Continuing surgical education

Jonothan Earnshaw, Directory of BJS Academy, delivers his talk ‘Future of scientific surgical publication’. A reprise of his presentation at the Association of Surgeons of Great Britain and Ireland (ASGBI)’s 2024 Annual Meeting.

Ville Sallinen

Ville Sallinen, Editor-in-chief of BJS Open, gives an ACTA lecture on How to write a scientific surgical manuscript and be published' at the Swedish Surgical Society's 2024 Kirurgveckan.

Matti Tolonen, MD, PhD, presents his BJS Lecture “Emergency general surgery model and acute mesenteric ischaemia – pathway” from the 2024 Association of Surgeons of Great Britain and Ireland (ASGBI) International Surgical Congress.

Sian Farrell presents her BJS Prize winning lecture “Tumour targeted oxygen-generating nanoparticles for enhanced radiotherapy in the treatment of pancreatic cancer” from the 2024 Association of Surgeons of Great Britain and Ireland (ASGBI) International Surgical Congress.

Lucia Sobrinoa, Marta Climent, Clara Santanach, Sebastiano Biondo

Diverticular disease is a common disorder, and recent guidelines report on new treatment strategies such as non-antibiotic management. Patients with diverticular disease are increasingly being treated as outpatients. In addition, fewer patients are undergoing emergency surgery whereas there is an increase in the use of elective and laparoscopic surgery in the management of diverticulitis. However, several aspects are still controversial. Strong evidence still lacks for the therapeutic management of patients with recurrent episodes of acute diverticulitis or patients with persistent abdominal symptoms after acute attacks. The European Society of Coloproctology (ESCP) guideline committee reviewed the literature and developed the European guidelines for the management of diverticular disease of the colon in 2020. In spite of the existence of several different classifications for diverticulitis, the committee decided neither to create another classification nor to endorse any of the existing ones. Nevertheless, phlegmonous diverticulitis, considered as uncomplicated by most of the classifications, is a matter of concern since it includes about 70% of the patients with acute diverticulitis. This group of patients may be clinically heterogeneous in terms of characteristics or disease evolution, which in some cases might be complicated. Patients at risk that belong to initially uncomplicated stage need to be identified in order to prevent complications and receive the most appropriate medical/surgical treatment. Classically, colonic resection after the second episode of acute diverticulitis has been supported, since any following episodes will respond insufficiently to medical treatment and with higher morbidity and mortality2. Recently, it was reported that 6.8-27.7%3,4 of patients with acute diverticulitis treated conservatively may require surgical intervention due to complicated diverticulitis or persistent symptoms, most of them during the first year of follow-up. In addition, elective sigmoidectomy seems to be related with a better quality of life (QOL) compared with conservative management in patients with recurring diverticulitis and/or ongoing complaints5,6. Nowadays, the main reason to perform elective sigmoid colectomy (Fig 1) in patients with recurrent disease or with ongoing symptoms after an acute episode of diverticulitis is to improve their QOL. In fact, there are many patients in whom initial antibiotic treatment fails, leading to sub-acute / chronic diverticulitis. In these patients the differentiation between sub-acute ongoing diverticulitis which never resolved, i.e.  persisting disease, and a true recurrence is very difficult7. Chronic diverticulitis (Fig 1), considered as a true condition for the first time by the ESCP group, occurs when there is colonic wall thickening or chronic inflammation of the mucosa1. It can appear when an acute diverticulitis does not resolve completely, and it can have an important impact on QOL of the patients, causing persistent abdominal symptoms (abdominal pain, bloating) and changes in bowel habit. However, the uncertainty of the evolution of the disease and the lack of clear signs to identify which patients will develop a chronic condition, make the selection of patients and the best moment to advise surgical resection difficult. Colonic resection has been shown to effectively reduce the number of recurrences, but it should be kept in mind that it is a major surgery with potential severe complications1. The distinction between Irritable Bowel Syndrome (IBS) and symptoms related to chronic diverticulitis after an episode of diverticulitis is of utmost importance, because IBS is a functional disorder and should not be treated surgically8. Endoscopy could help in those cases where differential diagnosis is difficult5. It should be noted that after sigmoidectomy, 25% of patients persist with functional symptoms and abdominal pain9.

