legal teams have looked at the material and decided on common sense grounds that there is prima facie case of plagiarism, the case must be put in writing to the perpetrator, who in turn may: event and the suspect paper in the public domain. The US National Library of Medicine makes a clear statement of general application on the issues of retraction and partial retraction, which can be accessed at www.nlm.nih.gov/pubs/factsheets/errata.html Partial Retractions of erroneous data may also be published. Association of Surgeons of Great Britain and Ireland Actions on suspicion of plagiarism Wise editors and publishers proceed with caution when made aware of alleged fraud and plagiarism, both because of the laws of libel and because the consequences can be career changing for those who commit plagiarism or who are accused on it. Checking can be a time-consuming process, and the evidence must be very strong, as no deliberate fraudster can or will safely admit to the fraud. Editors must develop a sensitive approach and a thick skin during investigations. Selected References and web links UK Office for Research Integrity ORI publication Analysis of Institutional Policies for Responding to Allegations of Scientific Misconduct: http//ori.dhhs.gov/html/polanal2.htm http//ori.dhhs.gov/html/publications/studies.asp CrossCheck and CrossRef: www.crossref.org/crosscheck.html and www.crossref.org/03libraries/index.html M Errami and H Garner A tale of two citations Nature (2008), 451, 397-399 33 Cavendish Medical CAN PIIGS FLY? This useful acronym - PIIGS - is thought to have first appeared in 2009 to describe the European nations (Portugal, Italy, Ireland, Greece and Spain) whose governments had overextended themselves in the years of plenty and would now need to follow a crash diet or face serious financial indigestion. Sure enough, in May 2010 a Euro 110 billion loan facility was extended to the Greek government to help control their cost of borrowing on the international financial markets and ensure that all of their liabilities could be met in full. This was the culmination of a number of months of jittery share prices, volatile currencies and last-minute political wrangling between the Greek government, the EU and the IMF. Prior to the loan being agreed, it was even whispered that the Euro might not survive as a currency unless decisive action was taken and quickly. Following the Greek crisis, a relative period of calm descended. In addition to the initial “bailout” and austerity budget, this calm was attributed to the apparent success of “stress testing” the loan books and financial standing of all the major European banks, an exercise deemed necessary to get any further bad news out in the open. Being able to raise new debt, along with new taxes, is integral to the ability of any government to function, as this cashflow is required to pay public sector wages and effectively ensures the lights are not switched off prematurely. The problems faced by Ireland and the other PIIGS in the single currency are presumed understood – in a crisis you cannot devalue your currency at the expense of others to increase competitiveness and stimulate your own economy. When Ireland’s cost of borrowing over 10 years rose above 8.5% and kept rising, it seemed evident that they would require external assistance or risk running out of money and not being able to meet existing liabilities in full. If existing borrowers had been faced with “taking a haircut,” or not being paid back their loans in full, then who would be willing to lend? The only alternative would surely have been for Ireland to quit the Euro, an option with unthinkable consequences. 34 The UK Coalition Government appears to be united in the firm belief that a similar sovereign debt crisis could arise in the UK without some very strict medicine. Just how strict this medicine should be is the subject of fierce debate, although less direct action than has been seen in France and Greece to date. The slogan that “we are all in this together” is a catchy one and goes some way to limiting the pain when the axe falls in our own back yard. Fairness is a word that seems to be frequently deployed, but is less easy to define in practice. There have been many changes over the last three years that affect Surgeons in the UK and Ireland in particular, not including whatever efficiency savings have already been accounted for in your own unit or hospital. We have seen a gradual increase in the tax burden for UK “higher earners.” The entry point for a higher earner is understood to be £100,000 gross per annum and includes earnings, bank interest, dividends, rental income, etc. This is the point above which your annual tax free personal allowance, the first £6,475 that you would otherwise have received free of tax, is lost, resulting in a 60% tax charge. Planning tip: If your total income is less than £130,000 per annum you can regain your tax free personal allowance by making a gross lump sum pension contribution. This attracts full tax relief, mitigates the 60% tax and your personal allowance is maintained. Whether or not you think that it is fair to continue to tax those adjudged to have “the broadest shoulders” the most, it seems that this is the stated intent of the government taxation policy. From April 2011 it is proposed that a new maximum “annual pension allowance” of £50,000 will be introduced. This measure is designed to raise £4 billion in revenue for the Treasury in the tax year 2011 / 2012. In order to calculate an annual allowance we need to know how much the nominal value of your NHS pension benefits have increased over 12 months to gauge whether this is more than £50,000. If so, any “excess” will be added to your other income and taxed accordingly (at 40% or even 50%). This can lead to a nasty tax charge, potentially running into the thousands, for those caught unawares. The trigger for a tax charge in almost all cases is an increase in pensionable pay. This is typically the award of a CEA, taking up a management position or reaching the next increment of the new consultant contract. For those with particularly high pensionable pay, an additional year’s service in the NHS pension can be enough. Example calculation: 38/80 X £109,696 (penultimate increment plus CEA level 5) = £52,105 X16 + £156,316 (£989,996) X CPI 3.1% = £1,020,685 39/80 X £135,930 (final increment plus CEA level 9) = £66,265 X 16 + £198,797 = £1,259,037 from the NHS or when accessing personal pensions or AVCs. Although one should never consider doing anything for tax reasons alone, the two changes highlighted above inevitably refocus the minds of those close to normal retirement age who may have the opportunity of taking pension benefits before any changes are introduced. Excess is (£1,259,037 - £1,020,685) = £238,352 (less £50,000 annual allowance) = £188,352 As we have said before, at a time when taxes are on the increase and interest rates are low, it becomes ever more important to use the allowances available on an annual basis to shelter savings and investments from unnecessary tax. At this point if you have any unused allowance from the previous three tax years you can discount this, otherwise £188,352 is liable to income tax at 40% and 50% (a liability of £92,769!) The current ISA rules state that up to £10,200 can be sheltered in this tax year; this is increasing to £10,680 from April 2011. The allowance also extends to your partner and other family members. The alternative proposal is that this tax can be paid through a reduction in your eventual pension benefits at retirement. Bearing in mind the usual disclaimer that past performance is no guarantee of future returns stock markets have performed well in 2010 with returns of close to 10% in some cases. I must stress that the legislation remains in draft form only and is subject to revision, however, this is our understanding from the examples provided by HMRC. To add insult to injury, a further proposal has been advanced to restrict total tax relievable pension savings to £1.5 million from April 2012. For those who have followed the “Lifetime Allowance” (LTA) saga closely since its introduction in April 2006 this may come as a surprise. Current legislation allows an individual to retire with accumulated savings of up to £1.8 million in Superannuation and private pensions. Any excess above £1.8million will be taxed at 55%! To reach £1.8 million, an individual usually needed a CEA, 38 to 40 years service in the NHS pension with Added Years and a personal pension. Superannuation 38/40 X £150,000 = £71,250 X 23 = £1,638,750 Personal pension fund Standard Life £350,000 Total value: £1,988,750 Excess above LTA in March 2012: £188,750 LTA tax charge in March 2012: £103,812 Excess above LTA above LTA in May 2012: £488,750 LTA tax charge in May 2012: £268,812 If you are willing to accept risk, historical evidence suggests that you can still expect that you will be rewarded with a higher long-term return. This is particularly important when inflation is taken into consideration. Whether we are using the government’s preferred CPI (consumer prices index) or the more traditionally understood RPI (retail prices index) we need a return in excess of 3.1% just to break even. This is particularly hard when headline savings rates are poor, unless funds are tied up for years and with any interest being taxed. If you wish to discuss any of the changes discussed above you can contact Simon Bruce in confidence at 0207 636 7006 or [email protected] May we take this opportunity to wish all Members, Fellows and staff of the ASGBI a very happy Christmas break and a healthy and successful New Year. This article is not and should not be treated as financial or investment advice. Cavendish Medical is regulated and authorised by the FSA as an independent financial planning practice. The firm is also a Professional Partner of the ASGBI. Cavendish Medical Ltd is registered in England and Wales, registration number 05448773. Representing an increase in tax of 156% over two months! Pensions are only tested against the LTA when you draw benefits either by retiring experience the difference 35 “WHAT A MESSY THING IT IS TO KILL A MAN” Pierce A Grace Number 32, December 2010 Sentence of Death At the Central Criminal Court at the Old Bailey on the 22nd of October 1910, Lord Chief Justice Baron Alverstone asked the prisoner before him if he had anything to say before passing sentence on him. The prisoner replied: “I still protest my innocence”. The judge donned his black cap and sentenced the man “to be taken hence to a lawful prison, and from thence to a place of execution, and that you there be hanged by the neck until you are dead, and that your body be buried in the precincts of the prison. And may the Lord have mercy on your soul”. NEWSLETTER Association of Surgeons of Great Britain and Ireland Put this in any liquid thing you will And drink it off, and if you had the strength Of twenty men, it would dispatch you straight. Romeo & Juliet, Act V, Scene 1 Hawley Harvey Crippen Lord Chief Justice Alverstone The prisoner appealed his sentence to the Court of Criminal Appeal, which upheld the sentence on 5th of November. A Petition for Clemency was submitted to, and rejected by, the Liberal Government’s Home Secretary, Winston Churchill, and the execution was carried out as ordered at Pentonville Prison on November 23rd 1910. The man who was hanged was an American, Dr Hawley Harvey Crippen, and the crime for which he was convicted was the murder of his wife Cora who had disappeared without trace from their home, 39 Hilldrop Crescent, on the 31st of January 1910. Her dismembered remains were found under the coal cellar of the house. The case was a sensation in 1910 and it would become one of the most famous and controversial murder trials of the 20th century. Training in Homeopathy Henry Harvey Crippen was born in 1862 in Coldwater, Michigan, the only child of Myron 38 Augustus Crippen (1827-1910), a storekeeper, and his wife Andresse Skinner (d. 1909). In 1884, Crippen qualified from the Cleveland Homeopathic Medical College, which had been founded in 1850 as the Western College of Homeopathy, the second such institution in America. Crippen stated at his trial that he had “not been through a practical course of surgery but a theoretical course”. Abraham Flexnor, in his famous (and scathing) report on medical education in the US, commented about the Cleveland Homeopathic School that: “it was weak and uneven; beyond ordinary dissection and elementary chemistry, they offer little else. Equipment for pathology and bacteriology is meager”. Flexnor concluded that: “the organization of medical education in this country (i.e. USA) has hitherto been such as…to obscure in the minds of the public any discrimination between the well-trained physician and the physician who has had no adequate training whatsoever”. It would appear that Dr Crippen was one of the all too numerous latter. Marriage and remarriage In November 1887, Crippen married Charlotte Bell, a student nurse who had emigrated from Dublin. United States immigration records show that a Charlotte Bell aged seven years entered the US from Ireland in June 1866, and this may have been the Charlotte that married Crippen. They moved to San Diego where Charlotte gave birth to a son, Otto, in 1888. Crippen then worked as eye and ear specialist in Salt Lake City where, in January 1892, Charlotte collapsed and died of apoplexy just as she was due to give birth again. Otto was sent to his grandparents in California while Hawley headed back to New York where he worked as an assistant to Dr Geoffrey of Brooklyn. Within a year he had met and married in Jersey City the 17-year-old Cora Turner whose real name was Kunigunde Mackomatzki of Russian/German extraction. Cora had ambitions to be an opera singer and Crippen paid for music lessons for her. Shortly after they were married, Cora’s sister noticed that Cora had a recent scar on her abdomen but she ‘Dr’ James Munyon In the late 1890s, Crippen started to work for the famous and very rich ‘Dr’ James M Munyon. Munyon had been a publisher for a while but found homeopathy more profitable especially the production of patent medicines, which consisted mostly of sugar and alcohol. A specialty of the company was “Munyon’s Homeopathic Home Remedies Cabinet”, which consisted of a tin box with 10 drawers, each of which contained the cure for a specific problem, e.g. cold remedies in Drawer 5, general debility in Drawer 7 etc. The contents of the drawers included pills, powders or phials of liquid. In spite of his claim that “no punishment is too severe for those who deceive the sick”, Munyon made a fortune out of doing just that. Crippen eventually became a general manager and advisory physician to Munyon’s company and he and Cora came to London around 1898; he, to manage Munyon’s London office, she, to pursue a music hall stage career, having given up the idea of becoming an opera singer. Crippen said that Cora was “always rather hasty in her temper”. She took to the stage as Belle Ellmore and was not a success. An Affair Around 1902, Crippen went back to America leaving Cora in London for several months on her own and when he returned he found that she was having an affair with Bruce Miller, a music hall artist; she told Crippen that she did not care for him anymore and did not wish to be familiar with him. According to Crippen’s testimony, Cora picked quarrels with him over trivial incidents and that she would frequently get into great rages, and threaten to leave him. Ironically, Munyon eventually fired him because he was spending too much time promoting Belle’s stage career rather than promoting Munyon’s business. However, he seems to have worked with the company until 1909. Douret’s Institute for the Deaf In 1903, Crippen got a job working for Douret’s Institute for the Deaf in London. This was another dodgy enterprise, this time claiming to cure deafness by the application of plasters behind the Ethel Le Neve Douret’s Institute was significant for Crippen because there he met the 18-year old Ethel Le Neve who became his secretary and had, like Cora, changed her name; she was born Ethel Clara Neave in Norfolk in 1883. Ethel was everything Cora was not. She was gentle, retiring and sympathetic, and she and Crippen got on very well together. By 1906 they had become lovers and she appears to have had a miscarriage in 1909. Crippen told her that Cora was going to leave him and, as soon as that happened, he was going to divorce Cora and marry Ethel. 