31 July 2019

Recipient: Timothy Chittleborough, 2nd year CSSANZ fellow

ACPGBI presentation: “Laparotomy results in more desmoid tumour when compared to laparoscopy in a preclinical model of desmoid tumours in familial adenomatous polyposis” Units visited:

1. The Western General Hospital, Edinburgh
2. The John Goligher Colorectal Unit, Leeds
3. St Mark’s Hospital, Harrow

The ACGPBI travelling fellowship afforded me the opportunity to attend and present at the ACPGBI meeting in Dublin and then visit a number of units in the UK. I commenced my visit with the ACPGBI conference in Dublin. I was grateful to be able to present my research “Laparotomy results in more desmoid tumour when compared to laparoscopy in a preclinical model of desmoid tumours in familial adenomatous polyposis”, which was well-received and generated some interest from our northern hemisphere colleagues. I was also most appreciative of the invite to attend the ACPGBI council dinner, where I was fortunate to be seated next to Prof. Bill Heald, allowing dinner discussions about the evolution of minimally invasive approaches to TME. The ACPGBI meeting was excellent in its breadth and quality. Keynote addresses including the BJS lecture by Prof Michael Solomon on decisional conflict and interpretation of evidence from trials were inspiring, as was Dr Scott Steele’s Duke club address discussing the evolution of training, balance and, of course, the “Behind the knife” podcast. The research session highlighted existing and ongoing surgical trials being conducted in the UK. The results of the FOXTROT, HIP trial and CLOSE-IT were presented and a “spotlight session” provided delegates with updates on current and upcoming multicentre trials in order to encourage sites to participate in studies. I was impressed by the ability of the UK units and ACPGBI to facilitate multicentre studies, which we could aim to emulate in Australasia. I was pleased to see Dr Bree Stephenson present the results of the Australian led PREDICT study investigating the role of CRP trajectory in anastomotic leak, the first Australasian trainee-led multicentre study. Among other highlights was the advanced malignancy session that included the results of the PRODIgE 7 trial presented by Dr François Quenet that will no doubt influence future directions in HIPEC and the management of peritoneal carcinomatosis. In the same session a moving presentation by palliative care physician Dr Anna Wilkinson highlighted the importance of early discussions with patients regarding prognosis and involvement of palliative care. Following the ACPGBI meeting I had the opportunity to attend the PelvEX meeting hosted by Prof Des Winter. I was impressed by the research arising from the PelvEX collaborative. There was discussion regarding the future direction of research in exenterative surgery with two trials commencing; GRECCAR 15 and the PELVEX2, both investigating the role of re-irradiation in recurrent rectal cancer.

ACPGBI council dinner with Prof. Heald	Western General Hospital, Edinburgh with Mr Doug Speake

I then travelled to Edinburgh where I was hosted by Mr Doug Speake at the Western General Hospital. Among my three days there I was able to attend clinical meetings and observe in theatre. I was pleased to see an Australian fellow, Hasitha Balasuriya, training on the unit. Whilst at the Western General I was impressed by the opportunities that centralization and a subspecialized unit provides. The unit has three simultaneous theatre sessions including a dedicated emergency colorectal theatre. The service is largely consultant led. A key benefit of this service approach was that there were ample opportunities for trainees and consultants to seek second opinions and support from the consultant in the next theatre in complex cases. I then took the train to Leeds to visit the Goligher colorectal unit at St James University Hospital. I was hosted by Mr Jim Tiernan and had the pleasure of attending theatre with Mr Tiernan and also Mr Kallingal Riyad. There were constant updates from the theatre nurses on the cricket score for the world cup semi-final between Australia and England. I had the opportunity to meet with a research fellow and saw the intraoperative use of ICG fluoroscopy as part of the IntAct trial (IFA to prevent anastomotic leak in rectal cancer surgery). I also had the opportunity to attend clinic, where I was envious of the high level of specialist nursing support, increasing patient throughput and facilitating the patient journey by assisting patients in scheduling investigations and navigating the hospital.

John Goligher Unit Leeds with Mr Tiernan	Davinci Xi with Mr Miskovic at St Mark’s Hospital

I then travelled to Harrow to visit St Mark’s Hospital. My visit to St Mark’s commenced with a tour of the hospital by my host Mr Danilo Miskovic. He gave me some background history of the hospital, including its move to the current location at Northwick Park Hospital in Harrow. I then attended theatre for the morning with Mr Peter McDonald for a proctology list. I was amazed by the number of international visitors and was informed they almost always had overseas surgeons visiting the hospital. I was privileged to attend Prof Sue Clark’s clinic. I witnessed Prof Clark’s exceptional rapport with patients that are often young and anxious about their familial diagnoses. Unique is her dictation of the letter with the patient in the room and always sending a copy to the patient to ensure patients are always up to date with their treatment plan. Her clinic was comprised almost exclusively of patients with FAP and patients with ileal pouches. Attending Prof Clark’s clinic significantly increased my exposure and knowledge in the investigation and management of pouch dysfunction and pouchitis. I was also impressed with level of nursing support available at St Marks with specialist nurses having skills in the management of ileal pouches and also in FAP. This no doubt contributes to the patient experience and outcomes. I was pleased to meet another Australian fellow Rebecca Seton, who is competing the minimally/maximally invasive fellowship at St Mark’s. I also had the opportunity to attend a robotic anterior resection performed by Mr Milosovic on the Davinci Xi system. A challenging case due to adhesions from a previous midline laparotomy, this case demonstrated the ability of the robot, in particular the advantages of the platform over laparoscopic TME. In addition I was able to attend Mr Ian Jenkin’s exenteration theatre, with discussion about variation in the management of advanced and recurrent rectal cancer worldwide. Whilst in London I visited the operating theatre museum at the old St Thomas’s hospital. This highlighted the progress in surgery since the 1800s. The operating theatre had rules outlining where the “dressers” (assistants) and medical students could stand depending upon seniority.

The Old Operating Theatre Museum, old St Thomas’s Hospital, London	UK advertising to obesity and cancer risk, King’s cross underground station

I feel privileged to have been the recipient of the 2019 ACPGBI travelling fellowship. I am grateful for the the learning opportunities it has afforded me, including attendance of the excellent ACPGBI meeting as well as visiting a number of specialist colorectal units. This has provided me with insight into colorectal practice and training in the UK, as well as allowing me to network with many accomplished colorectal surgeons. I am very appreciative of the ACPGBI and my hosts in arranging an excellent travelling fellowship.

Download the Fellowship report

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