Upper gastrointestinal training in the UK and Ireland: a Roux Group Study.

INTRODUCTION: Surgical training programmes in the United Kingdom and Ireland (UK&I) are in a state of flux. This study aims to report the contemporary opinions of trainee and consultant surgeons on the current upper gastrointestinal (UGI) training model in the UK&I. METHODS: A questionnaire was developed and distributed via national UGI societies. Questions pertained to demographics, current training evaluation, perceived requirements and availability. RESULTS: A total of 241 responses were received with representation from all UK&I postgraduate training regions. The biggest discrepancies between rotation demand and national availability related to advanced/therapeutic endoscopy and robotic surgery, with 91.7% of respondents stating they would welcome greater geographical flexibility in training. The median suggested academic targets were 3-5 publications (trainee vs consultant <3 vs 3-5, p<0.001); <3 presentations (<3 vs 3-5, p=0.002); and 3-5 audits/quality improvement projects (<3 vs 3-5, p<0.001). Current operative requirements were considered achievable (87.6%) but inadequate for day one consultant practice (74.7%). Reassuringly, 76.3% deemed there was role for on-the-job operative training following consultant appointment. Proficiency in diagnostic endoscopy was considered a minimum requirement for Certificate of Completion of Training (CCT) yet the majority regarded therapeutic endoscopy competency as non-essential. The median numbers of index UGI operations suggested were comparable with the current curriculum requirements. Post-CCT fellowships were not considered necessary; however, the majority (73.6%) recognised their advantage. CONCLUSIONS: Current CCT requirements are largely consistent with the opinions of the UGI community. Areas for improvement include flexibility in geographical working and increasing national provisions for high-quality endoscopy training.

Immunohistochemical hENT1 expression as a prognostic biomarker in patients with resected pancreatic ductal adenocarcinoma undergoing adjuvant gemcitabine-based chemotherapy.

BACKGROUND: Human equilibrative nucleoside transporters (hENTs) are transmembranous proteins that facilitate the uptake of nucleosides and nucleoside analogues, such as gemcitabine, into the cell. The abundance of hENT1 transporters in resected pancreatic ductal adenocarcinoma (PDAC) might make hENT1 a potential biomarker of response to adjuvant chemotherapy. The aim of this study was to see whether hENT1 expression, as determined by immunohistochemistry, was a suitable predictive marker for subsequent treatment with gemcitabine-based adjuvant chemotherapy. METHODS: A systematic review was performed, searching databases from January 1997 to January 2016. Articles pertaining to hENT1 immunohistochemical analysis in resected PDAC specimens from patients who subsequently underwent adjuvant gemcitabine-based chemotherapy were identified. Eligible studies were required to contain survival data, reporting specifically overall survival (OS) and disease-free survival (DFS) with associated hazard ratios (HRs) stratified by hENT1 status. RESULTS: Of 42 articles reviewed, eight were suitable for review, with seven selected for quantitative meta-analysis. The total number of patients included in the meta-analysis was 770 (405 hENT1-negative, 365 hENT1-positive). Immunohistochemically detected hENT1 expression was significantly associated with both prolonged DFS (HR 0·58, 95 per cent c.i. 0·42 to 0·79) and OS (HR 0·52, 0·38 to 0·72) in patients receiving adjuvant gemcitabine but not those having fluoropyrimidine-based adjuvant therapy. CONCLUSION: Expression of hENT1 is a suitable prognostic biomarker in patients undergoing adjuvant gemcitabine-based chemotherapy.

Role of staging laparoscopy in the stratification of patients with perihilar cholangiocarcinoma.

BACKGROUND: Cholangiocarcinoma is a rare cancer with a poor prognosis. Radical surgical resection is the only option for curative treatment. Optimal determination of resectability is required so that patients can be stratified into operative or chemotherapeutic treatment cohorts in an accurate and time-efficient manner. Staging laparoscopy is utilized to determine the presence of radiologically occult disease that would preclude further surgical treatment. The aim of this study was to analyse the utility of staging laparoscopy in a contemporary cohort of patients with perihilar cholangiocarcinoma. METHODS: Patients diagnosed with potentially resectable perihilar cholangiocarcinoma between January 2010 and April 2015 were analysed retrospectively from a prospective database linked to UK Hospital Episode Statistics data. Patients with distal cholangiocarcinoma and gallbladder cancer were excluded from analysis. RESULTS: A total of 431 patients with perihilar cholangiocarcinoma were referred for assessment of potential resection at a supraregional referral centre. Some 116 patients with potentially resectable disease subsequently underwent surgical assessment. The cohort demonstrated an all-cause yield of staging laparoscopy for unresectable disease of 27·2 per cent (31 of 114). The sensitivity for detection of peritoneal disease was 71 per cent (15 of 21; P < 0·001). The accuracy for all-cause non-resection for staging laparoscopy was 66 per cent (31 of 47) with a positive predictive value of progress to resection of 81 per cent (69 of 85). Neither the Bismuth-Corlette nor the Memorial Sloan Kettering Cancer Center preoperative scoring system was contingent with cause of unresectability at staging laparoscopy (P = 0·462 and P = 0·280 respectively). CONCLUSION: In the present cohort, staging laparoscopy proved useful in determining the presence of radiologically occult metastatic disease in perihilar cholangiocarcinoma.