39 Hilldrop Crescent In September 1905, Crippen and Cora moved into a large house, 39 Hilldrop Crescent, Camden Road, North London at an annual rent of £52-10s-0d. Number 32, December 2010 Cora Crippen (Belle Elmore) NEWSLETTER ears. A report in the British Medical Journal in 1904 about another employee of the Douret Institute, Dr H N Dakhyl, stated: “Possibly this gentleman may possess all the talents, which his alleged foreign degrees denote, but, of course, he is not a qualified medical practitioner, and he happens to be the late ‘ physician’ to the notorious Drouet Institute for the Deaf. In other words, he is a quack of the rankest species”. Association of Surgeons of Great Britain and Ireland could not say whether this was due to an operation or not. At his trial Crippen said that Cora had had an “ovariotomy” about this time. 39 Hilldrop Crescent 39 Number 32, December 2010 NEWSLETTER Association of Surgeons of Great Britain and Ireland Cora became involved with the Music Hall Ladies Guild which was a charity devoted to looking after artists’ wives and children. They had an office in Albion House, New Oxford Street, in the same building as Crippen’s office. The Crippens continued to live together, harmoniously as far as their acquaintances could tell, and Hawley started a new venture called ‘The Yale Tooth Specialist’ with a dentist named Gilbert Rylance. Their friends seemed to know nothing of the family turmoil and described Hawley as “a kind-hearted and good-tempered man”. On 31st January 1910 the Crippen’s had a ‘pot luck’ dinner at home with friends from the Music Hall Ladies Guild, Paul and Clara Martinetti. Mrs Martinetti stated that: “After dinner we went upstairs to the parlour on the first floor and had a game of whist. I and my husband left the house at about 1.30 in the morning. We spent a pleasant evening, and there was no quarrel of any sort. Mrs. Crippen came to the top of the steps and wished me good-bye. She was in quite good health. I never saw her again after that night”. Cora Disappears Nobody ever saw her again. Cora simply disappeared. Crippen told the Martinettis that she had gone urgently to America, to California, and that he had received a letter saying that she was very ill with double pleuro-pneumonia. However, Crippen turned up at the Music Hall Benevelont Fund Ball accompanied by Ethel Le Neve on February 20th. The observant or suspicious Mrs Martinetti noticed that Ethel was wearing on her bodice “a brooch similar to one I had seen Mrs Crippen wearing”. On the 24th of March, Crippen gave the news that his wife had died in California and that she was to be cremated. He placed a notice of her death in the weekly theatrical affairs newspaper The Era which appeared on the 26th of March 1910. Crippen and Ethel went to Dieppe for a week and, on his return, he told his partner, Gilbert Rylance, that he had married Miss Le Neve. In March 1910, Ethel moved into 39 Hilldrop Crescent, and Crippen arranged for a French maid to help her. Music Hall Ladies Guild’s Suspicions The Music Hall Ladies Guild members were, however, unconvinced by Crippen’s explanations regarding the death of his wife. On June 30th John Nash, husband and manager to music hall artist, Lil Hawthorne, called to Scotland Yard and made a statement regarding their suspicions about Cora’s disappearance to Superintendant Frank Froest of the Criminal Investigation Department. Froest asked Detective Inspector Walter Dew to investigate. On the 8th of July Dew went to 39 Hilldrop Crescent and met Miss Le Neve. Crippen was at his office in Albion House, so Dew and Ethel went there together to talk to him. Dew said that neither Cora’s friends nor the police were satisfied with what he had told them as to his wife’s disappearance, to which Crippen replied: “I suppose I had better tell the truth”. Avoid Scandal Crippen then made a statement outlining his early life and subsequent marriage to Cora. He stated that, after the Martinettis had left on the 31st of January, “his wife abused him and said she would 40 not stand it any longer; she would leave him next day and he would not hear of her again”. To avoid a scandal, he had put it about that she had gone to America and then died but this was not true. He believed that she was alive and had gone to Chicago with Bruce Miller. All three of them then returned to 39 Hilldrop Crescent where Dew looked over the house. He seemed satisfied and said to Crippen: “Of course, I shall have to find Mrs Crippen to clear this matter up”. Crippen agreed and offered to place an advertisement in various American newspapers. Inspector Dew finds a body (or parts of it) Dew returned on the 11th of July, but Crippen and Ethel were nowhere to be found. He began a more thorough search of the house and, on the 13th, he probed the cellar floor with a poker; “at one place I found that the poker went rather easily in between the crevices, and I got a few bricks up. I then got a spade and dug the clay immediately beneath the bricks. After digging about four spadesfull down, that is, about nine inches below, I came across what appeared to be human remains”. They were human and were wrapped in pyjamas. A warrant was issued immediately for the arrest of Hawley Harvey Crippen and Ethel Le Neve for the murder of Cora Crippen (Belle Ellmore). Inspector Dew was entrusted with its execution. Hue and Cry The police issued a dramatic bulletin on the 15th of July 1910: MURDER AND MUTILATION. Portraits, Description and Specimen of Handwriting of HAWLEY HARVEY CRIPPEN, alias Peter Crippen, alias Franckel; and ETHEL CLARA LE NEVE, alias Mrs. Crippen, and Neave. Wanted for the Murder of CORA CRIPPEN, otherwise Belle Elmore: Kunagunde Mackamotzki: Marsangar and Turner, on, or about, 2nd February last. The bulletin was distributed widely to newspapers in England, Europe and North America and a reward of £250 was offered. Mr William Thorne MP asked in the House of Commons how the police had allowed Dr Crippen to slip through their fingers. The Inquest An inquest was held at the Islington Coroners Court into the cause of death of the remains found under the cellar of 39 Hilldrop Crescent. Mr Nash, whose suspicions had led to the discovery of the remains, gave evidence. He was familiar with San Francisco, and said that Dr Crippen became very nervous when he (Nash) asked him where exactly in California his wife had died, or what the name of the crematorium was, or what certificates were issued in relation to the death. This had prompted Nash to go to the police. Inspector Dew described how he found a mass of human flesh under the cellar floor but no head or bones whatsoever. “It seems as if someone had carved the flesh to pieces”. There was also a quantity of lime and some hair. The police surgeon Dr Thomas Marshall said that it was not SS Montrose The World Watches As the SS Montrose made its way across the Atlantic the world was treated to a day-by-day account of the on board activities of Crippen and Miss Le Neve; what they ate, what books they read and how often they strolled the deck; the fact that Ethel’s suit and hat did not fit very well. Crew members surreptitiously took photographs of them on board, which would be reproduced later. The arrest in Canada was a media circus. On the 31st of July 1910, Dew went on board the SS Number 32, December 2010 Marconigrams Using the new wireless technology that had been installed on his ship, Kendall sent the following message (Marconigram) to Scotland Yard: “HAVE STRONG SUSPICIONS THAT CRIPPEN LONDON CELLAR MURDERER AND ACCOMPLICE ARE AMONG SALOON PASSENGERS”. In response, Scotland Yard sent by wireless a fuller description of the fugitives, which confirmed Kendall’s suspicions. Inspector Dew was dispatched to Canada on The Laurentic, a faster liner than the SS Montrose so that he would be in place to arrest Crippen and Le Neve when they arrived. NEWSLETTER Captain Kendall’s Suspicions While the inquest continued, the police were searching for Dr Crippen and Ethel Le Neve. One of people who read of the murder and the disappearance of Crippen and ‘his typist’ in the newspapers was Henry Kendall, captain of the Canadian Pacific Steamship Company’s 5431-ton cargo ship, SS Montrose, bound for Quebec out of Antwerp. newspaper photos. What he saw convinced him that that Robinson and his ‘son’ were in fact Crippen and Ethel Le Neve disguised as a boy. Association of Surgeons of Great Britain and Ireland possible to state on anatomical grounds the sex of the flesh saying that: “the man had evidently endeavoured to remove every evidence of sex”. William Long, a dental mechanic, told of buying a suit of clothes and hat at Crippen’s request and then receiving a letter in which Crippen asked him to wind up his household affairs, including paying the rent for the previous quarter. Mr Augustus Pepper, a consulting surgeon to St Mary’s Hospital, gave evidence that he believed the remains to be those of a human adult and that the dissection “must have been done by someone with anatomical knowledge”. There was a surgical scar on the abdominal tissue but the sex was not discernable. Dr William Wilcox, senior scientific analyst to the Home Office, described his extensive chemical analysis of the remains and how he had found considerable amounts of the alkaloid, hyocine, in the tissues, which was the cause of death. The coroner’s jury returned a verdict stating that the remains were those of Cora Crippen, that death was by poisoning by hyocine, and accused Dr Crippen of the willful murder of his wife. Captain Henry George Kendall Among the passengers on Kendall’s ship were John Philo Robinson, merchant, aged 55 and his son, John C Robinson, aged 16. Captain Kendall noticed this strange father and son who held hands frequently and he observed that the father had shaved off a moustache recently and had marks on his nose from wearing spectacles. Kendall used bits of cardboard to block out Miss Le Neve’s hair and he chalked out Crippen’s moustache from the Crippen and Le Neve on board ship 41 42 Ethel is Acquitted Ethel Le Neve was tried a few days later, the charge being an accessory after the fact and a fugitive to justice. However, she was defended by the brilliant F E Smith, the future Lord Birkenhead, who would eventually hold all the important law offices of England (Solicitor General, Attorney General and Lord Chancellor). Smith painted a picture of Ethel as an innocent young woman merely following the instructions of her lover. She was described as a “gentle inoffensive girl”. Her trial lasted all of one day and it took the jury only 12 minutes to acquit her of all charges. Inspector Dew arrests Crippen Number 32, December 2010 NEWSLETTER Association of Surgeons of Great Britain and Ireland Montrose disguised as a pilot and arrested Crippen with the words: “Good afternoon, Dr Crippen”. Crippen told Dew that Ethel “knows nothing about it; I never told her anything.” Dew and his prisoners returned to England in August and both were formally charged at Bow Street; he with the willful murder of Cora Crippen, and she: “that she did feloniously receive, comfort, harbour, assist, and maintain him” (ie. Crippen). The Trial On the basis of the coroner’s verdict, Crippen was brought to trial on the 18th October 1910. A famous barrister, Richard C Muir, KC, led the prosecution team while Alfred Tobin, KC defended him - rather poorly. But for the pigheadedness of his solicitor, Crippen might have had Edward Marshall Hall defend him. Marshall Hall was the most famous defence counsel of his day, but Alfred Newton, the solicitor, had a row with Marshall Hall’s clerk regarding the fee, resulting in Tobin getting the brief. The evidence presented at the trial was a rerun of that presented to the coroner. The defence was that the remains under the cellar floor were there when Crippen moved into 39 Hilldrop Crescent. The prosecution showed clearly that the pyjamas in which the remains were wrapped were made after that date the label contained the words “Jones Brothers, Limited”. Jones Brothers became a limited company in 1906, one year after Crippen moved into the house. Medical Expert Witnesses A considerable number of medical experts were quizzed about the scar on the torso and whether it was a surgical scar or not. Dr Bernard Spilsbury, who would become a very famous forensic pathologist, offered to bring his microscope into court to show that the scar on the torso was in the lower midline and was consistent with a surgical scar for an oopherectomy. Dr Wilcox repeated his evidence that death was due to poisoning by hyocine. It emerged that Crippen had purchased five grains (325mg) of the drug from Lewis & Burroughs, a London chemist, on 10 January 1910 and had signed the Poison’s Register. He claimed that he had seen a dilute solution of hyocine being used as a drug to subdue violent psychiatric patients at the Bethlehem Hospital (Bedlam) a few years earlier and that he had used it to make up small tablets. The medical evidence convinced the jury after a mere 27 minutes of deliberation that Crippen was guilty. Dr Crippen and Miss Le Neve in court Epilogue Ethel visited Crippen every day in prison. Before his execution, Crippen wrote that Ethel was innocent of any crime save that of yielding to the dictates of her heart and he prayed that God would protect her and allow him to join her in eternity. On the day of Crippen’s execution Ethel changed her last name to Nelson and went to Canada. She later moved back to England and married an accountant named Stanley Smith who never knew his wife’s previous notoriety. She died in Croydon in 1967 at the age of 85. Captain Kendall collected the £250 reward money but was almost drowned when, in 1914, his ship SS Empress of Ireland was destroyed off Father Point, close to where Crippen had been arrested. Chief Inspector Dew retired from the police force, having successfully sued several newspapers for libel for comments about his conduct of the Crippen case. He set up a private detective agency and became a crime expert for the press. He died in 1947. Sir Bernard Spilsbury became the most famous pathologist of the age and gave evidence in numerous murder trials. He committed suicide in his laboratory in London aged 70 in 1947. The Further Reading Hitchcock A In films murders are always very clean. I show how difficult it is and what a messy thing it is to kill a man Hitchcock Quotes Available at: http://www.hitchcockwiki.com/wiki/Hitchcock_Quot es accessed 22-06-2010 Murder Case Magazine 9 The Mild Mannered Murderer. Dr Crippen, The London Doctor who killed for the woman he loved Marshall Cavendish Partworks Ltd, Tarrytown, NJ. 1990 Encyclopaedia of Cleveland History Available at: http://ech.cwru.edu/echcgi/article.pl?id=CHH1 accessed 12-06-2010 Hawley Harvey Crippen. The Proceedings of the Old Bailey. t19101011-74. Available at: http://www.oldbaileyonline.org/browse.jsp?id=t1910 1011-74&div=t19101011-74&terms=crippen accessed 12-06-2010 Flexnor A. Medical Education in the United States and Canada. A repost to The Caregie Foundation for the Advancement of Teaching. Available at: http://www.carnegiefoundation.org/sites/default/files/ elibrary/Carnegie_Flexner_Report.pdf p 159-160 accessed 12-06-2010 Charlotte Bell The Battery Conservancy, 2009 Available at: http://www.castlegarden.org/index.php accessed 13-06-2010 Medico-Legal. Brit Med J 1910, 2: p1372-1383 (29th Oct 1910) Medico-Legal and Medico-Ethical Brit Med J 1904, 2 p 359 (13th Aug 1904) Dr Munyon Dies in Florida The New York Times, March 11th 1918. Available at: http://query.nytimes.com/mem/archivefree/pdf?res=990DE3D61538EE32A25752C1A9659 C946996D6CF accessed 21-06-2010 Ethel Clara Le Neve. The Proceedings of the Old Bailey t19101011-75 Available at http://www.oldbaileyonline.org/browse.jsp?id=t1910 1011-75&div=t1910101175&terms=Le|Neve#highlight accessed 21-06-2010 Number 32, December 2010 Technology then and now Lastly, the case had caught the public imagination because the wireless telegraph was able to provide a day-by-day voyeuristic account of the hunt across the Atlantic. Given the extraordinary press coverage, it is doubtful that Crippen could ever have a fair trial. In 2007, Dr David Foran, a forensic scientist at Michigan State University, caused a sensation when he revealed that mitochondrial DNA isolated from one of Spilsbury’s slides, which had been carefully preserved in London, did not match the living female relatives of Cora Crippen. This evidence demonstrated that the human remains under the cellar floor could not have been Cora’s. Dr Foran’s team then went on to state that the body parts were not only not Mrs Crippen they were not even female. The mystery remains as to who was under the floor of 39 Hilldrop Crescent and, if Dr Foran is right, how did he get there. Should Hawley Harvey Crippen be pardoned and what happened to Cora? Fido M Crippen Hawley Harvey, Murderer (1862-1910) Oxford Dictionary of National Biography. Available at: http://www.oxforddnb.com.proxy.lib.ul.ie/view/articl e/39420 accessed 21-06-2010 NEWSLETTER Why? The Crippen case is notable. Why would an intending murderer openly purchase a rare poison and sign for it in the Poison’s Register? Why would he dismember the body? – the whole point of poisoning is to make it look as though the victim died naturally. Why place the torso and organs under the cellar floor, why not dispose of them with the head, bones and limbs, which were never found? Was Crippen capable of dismembering the body with the surgical precision attested to by the medical experts? Why did he run away and why did he use such a poor disguise for Ethel? In the absence of an identifiable body, the prosecution’s case rested on proving from the abdominal scar that the remains were Cora Crippen’s. These remains contained a lethal quantity of hyocine, a drug Crippen had bought. However, it was impossible to say for certain in 1910 that the remains were definitely those of Cora Crippen. A more robust defence might have had the charge reduced to manslaughter at the most. The Lord Chief Justice, in summing up, advised the jury that they “must give the benefit of any doubt to the prisoner”. It would seem, 100 years later, that the evidence was not beyond reasonable doubt. Clough B Dr Crippen, The most infamous murderer in AngloAmerican relations. Available at: http://www.drcrippen.co.uk/ accessed 11-06-2010. Association of Surgeons of Great Britain and Ireland Luftwaffe destroyed 39 Hilldrop Crescent during the London blitz, and the SS Montrose broke her moorings and was wrecked off Dover in 1914. Hilldrop Crescent Case The Irish Times (1874-1920) Sept 27, 1910. ProQuest Historical Newspapers The Irish Times (1859-2000) pg 9A English Early J. Technology, Modernity, and ‘The Little Man’: Crippen’s Capture by Wireless. Victorian Studies, Vol. 39, No. 3 (Spring, 1996), pp. 309-337 Available at http://www.jstor.org/stable/3829449 accessed 16-062010 Foran D. Executed in error Available at http://www.pbs.org/wnet/secrets/features/executedin-error/david-foran/204/ accessed 21-06-2010 43 OPERATION TELIC IRAQ 2003-2009: A SURGICAL PROFESSIONAL RETROSPECTIVE David A Rew Number 32, December 2010 Tommy (Atkins) Rudyard Kipling (1865-1936) MILITARY SURGERY Association of Surgeons of Great Britain and Ireland For it’s Tommy this, an’ Tommy that, an’ “Chuck him out, the brute!” But it’s “Saviour of ‘is country” when the guns begin to shoot; An’ it’s Tommy this, an’ Tommy that, an’ anything you please; An’ Tommy ain’t a bloomin’ fool - you bet that Tommy sees! Painting: The defence of CIMIC House by 1st Bn Princess of Wales Royal Regiment, Al Amarrah, 2004: Oil on Canvas by David Rowlands, reproduced by kind permission of the Artist The troops have come home. The official documents are locked away in the Army’s Corporate Memory Vaults. The doors are closed on Operation Telic, a campaign in Southern Iraq which outlasted the Second World War, running for six years, from March 2003 to April 2009. 