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Image-guided ablation for liver tumours – an addition to the armamentarium of multidisciplinary oncological and surgical approaches
Petter Frühling MD, PhD, Barbara Seeliger, MD, PhD, Ana Karla Uribe Rivera, MD, Jacob Freedman, MD, PhD, Mariano Giménez, MD, PhD
The treatment of primary and metastatic liver tumours by ablation is not new. Advances in guidance systems, image fusion and new concepts of 3D tumour localisation and treatment, together with the current concepts of computer-assisted surgery that augment the senses (image-guided surgery), cognition (artificial intelligence), and execution (robotics), have enabled a fundamental change in the concept of ablation and have shaped image-guided ablation, also called precision ablation or Ablation 2.01. These changes have improved accuracy and in many cases made the oncological outcomes of ablation equal to those of surgical resection. Indications for ablation therapies in liver tumours Treatment options for colorectal liver metastases (CRLM) and hepatocellular carcinoma (HCC) include a combination of surgery, local ablation, and chemotherapy. For HCC, ablation is part of the treatment guidelines, such as the Barcelona Clinic Liver Cancer (BCLC) classification2, 3 and the ESMO (European Society for Medical Oncology) clinical practice guidelines4. It is used for smaller tumours and in patients with advanced cirrhosis, where resection may be more difficult3, 5. Liver resection is considered the gold standard for CRLM6-8. Recently, however, the COLLISION Trial Group presented a treatment algorithm for patients with CRLM without extrahepatic disease, recommending ablation for deeply situated metastases and unresectable metastases smaller than 3 cm7.
Widening participation in cardiothoracic healthcare: INSINC Insight
Kirstie Kirkley, Georgia R. Layton, Javeria Tariq, Heen Shamaz, Mostin Hu, Alana Atkinson, Deborah Harrington, Elizabeth Belcher, Jason Ali, Narain Moorjani, Farah Bhatti, Karen Booth
Equality, diversity and inclusion (EDI) within surgery is important.1 The recent Kennedy Review on Diversity and Inclusion, commissioned by the Royal College of Surgeons of England, made 16 recommendations to improve EDI in the surgical workforce.2 Cardiothoracic surgery in the UK lacks diversity, exemplified with only 13% of the consultant workforce being female, despite females accounting for 49% of UK doctors.3 One method of improving EDI in the specialty, is to focus on widening participation (WP) activities.
In the UK, WP activities and government policies aim to increase representation of lower socio-economic groups in higher education. Published schemes focus on peer-to-peer mentorship from medical to school students. The King’s College London scheme is a monthly seminar series offered to WP school students, publishing a 50% success rate of translation to successful application to medical school.4
Resident selection in surgery
Kristine Hagelsteen, MD PhD, Chris Mathieu
There is a global interest in and growing knowledge about how best to select residents in surgery. In 2010, Paice et al claimed that selection was “the missing link in patient safety work”1. The starting point for collegial discussions on the matter and opinions about selection are things we know and have experience of; and we know that there is a spectrum running from excellent to unsuitable surgeons. Some continue to ask, are surgeons “born or made”, i.e., is it innate talent, or their training that matters? Is competence-based education better than the apprenticeship model?2,3. Further, it is well-established that all facets of competence matter for patient outcomes, not only technical skill4-6. The detrimental effect a less competent or even dysfunctional colleague can have on patients and the workplace environment is also widely recognised7. Attrition from surgical residency programs has been reported to be up to 20%, reflecting bad investments of resources8. Another challenge is that surgery accounts for most adverse events in health care, and that up to 15 % of patients in elective surgery suffer a treatment-related injury9,10. We all want the next generation to be better than us. Selection is thus a foundational factor in raising the standard level of treatment and care, reducing adverse events, improving workplace collaboration and heightening the reputation of the profession.
Some characteristics have been found important for surgeons to be successful, such as having a strong academic background and commitment to lifelong learning; possessing sufficient manual dexterity and fine motor skills to reach proficiency; displaying emotional stability; extroversion and conscientiousness; good communication skills and ability to work in teams; critical thinking ability; situational awareness; robust decision-making and problem-solving skills11-14. A more recent addition to the list is “technical orientation”, i.e. willingness and ability to work in a technology-based environment15.
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