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EDITORIAL
Welcome to this third issue of the London Student Journal of Medicine. It has now been a year since the LSJM’s inception and a continuing theme throughout this period has been new practices with the explicit aim of improving patient care. One example of this has been the wider topic of patient safety and specifically the World Health Organisation Surgical Safety Checklist which we introduced in our first issue1 and featured the role of the healthcare student in its dissemination in the second issue2. However, as has been recently discussed, there is still much to achieve within this rapidly developing sphere of medicine, bringing with it additional challenges such as how to incorporate these new ideas into the already crowded undergraduate curriculum of healthcare students3. A further theme this year has been the future of surgery, both in terms of technological advances and as a potential career. This is continued in the present issue with a personal account of the use of a laparoscopic simulator, one of a number of new training tools to assist trainees. Additionally, we also feature two contrasting profiles of surgeons at different ends of their careers, a senior trainee in the United Kingdom advancing the cause for female surgeons and a distinguished professor of surgery in Mexico who truly pushed the boundaries of his specialty. However, our work has not just included the review and selection of potential manuscripts for publication, but has also revolved around building relationships with stakeholders interested in the LSJM and this issue features the fruits of a successful partnership between the LSJM and Scalpel, the Surgical Society of the University of Manchester. The following pages contain a synopsis of their Undergraduate Surgical Conference, held in November 2009 and the abstracts of the winning submissions. The posters and presentations of the winning entries will be available online in the near future. Furthermore, we are pleased to announce a new partnership with the King’s College London Surgical Society and their forthcoming Trauma Conference. We are always interested in supporting undergraduate surgical events so please get in touch if you have any events in the pipeline. As has been previously highlighted, change in Medicine is both necessary and inevitable and so is the case with the Surgery Section. This will be our last contribution to the LSJM and a new leadership team is therefore sought. Application will be through the process outlined on the LSJM website (www.thelsjm.co.uk), but if anyone would like to discuss the editor’s position informally, please feel free to contact us at surgery@thelsjm.co.uk. We concluded our first editorial by stating that our aim was for you, our readership, ‘to consider the LSJM as a place to publish your work and begin to make it part of your regular reading – hopefully’ our work over this past year has begun to realise this aim.
Jonathan Cheah and Milan Makwana Associate/Section Editors, Surgery Section
References: 1. 2.
Yuen S. What is the WHO Surgical Safety Checklist. The London Student Journal of Medicine {Surgery}. 2009;1:51. Carson-Stevens A, Hafiz S, Bohnen J, Rose Jr. J, Gutnik L, Henderson D, et al. Transforming the Culture of Surgical Safety. The London Student Journal of Medicine {Surgery}. 2009;1:128-9.
3.
Donaldson LJ, Lemer C, Noble DJ, Greaves F, Fletcher M. Finding the Achilles’ heel in healthcare. Journal of the Royal Society of Medicine. 2010;103:40-1.
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INTERVIEW
Foetal Cleft Lip and Palate Repair Priyanka Chadha
Year 3 Medicine, Imperial College, London priyanka.chadha06@imperial.ac.uk Pioneer Professor Ortiz Monasterio speaks about the ethics and realities of his foetal repair surgery many years ago
Fig 1: Professor Ortiz Monasterio
Cleft lip and/or palate is the most common congenital malformation of the head and neck and accounts for 65% of all head and neck anomalies. Foetal cleft lip and palate repair became a reality after the advent of high resolution ultrasound imaging allowed an anomaly to be identified prior to delivery. The benefits of this type of operation were numerous and included the inherent characteristics of foetal wound healing, which is scarless at mid gestation, in contrast to wound healing in adults. In addition, the ability to prevent damaging consequences of the malformation, for example maxillary growth restrictions should no longer occur and there would be a decreased need, or no need at all, for additional treatments or other after care. Professor Ortiz Monasterio (figure 1) attempted the first foetal cleft lip repair in humans two decades ago. His initial attempt of foetal lip repair was in rats and a successful outcome of scarless wounds was achieved. He then moved on to primates. Using high resolution ultrasound, his team were able to identify the gestation period of each foetus. They operated, through an open approach, on a total of 38 foetus. The team entered the uterus, whilst avoiding the placenta, and removed a section of the upper lip from the foetuses, sutured it back together and observed the behaviour of foetal wound healing and general physiology through into adulthood. Through these operations, Professor Monasterio learnt to operate “fast and well” and was confident enough to attempt a foetal repair in a human.