179 UK service personnel who died and 1,000 or more who were seriously injured in Iraq bore witnesses to a brutal new phase of warfare, in which the suicide bomber was pushed to the fore, and the Internet propagandised the work of the belligerents in gruesome fashion. Operation Telic will not be judged a military or a political success. The Iraq campaign, which was conducted against the popular mood on the basis of very suspect evidence, will become synonymous with the inner workings of the late Blair government. These were dissected in genteel but effective fashion during 2010 by the Chilcott Inquiry. Operation Telic nevertheless spawned at least one remarkable story which should not be overlooked in the Great Yawn of History. Collectively, our Military Medical Services, in which surgeons played a significant role, have overseen a transformation in the care of casualties from the point of wounding to longterm rehabilitation and advanced prosthetics; and in the management of the most extreme 44 injuries which are at, and have previously been beyond, the boundary of survivability. This experience has also transformed casualty care in the campaign in Afghanistan, which has yet to stand the judgement of history in the round. More importantly, it has helped, at last, to bring about the long-overdue modernisation of the NHS Trauma Service, a process in which military doctors, fresh from overseas battlefields, have also played a very significant role. As a junior Surgeon Taken Up From Trade in March 1991, I stood among the burning oilfields in Northern Kuwait after a race across Southern Iraq in front of the Big Guns with the Field Surgical Team attached to 4th UK Armoured Brigade. Exactly 12 years later, as a Consultant Surgical Reservist with 202 Field Hospital (TA) in Northern Kuwait, I stood on the same ground observing the launch of Operation Telic 1. A junior doctor, observing the frenetic military activity around us, commented that “we had never done anything like this before”. In fact, not only had we done it only 12 years earlier, but much of our equipment and procedures would have caused no discomfort or surprises to our predecessors at El Alamein and in the North African Desert from 1940-1943, about which the late Mr Bernard Williams FRCS had tutored me in his retirement. I therefore resolved to seek to improve the medical corporate memory of Operation Telic. We held a study day in Kuwait in early May 2003, and subsequently I cajoled colleagues across the Forces to write down their stories and empty their digital cameras in a higher cause. The upshot was the e-book Blood Heat and Dust, which covered the Entry Campaign, Op Telic 1, from March to June 2003. The book was contemporaneous and richly illustrated with imagery and personal vignettes, and some 1,500 copies were taken up by the MoD for onward distribution. The book remains directly, fully and freely available as a download on the Internet at: www.pangrafix.com/bhd That account left many professional themes open ended. Events in Iraq ran for much of the decade in parallel with events in Afghanistan, which causes even more confusion and distortion in the personal and collective memory. The end of Operations in Iraq in the Spring of 2009 thus provided the opportunity and the stimulus to wholly revise Blood Heat and Dust in a Second Edition. The draft of this book is now broadly complete with such additional material as I have been able to secure, and under official scrutiny prior to intended publication in 2011. Relevant material has also been published in 2010 by Penguin Viking in the book Medic by John Nichol and Tony Rennell. Specifically, in respect of surgeons, the Definitive Surgical Trauma Skills (DSTS) Course at the Royal College of Surgeons of England, and more recently the Military Operational Surgical Trauma (MOST) Course, have been invaluable in developing skills, insight and experience in a workforce for whom injuries of the type seen in Iraq had never been met in civilian practice in the UK. As the insurgency gathered steam through 2004 and 2005, UK forces withdrew progressively towards Basra, and by mid 2007 the situation in the outposts in Basra itself became untenable. Insurgent tactics, including improvised explosive devices, ambushes and suicide bombings were progressively refined, severely restricting the intended efforts at “nation building”. Conventional forces were withdrawn to the Contingency Operating Base at Basra Airport, where they were under regular and heavy mortar and missile fire through late 2007 and into 2008. The field hospital at the COB itself was frequently hit during this time, and a number of injuries were sustained by staff. The unheralded Operation Charge of the Knights by the Iraqi Army in March 2008 effectively routed the insurgency in Basra, allowing the remaining 4,000 or so UK forces personnel to draw down and extract peacefully by April 2009, along with the remaining medical support units and hospital squadron. As the casualty rate rose, Iraq taught us much about surgical trauma, and obliged the relearning of old lessons from past military ventures into Mesopotamia. An Iraqi military doctor told us in 2003 how Basra had been regarded as a punishment posting in Saddam’s Army, and as the thermometer passed 50deg C in May and dust devils tore through the hospital tentage, we understood why. The medical and surgical lessons of Operation Telic What were the key areas of transformation in Trauma care through Operation Telic? In terms of the individual and collective preparation of From the front line, advances in the training, deployment and equipping of individual soldiers and of combat medics, with much improved body armour, tourniquets, chest seals and clotting accelerators, combined with a move almost universally to rapid helicopter transit, saw the delivery of “unexpected survivors” of the immediate blast injuries. This created substantial clinical pressures for the trauma teams and for the supply of blood and blood products. At field hospital level, Operation Telic 1 saw us enter Iraq with “Cold War” scales of equipment, in old tentage for which thermal, dust and environmental controls were impossible despite sterling ‘Make and Mend’ efforts; with the old collapsible, air portable rigid McVicar operating tables; and without CT scanners, digital imagery, or specialist paediatric equipment. Teamworking among multidisciplinary professionals has been elevated to new levels, and reserve and regular personnel have integrated seamlessly. Fortunately, preparatory work during the Balkan campaigns of the late 1990s had allowed our anaesthetic colleagues to make considerable advances in preparing Field ITUs, with appropriate and ruggedised equipment. In later phases of Op Telic, all of the material deficiencies were addressed, other than for the continued use of tentage, albeit that the working accommodation was “much improved”. From this experience, lessons were learned which led to the commissioning of the remarkable Camp Bastion hospital in Helmand in 2008 in a prefabricated special to purpose building. Number 32, December 2010 Operation Telic 1, the overwhelming military “entry” by UK forces into Southern Iraq, was conducted by some 45,000 UK troops, with remarkably few deaths. This was despite adverse publicity about equipment, as for example the local shortage of body armour for some forward troops. A political decision was made to draw down this force by more than a half by the end of Op Telic 1, and by half again over the next two years, such that, at the height of the insurgency in 2006-2007, a light brigade of some 7,000 troops, of whom many were not in the “fighting arms”, were holding the ring against a major uprising within a population of two million Iraqis around Basra. MILITARY SURGERY medics for deployment, considerable advances were made in training programmes and in predeployment hospital exercises, such that by the end of Operation Telic, all deploying medical units were subject to rigorous assessment and governance oversight, along with feedback of practical experience into the trauma management drills and procedures. The National Field Hospital Trainer at Towthorpe near York has proved invaluable in this process. Association of Surgeons of Great Britain and Ireland The military events in Southern Iraq selfevidently created the framework upon which many medical advances were built. They paralleled the experience of US forces elsewhere in the country, but US casualties were an order of magnitude higher than ours, with more than 4,000 operational deaths. Our medical lessons drew heavily on this tragedy of trauma, and on the parallel suffering of large numbers of Iraqi combatants and civilians. Expansion of the Critical Care Aeromedical Strategic Transfer teams allowed large numbers of ventilated, stabilised casualties to be returned rapidly and safely to the UK, where care was progressively consolidated through East Midlands Airport to Selly Oak Hospital in 45 This led to the next challenge, which was one of adaptation of a now largely civilianised NHS hospital resource to military needs, following the closure of most of the UK’s remaining military hospitals through the 1990s. The early overload of Selly Oak with complex military casualties; the admixing of these casualties with civilian patients and a number of resulting problems led to critical internal MoD reports and to adverse media coverage. This pressure, in turn, produced a substantial improvement in capacity and form of care for military casualties and a drive for improved facilities in the new Queen Elizabeth Hospital in Birmingham, opened in 2010. Number 32, December 2010 MILITARY SURGERY Association of Surgeons of Great Britain and Ireland Birmingham, where the Royal Centre for Defence Medicine was collocated. The next level of care to come under pressure and scrutiny was the military rehabilitation service. This was focussed upon RAF Headley Court Rehabilitation Centre, which was in danger of becoming overloaded both with the volume and complexity of its workload in its peacetime configuration. Whereas, in the past, single limb trauma has been the norm there, double and even triple amputee survivors were now posing major challenges for rehabilitation and prosthetic design. An improved national rehabilitation service was put in place with 12 regional centres, so that Iraq casualties with their particular and unique needs did not become a lost tribe, drifting alone and poorly understood through civilian health facilities. On the academic and governance side, the collection and analysis of trauma data and injury causation has been rigorously systematised by colleagues at the RCDM, whose work has been rightly recognised in the National Honours. Weekly conference calls between the deployed trauma teams in Iraq, Afghanistan and the UK leads allowed the rapid dissemination of lessons and experience across theatres and in feedback to the deployed teams. Wars in Peace throw up huge psychological problems for service personnel cast adrift in a seemingly uncaring civilian world, as the Vietnam Veteran experience in the US and that of the “Afghanisti” in Russia have shown us. We now have much better understanding and collective sympathy for the problems and casualties of post traumatic stress. Much work has been done in psychological Trauma Risk Management (TRIM) debriefings in the field, homeward bound decompression (in Cyprus) and in long-term support. Programmes such as “Battle Back” and “Toe in the Water” have provided teamworking and physical challenges for the badly injured, while continued employment in the Forces for all but the most severely injured has provided a breathing space for individuals to re-align their lives. 46 One remarkable pointer to the discontinuity between overt public antipathy to the politicians for their responsibility for events in Iraq, and public support for the troops themselves has been the remarkable boom in charitable giving, both to the established service charities, and to new start-ups. Most remarkably, Help for Heroes has raised some £50,000,000+ in five years from a standing start. It is very difficult fully to appreciate the courage and loyalty of the young service personnel, men and women, soldiers and medics who went out on patrol or on convoy duties in the hellish alleys of Al Amarrah, Az Zubayr, Umm Qasr or Basra city; or who sat through mortar fire onto tented wards and operating theatres during the dark days of Operation Telic; and who lost life and limb for what was progressively seen at home to be a lost political cause, but which remained a matter of intense personal, subunit, regimental and military honour and pride on the ground. In crude numerical and historical military terms, deaths and casualties were relatively light across the breadth of Operation Telic. The advances in trauma care which were forced by events upon our clinical teams in Iraq and in the UK, helped to ensure that significant numbers of service personnel and Iraqi nationals survived injuries from which they might otherwise have died. Many lessons were learned, for which we owe the casualties a great debt, and our duty is now to ensure that these lessons will endure. For many years to come, the long-term casualties of the Iraq Campaign of 2003-2009 will continue to trickle through the nation’s hospitals. The passage of the years will increase the wear and tear on broken bodies, and the exhaustion of daily activities without limbs or orientating senses will increase. Some of these people may pass though your own hands. Their care will remain our moral duty and obligation for at least another generation. They will not ask your sympathy, but they will deserve your understanding and respect for what they have sacrificed in the Heat and Dust of Iraq. Painting: 1 Close Support Medical Regiment at Bridge 4, Basra, 2003. Oil on Canvas by David Rowlands, reproduced by kind permission of the Artist The Management of Knife Injuries CONSENSUS CONFERENCE Sponsored by The Surgical Foundation and the Metropolitan Police Monday 15th November 2010 saw 114 delegates, from across surgery, law enforcement and social work, attend the Association’s Consensus Conference on improving co-operation and effectiveness of harm prevention and crime reduction associated with knives. The event, which was held in partnership with The Surgical Foundation and the Metropolitan Police Service, received extremely positive feedback, a good deal of national media coverage and resulted in the following joint statement, laying out the major areas of agreement: Sharing of data and public health measures: • Data sharing between emergency departments and community crime reduction partnerships must become standard practice in every hospital in the UK. ASGBI commits to encouraging surgeons to work to set this up in their local hospitals. • ASGBI and the Metropolitan Police are of the opinion that we should go further on the quality and nature of data shared. Fears over patient anonymity are inhibiting the ability to properly target services for some hospitals. Non-anonymised data sharing between public services for violent injuries would support approaches to safeguarding children and adults. This would require ratification by the General Medical Council. • ASGBI would support the restrictions on access to alcohol. The evidence suggests that this would have a dramatic effect on violent behaviour in the young. Surgical training: • ASGBI and The Surgical Foundation endorse the development of regional trauma networks – these must be supported by accredited training programmes and courses that include the management of violent injuries. KEY PRINCIPLES Background: • Tackling violence needs close co-operation with police and other partners across the public, private and voluntary sectors. There is a need for all public services to work together more cohesively to break down barriers and tackle violence in the community and the role of the extended family requires support. • ASGBI strongly recommends that all general surgeons involved in the treatment of trauma should attend one of these accredited training programmes. • Surgeons should be trained to appreciate forensic requirements of the criminal justice system by preserving evidence. • There is a need for long-term policy focusing on prevention – the best evidence for prevention lies in targeting children before they become involved in violence as either victims or offenders. • Police enforcement activity is crucial, but cannot be a long-term solution and is often not a deterrent for this group. Extending education programmes: • Surgeons should get involved in early years peer group education programmes involving schools, youth organisations and local police forces. • More needs to be done to link up new local violence campaign/support groups and agencies to work collaboratively with existing organisations and pre-existing infrastructure. A