30 July 2019

The Association of Coloproctology of Great Britain and Ireland (ACPGBI) South Africa 2019 traveling fellowship involves an invitation through the South African Colorectal Society (SACRS) to colorectal fellows and young consultants to apply for a 1 month observership in the United Kingdom and to attend the ACPGBI 2019 congress in Dublin (1-3 July 2019).

My report as the ACPGBI 2019 Traveling fellow includes the following subsections:

• Objectives
• ACPGBI 2019 Council Dinner
• ACPGBI 2019 Congress
• St Vincent’s University Hospital Colorectal Surgery Unit visit
  • Social Events
  • Dublin: The culture, the people and the city
• Nottingham University Hospital Colorectal Surgery Unit visit
  • England: The culture, the people and the city
• Overall experience
• Acknowledgements

Objectives of my fellowship 

1. Attend the ACPGBI 2019 Congress. This will be my first international congress
2. Attend the Endoanal Ultrasound Course organized by The Pelvic Floor Society of ACPGBI
3. To explore the multidisciplinary team approach at St Vincent’s University Hospital and Nottingham University Hospital. The observe the role of the dietician, stomatherapist, nurse practitioners, physiotherapist, biofeedback, social workers
4. To observe how Enhanced Recovery After Surgery (ERAS) principles are utilised at these centres
5. To participate in multidisciplinary team meetings with radiology
6. The management of Inflammatory bowel disease: Ulcerative Colitis and Crohn’s disease
7. The management of colorectal cancer especially cancer screening. There is no national screening program in South Africa
8. I wanted to be exposed to new techniques, equipment and surgical skills and tricks especially in laparoscopic surgery and minimally invasive surgery. To be exposed to instruments and devices that could improve surgical outcomes, time efficiency and ergonomics in theatre.
9. I wanted to be exposed to new techniques, equipment and advanced skills in endoscopy
10. An approach to proctology
11. An approach to female related diseases: Obstetric Anal Sphincter Injuries; Pelvic floor disorders; Obstructive defecation Syndrome; Fecal Incontinence
12. To observe the setup of the endoscopy suites and patient safety systems in place
13. To observe how other universities and surgical departments carry out research
14. Establish an international network and build relationships with leading colorectal surgeons
15. This was my first visit to Europe. I would like to go sightseeing in both Ireland and England. To learn about the cities, food, culture and the people.