Olle Ljungqvist, Ulf Gustafsson, Hans D.  de Boer

ERAS so far It is more than 25 years ago that a multimodal approach to recovery after major surgery, called fast track surgery, was first proposed1,2.  Combined with laparoscopic surgery it showed that old and frail patients were fit to leave the hospital in two days after major surgery3. Larger follow up studies reported that this could be achieved with fast track surgery alone. This inspired a group of surgeons from Northern Europe to form the Enhanced Recovery After Surgery (ERAS) Study Group in 20014. The members hypothesized that bringing together all potential stress reducing and recovery improving care elements into one program, would enhance recovery after surgery. The first ERAS protocol was published in 20055. But alongside the guideline there was a need to also organize care in a new way to make ERAS fully functioning6 (Table 1). When the guideline was tested a clear relationship was shown with more care elements in the protocol in use and improved outcomes regarding both complications, length of stay and readmissions suggesting that detailed audit would be key7-9.

Short BJS Course – Part 1 of 4 Martyn Evans, Course Lead and Editor, BJS

Omar Yusef Kudsi, MD, MBA, FACS

Introduction With multiple advantages over laparoscopic and open surgery, including stereovision, enhanced precision and dexterity, surgeons are transitioning to robotic surgery. Practicing robotic surgeons praise the platform’s improved ergonomics and camera control, advantages that are worth the challenge of overcoming the steep learning curve. Thus, robotics is becoming the cornerstone for advancing the field of minimally invasive surgery. An obvious pattern in the diffusion of cutting-edge technologies is that it starts with one manufacturer – Intuitive Surgical has currently near complete dominance of the robotic surgery market. However, in the future, new robotic platforms will become available. Here we discuss the advantages and challenges with robotic surgery.

Matthew J Lee

Hernia repair is a common component of the general surgery curriculum, and with good reason. Surgeons will be aware that acute presentations of hernia account for a significant proportion of emergency work. With challenges in accessing routine care in recent years, it is likely that the rate of acute presentations will increase in the near future1. What are the issues Acute hernia can be a high-morbidity condition. Risk of mortality ranges from 1.7% in older large datasets2, 5-6% in modern cohorts3,4, and up to 11% in a hernia causing small bowel obstruction5. These numbers mask some of the heterogeneity in the underlying population. A fit young adult with an incarcerated umbilical hernia containing fat should have a low mortality. The frail, elderly patient with an obstructed or strangulated femoral hernia might not be expected to fare as well6.

Short BJS Course – Part 2 of 4 Ville Sallinen, Editor-in-Chief, BJS Open

Short BJS Course – Part 3 of 4 Malin Sund, Editor, BJS Surgical publishing is an important part of core surgical training; every surgeon should know how to get their papers published.

Short BJS Course – Part 4 of 4 Des Winter, Editor-in-Chief, BJS

Dr Agnes Arnold-Forster

Military metaphors The place (and some of the problem) of resilience in surgery lies in its origins in the profession’s long historical association with the military. In the nineteenth century, members of the medical professions exploited and elaborated, as historian Michael Brown has put it, “visions of masculinity framed by war, heroism, and self-sacrifice.”1 Clinical practice was conceptualised as a form of warfare against a malevolent enemy and military metaphors were used to refer both to the activities of germs, gangrene, and cancerous tumours, and to the actions of surgeons and physicians. The military metaphor worked on multiple levels. Surgeons were waging war against damage, disability, and disease – inanimate, if deadly foes. Surgeons were also increasingly seen as part of a society-wide conflict between life and death, cures and killers, progress and stagnation. In 1900, Surgeon-Extraordinary to Queen Victoria, Frederick Treves, spoke at the annual meeting of the British Medical Association. His address entitled, ‘The surgeon in the nineteenth century,’ concluded with a flourish, reflecting on the future of surgeon in a passage suffused with military language: “So as one great surgeon after another drops out of the ranks, his place is rapidly and imperceptibly filled, and the advancing line goes on with still the same solid and unbroken front.”2  