detailed Consensus Statement supporting, and expanding on, the above Key Principles will be published by the Association in the New Year. ENDOVASCULAR FELLOWSHIP 2009: PERTH, WESTERN AUSTRALIA Number 32, December 2010 Background Similar to the majority of today’s vascular trainees, I became increasingly concerned as I headed into the latter stages of my surgical training regarding my limited experience and opportunity in endovascular intervention. Simply performing EVAR cut-downs and consenting our patients for peripheral intervention that radiological colleagues would ultimately perform had grown tiresome. I therefore decided early that I needed to leave the UK for a dedicated period of time in order to obtain the required endovascular training that, in my opinion, needed to be surgeon-delivered. NEWSLETTER Association of Surgeons of Great Britain and Ireland Philip Davey Perth City and Swan River SCGH) promising to keep me in mind for any future appointments. Undeterred, I remained positive and, after having successfully negotiated the inter-collegiate exam in February 2008, I decided to make further contact with all three units, giving SCGH priority. I emailed the lead clinician (CV attached) asking specifically if he would have any objection to a subsequent telephone call from me to discuss a possible fellowship further. This approach prompted an immediate positive email response and, four weeks later, I was appointed following an informal telephone interview. It was always my intention to count this fellowship as training within my higher surgical training programme and, immediately after successful appointment, I began the now compulsory process for prospective approval with the Deanery, SAC and PMETB. While this procedure wasn’t complicated, it did have the potential to be quite time-consuming so one should bear this in mind if planning a similar strategy. Temporary registration with both the WA medical board and Royal Australasian College of Surgeons was mandatory and relatively straightforward. Although several visa options were feasible, I opted for a type 442 sponsored occupational trainee temporary visa. A distinct advantage of this visa class was the ability to claim financial remuneration for assisting in the private sector. Full medical examinations were required for all people included on the visa (wife and children) with compulsory HIV, Hepatitis B & C testing for me. Selection, Planning & Application Having decided to apply for an endovascular fellowship abroad, I was only ever really interested in securing a position in Perth, Western Australia (WA). The region’s pedigree in the worldwide endovascular arena remains undisputed, and the reports I sought regarding the high quality of training delivered were very attractive. The added advantages of no language barrier, a healthcare system similar to the UK, good quality of life, climate and an agreeable family left me with little decision to make regarding our planned destination for 2009. Consequently, in early 2007, I made direct contact (letter and CV) with the Heads of Department of all three tertiary vascular units in Western Australia. The initial response was slightly disappointing, a single email from one unit (Sir Charles Gairdner Hospital, Sir Charles Gairdner Hospital CVIL (Cardio-Vascular Invasive Laboratory) at Sir Charles Gairdner Hospital. Note the absence of interventional radiologists and the resident anaesthetic equipment for EVAR Although I didn’t manage to secure any corporate sponsorship for the fellowship, it is always worth a try through your local reps. I was, however, successful in securing a £5000 Endovascular travel grant (two available annually) from The Circulation Foundation which was obviously gratefully received. There are several other travel grant and bursary schemes open for application and these should all be considered during the planning stage of the fellowship. 48 Vascular Services in Western Australia The entire state-wide population of Western Australia (approximately 2.25 million) is served by the three vascular units centrally located in the metropolitan Perth region. Royal Perth Hospital (RPH) is historically the core of Perth vascular services that housed much of the Cook endograft development by Michael Lawrence-Brown and David Hartley. In truth, it has now probably been surpassed by SCGH for both elective open and endovascular activity. The differing case-mix between RPH and SCGH results mainly from two factors. Firstly, RPH remains the major trauma centre for the state and, for this reason, tends to generate a heavier emergency workload. Secondly, unlike SCGH, the vascular unit continues to provide all renal access services at RPH. The other main centre providing a comprehensive vascular service is Fremantle Hospital (FH). It is probably quieter at FH with perhaps slightly less enthusiasm on endovascular management than exists at both SCGH/RPH. Relationships between the departments of SCGH, RPH and FH are generally very good. The monthly WAVES group meeting (Western Australian Vascular and Endovascular Surgeons) serves to both co-ordinate WA vascular services and is a regular forum for group/individual discussion and debate. Contrary to the trainees who are hospital-based, the on-call commitment for consultants is state-wide (1 in 12/13) and this frequently involves operating remote from their base hospital at the other two sites. More rural WA vascular services remain limited. Visiting centrally-based surgeons do provide outpatient clinics in Broome, Geraldton, Bunbury and Albany, but these usually only occur on a monthly basis. For all vascular emergencies, and Number 32, December 2010 An Office with a view Outlook from the SCGH Vascular department office towards King’s Park with City of Perth on horizon Facilities for open and endovascular surgery at SCGH were enviable. In addition to the dedicated vascular operating theatre (with DSA-capable high-specification mobile image intensifier), there was capacity for angiosuite intervention in both main X-Ray and a Vascular-specified catheter laboratory that was shared with cardiology (CVIL: cardio-vascular invasive laboratory). As one would expect, the former were policed by the interventional radiologists, but the latter CVIL sessions were for exclusive use by the vascular surgeons and, hence, it was where the majority of the endovascular work was performed. In practice, it was only the complex EVARs (e.g. fenestrated (FEVAR), iliac branched devices) that were done in X-Ray in a team approach with IR. Similarly, the vascular team worked well with the resident cardiology/cardiothoracic team in the management of both acute and chronic thoracic aortic pathology. Contrary to the UK, standard EVAR and TEVAR were largely done independently by the surgical team in the cathlab with full anaesthetic support. Approximately 85% of AAAs were repaired at SCGH by EVAR, with an established protocol for endovascular management of ruptured AAA (eEVAR). Routine peripheral work included iliac, femero-popliteal and tibial interventions (angioplasty/stenting) as well as mesenteric and renal artery procedures. NEWSLETTER The SCGH Endovascular Fellowship The Vascular department at Sir Charles Gairdner Hospital comprised five Consultants (4 part-time, 1 full-time), the Fellow, a local junior registrar and two Interns (F1 equivalents). In the extended team there was a dedicated vascular sonographer, vascular nurse specialist and the expected allied healthcare specialities. The Unit was combined with the Cardiology ward at SCGH, consisting of 24 in-patient beds with adequate HDU/ITU support where appropriate. Patients for interventional procedures typically utilised the dedicated short-stay unit for day-case and overnight stay beds. Association of Surgeons of Great Britain and Ireland those patients requiring elective in-patient care, transfer to one of the three centres in Perth is necessary. Consequently, many acute admissions may have to travel a significant distance in order to receive definitive care, often with very advanced pathology. A typical weekly timetable of activity for the Fellow is shown below: Clinical responsibilities of the fellowship included involvement in the vascular outpatient clinics (consultant-led, ulcer and surveillance), leading 49 Number 32, December 2010 NEWSLETTER Association of Surgeons of Great Britain and Ireland the multi-disciplinary grand rounds, audit, theatre/cathlab bookings and the general day-today management of the unit. Furthermore, I was expected be directly involved in teaching junior medical staff, students and nursing staff, and participate in a variety of in-hospital education sessions. We also arranged the weekly unit Consultant rounds and combined unit radiology meetings. The out of hours on-call commitment was 1 in 3 non-resident, the rota shared with both the junior registrar and a third-nightly contribution from the General Surgical trainee. The vascular fellow had no reciprocal commitment, however, to General Surgery. In order to maximise the endovascular experience, the fellow was encouraged to assist in appropriate cases within the private sector assuming adequate in-house cover was in-place at SCGH. Living in Perth Situated on the banks of the picturesque Swan River, Perth is one of the most modern, cleanest and safest cities in the world. The city has all one would expect of a major urban centre with excellent shopping, restaurants and nightlife. Despite being one of the most isolated cities in the world, it is well-served by road, rail and air links regionally, nationally and internationally. In twelve months I was involved in over 600 emergency and elective cases with the salient procedure numbers shown in tabular format below (P-performed independently; S-performed supervised; A-assisted). Unsurprisingly, in over 90% EVAR cases the Cook Zenith device was used. Other devices deployed were the Medtronic Endurant and Gore Excluder. Note that an appreciable volume of work continues to be conventional open surgery and also the refreshing paucity of varicose veins. Our Campervan adventure up in Northern WA The ‘rig’ at Monkey Mia (above) & Sunset at Coral Bay (below) Table 1: EVAR experience Table 2: Catheter Intervention Table 3: Open Surgery There was ample opportunity to attend the monthly state-wide vascular trainee education sessions and the weekly Cook Endovascular planning meetings, where worldwide complex aortic and thoracic endograft repairs were discussed and planned by a multidisciplinary team of Vascular Surgeons, Interventional Radiologists and Cook Planners. The SCGH fellowship employment contract is typically for a 12-month period, commencing each January. The basic 38-hour weekly salary is far better than the UK (approximately A$110,000) 50 and overtime, on-calls and call-backs are added pro-rata following monthly submission of claim forms. One should also pay attention the advantageous salary-packaging schemes established for the public sector workforce. As a temporary resident, tax is paid as an Australian with additional automatic pay contributions to a superannuation plan that can be reclaimed following permanent departure from the country. SCGH itself is centrally located opposite Kings Park within the affluent suburb of Nedlands. Having had our children accepted, in advance, into one of the local public primary schools, we opted to stay nearer the coast in City Beach. We certainly did not regret it. Average rental costs in WA are expensive and the market is notoriously fierce, irrespective of location. That said, the cost of living was roughly equivalent to the UK: high-priced groceries and water offset by cheaper fuel and utility bills. The hot, dry climate in WA lends itself to a lifestyle that is essentially outdoor. In addition to the countless beaches, there is the Swan River to enjoy for all manner of water-based activities. Away from the coast, there is the beautiful countryside of the Swan Valley and Perth Hills. There were excellent park facilities to enjoy a barbeque at throughout WA, none more so than the world-renowned Kings Park. Other favourite daytrip locations included the port of Fremantle, Rottnest Island, Mandurah and Hillary’s Boat Harbour for the children. Weekends were often spent some three hours south of Perth in the Margaret River area either exploring caves, winetasting or simply relaxing on the white sanded beaches coasting the Indian Ocean. essentially delivered by interventional radiologists. Despite the undisputed credibility of many of these latter programmes, the advantages of a more contemporary and seamless training fellowship are clear. Rural attractions of Western Australia Kalbarri (above) & The Pinnacles National Park (below) Smith’s Beach, Yallingup (Margaret River). One of our favourite weekend locations The Future: Home and Down Under The SCGH fellowship certainly fulfilled all my prior expectations regarding surgeon-led endovascular training. Although similar UK-based training opportunities currently remain elusive, this should improve over time as an increasing number of true ‘vascular & endovascular surgeons’ continue to be appointed at home. In the interim, vascular trainees will have to decide whether they are willing to travel or apply for positions where endovascular training is Conclusion The SCGH fellowship is to be strongly recommended, and has been one of the best experiences of my professional career to date. There is little doubt in my mind that the surgeondelivered endovascular training I received would be difficult to better anywhere in the world. As with all these oversees appointments, the main piece of advice I’d give would be to plan well in advance and research the fellowship extremely carefully before committing. Unfortunately of late, I have been made aware of a few Australian endovascular fellowships that aren’t all that they claim to be. Assuming that you do manage to get a position in a similar set-up to SCGH, however, you’ll be well set. Number 32, December 2010 The anxiety for current UK trainees regarding Australasian endovascular fellowships is that their availability may soon become extremely limited. Many native vascular trainees are beginning to exercise their right to take up a supplemental year of supervised experience at the end of their training, prior to taking up a Consultant post. In effect, this would reduce the number of fellowships available for oversees trainees who may end up having to look elsewhere such as North America or mainland Europe. NEWSLETTER Floreat Beach - our local haunt. Only 5 minutes walk from City Beach and typically as busy as is seen Association of Surgeons of Great Britain and Ireland One of the highlights of our entire year was a family adventure we took in a hired six-berth campervan up to Northern WA. During the 2200km round-trip to the unspoilt Ningaloo Reef at Coral Bay for some diving, we took in the eerie moonscape of the Pinnacles, Kalbarri and also Monkey Mia where we were lucky enough to be chosen to hand-feed the famous local dolphins. Good on ya! Acknowledgement The Circulation Foundation for financial support with a £5000 Endovascular Travel Grant. 