Council Dinner It was a great privilege to receive a formal invitation to the Council dinner, which was held at The Merrion Hotel in Dublin. Mr Brendan Moran who was the current ACPGBI President and Mr Charles Maxwell Armstrong, the Honorary Secretary had introduced me to many renowned leaders in Coloproctology. During the dinner, I was fascinating to meet the authors of the articles that I had read during my surgical gastroenterology fellowship training in South Africa. I was fortunate to be seated at a table with Professor Bill Heald, the pioneer in the Total Mesorectal Excision (TME) whose oncological principles were a major game changer in rectal cancer surgery and outcomes thereof. It was an absolute delight to converse with him about his visit to South Africa and that he had performed a TME many years ago at Chris Hani Baragwanath Hospital which is a tertiary level hospital that I work at. His name is still fondly mentioned in our surgical department. I had the pleasure of sitting next to Professor John Northover, a Past-President of ACPGBI who was not only excellent company with fascinating dinner table conversation topics but also a renowned leader in Coloproctology. He told me of his visit to South Africa where he had investigated and developed techniques in bile duct anastomoses for liver transplants. I also had an insightful chat with Ms. Nicola Fearnhead, who is the current ACPGBI President. She described to me what it was like to be a female Coloproctologist in the UK and her predominant interest is advanced colorectal cancers. I met other international ACPGBI traveling fellows and it was interesting to hear about their training program and experiences. The Congress The ACPGBI 2019 Congress was held at the Dublin Convention Centre 1-3 July 2019. This was my first international Congress and had catered for a variety of interests and there were multiple sessions, talks, discussion and activities. Day 1 Emergency Surgery Session I enjoyed this session and must comment that back home in South Africa we have a variety of fellowships; and subspeciality care is predominant at the main academic centres; however South Africa still has areas where general surgeons are catering to the population and have to perform a variety of emergency operations. Sub specialist consultants at the major centres in South Africa are also involved in performing emergency operations, especially when there is a staff shortage. The Dukes’ Club Symposium  I was fascinated by 3D reconstruction and printing used for complex perianal fistulae, pelvic exenteration and CME. The technology allows for better delineation of anatomy, teaching of trainees and in the process of explaining disease pathologies to patients and obtaining informed consent. I enjoyed the session on “Illuminating Fluorescence Colorectal Surgery” by Prof Jayne & Prof Cahill who described the use of this real time technique to determine if pathology was malignant vs benign. Lastly, the pendulum has swung back to mechanical bowel preparation and oral antibiotics and the discussions including the challenges of this approach were highlighted including concerns of antibiotic resistance and risk of clostridium difficile infection. Inflammatory bowel disease session The new IBD UK Standards 2019 where highlighted and these statements will be valuable in my clinical practice in South Africa. Speed dating This activity was an eye opener to what the world has to offer. The consultants from various academic hospitals described what fellowship programs they ran. The laparoscopic and robotic surgery fellowships were fascinating. Day 1 ended at 7pm with drinks at the welcome reception in the exhibition area. I chose to attend the reception as I wanted to interact with the unit heads and consultants and part take in the exhibitions so that I could learn about new equipment and instruments. Day 2  The Endoanal Ultrasound Course The course was organized by The Pelvic Floor Society of ACPGBI and was run by Professor Williams. The first session outlined the ultrasound machine and how it works and applied anatomy and was followed by a practical exercise using the machine to view the anatomical landmarks and observe the anatomical variations in men and women. The second session was an approach to obstetric anal sphincter injuries, first outlined definitions, applied anatomy followed by a practical exercise of various obstetric anal sphincter injuries. The third session was an approach to perianal fistula/e and had outlined the differences of simple and complex fistula/e in terms of definitions, classifications and applied anatomy and was followed by a practical exercise utilizing the endoanal sonar machine to evaluate various fistula/e. My application Having attended this course, I have developed an approach to its use in the diagnosis and management of obstetric anal sphincter injuries and perianal fistula/e which are both common conditions in South Africa. Not only will I now be able to perform an endoanal ultrasound correctly with the view to diagnosis and treat; I will also be able to teach other trainees and doctors. The course has also assisted me with an approach to interpretation of the results of the endoanal sonar. Fellows’ Presentations The fellows’ presentations highlighted training and education. Dr David’s presented her paper entitled: “Female Representation and Implicit Gender Bias at the 2017 American Society of Colon and Rectal Surgeons' Annual Scientific and Tripartite Meeting.” which was published in Diseases of Colon and Rectum 2019. The themes outlined included implicit bias resulting in gender inequity and that female surgeons were under-represented in senior and leadership roles. In the paper female surgeons were less likely to be moderators or named speakers. Additionally, it found that their full names and titles are were not announced in a formal manner as compared to when male surgeons were introduced. There was a bias on topics presented, woman surgeons presented predominantly on education and male surgeons on robotic surgery and new techniques. The implications of this were in order to improve gender equity; awareness was needed. This will not only foster a culture where women will be included but also mutual respect and inclusiveness will be achieved professionally and academically. This will allow for talented female surgeons to be recruited and integrated in an academic environment. This will translate in the patients having a better team of healthcare providers caring for them. This made me realize that internationally gender equity was being looked into and this was evident in the availability of a dedicated breastfeeding room. But what was important was that there was a live feed in the room and one could continue to listen to speakers and learn during child care. My application I am currently chairing the University of Witswatersrand Department of Surgery Gender Equity Committee and acknowledge that these lesson learned should be implemented back home. The first step for us is awareness which will result in change in the immediate future. I am grateful to have been exposed to this session and it will assist our department in moving forward. Day 3 The role of faecal Immunochemical test as a screening tool was discussed and its implementation in various screening programmed throughout Europe. My application In South Africa, there is no national screening program for colorectal cancer. The considerations discussed will be valuable in my clinical practice and the progression to development of a national screening program. The Dukes’ Club Annual Lecture A stunning insight into those who train the future coloproctologists and the origins of the Dukes’ Club. Brilliant discussion on the use of social media particularly Podcasts and Twitter as learning tools. An insight into the Libby Zion Law which led to regulation of the working hours for trainees was shared. This was an important change for the safety of patients and doctors alike. However surgical training is a hands on discipline and skill is learnt from a surgical consultant in mentor-mentee relationship. On the flip side of the argument; time restrictions affect continuity of care and the number of procedures the trainee is exposed to otherwise known as the volume effect which is important during