"Learning from the experts" - a novel advanced cadaveric course for Gynaecological Oncology (GO) Cytoreductive Surgery.

Background: Ovarian cancer cytoreductive surgery necessitates the use of advanced Simulation-Based Learning (SBL) to optimise skill-based teaching and achieve technical proficiency. Objective: We describe and appraise the role of a novel postgraduate cadaveric course for cytoreductive surgery for advanced ovarian/fallopian tube or primary peritoneal cancer. Materials and Methods: Several consultant-level surgeons with expertise in upper gastrointestinal, colorectal, hepatobiliary and urological surgery, were invited to teach their counterpart gynaecological oncology (GO) surgeons. The 2-day course curriculum involved advanced dissections on thiel-embalmed cadavers. All dissections included applicable steps required during GO cytoreductive surgeries. Outcome measures: We used a feedback questionnaire and structured interviews to capture trainers and delegates views respectively. Results: All delegates reported a positive educational experience and improvement of knowledge in all course components. There was no difference in the perception of feedback across junior versus senior consultants. Trainers perceived this opportunity as a "2-way learning" whether they got to explore in depth the GO perspective in how and which of their skills are applicable during cytoreductive surgery. Conclusions: Collaborating with other surgical specialities promotes a "learning from the experts" concept and has potential to meet the rapidly increased demand for multi-viscera surgical excellence in GO surgery. What's new?: The concept of involving experts from other surgical disciplines in advanced cadaveric courses for cytoreductive surgery in ovarian cancer, will solidify the effort to achieve excellence in the GO training. Such courses can be essential educational adjunct for most GO fellowships.

The impact of COVID-19 on obstetrics and gynaecology trainees; how do we move on?

BACKGROUND: Obstetrics and Gynaecology (O&G) is an evolving specialty that encompasses women's health at its core. The COVID-19 pandemic has caused significant patient care challenges, however simultaneously it has resulted in the interruption of clinical training and cessation of all elective work. Our primary aim was to assess the impact of the pandemic on the experiences of O&G trainees. METHODS: An email invite was sent to all 127 O&G trainees in Kent, Surrey and Sussex (KSS), inviting them to participate in an anonymous 33-question survey. The survey data was collected and analysed over a 4-week period. RESULTS: Of the 127 trainees sent the survey, 87 responded (69%). 39% and 75% of trainees agreed that the pandemic had a negative impact on their overall physical and mental wellbeing respectively. 43% agreed that the COVID-19 pandemic had adversely affected their obstetric training experience whilst almost all trainees stated a significant negative impact on benign gynaecology surgical training. Reassuringly, over 80% were positive they would recover from the negative impacts of COVID-19. CONCLUSIONS: It is evident that COVID-19 has impacted O&G trainees in several ways. Whilst we face uncertain times, we must firstly ensure the physical and mental well-being of all trainees. It is encouraging that non-emergency consultations and benign surgery are being restarted nationwide and whilst this will inevitably help with re-booting surgical training, we must also think "outside" the box and utilise other modes of teaching and training to safeguard learning whilst mitigating against the negative impacts of subsequent waves.

Caesarean section in women following an abdominal myomectomy: a choice or a need?

Delivery options following both open and laparoscopic myomectomy remains a controversial topic and opinions vary between obstetricians and gynaecologists. The historical advice of planned caesarean section before 39-weeks persists despite the movement towards the minimal access approach for myomectomy. The main concern remains the small, but potentially catastrophic risk of uterine rupture. Unfortunately, there remains a paucity of data assessing factors that can affect the uterine integrity following laparoscopic myomectomy, such as number, size and type of fibroids, uterine cavity breach and electro-cautery usage. Despite this, the cited 1% overall risk of rupture following myomectomy is similar to the quoted risk following trial of labour after caesarean section, and a successful and safe vaginal delivery can be achieved in as high as 90%. Patient choice and informed consent are essential in the holistic approach to managing these women and safely supporting their delivery choices.

Elderly patients have more infectious complications following laparoscopic colorectal cancer surgery.

