Continuing surgical education

Jonothan J Earnshaw DM FRCS

Theophilus TK Anyomih, Antonio Ramos De La Medina, Laura Martinez

Emma Sewart, Kitty H. F. Wong

The recent submission of the Tobacco and Vapes Bill to parliament has shone a spotlight on British public health legislation. If passed, anyone born after 2009 will be banned from buying tobacco products. Despite the success of other public health policies in reducing smoking over the past 20 years, tobacco remains the leading cause of premature, preventable death in the UK and worldwide, killing about half of lifelong smokers.1 Smoking is particularly common among surgical patients, reported in up to 50% of trauma patients in North America.2 In Britain, approximately 25% of patients admitted to hospital under surgical specialties currently smoke, compared to 13% of the general population.3,4 Worryingly, the prevalence appears to be rising in some cohorts, such as vascular surgery, and is as high as 33% in those undergoing lower limb bypass surgery.5 This may reflect increased risk of surgical pathology in smokers, but nonetheless highlights an opportunity to improve surgical health outcomes and to reach a population that seems more resistant to the available community-based smoking cessation interventions. As the demand for surgical care increases globally, and surgical populations become older and increasingly comorbid, there is an urgent need to optimise perioperative care pathways. For many patients, this now involves a preoperative assessment clinic and access to prehabilitation. The Royal College of Anaesthetists Centre for Perioperative Care (CPOC) has identified smoking cessation as one of seven key perioperative interventions to improve efficiency and tackle waiting lists, but cessation support services are often poorly integrated into current pathways.6 Substantial geographical and socioeconomic variation in smoking prevalence also represents a clear quality improvement target.5

Dhananjaya Sharma, MBBS, MS, PhD, DSc, FRCS, FCLS (Hon), FRCST (Hon)

1. Preferably write about the solution rather than the challenge: Global Surgery (GS) is all about finding affordable solutions to challenges in resource-constrained situations. The challenges (the famous 5S – staff, stuff, space, systems and support) are well known and the editors are more likely to publish a paper which provides a solution rather than the one which dwells upon the challenges. The significance of such a research project and the benefits associated cannot be emphasized enough.1,2 Focusing on addressing knowledge plus evidence gaps in access to surgical care, surgical capacity building, epidemiology of surgical conditions, health economics of surgery, quality and safety in surgery, surgical innovation, surgical education and training, and health systems strengthening is crucial for making meaningful contributions.  Paraphrasing U.S. President Abraham Lincoln’s famous Gettysburg Address: any research ‘by the people, for the people and with the people’ cannot go wrong and will always provide value.3,4

Fabio Stocco, Jing Yi Kwan, Marc A. Bailey, Patrick A. Coughlin

The incidence of peripheral arterial disease (PAD) has risen dramatically, and it is estimated to affect around 200 million people worldwide. This rise can be explained by an ageing population, persisting high rates of tobacco smoking and the increasing incidence of diabetes mellitus (DM).1,2 Chronic limb-threatening ischaemia (CLTI) is the most severe manifestation of PAD and is characterized by rest pain and/or tissue loss (e.g. ulceration or gangrene).1 It is estimated that CLTI affects about 10% of all patients with PAD.3 Figure 1. Typical critical ischaemia of the left foot. Patients with CLTI are at high risk of major limb amputation (MLA) and major adverse cardiovascular events (MACE – myocardial infarction and stroke)1 with a significant reduction in life expectancy. Overall mortality rates are similar to that of advanced cancers.3 They also commonly experience poor quality of life.

Zahra Ahmed, Alexander Zargaran, Matthew Harris, Angela Lam, Christian Asher, Allan Ponniah, Ali Esmaeili, Afshin Mosahebi

Short BJS Course – Part 4 of 4 Frank McDermott, Consultant Colorectal Surgeon and Editor, BJS Open. Part 1 of 4 can be viewed here:

Adesoji O. Ademuyiwa, Maria Picciochi

Kristine Hagelsteen, MD PhD, Chris Mathieu

Barbara Seeliger MD, PhD, FACS, Alexandros Karargyris PhD, Didier Mutter MD, PhD, FACS, FRSM

Daniel Ansari, Roland Andersson

Despite major advances in modern medicine, pancreatic cancer remains for the most part a death sentence. If we are to change the trajectory of pancreatic cancer, early diagnosis is probably the most effective tool at hand. Patients diagnosed with pancreatic cancer at an early stage have the best chance of curative treatment and long-term survival. For example, localized cancer confined to the pancreas has a 5-year survival rate of 42%1. Once the disease has spread to regional structures or lymph nodes, the 5-year survival drops to 14% and only 3% of those diagnosed with distant metastases survive beyond 5 years. However, developing early detection methods for pancreatic cancer remains an elusive task and still today, only around 13% of patients have their tumour detected at a localized stage. The striking difference in survival between early- and late stage tumours has spawned decades-long efforts to find biomarkers that will enable earlier detection of pancreatic cancer. The US National Institutes of Health (NIH) defines a biomarker as “a characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacologic responses to a therapeutic intervention.”2 Carbohydrate antigen 19-9 (CA 19-9), discovered in 19793, is the only FDA-approved serum biomarker for pancreatic cancer. CA 19-9 has a sensitivity of 79-81% and specificity of 82-90%4. However, CA 19-9 has a limited sensitivity in early-stage disease. False positive values may occur in patients with benign biliary obstruction and several inflammatory conditions in the pancreas and hepatobiliary system. Furthermore, approximately 5-10% of the general population are Lewis antigen negative and lack the enzyme necessary to produce CA 19-9, leading to potentially false negative results. For these reasons, CA 19-9 cannot be used for screening purposes and the indication is mainly restricted to treatment monitoring. The recent revolution in genomic, transcriptomic, proteomic and metabolomic technologies have contributed to the discovery of thousands of potential biomarker candidates for pancreatic cancer. These biomarkers are measurable in blood as liquid biopsies and have been evaluated either as single markers or as multimarker combinations, including protein panels5, 6, metabolites7, autoantibodies to tumour antigens8, 9, exosomes10, microRNAs11, nucleosomes12, circulating tumour cells13 and circulating tumour DNA14-16. Despite initial promise, no investigational biomarker has yet entered routine clinical practice. The question remains: Why do so many initially promising biomarkers fail to reach the clinic?