51 A LETTER FROM MALAWI It would not have won any prizes, or even troubled the scorers at the City & Guilds examinations – we would probably have been sent away with a large flea in our ear and told to go back to page 1 of the manual – but, as we stood before the wall we had built, there was an unquestionable sense of pride and achievement to be had. This was, when all was said and done, the product of our own sweat and toil and stood proudly against the African sky, warts and all. Number 32, December 2010 A LETTER FROM... Association of Surgeons of Great Britain and Ireland Nicholas Markham The mission of the CharChar Trust is to help end a legacy of poverty, not by telling Africa how to meet the challenges many of us can hardly grasp, but by helping Africans to find their own solutions and determine their own futures by providing them with the materials they need to read and write, communicate, teach and learn through English or their own local languages. As summer holidays go, this was about as different as it gets. Sun, but no sun loungers; filling fare but no gourmet. What had made a Devon family opt for something so different? Almost a year before, we had listened with a deep sense of shock to the story of a British family - a 10? year old girl and her parents - on a walking safari in Zimbabwe. What had made the elephant institute its lethal charge was unclear - a perceived threat to its calf perhaps but after it was over, a grief stricken father was left to try to find some meaning in his life, in ruins without his wife and daughter. Determined to honour their memory, he set up a charity, the Char-Char Trust, to provide educational facilities for African children - not by giving money, but by practical action in the building of schools and provision of books and educational opportunities. Two thirds of African children have no access to formal education. Intensely moved by the story perhaps there was a chance to make a contribution, do something practical and learn some valuable lessons? As it happened, a school in Suffolk (Culford) assemble a party of sixth formers each summer to go to Malawi to do just that, and contact with them established that an extra two teenagers 52 and their parents would not perhaps destabilise the dynamics too much. In truth, in accepting that we join, they were taking a big risk that the essentially unknown outsiders would not disrupt the party. And so it was that we touched down at Lilongwe airport in Malawi one Saturday afternoon in July, not quite sure of what exactly to expect. A four-hour coach ride south to Blantyre brought the first glimpses of Africa, its people and the extraordinary scenery. Coffin-makers manufacturing their wares and selling them beside the road, alongside others with foodstuffs of every description from piles of maize to colourful fruits. Others with vast arrays of old tyres presumably restored to some sort of usefulness - whole communities seem to exist by the roadside living their days in what appeared to be a somewhat fruitless existence. The greeting from the Culford school group (who had arrived a few days before us) was warm and genuine - each party finally able to begin to answer the question of whether the mix would work or not. For our parts, we did not need to give it a second thought - this was an exceptional collection of 16 children and their five teachers, focused on the tasks that lay ahead and eager to maximise every experience this opportunity would give them. The work was hard but it never seemed so. Dried mud was excavated and mixed liberally with water drawn from a nearby (and often not so nearby) well. Mixing, not with tools, but with feet until a gooey mess could be scooped by hands into wooden moulds and then turned out onto the scorched earth to dry out in shapes that were supposed to be brick-like. We got better at it I like to think - as with so many other tasks with which we were completely unfamiliar - as time went on. Dried mud makes brick-like structures (even in our hands) but will largely disintegrate in the rains unless they are fired. The rural African version of the kiln is a pile of bricks about two metres cubed with spaces underneath the bottom two rows in Number 32, December 2010 Once the bricks had been fired (and for us, this meant using ‘one I made earlier’ as the ones we had created would be weeks away from being ready) they had to be transported to the site where they would be used. No 3-ton HGV solution here – just form a couple of lines of people and pass the bricks, one at a time, along the lines until the pile at the distant site had been recreated some 100 metres away. Singing as the ‘pass the parcel’ exercise continued somehow made the whole experience so much more pleasurable, even if we struggled to get the tunes right, never mind the words. And still they smiled with those big infectious grins. A LETTER FROM... What nobody (except perhaps Andy) had expected, was the site and the cacophony of sound that greeted us as we arrived. Seemingly, the whole village had assembled - upwards of 100 men women and children, dancing and singing and waving their welcome to the work party. Through the dust clouds that their enthusiasm had generated it became very clear that their faces were as radiant as their minimal clothing was threadbare. Such images remain clearly imprinted on the soul - such happiness despite such abject poverty. And just yesterday, I found myself - just briefly - moaning that the price of balsamic vinegar had risen again in Tesco’s. One lesson, almost learnt. which a fire would be lit, to burn for days until the heat had filtered through to the top and hardened all the bricks. Simple, yet seemingly remarkably efficient. This was one of many examples where necessity was able to prove the mother of invention in the African bush. Association of Surgeons of Great Britain and Ireland We all stayed in an international school in Blantyre (where Andy, the party leader, had taught for several years before returning to the UK to teach in Culford). Each day we would all depart in the school bus for an hour’s journey down some very bumpy tracks (let’s be honest, more craters than divots) out into the depths of the African bush to one of the four building projects financed by the Char-Char trust or the Methodist Relief and Development Fund. Bit by bit, the walls of the classroom we were building rose up. Somewhat wonky it may have looked – we blamed the misshapen bricks – but local folk were on hand to correct our mistakes and realign and reposition where necessary. Water had to be brought from the wells by bucket – deftly carried on the head – and the sand and cement mixed together in the correct amounts to create mortar. Teams were assigned to each of the tasks and would rotate regularly to ensure that all the experiences could be shared together. Three days spent visiting an orphanage some 50 miles further south presented a different 53 Number 32, December 2010 A LETTER FROM... Association of Surgeons of Great Britain and Ireland 54 sort of challenge. A handful of unpaid volunteers looked after about 100 orphans in conditions that left most of the party reeling in disbelief. Children between the ages of one and eighteen, deprived of their parents through the ravages of HIV/AIDS, malaria or other causes, lived together in a commune that was seemingly devoid of all but the most basic of life’s needs. Water and scraps of food were evident, but not much else. Two rooms – probably about 6m square, housed the boys and the girls. That meant 50 in each room, yet what bunk beds there were would only have catered for about a third of them – the rest would lie on the floor. Most of the bunk beds were broken and essentially useless. Any mattresses were so dilapidated, filthy and flearidden that the bare floor was probably a better option anyway. Even understanding the importance of protection against malaria - maybe they didn’t, it was hard to know – had not resulted in more that a couple of nets between all of them. Their one communal building – where they would eat and have some semblance of teaching – had been rendered useless when its roof had been blown off in a recent storm, the same storm that had destroyed their chicken hut and most of the chickens with it. As we toured the premises some of the party became visibly distraught and the sense of utter helplessness was universal. Yet even ‘though what we succeeded in doing was barely a scratch on the surface, after two days of making makeshift repairs to the bunks, painting the walls, hanging mosquito nets over each of the refurbished beds and general cleaning, the consensus was that we had really done something useful. And once again the welcome we were afforded and the goodbyes each day (and especially when we left for the last time) were a cacophony of singing, music (improvised instruments testing the very boundaries of ingenuity) and gleeful noise that completely defied the desperate nature of their plight. Yet again, we had a reminder that ‘those who have nothing seem to be the most tranquil’ and a more humbling message would be hard to find. Whilst it was true that much of what we saw made us feel sad, there were so many things that produced real joy and fulfilment. Africa is stunningly beautiful and the expression ‘Malawi is the warm heart of Africa’ is palpably true. The landscape – especially when viewed as the sun sets – can be stunning, and the people who live there have a rich warmness to them which completely belies their situation. The camaraderie we enjoyed with the students and staff from Culford School was remarkably fulfilling and we made friendships that will last a long time. We were truly impressed with them and the energy and commitment they put into the project. We are so grateful to them for allowing us share their adventure and only hope that they felt we had made something of a positive contribution. What now? Experience of life in Malawi has resulted in an understanding of the need to prioritise resources into education for the longterm benefit of its people. The work of the Char-Char Trust focuses on such goals and we would hope to be involved in other ways in the future to support them. A re-evaluation of personal priorities and objectives began before we had even returned. To have experienced what we did as a family was immensely valuable and produced a measure of consensus in many areas that otherwise might be unobtainable between combatative teenage girls and their stubborn parents. A couple of weeks on the beach next summer will not be on the menu, whatever else we decide. New initiative for UK medical students launched The UKMSA is a new student-doctor collaboration, which aims to unite over 40,000 medical students across the UK and provide them with the resources they need to maximise their experience of university. Fifth-year medical student Mahiben Maruthappu is the founding President of UKMSA, the United Kingdom Medical Students’ Association, which also involves a number of other professors, senior clinicians, researchers and students. Honorary Chairman is Lord Walton of Detchant, a significant figure in British medicine, being the only person to have been President of the British Medical Association, the Royal Society of Medicine and the General Medical Council during his career. “This is the first time medical students across the UK have been linked in this way to share experiences and resources, wherever they are studying,” explains Mahiben. “We aim to provide free resources to students nationwide, including careers and examination advice, information on research opportunities, competitions and prizes, grants, discounts on medical books and equipment, podcasts and an online forum. There are currently a vast number of medically related societies out there and the opportunity to create and facilitate links between them would have significant benefits for students.” The UKMSA will be holding its inaugural International Medical Student Conference on Wednesday May 11th 2011 and the event is kindly being hosted by the ASGBI 2011 International Surgical Congress. Thus, as well as over 1500 surgeons attending the ASGBI Congress, we hope to additionally welcome over 300 medical students to the UKMSA Conference at the Bournemouth International Centre. It is hoped that this will be one of the largest and most prestigious single-day medical student conferences in Europe. “We are delighted to be affiliated with an organisation as impressive and influential as the ASGBI,” says Myura Nagendran, a fourth year medical student and Vice-President of the UKMSA. “Our annual conference will be a fantastic opportunity to bring medical students together for networking and debate, as well as giving them a chance to present their scientific work through posters. We feel strongly that it will also facilitate productive dialogue with students for the ASGBI, a society keen to engage all levels of medical professionals with an interest in surgery.” The student committee is guided by an Executive Trustee Board of which Professor Shervanthi Homer-Vanniasinkam, a surgeon with a significant interest in medical student affairs, is a member. She remarked that “…the UKMSA seeks to provide medical students with a forum to both interact, and further their aspirations in medicine. In the short time I have been associated with the organisation, I have been particularly impressed by their vision, and the diligence with which they pursue their goals. I would like to take this opportunity to wish them every success in their future endeavours.” Professor Robin Williamson, a former President of ASGBI, had this to say: “I remain closely involved with the teaching of surgery and anatomy, so it is a pleasure to be an Executive Trustee of UKMSA. I am delighted about the new affiliation with ASGBI, an association with an Association that is close to my heart.” Guided by the vast experience of the executive trustees which also include such influential clinicians and surgeons as Professor Sir Graeme Catto, Professor Michael Baum and Professor Christopher Bulstrode, the student team hopes to expand the UKMSA into the premier go-to website and umbrella organisation for UK medical students seeking information and support. The organisation is currently recruiting representatives across medical schools nationwide. For more information please visit www.ukmsa.org or contact the Vice-President Myura Nagendran on: [email protected] THE SECRET LIFE OF … Chris Imray After climbing through the night, the red glow of dawn gradually began to fill in the eastern sky over the vast Himalayas. Nearby, the shadows of Lhotse (8,516m) and Makalu (8,462m) could almost be felt and, over 150 miles away, Kanchenjunga (8,586m) was silhouetted by the growing red, golden tinge that was the horizon. At these altitudes, the horizon dips perceptibly due to the gentle curvature of the earth. With each breathless step, we had climbed inexorably upwards until eventually we crested the South Summit of Everest. An Xtreme dream was about to be realised. Number 32, December 2010 THE SECRET LIFE OF... Association of Surgeons of Great Britain and Ireland Caudwell Xtreme Everest Medical Research Expedition Cho Oyu 2006 I first met Mike Grocott as a fellow ‘diplomat’ on the UK Diploma in Mountain Medicine Course in 2003. Mike had a plan which had seemed so ambitious as to be verging on the foolhardy. He proposed a medical research expedition to climb Everest. In preparation, he organised an expedition to the sixth highest mountain in the world, Cho Oyu (8,201m), the aim to test both equipment and climbers at extreme altitude. One of the pre-requisites for inclusion in the Everest summit climbing team was an uneventful prior ascent of an 8,000m summit. On the summit of Cho Oyu (8,201m) with Everest and Lhotse 25 miles to the east carry to the road-head. From there, it was a day by jeep to the Tibetan/Nepalese border. As a result, I thought I had lost out on any serious chance of climbing the mountain. However, I managed to catch up the others and summit with them. On the return journey, Mike asked me to join the Xtreme Everest Expedition. The difficult conversation with my wife went along the lines “Darling, you know I said I always wanted to climb an 8000m peak, well there is just one more mountain...” Everest 2007 The expedition was four years in the planning and is the largest medical research expedition ever undertaken. There were 200 participants, 22 tons of equipment and the total cost was approximately £2,000,000. The complex science programme investigated the adaptation of the human body as it acclimatises to extreme altitude, using the shortage of oxygen as a possible model for patients in intensive care units. The expedition subsequently featured in BBC 2’s science programme Horizon ‘Doctors in the death zone’. Two months before the expedition left for Nepal, the entire team underwent a week of baseline testing. This was also the final opportunity to test equipment before shipping it to Nepal. Arrival in Nepal After a somewhat fraught journey from the UK, we arrived in Kathamndu. Our base, the Summit Hotel, has wonderful walled gardens which act as a haven of peace from the frantic hustle and bustle of the streets of Kathmandu. We wandered around this enigmatic city, visiting old haunts, finding last bits of equipment and getting to know the rest of the climbing group and our sherpa team. I certainly felt a degree of nervousness as we completed our preparations. We flew from Kathmandu in a tiny propeller driven plane getting incredible views of the Himalayan chain. Lukla (2,860m) airstrip is angled upwards at 15-20 degrees, which means not only that it is the runway unfeasibly short, but also that the pilot has only one attempt to get the approach correct. At the ‘airport’ we were greeted by a chaotic crowd of porters, sherpas, yak drivers and lodge owners, each vying for potential business. Trekking out of the village, the pace of life slowed. On a typical day, one would walk for a couple of hours on steep narrow mountain paths, crossing swaying suspension bridges high above the roaring Dudh Kosi, and then take tea at a lodge, before moving on again. I had started climbing as a teenager and, in the following 30 years, had been lucky enough to have climbed all over the world. For me, Cho Oyu would be a quantum leap in altitude, and a challenge which I felt at the time would probably be beyond me, however this would be a once in a lifetime opportunity and I managed to persuade my wife to let me have to have just one crack at an 8000m peak. Whilst climbing Cho Oyu, a climber from another team had a stroke and we discussed at length who should accompany the casualty to the border. The next morning, with twelve Tibetan porters, I set off with the patient across the glacier on a six-hour 56 Everest from Namche Hill (3,400m) Khumbu Icefall and Western Cwm The route climbs rapidly through some of the most sensational ice landscape in the world. It tackles the vertical seracs and the gaping crevasses head on, using a combination of fixed ropes and rickety aluminum ladder bridges (using up to four tied together). In some ways, the route is a sociable place as one meets friends and climbers from other expeditions, but speed is the essence for safety, since it reduces the time spent in this exquisitely beautiful, but hostile and potentially dangerous, environment. Our strategy was to acclimatise elsewhere on safer ground, so that we could move through the icefall more quickly. On the ladders in the icefall (6100m) Lhotse Face Coffee, tea or French onion soup?’ Was the question Sundeep asked me, as we settled into Camp 3, perched halfway up the Lhotse Face at about 7,100m. The Face is a 1,500m (4,500ft) ice and snow slope angled at between 40-50 degrees. Our campsite (!) was a narrow strip of horizontal space and had been carved out of the steep ice and snow slope by our sherpas. On the one side blocks had been cut out of the slope, and on the other the blocks had been used to build up a ramp to give a six foot wide horizontal terrace to place our tent. The intention had been to spend the night at over 7,000m as part of the acclimatisation process. It was a couple of hours before sunset, and we were just settling down to a brew and the slow process of melting snow in order to rehydrate ourselves, when a crackle came over the VHF radio. The weather forecast predicted a storm which threatened 2030cms of snow. The Lhotse Face is no place to be in a snowstorm in particular because of the risk of avalanche. The options were to sit the possible storm out, and hope that the forecast was wrong so completing our acclimatisation sojourn, or to pack up rapidly and descend the fixed ropes and try to get back to the safety of Camp 2 before dark. A rapid conversation took place, and with safety paramount, we packed up and abseiled down the fixed ropes, getting into Camp 2 just as it was getting dark. Number 32, December 2010 To begin with, the food seemed good, but over time and with limited access to fresh food it became increasingly dull. At times I felt I was being forced to live out the Monty Python‘spam’ sketch with spam fritters, spam pizzas, and even spam curry! Appetite suppression and weight loss at altitude [1] are recognised phenomena and I dropped from 80kg to 66kg during the expedition. THE SECRET LIFE OF... Basecamp After ten days trekking, we arrived in Basecamp (5,300m). This bleak and desolate spot on the Khumbu Glacier was to be our home for the next three months. The Khumbu Icefall dominates Basecamp like no other glacier I know. Basecamp is actually placed on the glacier itself and is on the move in two ways all the time. Firstly, it is melting fast and rocks and tents are left high and dry as the surrounding ice melts giving the impression of the tide going out. Secondly, the entire camp is slowly on the move down the valley and, every so often, there are pistol shot noises as the ice readjusts its position. Association of Surgeons of Great Britain and Ireland On the long haul up to Namche Bazaar (3,800m), we turned a corner and caught our first glimpse of Mount Everest with a three mile plume of snow generated by the jet stream. At 29,035 feet (8,850m), every child learns that this is the highest mountain in the world. It has been formed by the up thrusting of land as two continental plates collide, and is continuing to grow in height. In 1856, the mountain was named after Sir George Everest, the Surveyor General of India from 1830 to 1843, and was first climbed by Edmund Hilary and Norgay Tenzing on May 29th 1953, just in time for Queen Elizabeth II’s coronation. We descended to Dingboche (4,280m) for a week to eat, enjoying a menu of chicken burgers, yak sizzlers and delicious Khumbu potatoes. Every meal ended with at least one deep fried Mars bar. Psychologically, leaving the relative ‘comfort’ and safety of the yak herder’s village and returning to the mountain was very difficult. Crossing a crevasse in the Khumbu Icefall (6,200m) Death Zone All too soon, it was time to turn around and head back up the mountain through the precarious 57 Number 32, December 2010 THE SECRET LIFE OF... Association of Surgeons of Great Britain and Ireland Khumbu Icefall, the immense and very hot Western Cwm, up the steep and treacherous Lhotse Face, through the Yellow Band, across the Geneva Spur and finally up to the South Col (7,980m). On first arrival, the South Col had a deceptively benign appearance. In the sun and without any wind, it was warm enough for T shirts. It was only later, when the sun set and the wind picked up, that we began to appreciate the true harshness of the place. Temperatures plummeted to as low as -35°C, and with oxygen levels 1/3 of those found at sea level, we began to appreciate what was meant by the term the ‘death zone’ [2]. At this altitude, the body is deteriorating all the time, and life is unsustainable for any prolonged length of time. Without oxygen, even simple tasks such as brushing ones teeth took on gargantuan proportions, and it was necessary to rest in order to complete the task. Evening light on the South Col (7,950m) Most teams arrive at the South Col in the early afternoon, they then spend a few hours rehydrating and sleeping before setting off on their summit attempt somewhere between 9.00pm and midnight. Our plan was different; we had the most ambitious range of scientific experiments ever undertaken at this altitude to undertake in the world’s highest ‘laboratory’. We spent a day setting up equipment, followed by two days of experiments ranging from transcranial Doppler cerebral perfusion studies to VO2 maximal bicycle exercise tests [3]. At rest, and off supplemental oxygen, our blood arterial oxygen saturations were between 48-56%, and with exercise these levels dropped further, understandably our bodies were deteriorating continuously. In total, we spent five nights on the South Col - we believe this is the longest anyone has ever spent there. Cardiopulmonary exercise testing and transcranial Doppler measurements on the South Col (7,950m) Whilst on the South Col, we became involved in one of the highest rescues ever undertaken. A 22 year old woman with cerebral oedema, or brain 58 swelling, was found alone and unconscious at 8,500m by an American guide Dave Hahn. He spent 30 minutes giving her his oxygen and, as she began to rouse, he radioed down to the South Col asking for assistance. We spent three hours stabilising her in a tent, before a team of climbers and sherpas began the long carry/lower down through the Yellow Band and Lhotse Face to Camp 3, arriving after dark. A second team spent the night resuscitating her before she was lowered the rest of the way down the Lhotse Face to Camp 2. She was finally carried through the Icefall to Basecamp 5,300m (the altitude ceiling for helicopters rescues) and flown to Kathmandu. She has subsequently lost a couple of toes and the tip of her thumb from frostbite [4], but has otherwise has made a complete recovery. Summit attempt Ten sherpas and five climbers had set off from the South Col (7,980m) at 9.30 pm on 22nd May. In a bitterly cold wind, we had crossed the South Col Glacier, and steep climbing had led to the 40° Triangular Face. The spindrift driven by the strong winds had filled in the previous steps, so breaking trail was hard work. We arrived at the Balcony in good time and took a short break, but a combination of the cold, the dark and the wind meant it was better to be moving. The cold clear starlight night silhouetted the South Ridge, which lead through a loose rocky section up towards the South Summit. The head-torches of our party twinkled above us as we tackled the steep rock. Approaching the South Summit (8,690m) After climbing through the night, the red glow of dawn finally and gradually began to fill in the eastern sky over the vast Himalayas. Nearby, the shadows of Lhotse (8,516m) and Makalu (8,462m) could almost be felt and 150 miles away Kanchenjunga (8,586m), was silhouetted by the growing red and golden tinge of the horizon. At these altitudes, the horizon dips perceptibly with the gentle curvature of the earth. With each breathless step, we had climbed inexorably upwards until eventually we crested the South Summit. An Xtreme dream was about to be realized. Between the South Summit and the Hillary Step, there is a switchback ridge made up of huge surreal whipped meringue cornices which overhang both the Kangshung Face to the East and the South West Face to the West. There was a strong blustery cross wind and, with drops of over 8,000 feet on either side, clearly this was no place to fall. The route twists and turns along a knife edge ridge to reach the Hilary Step. This short steep segment was adorned with a mass of rope, mostly old and tatty, but there was at least one in reasonable condition. Having surmounted the Step, a further 200-300m of relatively flat ground led to the summit of Everest, the highest point on earth. arterial blood oxygen levels. Four of us underwent femoral arterial stabs at 8,400m on the descent, and a sherpa ‘ran’ these down to Camp 2 at 6,400m for analysis. This descent took us two days, but Pasang managed it in two hours - with time for tea at the South Col! References [1] Imray C H E, Wright A, Subudhi A and Roach R Acute mountain sickness: pathophysiology, prevention, and treatment. Prog Cardiovasc Dis. 2010;52 (6): 467-84 [2] Firth P G, Zheng H, Windsor J S, Sutherland A I, Imray C H E, Moore G W, Semple J L, Roach R C and Salisbury R A Mortality on Mount Everest, 1921-2006: descriptive study. British Medical Journal. 2008; 337: a2654. doi: 10.1136/bmj.a2654 [3] Wilson M H, Newman S and Imray C H E The cerebral effects of ascent to high altitudes. Lancet Neurology. 2009; 8 (2): 175-91. [4] Imray C H E, Grieve A, Dhillon S, the Caudwell Xtreme Everest Research Group Cold damage to the extremities: Frostbite and nonfreezing cold injuries. Postgraduate Medical Journal 2009; 85:481-488 Number 32, December 2010 At last it was possible to climb no higher. There was a mass of prayer flags fluttering in the bitterly cold and strong wind. It was so cold that we spent the shortest possible time on Final few feet to the the summit. Initially, there summit was an enormous feeling of elation shared with Mike, Sundeep, Dan and Nigel, and huge thanks to Tashi, the sherpa, who had shadowed me for the entire climb. Then a few private moments were taken to contemplate the effort and commitment required to get to the highest point on earth. There was also time to remember the support and prayers of those nearest and dearest, and then it was time to leave before the penetrating cold and hypoxia endangered a safe return, focusing on each and every step of the return journey. THE SECRET LIFE OF... View from the South Summit (8,690m) towards the Hilary Step and summit (8,850m) Conclusions The mountain was climbed, everyone returned home safely, and great friendships were forged. Judged by conventional criteria, Mike Grocott has lead one of the most successful Everest expeditions ever. On the research side, tantalising initial insights into the pathophysiology of hypoxic ‘healthy’ individuals and the critically ill are beginning to emerge. However, perhaps the most remarkable aspect of the expedition were the incredible sherpas. With enormous good grace and humour, they performed amazing physical feats often in a very dangerous environment and under extreme hypoxia. Surely their genetic and physiological adaptation offers the most obvious line of research in trying to understand to the response of humans to extreme hypoxia? Association of Surgeons of Great Britain and Ireland ‘‘In four samples taken at 8400 m (27,559 ft) - at which altitude the barometric pressure was 272 mm Hg (36.3 kPa) - the mean PaO2 in subjects breathing ambient air was 24.6 mm Hg (3.28 kPa), with a range of 19.1 to 29.5 mm Hg (2.55 to 3.93 kPa). The mean PaCO2 was 13.3 mm Hg (1.77 kPa), with a range of 10.3 to 15.7 mm Hg (1.37 to 2.09 kPa).’’ [5] [5] Grocott M P, Martin D S, Levett D Z, McMorrow R, Windsor J, Montgomery H E; Caudwell Xtreme Everest Research Group Arterial blood gases and oxygen content in climbers on Mount Everest. NEJM. 2009; 360(2):140-9. Amongst the summit prayer flags (8,850m) Results Although much data is still in the process of being analysed, there are some interesting and potentially important messages emerging from the preliminary data [5]. Perhaps the most notable being Mike Grocott’s paper in the NEJM on arterial blood gases and oxygen content in climbers on Mount Everest. It demonstrated that individuals appear to be able to function reasonable normally (!) with exceptionally low Acknowledgements The expedition was supported by John Caudwell, BOC Medical, Eli Lilly, the London Clinic, Smiths Medical, Deltex Medical, the Rolex Foundation, the Association of Anaesthetists of Great Britain and Ireland, the United Kingdom Intensive Care Foundation, and the Sir Halley Stewart Trust. Caudwell Xtreme Everest is coordinated by the Centre for Altitude, Space, and Extreme Environment Medicine, University College London. http://www.case-medicine.co.uk/ 59 WHEN VENUS CAME TO THE AID OF AESCULAPIUS, SURGERY TOOK ON A WHOLE NEW DIMENSION In 1890, Dr William Stewart Halstead, surgeon-in-chief and later professor of surgery at the newly opened Johns Hopkins University Hospital in Baltimore, USA wanted to find a solution to his chief nurse (and fiancée) Caroline Hampton’s severe dermatitis caused by contact with the carbolic acid they routinely used at the time to sterilise their hands. Number 32, December 2010 CORPORATE PATRONS Association of Surgeons of Great Britain and Ireland Few would have thought that the very first surgical glove to be produced using rubber would have been born out of a love affair between a surgeon and his assistant. But that is precisely what happened. Halstead approached the Goodyear Rubber Company to see if it was possible to make a pair of thin rubber gloves that could be dipped in carbolic acid without compromising its ability to perform well during surgical procedures and ensure adequate protection for the hands. And the result was the world’s first rubber operating glove. The process involved in manufacturing surgical gloves has come a long way since the early days of this innovative frequent use, multi-procedural, glove that was pioneered by Halstead more than a century ago. Today, latex surgical gloves undergo a multi-stage process to ensure ease of donning, grip, sensitivity, fit and the comfort characteristics required in the modern surgical environment. But before they reach hospital theatres, surgical gloves must undertake a comprehensive and often demanding journey which starts thousands of miles away at the very source of the manufacturing process Southeast Asia. Tapping into resources Southeast Asia is the centre of rubber activity and home to the largest number of rubber plantations in the world, with the three biggest producers (Malaysia, Thailand and Indonesia) accounting for 72 per cent of global natural rubber production. While the sourcing of raw materials such as oil or natural gas employ sophisticated technology, tapping a rubber tree to extract its latex remains an antiquated, manual process that has remained relatively unchanged since the days of the Olmec’s in Mexico around 1,000BC, with each tree capable of producing liquid latex for around 25 years. Starting the manufacturing process Before the latex leaves the plantation, it needs to undergo a process of centrifugation to reduce the level of water content within the latex from between 70 and 80 per cent to 30 per cent. Once this has been done, it is transported to the factory where modern technology comes into play and man and machine work in tandem to convert the latex into favourable surgical glove material. Now the manufacturing process really begins. At this stage, the latex must be formulated with chemical compounds to ensure the end product has sufficient tensile strength, and anti-oxidants added to improve the shelf-life of the finished product. The next step takes the glove formers (or moulds) through a series of stages of ‘dipping’ to achieve the desired elasticity and thickness (controlled by the amount of time spent in the latex) of the glove before subjecting it to a leaching process which removes all the excess residual chemicals and proteins from the surface of the latex itself. But the cleansing process does not end there. Having been shaped and given their glove-like aesthetic by the formers, the gloves are then placed in a tumbler where they will be doused and chlorinated in a chlorine water or hypochlorite-hydrochloric acid mixture. This serves to harden the surface and optimise performance of the glove in wet and dry 60 Quality control Whilst the factory conducts a series of rigorous tests prior to shipping, sometimes the freight can take a month or longer to reach the UK from Southeast Asia, by which time the gloves properties can be altered. To ensure that Biotex GL and Synthesis’ surgical gloves exceed all existing UK and European regulatory requirements, Polyco will re-test the gloves at point of distribution in the UK to ensure the products perform above the industry standard. Formed in 1979, the company pioneered the concept of tailoring products to match the needs of our customers. And, through continual investment in research and product development combined with a reputation for innovation, quality and exceptional levels of customer service, BM Polyco has set the standard for an industry that is constantly under pressure to meet and respond to the increasing demands of the modern healthcare sector. Dr Halstead is heralded as the father of American surgery and is credited as being the first surgeon to use rubber gloves in the operating theatre. Ironically, the very hand he wanted to protect he was soon to take in marriage in a move that many of the Halstead’s peers regarded as “Venus coming to the aid of Aesculapius” – although it is not clear if the gloves had anything to do with it. Number 32, December 2010 Sterilisation With the coating, rinsing and drying process complete, the surgical gloves are ready for testing and sterilisation using gamma irradiation. Gamma rays penetrate the sealed packaging and kill any living organisms inside. This irradiation process is conducted remotely as gamma radiation would also kill any person within close proximity. British company, world-class reputation BM Polyco is the largest British-owned manufacturer and provider of hand and arm protection in Europe, and the first surgical glove manufacturer in the UK to be approved as Corporate Patron of the Association of Surgeons of Great Britain and Ireland, in recognition of their technically advanced Biotex GL surgical glove. CORPORATE PATRONS Because the medical profession is moving away from powdered latex gloves in light of latex allergy concerns, surgical gloves such as Biotex GL and Synthesis by Polyco have polymer coatings on the inside which reduce the amount of friction between wet skin and the gloves allowing them to be damp and intra op donned with greater ease than their uncoated counterparts. This further reduces incidences of hand fatigue as a consequence of prolonged surgical glove use. Association of Surgeons of Great Britain and Ireland conditions (grip), coat the exterior and remove the stickiness which impedes smooth donning. 