Martin Almquist, Frédéric Triponez, Carolyn D. Seib

Graves’ disease (GD) is an autoimmune disease in which thyroid receptor stimulating antibodies cause the thyroid to overproduce thyroid hormone, leading to hyperthyroidism. Untreated hyperthyroidism can lead to adverse clinical outcomes, including severe hypertension, cardiac arrhythmias and death. Graves’ disease is named after the Irish surgeon Robert James Graves, who was the first to identify the hallmark clinical features of GD, which include symptoms of hyperthyroidism associated with a diffuse goitre, thyroid eye disease, and pretibial myxoedema. Public figures with GD include the British Comedian Marty Feldman, singer-songwriter Missy Elliott, former U.S. president George H.W. Bush and his wife, former first lady Barbara Bush. Marty Feldman, Missy Elliot, and Barbara Bush all had thyroid eye disease or Graves’ ophthalmopathy, which occurs in up to 25% of patients with GD.1,2 Graves’ ophthalmopathy is caused by autoantibody stimulation of orbital fibroblasts and adipocytes, which leads to inflammation due to cell proliferation and the local accumulation of glycosaminoglycans.3 Guidelines by the European Thyroid Association (ETA), the American Thyroid Association (ATA) and the American Association of Endocrine Surgeons (AAES) state that antithyroid drugs , radioiodine ablation (RAI), and thyroidectomy are treatment options for GD.4-6 The administration of drugs, most commonly methimazole, results in remission in approximately 50% of patients with GD, but is associated with adverse events including pruritic rash, agranulocytosis, and hepatotoxicity.7, 8 Given the majority of adverse events occur early in the medical treatment of GD, long-term treatment is safe and may lead to higher rates of remission.9,10 The ETA and ATA recommend total thyroidectomy for GD with ophthalmopathy, large goitres, co-existing primary hyperparathyroidism, suspected or proven thyroid cancer, and current or planned pregnancy.4,5. Relative contraindications include significant patient comorbidity and/or limited life expectancy, prior neck surgery and/or irradiation.4

Rebecca Winterborn

I have often wondered why as Consultant Surgeons we do not have coaches. Professional sportspeople, singers and even high-end executives receive coaching throughout their careers. Why is it that we think as surgeons we magically become competent and stay competent? Why do we still follow a model of pedagogy, where there is a presumption that, following a period of teaching, after a certain point, instruction is no longer needed. ‘You’re cooked’ and you can go the rest of the way yourself, with a reliance on continuing personal development. Back in 2011, Atul Gawande authored an article in The New Yorker entitled Personal Best1. He noted that within 10 years of completing his surgical training he had reached a plateau. His rate of complications steadily lowered to better than average and there they stayed. It felt to him like the only direction they could go, was backwards. He reflected that his outcomes were not necessarily about his evolving practical skills but more about familiarity and judgment. Would coaching help to maintain his outcomes, in the same way that coaching helps to maintain Rafa Nadal’s outcomes playing tennis. He enlisted the support of a retired colleague who observed him in theatre and offered advice and coaching. He noted that his complication rates started to reduce again as he applied the insights.

Eider Talavera-Urquijo, MD PhD, Bas P. L. Wijnhoven, MD PhD

Introduction Oesophageal cancer ranks seventh in terms of incidence and sixth in mortality overall, being responsible for one in every 18 cancer deaths in 2020 worldwide1. There are two main histological types: squamous cell carcinoma and adenocarcinoma. The overall 5-year survival of patients diagnosed with oesophageal cancer is approximately 15%2. Apart from some areas in Asia, there is no screening programme worldwide. Hence, patients often present with advanced disease stage and cure is seldom possible. Some 50-60% of patients can be offered treatment with curative intent including surgical and non-surgical modalities3. Disease stage, patient’s fitness/frailty and expertise of the multidisciplinary team guide decision making.  Anatomy of the oesophagus (figure 1)

Mr Aneel Bhangu NIHR Clinician Scientist in Global Surgery University Hospitals Birmingham, UK

Patricia Tejedor, M.D., Ph.D., EBSQ Col.

Knowledge of the basics and fundamentals is essential to understand the potential benefits and risks of Artificial Intelligence (AI). AI refers to the field of science aiming to provide machines with the capacity of replicate human cognitive functions such as reasoning, learning from experience and self-correction. AI means enabling computers do things that would require intelligence if done by humans. The term AI was first mentioned by Claude Shannon and Nathan Rochester, two scientists from IBM, at Dartmouth Conference in 1956 (New Hampshire, USA). They presented a computer able to solve problems and learn to speak English, and predicted a completely intelligent machine would be available in the next 20 years. We are not there yet, but AI has already been incorporated into many areas such as renewable energy systems, weather prediction, manufacturing and, of course, medicine. AI eliminates human error, so in medicine it is expected to reduce the number of misdiagnoses, errors in treatment etc. AI can easily maintain up-to-date medical information from journals and textbooks, and put it into practice for patient care. Another advantage of AI is its speed, reducing the time needed to perform a task.