AIM: Elderly patients may be at higher risk of postoperative complications, particularly infective, than younger patients. METHOD: We prospectively followed 163 consecutive patients undergoing elective laparoscopic resection for cancer. We compared patients < 65, 65-80 and > 80 years of age at the time of surgery. RESULTS: Seventy (42.9%) patients had no complication; 93 (57.1%) had at least one complication following surgery and in 20 (12.3%) this was major. There was no difference in major complications between the groups (P = 0.47). Patients over 65 years of age were more likely to have a complication of any severity [< 65 years, 39.3%; 65-80 years, 69.3%; and > 80 years, 63.0% (P = 0.002)]. The frequency of gastrointestinal complications (30.1%) was similar in the groups (P = 0.29), as was wound infection (25.2%) (P = 0.65). There was an increase in the frequency of infectious complications, especially chest infection, with age, from 14.8% in patients < 65 years, to 22.7% in patients 65-80 years, to 44.4% in patients > 80 years (P = 0.01). Multivariate analysis showed no increase in overall complications in elderly patients, but Stage II or Stage III cancer (OR = 2.59, P = 0.04) and increasing body mass index (BMI) (OR = 1.07 for each unit increase in BMI, P = 0.04) were related to complications. Age remained the only predictor of an infective complication on multivariate analysis. Patients > 80 years of age had 4.21 times the OR of an infective complication (P = 0.03). CONCLUSION: Older patients are more susceptible to infective complications postoperatively, particularly chest complications. Surgeons should alter their practice to reduce morbidity, such as adopting protocols requiring early physiotherapy.

Endoscopic transgastric procedures in anesthetized pigs: technical challenges, complications, and survival.

BACKGROUND AND STUDY AIMS: An incisionless endoscopic peroral transgastric approach to the peritoneal cavity has shown promise in animals as a potentially less invasive form of surgery. We present our experience with various endoscopic peroral transgastric procedures, reporting on the technical aspects and challenges that arose. MATERIALS AND METHODS: The following procedures were performed in 10 anesthetized pigs using a double-channel endoscope: peritoneoscopy (10 pigs), liver biopsy (one pig), cholecystectomy (six pigs), fallopian tube excision (one pig), and hysterectomy (one pig). RESULTS: All the procedures were accomplished successfully. There were six minor intraoperative complications. Complete gastric cleansing and elimination of all bacteria was found to be impossible to achieve in the porcine model. Overinflation was a common problem. The lack of adequate endoscope support was a major limitation. Safe closure of the gastrotomy incision was difficult using the available clipping devices. Six pigs made an uncomplicated recovery after a follow-up period of 4-6 weeks. Subsequent pathological examination revealed deep gastric ulceration in one animal and a gastric wall abscess in another. CONCLUSIONS: Peroral transgastric surgery is technically feasible and safe in a porcine model. Although all the procedures were performed successfully, the study highlights some technical difficulties and illustrates the need for major technical innovations and extensive animal studies in order to evaluate the merits of incisionless surgery.

Cloning and characterization of a novel human histone deacetylase, HDAC8.

Histone deacetylases (HDACs) are a growing family of enzymes implicated in transcriptional regulation by affecting the acetylation state of core histones in the nucleus of cells. HDACs are known to have key roles in the regulation of cell proliferation [Brehm, Miska, McCance, Reid, Bannister and Kouzarides (1998) Nature (London) 391, 597-600], and aberrant recruitment of an HDAC complex has been shown to be a key step in the mechanism of cell transformation in acute promyelocytic leukaemia [Grignani, De Matteis, Nervi, Tomassoni, Gelmetti, Cioce, Fanelli, Ruthardt, Ferrara, Zamir et al. (1998) Nature (London) 391, 815-818; Lin, Nagy, Inoue, Shao, Miller and Evans (1998), Nature (London) 391, 811-814]. Here we present the complete nucleotide sequence of a cDNA clone, termed HDAC8, that encodes a protein product with similarity to the RPD3 class (I) of HDACs. The predicted 377-residue HDAC8 product contains a shorter C-terminal extension relative to other members of its class. After expression in two cell systems, immunopurified HDAC8 is shown to possess trichostatin A- and sodium butyrate-inhibitable HDAC activity on histone H4 peptide substrates as well as on core histones. Expression profiling reveals the expression of HDAC8 to various degrees in every tissue tested and also in several tumour lines. Mutation of two adjacent histidine residues within the predicted active site severely decreases activity, confirming these residues as important for HDAC8 enzyme activity. Finally, linkage analysis after radiation hybrid mapping has localized HDAC8 to chromosomal position Xq21.2-Xq21.3. These results confirm HDAC8 as a new member of the HDAC family.