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Was operating on human foetuses an easily attainable goal? Following the Declaration of Helsinki in 1975, (ed. a statement of ethical principles for medical research involving human subjects, including research on identifiable human material and data), operations of this type became very complicated. I discussed all of the risks with the mother, for example, the risk of premature labour, loss of life, the possibility of hysterectomy, bleeding etc. After all of this information the mother consented to the procedure and it was possible to go ahead with it. Although the child was born prematurely, it was viable. However, it was born with a scar much worse than those seen in post-natal repair. Although similar research was being done with regards to foetal repair for congenital diaphragmatic hernia, the laboratory in San Francisco doing this had much more money, many more resources and a larger team to help. It was much more difficult for me. I was just a craftsman trying to develop a technique. I can do nose operations now, on babies
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who are two months of age, beautifully. It is much easier and the technical difficulties found in foetal repair are not there. In 1965, 65% of our cleft lip and palate repairs (as done by the whole team, including the residents) had velopharyngeal insufficiency (failure of the soft palate to reach the posterior pharyngeal wall, often resulting in defective speech – VPI). This reduced to 25% in 1985 and in 2003, 7% of my own, private patients, solely operated on by me, had VPI. It is through a lifetime of dexterity that I have been able to achieve such results (figure 2). This illustrates the great progress that is being made in the field of cleft lip and palate repair without the need for risky surgeries, such as foetal repair. Do you think that foetal repair is realistic in the future, with more accurate ultrasound scanning and a more precise gestation period identified for scarless healing? No, it’s not attainable. It’s just too risky. It involves very difficult and complicated techniques in open surgery and feto-endoscopic surgery. It is technically very hard. Even with the advent of fetoendoscopic surgery, of which there is very little evidence, one is still manipulating intricate structures inside of the mother and this itself is very difficult. Placental bleeding is still a very real possibility as are all of the other risks. There’s no concrete evidence for regeneration. It’s just wishful thinking unfortunately. Never shall the evidence of scarless wound healing outweigh the risk of premature labour.
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INTERVIEW Do you think that it is ethically viable to attempt to continue with these operations and that the benefits may outweigh the risks? What benefits? There is no evidence. It is not ethically acceptable. The benefits simply don’t outweigh the risks. The main advantage Fig 2: Current cleft lip and palate surgery, performed by Professor Monasterio
great risks and is very complicated. Closing the skin and aligning the orbicularis oris muscle is very difficult. Cleft lip and palate repair is an exciting adventure and currently, we are limited by bioethics, costs and benefits. If you’re talking about congenital diaphragmatic hernia, then of course, this is different. It is life saving and therefore much more justified. This condition is something very different. Are you still enjoying your career? Of course! I am still enjoying it. I graduated 63 years ago and I am still operating but I think I should stop! I like to try and pass my experience on to the residents. I try to communicate experience. I have enjoyed my life to the full. I originally did my general surgery residency in Mexico, I then did my plastic surgery training in the U.S. In 1955, I returned to Mexico and my time here led to the first full time residency in a specialty, which was plastic surgery. Now, there are over 50 residencies in varying specialities. People came to us for a cleft lip and palate repair very late in their lives. We wanted to find people who required a repair and so we organised a mobile unit to travel to rural areas. We provided free health care, with a team and recruited people of all ages for cleft lip and palate repair. In total, our group has performed around 24,000 cleft lip and palate repairs in just over 50 years!
now of early post natal surgery is that the shock for the family is diminished. But with proper psychological support, the family are able to understand the child’s condition more. Foetal repair has
Do you have any regrets? Would you repeat the decisions that you’ve made? I have no regrets. None. I am an adventurous surgeon and I have no regrets about my previous work. There is nothing to regret – one does operations and learns from them and the information gained whilst performing them, and then one moves forward.