Andrew Bradbury

I have been asked to offer some thoughts on what the BASIL-2 trial may mean following publication of the headline results in the Lancet on 25 April 2023. The journey to BASIL-2 started around 25 years ago when I was a Senior Lecturer in Vascular Surgery at Edinburgh University, Scotland, and was fortunate enough to be awarded an NIHR HTA grant for the first BASIL, now known as the BASIL-1, trial. In the late 1990’s, the idea that one could treat chronic limb-threatening ischaemia (CLTI), in those days called CLI or SIL (critical limb ischaemia or severe ischaemia of the leg), other than by means of bypass using either vein or prosthetic conduit was considered extremely controversial. There were real concerns that the endovascular management of CLTI was being adopted in the absence of good evidence that it was a clinically and cost effective treatment option. And that is why NIHR HTA put out a call for an RCT in this area of practice. We ran BASIL-1, first in Scotland, and then when I moved to Birmingham in 2000, across most of the UK between 1999 and 2004. In BASIL-1, a bypass first and a plain balloon angioplasty first revascularisation strategy resulted in similar amputation free survival out to 2 years. However, in patients who survived for two years, randomisation to bypass first was associated with significant improvement in overall survival and a trend towards improved amputation free survival. About 25% of the bypasses were prosthetic, which reflected practice at that time. Around 75% of the patients in BASIL-1 had a revascularisation that was limited to the femoro-popliteal segment. A post-hoc, sub-group analysis of approximately 100 BASIL-1 patients that had an infra-popliteal, with or without a femoro-popliteal, revascularisation also showed a trend in favour of (vein) bypass surgery.

BJS Academy

Recording of BJS Academy Strategic Partner webinar: Overcoming adversity as a surgeon from October 2022. Chair: Jonothan Earnshaw. Panel: Christine Hall, Rebecca Winterborn, Derek Alderson and Agnes Arnold-Forster.

Ameera J M S AlHasan

Opportunities, functions and three wise monkeys Originally designed to mimic human intelligence, it now seems clear that artificial intelligence (AI) can surpass human performance in many domains. In surgery, the practical application of AI is still very limited. However, the technology is advancing at an exponential pace, and it is only a matter of time before it is adopted into routine use both at the bedside and in the operating theatre. In order to realize where AI will be most useful in surgery, opportunities for its application must be identified. An opportunity is where there is a problem or a difficulty that AI can help solve. Such opportunities are dictated by either the situation at hand or the innately human limitations of the surgeon (Figure 1). Situations that pose challenges are those that harbour uncertainty, tedium or risky outcomes at their core. These include clinical decision-making, prediction modelling1, documenting and searching electronic health records, and performing challenging tasks such as constructing a standard airtight anastamosis. Surgeons are human beings whose performance is subject to anatomical and physiological limitations, such as limited sensory perception (vision), motor function (reach, precision, or speed), and fatigue. AI driven automata, such as surgical robotics, are designed with the objective of overcoming some of these limitations. Where a situation is most challenging and the abilities of the surgeon are most limited is the exact point where AI should provide maximum benefit.

Nicolas Padoy

Dileep N. Lobo, MB BS, MS, DM, FRCS, FACS, FRCPE
Professor of Gastrointestinal Surgery Nottingham Digestive Diseases Centre and
National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham
University Hospitals and University of Nottingham,
Queen’s Medical Centre, Nottingham, UK

Andrew J. P. Lewington, BSc, MB BS, MA (Ed), MD, FRCP
Consultant Renal Physician/Honorary Clinical Associate Professor
Leeds Teaching Hospitals,
Leeds, UK

Simon P. Allison, MD, FRCP
Formerly Consultant Physician/Professor in Clinical Nutrition
Nottingham University Hospitals,
Queen’s Medical Centre, Nottingham, UK

Download Part 1 BJS Academy is delighted to host the second edition of the textbook ‘basic concepts of fluid and electrolyte therapy’, by Lobo, Lewington and Allison. The authors have kindly divided the book into four easily digestible sections, and then some multiple choice questions at the end.

Julio Mayol

Introduction The industrial revolution, which brought about significant changes in manufacturing, transportation, and communication, is slowly fading into the past. In its place, digitization is advancing with unprecedented determination, generating massive amounts of data in the form of 0s and 1s. Technology has made it possible to accumulate endless strings of bytes that help us represent, explain, and even predict reality with varying degrees of accuracy. Surgery is one sector that will be greatly affected by this unstoppable process. The hope is that digital technology and data analysis will make procedures more precise and accurate, leading to better patient outcomes. But there are few success stories in our field because the digital transformation of surgery is not just about technology, it is a new culture. Surgeons need to learn how to collect and use data in a good and ethical way to solve complex problems and unmet needs.