61 Association of Surgeons of Great Britain and Ireland After three very successful years in post, Mike Wyatt is demitting office, at the conclusion of his term, at the Association’s AGM in May 2011. ASGBI now seeks, therefore, to appoint a successor as HONORARY EDITORIAL SECRETARY Here at Virgin Atlantic, we’re a bit like you. We’re dedicated to looking after people’s health and wellbeing, which is why we are delighted to announce that we’ve teamed up with ASGBI to present the Association’s members with an offer that’s bound to make you feel great! As a valued ASGBI member, every time you make a booking with Virgin Atlantic you’ll enjoy some exclusive benefits: • • • • 20% discount on our fully flexible return published fares for you and your immediate family. A Premier UK Service and Booking team open 24 hours a day, 5 days a week. Access to special offers from our partners including Virgin Holidays, V Cruises and Super Travel Golf. Membership to our frequent flyer loyalty programme, Flying Club. In the air and on the ground, Flying Club offers you better rewards than other loyalty programmes, including flights, upgrades and lots, lots more... About Us Virgin Atlantic is the UK’s second largest long-haul airline, with a route network spanning 33 exciting destinations, covering the US, the Caribbean, Africa, Asia and Australia. Based at London Heathrow, Gatwick and Manchester, we’re renowned for our focus on innovation, style, quality and above all, dedicated passenger service. When you fly with Virgin Atlantic, whichever cabin you choose, you’re assured of a truly memorable journey and some of the most sophisticated products and service in the air. In Economy, you can enjoy the great value of our free amenity kit and seatback TVs. With Premium Economy you can relax with some of life’s little luxuries in a bigger, wider seat. Number 32, December 2010 [email protected] NEWSLETTER A Job Description is available, via the ASGBI website, at: www.asgbi.org.uk/appointments Appointment to this post will be by competitive interview, and applications, in the form of a covering letter and a brief CV, should be received by the closing date of midnight on Monday 31st January 2011. Applications should be emailed, in confidence, to: Association of Surgeons of Great Britain and Ireland The Association produces a professional portfolio of publications including a quarterly Newsletter, frequent Consensus Statements, a Congress Newsletter Plus for each day of the International Surgical Congress, and a series of Issues in Professional Practice booklets. The Honorary Editorial Secretary assumes responsibility for the Association’s publications and takes an active part in the management and strategic direction of ASGBI. The post is for a maximum term of office of three years, and the post holder will be a member of the Association’s Executive Board, Council and other ASGBI committees including the Scientific Committee and Education and Training Board. The Upper Hand - If you want to travel in the lap of luxury, our Upper Class Suite and service are designed to give you ultimate privacy and comfort. On the ground you can enjoy our chauffeur-driven car service, Drive Thru Check In* and award-winning Clubhouses with full business and leisure facilities. For travellers taking advantage of our Upper Class Wing at Heathrow Terminal 3, you can also enjoy a Private Security Channel and our award-winning Heathrow Clubhouse. If you’re departing from Gatwick, our recently refurbished Clubhouse is a sumptuous retreat with a relaxed and friendly ambience where you can unwind with a Cowshed spa treatment before you fly. Once onboard, you can relax in your Suite, which boasts one of the biggest fully flat beds in the sky. Add to this a stylish onboard bar and a superb dining experience, and it’s easy to see why Upper Class is the choice of the discerning traveller. To book your next Virgin Atlantic flight, or for more information about this exclusive ASGBI member’s only offer, please call our Premier Service team on: 0844 209 7303 63 MASSIVE UPPER GASTROINTESTINAL HAEMORRHAGE FROM THE CYSTIC ARTERY: A RARE COMPLICATION OF DUODENAL ULCERATION 66 Number 32, December 2010 CASE STUDIES Association of Surgeons of Great Britain and Ireland D A Lees, D W Borowski, S Filson, S M Griffin and J Shenfine Northern Deanery and Royal Victoria Infirmary, Newcastle upon Tyne Summary A 56 year old man with a history of alcohol excess presented with refractory upper gastrointestinal bleeding from an anterior duodenal ulcer. This was initially managed with endoscopic injection therapy. Subsequent haemorrhagic shock necessitated emergency laparotomy during which it was discovered that the cystic artery had been eroded by the previously noted ulcer. Ligation of the bleeding vessel was curative and the patient made a full recovery. Erosion of the cystic artery secondary to duodenal ulceration is a rare cause of upper gastrointestinal haemorrhage, but should be considered in cases of refractory bleeding from an anterior duodenal ulcer as this is difficult to manage endoscopically, whereas urgent laparotomy could be life-saving. Case Presentation: Part One A 56 year old male was admitted as emergency at 21.35 hrs with a 24 hour history of a mixture of melaena and fresh red rectal bleeding on a background of dyspeptic symptoms for the previous week, chronic alcohol dependency and long-term non-steroidal treatment for polyarthritis. Initially, the patient was haemodynamically stable with a haemoglobin count of 11g/dL, normal clotting profile, urea of 8.2mmol/L and creatinine of 59µmol/L. However, at 05.00 hrs (7? hours post admission), the patient experienced further fresh red rectal bleeding and became haemodynalically unstable with a decreased level of consciousness (GCS 14-13/15, BP 70/50mmHg, pulse 150 bpm, respiratory rate 30/minute). A repeat haemoglobin count was now 4.5g/dL, urea 7.0mmol/L, and creatinine 56µmol/L. The patient was resuscitated and stabilised with intravenous colloid, 6 units of packed red cells and 2 units of fresh frozen plasma. Urgent upper gastro-intestinal endoscopy demonstrated an anterior ulcer with no active bleeding. Nevertheless, the ulcer was injected with 1:10000 adrenaline and this was thought to be successful. An intravenous bolus of 80mg Omeprazole was given and an 8mg/hr infusion commenced. Post transfusion haemoglobin was measured at 9.7g/dL. Despite this, at 16.00 hrs (18? hours post admission and 11 hours after his last bleed), a further episode of bright red rectal bleeding occurred with haemodynamic instability (GCS 12/15, BP 70/50: increasing to 92/61mmHg with 1L colloid, pulse 123bpm, respiratory rate 26/minute) requiring further 4 units of packed red blood cells. Haemoglobin had again dropped to 7.9g/dL, urea 4.6mmol/L and creatinine 65µmol/L. Blood gasses were recorded as pH 7.402, pCO2 5.19, pO2 37.13, act HCO3 23.7, base excess -1.0, glucose 6.8, lactate 2.96, O2 saturation 99.7%. 1. What has happened to the epidemiology of upper gastrointestinal bleeding since the advent of proton pump inhibitors (PPIs) and endoscopic therapies? The development of histamine H2-receptor antagonists, proton pump inhibitors and Helicobacter pylori eradication therapy has greatly improved the management of peptic ulcer disease and it was assumed that this would reduce the incidence of ulcer-associated upper gastrointestinal bleeding. Although an association with a reduced re-bleeding and surgery has been demonstrated, the incidence (1500-3000 per 100 000 population per year) and overall mortality (1 in 13 overall, but 1 in 5 in people using ulcerogenic drugs) [1] remains unchanged. The widespread use of non-steroidal anti-inflammatory drugs, aspirin and clopidogrel increases the risk of ulcer development by 5 to 8 times [2 to 4], estimated to be responsible for 24% of the overall incidence [5]. Whilst proton pump inhibitors are effective for the management of nonbleeding ulcers, their exact role in the management of bleeding ulcers is controversial and unclear [6]. 2. What are the most common causes of acute upper gastrointestinal bleeding? • Duodenal or gastric ulcer. • Oesophageal or gastric varicies. • Mallory-Weis tear. • Oesophagitis/gastritis. • Neoplasm. • Angiodysplasia. 3. What scoring systems can be used to predict mortality and morbidly and the risk of rebleeding? When selecting patients with upper GI bleed for intervention, the endoscopic appearances (Forrest classification) is often used as a tool for stratifying patient’s mortality and re-bleeding risk [9]. Similarly, the Rockall and Blatchford scoring systems have their place, but all systems essentially ‘quantify’ common sense, it is no surprise that patients with ‘spurting haemorrhage’ have a high re-bleeding rate nor that patients with shock, major associated co-morbidity, cancer and organ failure have a high mortality rate (see Tables 1 to 3). 4. What are the endoscopic therapeutic options? The management of acute upper gastrointestinal bleeding (UGIB) has been revolutionised by endoscopy with the risk of re-bleeding reduced from 50-80% to as low as 10% with combination techniques. Endoscopic intervention for UGIB reduces the risk of re-bleeding or continued bleeding, the need for surgery, the transfusion requirement and total length of hospital stay. Endoscopic therapeutic options include: 1. Injection therapy (dilute epinephrine or sclerosants). 2. Ablative therapy (thermocoagulation, electrocoagulation, Argon plasma coagulation, cryotherapy, photocoagulation, dual therapy devices: electrocautery with needle injection, electrocautery with mechanical therapy). 3. Mechanical therapy (haemoclips, suture/snare devices or band ligation). Therapeutic modalities reduce the risk of rebleeding in patients with peptic ulcer disease with stigmata of recent haemorrhage to about 20%. However, studies now support combination of therapies, such as epinephrine injection (see Figure 1) followed by an ablative or mechanical therapy. A re-bleeding rate of only 4% was demonstrated in patients treated with a combination of epinephrine and haemoclip therapy compared to 21% for those receiving epinephrine injection alone (n= 105) [11]. This data is supported by randomised controlled Figure 1: Injection of trial evidence [12]. Epinephrine 5. Do PPIs make any difference? A Cochrane review in 2006 of 24 randomised controlled trials (n=4373) demonstrated the superior efficacy of PPIs compared to H2-receptor antagonists or placebo. PPI treatment significantly reduced re-bleeding (odds ratio (OR) 0.49; 0.37 to 0.65), surgical interventions (OR 0.61; 0.48 to 0.78) and further endoscopic haemostatic treatment (OR 0.32; 0.20 to 0.51) at a confidence interval of 95%. There was no evidence of PPI’s reducing all-cause mortality, however, a significant reduction was demonstrated when the analysis was restricted to patients with high-risk endoscopic findings of active bleeding or a nonbleeding visible vessel [13]. Figure 2: View of ulcer during laparotomy Number 32, December 2010 Table 3: Forrest Classification [10] CASE STUDIES Table 2: Blatchford Scoring System[8] Score <4 predicts resolution without intervention Score >5 indicates intervention required The gentleman was brought into theatre suite and, despite being stable during transfer, whilst in the anaesthetic room he became unstable. The patient was transferred immediately to theatre and an emergency upper midline laparotomy was performed. There was no free blood in the peritoneum but the anterior duodenum was closely applied to the neck of the gallbladder. This was pinched off to reveal a 15mm anterior duodenal ulcer which had eroded into the gallbladder neck and the cystic artery, which was the source of the ongoing blood loss (see Figure 2). The cystic artery was ligated and divided, with no apparent loss of viability of the gallbladder. Due to the patient’s instability, the decision was made to preserve the gallbladder assuming sufficient collateral blood supply. The duodenal ulcer was closed with an omental (Graham) patch repair. After 24 hour stay on the Intensive Care Unit, the patient was transferred to ward-level care and made an uneventful recovery. He was discharged 12 days postoperatively and reviewed as out-patient at six weeks with no further symptoms. Association of Surgeons of Great Britain and Ireland Table 1: The Rockall Scoring System[7] A score of less than 3 indicates a good recovery A score >8 indicates a high risk of mortality Case Presentation: Part Two Aggressive resuscitation was commenced with high flow oxygen, colloid and packed red blood cells. A further 7 units of packed red blood cells were given. Outreach services and the Intensive Care Unit were notified and attended the ward to assist with resuscitation. The on-call upper gastrointestinal surgical consultant made the decision to proceed immediately to theatre. The plan was to re-endoscope in theatre under general anaesthetic as the previous endoscopist had struggled to maintain a clear view of the anterior duodenum. 6. When should an operative approach be considered? Non-variceal bleeding that continues despite endoscopy requires surgical intervention. Repeat endoscopy can confirm ongoing bleeding and a further attempt made at achieving haemostasis. Clinical judgement, local experience and expertise dictate subsequent management. For the majority, a policy of close observation with the decision to proceed to laparotomy if bleeding occurs for a second time. However, the patient’s age, comorbidities and high risk endoscopic findings may demonstrate that a semi-urgent surgical intervention may prove to be in the patients’ best interests [14]. 67 7. Should we have removed the gallbladder? Number 32, December 2010 CASE STUDIES Association of Surgeons of Great Britain and Ireland The gallbladder was placed at a significant risk of ischaemia and infarction as the cystic artery is an end vessel and cholecystectomy should have been strongly considered at the time of laparotomy. Furthermore, if gallstones had been present this would further strengthen the case for removal. However, cholecystectomy was not done in the case described as there was no evidence of gallstones at the time of surgery and the gallbladder was well perfused with a collateral blood supply. 8. What are the learning points from this case? • When presented with a refractive upper gastrointestinal haemorrhage unresponsive to initial endoscopic therapy, laparotomy should not be delayed. • It is common to assume that an ‘anterior’ duodenal bleed is simply an endoscopic error but other causes such as cystic artery erosion should be considered as, although this is not common, endoscopic access to the bleeding point is not easily achieved and early surgery may be indicated. • Angiography would delineate the source of bleeding and allow embolisation, but this may result in gallbladder infarction. Definitive treatment should not be delayed if radiological embolisation is not to be undertaken, thereby placing an already compromised patient at further risk of mortality. References [1] Zittel TT, Jehle EC, Becker HD. Surgical management of peptic ulcer disease today indication, technique and outcome. Langenbecks Archives of Surgery 2000;385(2):84-96. [4] Henry D, Dobson A, Turner C. Variability in the risk of major gastrointestinal complications from non-aspirin non-steroidal anti-inflammatory drugs. Gastroenterology 1993;105(4):1078-1088. [5] Kurata JH, Nogawa AN. Meta-analysis of risk factors for peptic ulcer Nonsteroidal antiinflammatory drugs, Helicobacter pylori, and smoking. Journal of Clinical Gastroenterology 1997;24(1):2-17. [6] Leontiadis GI, Sharma VK, Howden CW. Systematic review and meta-analysis of proton pump inhibitor therapy in peptic ulcer bleeding British Medical Journal 2005; 330(7491):568. [7] Rockall TA, Logan RF, Devlin HB, Northfield TC. Risk assessment after acute upper gastrointestinal haemorrhage. Gut 1996; 3:316-321. [8] Blatchford O, Murray WR, Blatchford M. A risk score to predict need for treatment for uppergastrointestinal haemorrhage. The Lancet 2000; Oct 14(356):1318-1321. [9] Heldwein W, Schreiner J, Pedrazzoli J, Lehnert P. Is the Forrest classification a useful tool for planning endoscopic therapy of bleeding peptic ulcers? Endoscopy 1989;21(6):258-262. [10] Forrest JA, Finlayson ND, Shearman DJ. Endoscopy in gastrointestinal bleeding. The Lancet 1974;17:394-397. [11] Lo CC, al. e. Comparison of hemostatic efficacy for epinephrine injection alone and injection combined with hemoclip therapy in treating high-risk bleeding ulcers. Gastrointestinal Endoscopy 2006;63:767-773. [12] Chung SS, al e. Randomised comparison between adrenaline injection alone and adrenaline injection plus heat probe treatment for actively bleeding ulcers. British Medical Journal 1997;314:1307-1311. [2] Svanes C, Ovrebo K, Soreide O. Ulcer bleeding and perforation: non-steroidal antiinflammatory drugs or Helicobacter pylori. Scand J Gastroenterol Suppl 1996;220:128-31. [13] Leontiadis GI, Sharma VK, Howden CW. Proton pump inhibitor treatment for acute peptic ulcer bleeding. Cochrane Database of Systematic Reviews 2006 (Issue (1):CD002094.). [3] Garcia Rodriguez LA, Jick H. Risk of upper gastrointestinal bleeding and perforation associated with individual non-steroidal antiinflammatory drugs. Lancet (North American Edition) 1994;343(8900):769-772. [14] Palmer KR. Non-variceal upper gastrointestinal haemorrhage: guidelines. Gut 2002;51:iv1-iv6 TOTAL MIDLINE ECTOPIC THYROID N N Basu, D F Sallomi and P H Rowe Eastbourne District General Hospital aspiration cytology of the mass was inconclusive. An isotope scan confirmed that all of the patient’s