, At the LSJM
Su r g ery is only one
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PROFILE
Profile of: Miss Beryl de Souza Interviewed by: Niyati Lobo Year 3 Medicine, King’s College London niyati.lobo@kcl.ac.uk I probably did but was too thick-skinned to ever notice when it did happen. Certainly, the discrimination was never overt. Can you describe a person that has had the most influence on the way you practice today? I do not think there is just one person I can describe. My training has been influenced by various people who have trained me over the years. You’re married to a surgeon. Was he initially supportive of your surgical aspirations or did he want a more traditional wife who would have more time to raise a home and family? Because I went to medical school as a graduate student, I met my husband who was already along the surgical training pathway. He was aware of what I wanted to do as a career and has always been very supportive.
Current Post Senior Registrar in Plastic Surgery, Chelsea and Westminster Hospital, London Joint Honorary Secretary, Medical Women’s Federation BMA Council Member Undergraduate Studies BSc (Hons) Biochemistry, Chelsea College, University of London Postgraduate Studies MPhil Royal College of Surgeons of England, University of London 1987 MBBS St Bartholomew’s Hospital, University of London 1992 FRCS Royal College of Surgeons of England, University of London 1998
What made you decide to pursue a career in surgery? I did a degree in biochemistry and undertook a period of research at the Royal College of Surgeons prior to entering medical school. My project involved investigating different substances as matrices for peripheral nerve regeneration. The microsurgical techniques I learned during this time encouraged me to pursue a surgical career with a view to specialising in plastic surgery. During your years as a trainee, did you ever experience discrimination by your male counterparts for being a female surgeon?
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How do you balance raising a home and children with working in a highly demanding field? Well, we have to be very organised which is difficult. We have to ensure that we’re not on call at the same time and we need to have back-up. I’m lucky as my parents live nearby and are very supportive. I also have a group of friends who I can rely on to help us out when needed. Did you take a lot of time off work when you had children? No, I didn’t as my specialty is very competitive. For my first child I took 6 months off and for my second child, I took 3 months, which may be less than most people do. I do regret not being there and spending much time with them when they were growing up. But it’s very, very difficult to get the balance quite right. Describe a typical day. There is no such thing as typical day! I usually wake up around 6am and leave for work almost immediately. I arrive at the hospital between 7 and 7:20am and have breakfast in the mess. The morning is spent either on ward rounds or in theatre. I spend my afternoons in theatre or in clinics consulting and assessing patients for surgery. On average, I finish between 5 and 6pm, unless I’m on call! What would you say to those who believe it isn’t possible for a woman to combine a surgical career with being a mother? I would say it’s not impossible, but certainly requires resilience and support from your partner, friends and relatives. Determination and the ability to persevere is key. However, the most important thing is that it is not impossible. It may be more difficult along the way because you want to balance your responsibilities as a mother and as a surgeon. In addition to that you have exams to pass,
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NEWS Access to Obesity Surgery In a recent conference at the Royal College of Surgeons, it has been said that ‘access to NHS weight-loss surgery is inconsistent, unethical and completely dependent on geographical location’. A survey carried out before the conference found that 66% of surgeons said that patients eligible under NICE guidelines are refused surgery in their centres and that the criteria for surgery varies depending on geographical location. The Department of Health has been called upon to ensure that equal access to treatment for all patients is implemented. (For more information see www.rcseng.ac.uk) papers to write, research to do, teach, etc. You are an honorary secretary in the Medical Women’s Federation (MWF). Can you tell us a little more about this organisation and how it relates to female medical students? At the moment, 60% of medical school intake are women. This means that, in the coming years, the workforce will change and women will have to make certain choices in order to keep the workforce in a condition whereby all specialities are filled. Inevitably, some women will end up choosing harder specialities just to fill in posts. The recent report by the Chief Medical Officer (Women Doctors Making a Difference) has made certain recommendations for female doctors. The MWF campaigns for the very same recommendations, these being primarily to do with leadership roles, mentoring, flexible training and childcare facilities. I would urge female medical students to get involved with the MWF for the camaraderie and support that is provided.