training. My Visit to St Vincent’s University Hospital Colorectal Surgery Unit I was warmly welcomed to St Vincent’s University Hospital by Professor Ronan O’Connell. He gave me a grand tour of the hospital and introduced me to the members of his Colorectal Surgery Unit. I also had an opportunity to see St Vincent’s Private Hospital on the grand tour. Multidisciplinary team meetings I joined the grand rounds and ward multidisciplinary team meeting which included nurses, social workers, dietician and stomatherapist who were all crucial in the management of the patients. The senior registrar presented the cases and the consultants Prof O’Connell and Mr Sean Martin has expanded on the management plan of the patients. I was fortunate to join a combined radiology meeting where various subspeciality patients were discussed in a multidisciplinary team meeting. The Inflammatory bowel disease clinic was interesting and the cases were complex requiring consultant level of care. Theatre I was fortunate to observe the following cases in theatre • Laparoscopic extended right hemicolectomy with ligasure o 2 cases for malignancy • Reversal of Hartman’s using circular stapler • Open Sigmoid colectomy - patient with cirrhosis and portal hypertension • Laparoscopic Ileal pouch anal anastomoses for a patient with Crohn’s disease Many years ago, at a Surgical Research Society Congress in South Africa I had listened to a presentation on the use of an anaesthetic induction room and whether it was efficient in time saving and increase the number of cases. I was fortunate to observe the use of the induction room at St Vincent’s University Hospital and how it saved time especially for the preparation of cases requiring the placement of central lines and arterial lines. The surgical team completed the first case whilst the anaesthetic induction commenced in the dedicated room and on completion of the first case, theatre was cleaned and the surgical team was able to start with the second case timeously. Endoscopy  I was privileged to observe Professor Ronan O’Connell perform his last colonoscopies  to be performed at St University Hospital before retiring. I observed a few of his tricks and was amazed by the polyp catcher, I never knew that one existed. It was interesting to listen how Processor O’Connell counselled his patients and obtained informed consent. I also observed the setup of the endoscopy suite, how the scopes were cleaned and the recovery area. I paid attention to how the quality indicators were followed and observed how the team maintained patient safety. Patient education and counselling I was amazed by the patient information desk which was manned an oncology trained nurse practitioner to answer a variety of cancer related questions including prevention, screening, what to expect with surgery, how to prepare for surgery and recovery, symptoms relating to the cancer itself and the treatments, chemotherapy and radiotherapy. There were many pamphlets and books that patients could take home and read at their leisure and a computer with internet access for them to use at this wish to research their cancer related questions. This is such a fantastic service and provides comprehensive care for patients. This was a first of kind for me. The nurse practitioners who offer this service play a critical role in the comprehensive care of oncology patients and will be valuable in South Africa. Similarly these booklets in the 11 official languages of South Africa would be beneficial to oncology patients. Social Events I was invited by Professor Ronan O’Connell to join his end of term dinner at Milltown Golf Club. I had a chance to discuss the training program with the fellow, Dr Emma Carrington and different operative techniques and patient management with the medical officers and consultants over delicious food in a beautiful venue. What more could anyone ask for. Dublin: The culture, the people and the city Dublin is the capital of the Republic of Ireland and is located on the east coast. The people were friendly and spoke both English and Gaelic. The city had an efficient public transport system where one could hop on the Dublin bus or the Luas electric train and travel to the city centre. I took full advantage of the easy accessibility and visited the National Gallery of Ireland, Dublin Castle, Trinity College and went shopping in the city. I did search for a four leaf clover as a wanted to have a souvenir of Irish luck to keep; but the four leaf clover is rarity. There was a strong culture to cycle as a means of transportation. It was bike week when I visited St Vincent’s University Hospital and there were campaigns promoting cycling to work. The health benefits were described and that there was a tax incentive to cycle to work. This was an excellent example of health promotion. Throughout the city, there were many cyclists and areas to park your bicycle as well as places where one could hire a bicycle from. Over the weekend, I travelled to the West Coast of Ireland and saw the Cliffs of Moher which was one of the most beautiful sight I have ever seen. I also travelled to The Burren which was equally beautiful and went shopping in the busy, bustling town of Galway. My Visit to Nottingham University Hospital Colorectal Surgery Unit The Nottingham University Hospital Complex is managed by the National Health Service Trust in England and composes of three centres: Queen’s Medical Centre, Nottingham City Hospital and Ropewalk House. I visited Queen’s Medical Centre in Nottingham; where I was warmly welcomed by Professor Charles Maxwell Armstrong who gave me a grand tour of the hospital including the Accident and Emergency Unit, surgical wards, theatre complex and Nottingham University. There is a dedicated bus that travels between Queen’s Medical Centre and Nottingham City Hospital. I went for a ride on the bus as I needed to go to Human Resources and was amazed to see how having a dedicated bus route with wheelchair facilities improves access to healthcare. Some of the stops along the way at the Nottingham City Hospital were the radiotherapy centre, the Day Surgery unit and the Endoscopy unit. Imagine you could hop on after having your scopes and be taken straight back home, as we are all aware that one may not drive post sedation. Unit activities and meetings I attended the Monday academic meeting; where the weekend’s admissions and in-patients were discussed and weekly rosters and planning was carried out. This had opened the many doors and I could select the activities of interest and theatre cases I would like to observe. Multidisciplinary team meeting I also attended an Inflammatory bowel disease multidisciplinary team meeting consisted of surgeons(Dr Neena Randhawa, Dr Austin Acheson and Dr Kathryn Thomas) medical gastroenterologists, radiologists, pathologist, IBD nurses, surgical trainees and medical students. We reviewed the imaging and pathology sides and this assisted with the decision making and further management of the patients. I also attended the combined oncology meeting where the management of complex oncology patients were discussed. Theatre I found that theatre attire differed from South Africa. The staff wore different coloured hats; the surgeons wore blue ones, the nurse in charge theatre wore a yellow one, and visitors wore white caps. This allows for staff members to be easily identified in an emergency, staff members can be quickly identified and called to assist. When I entered theatre, I was surprised to find out that were no blue theatre overshoes. Instead, the staff wear theatre shoes. Additionally, during laparoscopic surgery, the surgeons did not wear masks, I was surprised to see this. Prior to stating the list, the team which consisted of the surgeons, anaesthetist and nurses did a “briefing” were the cases of the day were discussed. Surgical and anaesthetic concerns were highlighted including anticipated needs, positioning, surgical access either open or laparoscopic and which incisions, pain management intraoperatively and post operatively and post-operative care. I liked the format of this discussion. At the end of the list, a debriefing about the team’s performance and any issues was carried out. The induction room was also utilized by the anaesthetic team and was valuable in saving time. Theatre cases