active thyroid tissue was contained in this region (see Figure 2). Clinical Presentation A fifty-one year old gentleman presented with a painless lump in the upper midline of his neck (see Figure 1). This mass had been slowly increasing in size over many years. The patient’s primary concern was cosmesis. There were no systemic symptoms. Clinical examination revealed a three-centimetre tumour readily visible in the anterior midline of the neck, immediately below the hyoid bone. No cervical lymphadenopathy was present. Blood tests, including thyroid function, were normal. An ultrasound scan of the neck suggested a multinodular centrally elevated thyroid gland. Fine needle 68 Figure 1: Solitary lump in the midline of the upper neck – below the hyoid bone. Question? What is the differential diagnosis of a midline neck mass? Answer More common in children. Differential in all age groups include: thyroglossal duct cysts, sebaceous cysts, dermoid cysts, lymph nodes, lipomas, neoplasms and ectopic thyroid tissue[1]. Question? What is the embryological origin of the thyroid gland and its relationship to pathology? Answer The thyroid develops from a midline endodermal proliferation between the tuberuclum impar and the hypobranchial eminence in the fourth week of fetal life. This subsequently descends anteriorly and remains attached to the foramen caecum by a tubular stalk, the thyroglossal duct [2]. The Question? What is the main complication of ectopic thyroid tissue? Answer Malignant transformation has been reported in ectopic thyroid tissue. All common types of thyroid malignancy have been seen, the majority of tumours being papillary in nature. It is not known whether ectopic thyroid tissue is more likely to undergo malignant transformation. Studies suggest that ectopic thyroid tissue does not pose a threat to children, but carcinoma has developed in older patients. Current recommendations are removal of ectopic thyroid tissue after the age of thirty years because of the risks in later life. The case reported here would support this recommendation. Number 32, December 2010 Histological analysis confirmed a multinodular thyroid containing a large cellular lesion, which was mixed solid and follicular in architecture. This area showed considerable pleomorphism, was non-encapsulated and showed no definite vascular invasion. The nuclei did not show the features of a papillary carcinoma, and in some areas the nucleoli were prominent in otherwise generally round open nuclei. Local invasion was present in some areas. The conclusion was that of a low-grade microinvasive follicular carcinoma, probably related to its origin in developmentally abnormal thyroid. CASE STUDIES Question? What is thyroid ectopia? Answer It is defined as any functioning tissue not located anterior or lateral to the second, third or fourth tracheal rings. This tissue may be Figure 2: Anterior planar image of a Technetium-99m thyroid uptake scan which present at any position along the demonstrates a large rounded focus of increased uptake high within the neck. course of the descent of the This is in the midline below the level of the submandibular gland. A note is made thyroglossal duct. Ninety percent of of the marker representing the level of the suprasternal notch. cases occur at the foramen caecum, known as a lingual thyroid, and is The patient proceeded to Sistrunk’s operation and more prevalent in females (78%) [3]. Total thyroid ectopia is rare, accounting for at the time of surgery it was obvious that the thyroid gland was absent from its normal 1:6,000 cases of thyroid pathology. Total midline anatomical position. The postoperative course was ectopic thyroid has been reported in patients of all unremarkable and he was discharged on thyroid ages, but the majority of cases in the literature replacement therapy. apply to patients under the age of thirty [4]. Association of Surgeons of Great Britain and Ireland thyroglossal duct becomes bilobed and reaches its final position (anterior to the upper trachea and below the thyroid cartilage) by the seventh week of embryological life. The hyoid bone develops from the second and third branchial arches laterally and fuses in the midline in close association with the thyroglossal duct. Thyroglossal cysts occur when the duct fails to fuse correctly or where epithelial cells may persist at any level during its course. The attachment to the foramen caecum accounts for the clinical sign of protrusion of midline swelling on protrusion of tongue – pathognomic for thyroglossal cysts. References [1] Damiano A, Glickman A B, Rubin J S and Cohen A F Ectopic thyroid tissue presenting as a midline neck mass Int J Paediatric Otorhinolaryngology 1996. 34:141-48 [2] Al-Dousary S Current management of thyroglossal duct remenant J Otolaryngology. 1997 26(4):259-265 [3] Okstad S, Mair I W S, Sundsford J A, EIde T J and Nordrum I Ectopic thyroid tissue in the head and neck J Otolaryngology. 1986 15(1):52-55. [4] Gibson J R and Noblett H R Suprahyoid median ectopic thyroid Aust Paediatric J 1977. 13:49-52. 69 CONFIDENTIAL REPORTING SYSTEM IN SURGERY 70 This issue of Feedback contains cases which, once again, highlight the need for appropriate preoperative checks. The problem of lack of familiarity with new equipment is a perennial cause for concern. Always ensure that you know how the equipment you intend to use works, that the necessary components are present and functional and that you’ve practised using the new equipment BEFORE encountering your patient. We are grateful to the clinicians who have provided the material for these reports. The on-line reporting form is on our website www.coress.org.uk which also includes all previous Feedback Reports. Published contributions will be acknowledged by a “Certificate of Contribution” which may be included in the contributor’s record of continuing professional development. FLAMING (N)ECK An elderly patient was admitted for day case surgery to excise a lipoma from the back of her neck under local anaesthesia. The patient was placed prone, the operation site was cleaned with an alcohol-based skin preparation and draped. The patient was given mild sedation and oxygen through nasal cannulae. It appears that the disinfectant solution had collected in the patient’s hair because, when diathermy was applied to cauterise a small wound edge bleeding point, the patient’s head was suddenly engulfed in flames. The fire was rapidly extinguished but left small burns to one ear and loss of a large portion of hair. Reporter’s Comments: Several factors contributed to this incident. A flammable skin preparation was used and the presence of residual alcohol after cleaning went unrecognised. Accumulation of oxygen from the nasal cannulae beneath the drapes may have acted as an accelerant. The diathermy spark acted as an ignition source. Always be vigilant to the risk of surgical fires, particularly when operating on head or neck or in areas where a skin preparation solution may pool. CORESS Comments: All alcohol preparations are flammable. Even lower concentrations of alcohol containing solution (eg. (Ref: 96) povidone-iodine containing 30% alcohol) carry a moderate flammability risk with a documented flash point of 34°C [1]. There should be no hazard if alcoholic preparations are used correctly: • The amount used should be adequate to keep the site wet for the recommended time. • Sufficient time must be allowed for alcohol-based skin preparations to dry thoroughly before commencing the procedure, to ensure that all combustible ingredients have evaporated. • The preparation should be allowed to evaporate completely before electrocautery, diathermy or laser instruments are switched on. • Pooling of excess liquid below the patient, or in cavities or bodily contours, should not be allowed to occur. Reference [1] Recommendations for Surgical Skin Antisepsis in Operating Theatres. Centre for Healthcare Related Infection Surveillance & Prevention (CHRISP), Queensland Health, August 2009 http://www.health.qld.gov.au/chrisp/resources/rec_prac_skinprep.pdf CONSECUTIVE CHOLECYSTECTOMIES? A middle-aged female patient was referred to the outpatient clinic with a history of intermittent right upper quadrant pain and the report of an ultrasound scan, performed at a local community hospital, which described a contracted gallbladder with multiple gallstones. She gave a past history of appendicectomy and laparoscopic hernia repair, both performed more than 10 years previously. She was booked for elective laparoscopic cholecystectomy and seen in the preassessment clinic which elicited the same history of previous surgical procedures. On the morning of her surgery, she underwent informed consent for laparoscopic cholecystectomy when the procedure to remove her gall bladder was explained to her. At laparoscopy, adhesions around the gallbladder fossa were found and, when these were taken down, she was found to have no gallbladder. A second opinion was sought from a hepatobiliary surgeon, who confirmed the findings. After surgery, a frank discussion took place with the patient and it transpired that the patient had previously had “an operation on her gallstones”, but thought that she still had a gallbladder. (Ref: 99) She made an uncomplicated recovery and went home. A critical incident form was completed. Reporter’s Comments: An incomplete past medical history was obtained from this patient, perhaps because of her lack of understanding of previous treatment, and this was compounded by an erroneous ultrasound report, leading to inappropriate surgery. CORESS Comments: An ultrasound is best interpreted as a dynamic investigation. Without the scan itself, many surgeons would accept a report from an ultrasonographer known to them. However, an ultrasound scan is relatively cheap and easy to repeat. Surgeons should maintain a high index of suspicion and a repeat scan should have been undertaken pre-operatively in any circumstances of doubt. A check of the date of the ultrasound report was essential since the reported scan may have preceded the patient’s previous surgery. Finally, if the patient had been given a copy of the discharge summary following previous surgery, this might have helped to resolve her (and the surgeon’s) confusion about past procedures. MISSING KIT MISHAP (Ref: 95) Reporter’s Comments: This occurred pre-WHO checks which, if then in existence, might have saved the day. Always ask the rep to bring TWO of everything – there is always the possibility of stapler failure, dropping the handle on the floor, de-sterilisation, etc. CORESS Comments: This case is one of several, recently received by CORESS, in which operative delays have occurred because vital equipment was missing. ALWAYS check, yourself, that the correct equipment is present, that the parts match and can be assembled and, preferably, that a spare is available. Particularly when using new equipment, make sure you are familiar with its operation and assembly of component parts. If possible, practice using the equipment in a simulated setting first. TRACHEOSTOMY CONFUSION A tracheostomised patient, with no available previous medical records, was admitted requiring urgent abdominal surgery. The patient was only able to give a limited verbal history to the on-call anaesthetists. The patient was handed over to a new on-call team before surgery, and a trainee re-assessed the patient in the anaesthetic room. On hearing the patient speak, the doctor assumed the upper airway was patent and pre-oxygenation was attempted via a face mask. It became rapidly apparent there was no oropharyngeal communication with the trachea, and that the patient had a tracheostomy tube sitting in an end-tracheal stoma, with an indwelling tracheo-oesophageal valve permitting speech. Anaesthesia and ventilation were delivered via the tracheostomy, and the rest of the procedure was undertaken uneventfully. Reporter’s Comments: With improving outcomes from chemo and radiotherapy and organ preserving surgery, patients with laryngectomies are seen less frequently. Tracheostomy care is increasingly delivered by specialist nurses and, (Ref: 97) as a result, junior doctors gain little experience in tracheostomy management. CORESS Comments: Some tracheostomised patients may still have a patent upper airway, permitting delivery of gases, and occasionally intubation, but this must never be assumed. Most laryngectomy patients will have a visible permanent stoma in the neck, but some wear a bib, external oneway valve, or retain a tube to prevent stomal closure. Many laryngectomy patients have indwelling tracheooesophageal valves allowing them to produce oral speech, therefore the ability of the patient to speak must not be taken as a sign of upper airway patency. This case highlights, once again, the importance of good handover communications, appropriate use of preoperative checks. CPR training should include the care of tracheostomised patients, and all doctors should be aware of the principles of safe management for such patients. URETHRAL BALLOON INFLATION DURING URINARY CATHETERISATION An elderly male with known prostate cancer, in addition to colonic cancer with liver metastases, developed urinary retention and was referred to hospital where a Foundation Year 1 doctor performed urethral catheterisation. Catheterisation was painful and the balloon of the catheter was inflated although no back flow of urine was obtained. The doctor left the ward with instructions to contact her in 2 hours time if no urine had passed. After two hours, no urine had passed and the patient began passing frank blood and clots. The catheter balloon had been inflated in his prostatic urethra causing trauma. Urological assistance was obtained and the catheter inserted into his bladder with drainage of urine prior to inflating the balloon. The next day the patient had passed 2500ml of frank haematuria, and the bleeding continued. The patient had abnormal clotting secondary to his liver metastases. After consultation with the haematologist, the patient was treated with fresh frozen plasma 15ml/kg and vitamin K 10mg IV for 3 days. Following this, the haematuria ceased and the patient was discharged to palliative care. CONFIDENTIAL REPORTING SYSTEM IN SURGERY I was performing a laparoscopic gastric bypass on a male patient with a BMI of 54, and had arranged with a surgical instrument company representative to try out a new circular stapling head for gastro-enteric anastomosis. Everything was going smoothly and I had placed the new circular stapling head, when I asked the representative for the laparoscopic handle portion of the stapler to complete the anastomosis. A silence ensued, the rep went pale, and I felt that trickle of perspiration between the shoulder blades when she told me she had only brought the standard handle, which did not match the head. I waited in vain whilst efforts were made to obtain another handle, but eventually converted to a hand-sewn anastomosis. A post-operative leak occurred (inevitably) and the patient developed a wound infection, but survived. Eventually, to his satisfaction (and his surgeon’s relief!), he began to lose weight. (Ref: 100) Reporter’s Comments: The admitting doctor continued to catheterise the patient despite the procedure being painful, and did not seek help. The catheter balloon was inflated before flash back of urine was seen, causing trauma in the prostatic urethra. Despite the patient being in painful urinary retention, the doctor left the patient, before seeing any urine to drain from the catheter. CORESS Comments: Prostatic disease may render catheterisation difficult. However, in the event of significant pain or difficulty introducing a urinary catheter, attempts at catheterisation should cease and expert help should be obtained. Care should always be taken to avoid inflating the catheter balloon unless this is in the bladder. Failure to pass urine via the catheter, in a patient with urinary retention, should have alerted the practitioner in this case to the fact that the catheter was inappropriately sited. Always measure and document residual urine volumes ensuring that the output fits the clinical picture. FINALLY ……. The Medicines and Healthcare products Regulatory Agency (MHRA) receives many reports of incidents involving infusion pumps. These incidents are of concern, as many result in patient harm or death, primarily from over-infusions. MHRA have recently released a revised Device Bulletin on Infusion Systems which can be found at: http://www.mhra.gov.uk/Publications/Safetyguidance/DeviceBulletins/CON007321 This publication has been updated to take into account changes in devices and practices, as well as information gained from the investigation of adverse incidents and current trends in the use of infusion systems. CORESS is an independent Registered Charity (number: 1134175) and a company, limited by guarantee, incorporated in England and Wales (number: 6935638). CORESS is grateful to ASGBI for publishing this feedback. 71 THE BACK PAGE To celebrate the end of the Association’s 90th Anniversary year, we are pleased to enclose a complimentary limited-edition drinks coaster with this edition of the Newsletter. We hope that this will be a colourful and useful addition to your desk! The Association’s Executive Board, Council and Staff extend their seasonal greetings, and very best wishes for the New Year, to all our readers! Association of Surgeons of Great Britain and Ireland 35-43 Lincoln’s Inn Fields, London, WC2A 3PE Tel: 020 7973 0300 Fax: 020 7430 9235 www.asgbi.org.uk A Company limited by guarantee, registered in England 06783090 Printed on recycled paper 72 The opinions expressed in this Newsletter are those of the individual authors, and do not necessarily reflect the policy of the Association of Surgeons of Great Britain and Ireland