Aspirin and Breast Cancer Survival J Clin Oncol 2010 Feb 16. [Epub ahead of print]
What is the most important thing you learned as a student? It is important to be both able to relax and exercise discipline with regards to studying during your time at medical school. Things don’t get easier once you qualify, so it is important to learn this skill as a student. I am still trying to achieve a healthy work life balance!
Gastric Banding for Obese Teens JAMA 2010;303:519-526
American researchers have sought to evaluate aspirin’s effect on breast cancer following animal studies suggesting that the agent may inhibit breast cancer metastasis. Over 4,000 nurses were observed prospectively for diagnosis of breast cancer and length of time on aspirin via questionnaire. The relative risk for breast cancer mortality was decreased among women who used aspirin for 2–5 days/week (0.29, 95%CI 0.19–0.51) or 6–7 days/ week (0.36, 9%CI 0.24–0.54), compared to non-users. Distant recurrence was also reduced with regular aspirin use. The authors concluded that aspirin use was associated with a decreased risk of distant recurrence and breast cancer death.
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Do you have any tips for aspiring female surgeons? Decide early on what surgical specialities you’re keen to pursue. Once you’ve done that, look in detail at the career structure for those specialities so you have an idea about the jobs that will be available to you. Make use of career websites such as the Royal College of Surgeons and the Department of Health. Find out whether you would be able to tick the boxes required in order to overcome the competitive nature of surgical posts. Audit work, research, publishing and presenting and skills training at an undergraduate level are all useful.
A recent randomised controlled trial has sought to elucidate if obese teenagers lose weight better through lifestyle modification involving diet, exercise and behaviour modification or surgical intervention. 50 14-18 year olds from Australia with a Body Mass Index of greater than 35 were assigned to supervised lifestyle intervention or gastric banding. During the two year follow up, significantly more teens in the banding group than in the lifestyle group had lost at least half their excess weight (84% vs. 12%). Furthermore, the banding group experienced improved quality of life although 8 revision operations were required.
Reducing Post-surgical Infections N Engl J Med 2010;362(1):18-2 To determine the effectiveness of pre-operative skin preparation in reducing post-operative infections, American researchers randomised 849 patients to either chlorhexidine-alcohol scrub or povidone-iodine scrub and paint. The 30-day infection rate in the chlorhexidine-alcohol group was 9.5% compared 16.1% to in the povidone-iodine group (P=0.004). Additionally, chlorhexidinealcohol was superior in both superficial- and deep-incisional infections. The researchers state that ‘preoperative cleansing of the patient’s skin with chlorhexidine-alcohol is superior to cleansing with povidone-iodine for preventing surgical-site infection after clean-contaminated surgery’.