• Laparoscopic incisional hernia repair with Composite mesh. Noted the sterile plastic drape used over the camera cable to the machine.

• Reversal of ileostomy.

• Laparoscopic lower anterior resection using hook as main dissecting instrument.

• Laparoscopic left hemicolectomy converted to open for poor ventilation. Mr Ayan Banerjea had pointed out that it is important to identify challenges early especially those that prevent failure to progress laparoscopically and convert early instead of having the patient under prolonged anaesthesia.

• Laparoscopic proctectomy for a 53 year old female who previously had a subtotal colectomy for acute severe ulcerative colitis.

• Extended Right hemicolectomy - Single incision laparoscopic surgery (SILS).

• Laparoscopic caecectomy for a suspicious appendiceal mass on colonoscopy using a laparoscopic linear stapler. Mr Ayan Banerjea had described that they found that laparoscopic caecectomy was a superior alternative to a laparoscopic right hemicolectomy for benign caecal polyps.

• Abdomino-Perineal Resection following TME principles with Total Pelvic exenteration with hysterectomy and vaginectomy and perineal reconstruction with right and left gracilis flap for locally advanced low rectal adenocarcinoma.

• Laparoscopic right hemicolectomy and was intrigued to see that the Alexis wound retractor has a cap and is useful in laparoscopic surgery after removal of the specimen, one can have a look with the camera through the cap.

• Laparoscopic subtotal colectomy for a patient with ulcerative colitis.

• Reversal of loop colostomy with stapler.

• Laparotomy for adhesiolysis, reversal of colostomy and ileocolic anastomosis for previous Crohn’s disease fistula and sepsis. A hand sewn anastomosis was performed.

