In-house colorectal laparoscopic preceptorship: a model for changing a unit's practice safely and efficiently.

PURPOSE: There has been steady increase in demand for laparoscopic colonic resection as benefits are manifold compared to open and include smaller incisions, less pain, quicker recovery and convalescence, reduced morbidity and reduced analgesic demands. We devised a preceptorship programme with the aim of all four coloproctologists in our unit becoming proficient colorectal laparoscopic surgeons over a period of 12 months. METHOD: The surgeon in the unit with significant experience of laparoscopic colorectal surgery acted as a preceptor to the remaining three. A prospective database was set up to allow analysis of the impact of the preceptorship on the units' elective practice and outcomes from January 2006. RESULTS: Results were analysed 106 cases to assess the success of this novel method and were more than encouraging. During this period, 57 laparoscopic resections were performed compared 49 open resections. The proportion of patients undergoing laparoscopic resection had risen from 20% to 80% (p = 0.000). This was associated with a significant drop in post-operative stay from 14 to 4 days (p = 0.000). Analysis of patient demographics, pathology and type of resection found there to be no significant difference between the open and laparoscopic groups. The conversion rate was acceptably low (10.5%) and there were no re-admissions. CONCLUSIONS: For hospitals with the facilities and an appropriately experienced preceptor, we offer this as a patient-safe, cost-neutral method of significantly increasing a units' laparoscopic practice over a relatively short period of time.

Carcinoma of the body of pancreas in evolution: an aggressive disease affecting younger patients?

CONTEXT: Pancreatic body carcinoma has a poor prognosis with advanced disease at presentation. Recent experience at multidisciplinary team (MDT) meetings suggests increasing prevalence. OBJECTIVE: Our aim was to determine if introduction of MDT meetings has affected the natural history of this disease. DESIGN: Retrospective diagnostic and survival data were collected from 1995 to 2006 at two large teaching hospitals, and divided into pre- and post 2003 groups (based on MDT introduction). PARTICIPANTS: Thirty-one patients with pancreatic body carcinoma (median age at diagnosis 72 years; range 43-87 years). RESULTS: Commonest symptoms at presentation were abdominal pain and weight loss. Eight patients (25.8%) were diagnosed pre MDT (median age 71.5 years, range: 60-87 years) and 23 patients (74.2%) were diagnosed post MDT (median age 67 years, range: 43-85 years; P=0.299 vs. pre MDT). There was a significantly (P=0.024) greater prevalence of more advanced tumours post MDT (stage IV: 15/23, 65.2%) than pre MDT (stage IV: 2/8, 25.0%). Neither tumour markers nor liver biochemistry differentiated tumour stage. Best supportive care was offered to 16 patients (51.6%) while 12 patients (38.7%) were suitable for chemotherapy: 2 out of 8 pre MDT (25.0%) and 10 out of 23 (43.5%) post MDT (P=0.433). For stage III tumours, post MDT patients tended to be younger (median 59 years vs. 74.5 years, P=0.042). Survival was not significantly increased after MDT introduction but chemotherapy offered significant survival benefit on multivariate analysis (P=0.042; hazard ratio: 0.39, 95% CI: 0.16-0.97). CONCLUSION: The trend is towards increased prevalence of pancreatic body cancer and more advanced disease at presentation. Chemotherapy was associated with a survival benefit, although the introduction of the MDT has not significantly altered disease management.