Academic requirements for Certificate of Completion of Training in surgical training: Consensus recommendations from the Association of Surgeons in Training/National Research Collaborative Consensus Group.

BACKGROUND: Surgical trainees are expected to demonstrate academic achievement in order to obtain their certificate of completion of training (CCT). These standards are set by the Joint Committee on Surgical Training (JCST) and specialty advisory committees (SAC). The standards are not equivalent across all surgical specialties and recognise different achievements as evidence. They do not recognise changes in models of research and focus on outcomes rather than process. The Association of Surgeons in Training (ASiT) and National Research Collaborative (NRC) set out to develop progressive, consistent and flexible evidence set for academic requirements at CCT. METHODS: A modified-Delphi approach was used. An expert group consisting of representatives from the ASiT and the NRC undertook iterative review of a document proposing changes to requirements. This was circulated amongst wider stakeholders. After ten iterations, an open meeting was held to discuss these proposals. Voting on statements was performed using a 5-point Likert Scale. Each statement was voted on twice, with ≥80% of votes in agreement meaning the statement was approved. The results of this vote were used to propose core and optional academic requirements for CCT. RESULTS: Online discussion concluded after ten rounds. At the consensus meeting, statements were voted on by 25 delegates from across surgical specialties and training-grades. The group strongly favoured acquisition of 'Good Clinical Practice' training and research methodology training as CCT requirements. The group agreed that higher degrees, publications in any author position (including collaborative authorship), recruiting patients to a study or multicentre audit and presentation at a national or international meeting could be used as evidence for the purpose of CCT. The group agreed on two essential 'core' requirements (GCP and methodology training) and two of a menu of four 'additional' requirements (publication with any authorship position, presentation, recruitment of patients to a multicentre study and completion of a higher degree), which should be completed in order to attain CCT. CONCLUSION: This approach has engaged stakeholders to produce a progressive set of academic requirements for CCT, which are applicable across surgical specialties. Flexibility in requirements whilst retaining a high standard of evidence is desirable.

Temporary coverage of burns with a xenograft and sequential excision, compared with total early excision and autograft.

During the 80s and 90s, early and total excision of full thickness burns followed by immediate autograft was the most common treatment, with repeated excision and grafting, mostly for failed grafts. It was hypothesized, therefore, that delayed coverage with an autograft preceded by a temporary xenograft after early and sequential smaller excisions would lead to a better wound bed with fewer failed grafts, a smaller donor site, and possibly also a shorter duration of stay in hospital. We carried out a case control study with retrospective analysis from our National Burn Centre registry for the period 1997-2011. Patients who had been managed with early total excision and autograft were compared with those who had had sequential smaller excisions covered with temporary xenografts until the burn was ready for the final autograft. The sequential excision and xenograft group (n=42) required one-third fewer autografts than patients in the total excision and autograft group (n=45), who needed more than one operation (p<0.001). We could not detect any differences in duration of stay in hospital / total body surface area burned% (duration of stay/TBSA%) (2.0 and 1.8) (p=0.83). The two groups showed no major differences in terms of adjusted duration of stay, but our findings suggest that doing early, smaller, sequential excisions using a xenograft for temporary cover can result in shorter operating times, saving us the trouble of making big excisions. However, costs tended to be higher when the burns were > 25% TBSA.

Pendant ces dernières décades, l'excision précoce et totale des brûlures profondes, suivie immédiatement d'autogreffe a constitué le traitement le plus habituel avec souvent, en cas d'échec, des excisions répétées et de nouvelles greffes. Nous avons pensé, cependant, que la couverture par autogreffe retardée, précédée par une couverture temporaire par xénogreffe après des excisions itératives et moins larges permettait d'obtenir un meilleur lit receveur avec moins d'échecs, des sites donneurs plus petits et une durée d'hospitalisation moindre. Nous avons ainsi mené une étude analytique rétrospective dans notre Centre National de Brûlés pendant la période 1997-2011. Les patients qui avaient été traités par une excision précoce totale suivie d'autogreffe ont été comparés à ceux qui avaient eu des petites excisions séquentielles, couvertes de façon temporaire par des xénogreffes jusqu'à ce que la brûlure soit prête pour une autogreffe finale. Le groupe excision séquentielle et xénogreffe (n=42) a nécessité un tiers de moins d'autogreffes que les patients qui avaient une excision totale suivie d'autogreffe (n=45) et plus d'une seule opération (p<0001). Nous n'avons pas remarqué de différence dans la durée d'hospitalisation en fonction de l'étendue de la surface brûlée (durée du séjour TBSA%) (2,0 et 1,8) (p=0,83). Les deux groupes n'ont pas montré de différence majeure en terme de durée d'hospitalisation, mais l'excision précoce, limitée et séquentielle avec une xénogreffe temporaire, permet de réduire le temps opératoire et évite les excisions trop généreuses. Cependant les coûts ont tendance à être plus élevés avec les brûlures de 25% ou plus de TBSA.