The Nottingham rapid colorectal cancer pathway Colorectal cancer treatment follows the Nottingham rapid colorectal pathway which involves a 2 step process. The first step is a ‘straight-to-test' colonoscopy with maximum 2 week waiting period. This had resulted in a reduced time to diagnosis and an increased number of patients diagnosed with colorectal cancer. The second step involves time from decision to treat to actual first treatment should be a maximum of one month duration. The rapid pathway improves patients care and outcomes. England: The culture, the people and the city Nottingham is a city in England located in the East Midlands region; where legend of Robin Hood originated and I am fond of the story from my childhood. It was summer and I was lucky to experience some warm days, however there were a few rainy days. The city had an efficient public transport system including buses and the tram making it easy to travel to the hospital and the city centre where I visited the Victoria Shopping Centre and the famous Lace Market. Over the weekend I was fortunate to spend time with family in West Midlands and the pleasure of traveling through Wolverhampton, Telford, Shrewsbury and visited the Iron Bridge and Ludlow Castle whilst having lots of ice-cream and strawberries. I was fortunate to take a tram with my Aunt to Birmingham where we spent the day at the Birmingham Museum and Art Gallery and Sea Life. Overall experience The traveling fellowship was a once in a lifetime opportunity and I am glad that I applied as I thoroughly enjoyed the experience. I was able to meet my objectives and was exposed to many new techniques and equipment that I will use in my clinical practice. The highlight of my trip was the ACPGBI 2019 Congress Council Dinner. I was privileged to be in the company of leaders in colorectal surgery, many of whom are authors of articles and books that I read. I was fortunate to visit two colorectal units, and even more fortunate that they were in different countries allowing me to be maximally exposed to how patients are manage around the world. The timing in my career was perfect as I was 2 years into my colorectal sub-speciality training time and was able to enjoy my exposure in Dublin and Nottingham as I was mature and understood the procedures and controversies that surround them. It allowed me to ask specific questions and benefit by learning new techniques and about different equipment and instruments. Additionally I observed how systems and multidisciplinary team meetings differed and how to improve these back home. Both units followed Enhanced Recovery After Surgery (ERAS) principles and I observed implementation of these principles during the preoperative, intraoperative and post operative pathways. Even though I had not observed any proctology in theatre and had not seen patients with Obstetric Anal Sphincter Injuries; Pelvic floor disorders; Obstructive defecation Syndrome or Fecal Incontinence; I was able to pick up an approach at the ACPGBI 2019 Congress and speak to surgeons who manage these patients and perform Sacral Nerve Stimulator implantations. At the exhibition, I met the Medtronic representatives; we use the Medtronic product in Johannesburg. I also met the Axonics representatives and learnt of a rechargeable Sacral Nerve Stimulator system. The patients could recharge the battery at their own convenience and that eliminates the need for re-operation to replace the battery. I was lucky to see the Da Vinci Robot at St Vincent’s University Hospital and on exhibition at the ACPGBI 2019 Congress and to listen to research presentations about robotic surgery and hear about fellowships in robotic surgery. It was my first time to see the robot, unfortunately I did not see the Da Vinci Robot in use. A strong culture of research was displayed on ward rounds, unit meetings and in theatre. The one month duration was perfect to allow for learning and integration into the units; and a suitable amount of time for me as I needed to get back home to family and work. Acknowledgements I am grateful that the ACPGBI had funded the trip as this allowed me to book flights, accommodation, travel and live within the cities for the one month period without concerns of finances. This made the trip enjoyable and I could focus on my objectives. This also created a foundation for me to establish an international network and build relationships with leading colorectal surgeons. Thank you to Mr. Charles Maxwell-Armstrong for assisting me with the planning of the trip; letter for my Visa application; allowing me to visit Nottingham University Hospital – Queen’s Medical Centre and all the introductions. I would like to thank the following ACPGBI members:

• Anne O’Mara (Administration Manager) for her kind assistance in planning and administration
• Jared Torkington for assisting in planning and ensuring that my trip was in order

Thank you to the South African Colorectal Society for creating this opportunity for South African surgeons to explore the surgical world. Mr. Tim Forgan was instrumental in assisting with planning and helping me make contacts; for which I am grateful. A very special thank you to Professor Ronan O’Connell for his warm reception and assisting with integrating into his unit and inviting me to join the end of term function at the Milltown Golf Club. I am very grateful to Ms Neena Randhawa for allowing me to join her on her daily surgical activities and for showing me around Queen’s Medical Centre. Thanks to Dr Brendan Bebington and Dr Daniel Surridge who are my mentors in Colorectal Surgery back home in Johannesburg for encouraging me to apply for this fellowship. Thank you for your motivation and support. A heart-warming thank you to my husband and daughter for allowing me to be away for a month to once again purse my academic interests. A special thank you to my parents for their support during this time. Lastly, I am grateful to my relatives in England for hosting me over the weekends.

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