The feasibility of spinal anesthesia with sedation for laparoscopic general abdominal procedures in moderate risk patients.

BACKGROUND: One of the major advantages of laparoscopic surgery is minimizing postoperative morbidity. The previous limitations to the use of spinal anesthesia in laparoscopic surgery were the limited work space, high failure rate, more intra-operative morbidity and significant arterial blood gas alterations. However, the addition of a small-dose Ketamine infusion to propofol might provide a suitable sedative combination to be used with high spinal anesthesia, producing titerable sedation, increased hemodynamic stability, and minimal respiratory depression. PATIENTS AND METHODS: At KFSH & RC Hospital, after Ethical Committee approval and informed written consent, 18 ASA III patients scheduled for various laparoscopic abdominal procedures were enrolled. Exclusion criteria consisted of ejection fraction below 45% and or peak expiratory flow rate and forced vital capacity of less than 65% of predicted values. Following oral premedication with midazolam 7.5-10 mg 30 min preoperatively, spinal anesthesia was conducted by bupivicaine 0.75% 3-3.5 ml at L3-4, in the lateral position to reach a sensory level at T4. Sedation was started by intravenous injection of 0.4 mg/kg propofol and 0.1 mg/kg ketamine prior to spinal anesthesia. This was followed by infusion of 1.0-1.5 mg/kg/h and 0.3-1.0 mg/kg/h. of the same drugs respectively. The sedation requirements were adjusted to keep the patient sleepy with conservation of airway reflexes at level 3 on a 5 point sedation score. Heart rate, respiratory rate and SpO2 were monitored, together with direct arterial blood pressure monitoring and arterial blood gas analysis through arterial cannulation. Postoperative first time call for analgesia, total morphine consumption during the first hour and incidence of complications were recorded. Twenty Four hours later, surgeons' and patients' satisfaction were obtained and recorded. RESULTS: Heart rate and mean arterial blood pressure were significantly decreased after spinal anesthesia and intra-peritoneal insufflations of CO2, with significant increase in arterial carbon dioxide tension accompanied by increase in the respiratory rate. The increase in respiratory rate led to gradual decrease of CO2 level down to near the pre-operative PaCO2 values. However, there was insignificant decrease in oxygen saturation throughout the intra-operative time. Postoperatively there were excellent surgeon and patient's satisfaction. Only one patient regained sensation before completion of surgery and sedation was deepened to level 5 sedation score. The mean surgical time was 98.5 +/- 21.4 min while the mean anesthesia time was 117.7 +/- 20.1 min. First mean time call for analgesia was 50 +/- 8 min. 7/18 patients required single dose of morphine of 4 mg during the 1st hour postoperatively. CONCLUSIONS: The addition of a sedative combination of ketamine and propofol to spinal anesthesia was found to be safe and efficient from both the anesthetic and surgical point of view, especially for sick patients with intermediate clinical predictors.

Sequential effects of prostaglandins and interferon-gamma on differentiation of CD8+ suppressor cells.

We have previously demonstrated that differentiation of CD8+ Tp44- suppressor cells in pokeweed mitogen (PWM)-stimulated cultures requires soluble factors elaborated by CD4+ cells and monocytes, and that the monocyte signal for such differentiation can be replaced by prostaglandin E2 (PGE2). In this study, we explored the ability of interleukin 2 (IL 2) and interferon-gamma (IFN-gamma) to replace the CD4+ signal. When IL 2 or IFN-gamma was used at concentrations equivalent to those present in supernatants of PWM-pulsed cultures of CD4+ cells, no effect on differentiation of CD8+ cells was observed. However, a potent suppressor inducing activity was detected when IFN-gamma, but not IL 2, was mixed with supernatants derived from cultures of PWM-pulsed purified monocytes (M phi sup) or with 10(-8) M PGE2. Differentiated CD8+ suppressor cells (Ts) inhibited both PWM-stimulated proliferative response of CD4+ cells and immunoglobulin production by B cells. The signals mediated by the M phi sup or PGE2 and IFN-gamma were shown to act sequentially. That is, M phi sup or PGE2 was required initially, followed by an IFN-gamma-dependent differentiative step. These studies thus suggest a cascade of cellular interactions involving monocytes, CD4+ cells, and CD8+ Ts precursors that are required for the differentiation of CD8+ suppressor effector cells.