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SPECIAL REPORT
Scalpel Undergraduate Surgical Conference 2009 The Scalpel Undergraduate Surgical Conference was held on 7 November 2009 at Wythenshawe Hospital. It was the first national conference of its kind, and drew medical students from all over the country. The event was held in collaboration with The Royal College of Surgeons (RCS), The Association of Surgeons in Training (ASiT) and Doctors Academy. The conference was attended by 120 medical students from as far away as Dundee and Peninsula Medical Schools. It provided a platform for students to present their original research, audit or case reports at a national level to other students and a select panel of surgeons with a passion for teaching and research. The best presentations were awarded prizes, which were generously sponsored by Mr Peter Richardson, Mr Rory McCloy, and the London Student Journal of Medicine. The day was chaired by our local eminent surgeon, Professor Gus McGrouther. Speakers included Professor Nanchahal from Imperial College London, whose fascinating lecture covered the advancements in plastic surgery research. Professor Stanley, a local orthopaedic surgeon, discussed the role of the surgeon and shared wisdom from a full and varied career. The keynote address came from Miss Helen Fernandes, a consultant neurosurgeon from Cambridge and the Chair of Women in Surgery. Her talk covered the history of surgery, as well as her experiences as a female surgeon and the aspects of neurosurgery that drew her to choose it as a career. A fantastic array of workshops was available, kindly supported by Doctors Academy and the RCS. This was a great opportunity to learn some practical surgical skills or ask expert advice about getting into surgery. A lively evening dinner was held at Red Chilli restaurant, which allowed delegates to relax and share their experiences of other UK medical schools. The conference was the climax of a triumphant year for Scalpel, which has been gaining momentum since it’s re-launch in 2006. A second conference is planned for 2010, which promises to be even better than the last!
Elspeth Hill
President and Ambrose Boles, Conference Co-ordinator Scalpel Surgical Society, The University of Manchester scalpelmanchester@gmail.com
Audit
Incidence of MRSA colonisation and subsequent risk of infection in orthopaedic elective surgery Emma Murphy
Fourth Year Medical Student, University of Dundee ezmurphy@dundee.ac.uk doi: 10.4201/lsjm.surg.012 Background The incidence of methicillin-resistant staphylococcus aureus (MRSA) colonisation is continuing to increase in UK hospitals with the incidence of MRSA-positive orthopaedic patients, at the time of their admission, considered to be around 5.3%. A previous study has shown that the risk of developing MRSA surgical site infection (SSI) post-operatively in orthopaedic trauma patients colonised with MRSA is 2.5 times greater than that of the normal population, but the risk of developing a MRSA SSI in elective orthopaedic patients has yet to be determined.
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prophylactic antibiotics used during the procedure and subsequent development of a SSI in the year following surgery.
Purpose The aim of our study was to determine how effective screening and treatment of MRSA colonisation in all elective orthopaedic patients was on the subsequent risk of developing a MRSA SSI.
Results From January 2005 to April 2008, there were 5,933 admissions for elective orthopaedic inpatient surgery to our unit. 108 of 5,933 (1.8%) were MRSA colonisation positive with 5,825 (98.2%) MRSA colonisation negative. Seven out of 91 (7.7%) patients who were MRSA colonisation positive had a SSI within one year of surgery (95% CI 3.1%, 15.2%). Of these, deep sepsis occurred in four (4.4%) patients and superficial infection in three (3.3%) of the 91. Deep sepsis rates, in lower limb joint replacements, were high in the previously MRSA colonisation positive group, with two SSIs out of 28 total hip replacements (7.1%) and two out of 29 total knee replacements (6.9%).
Methods We analysed all orthopaedic elective patients screened for MRSA who were admitted between January 2005 and April 2008. For colonised MRSA positive patients, we determined the site of MRSA colonisation, if colonisation was eradicated before surgery, patient’s risk factors for MRSA colonisation,
Conclusions Our study indicates that patients colonised with MRSA at their pre-op assessment are at increased risk of developing MRSA SSI and that this risk is significant for total hip and total knee replacement patients. Where infection develops MRSA is the most likely causative organism.
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SPECIAL REPORT
The Role of Reconstructive Surgery in the Management of Urethral Strictures: a case study
Case Report
Hussein Taki
Fourth Year Medical Student, University of Bristol ht6031@bristol.ac.uk doi: 10.4201/lsjm.surg.009
Background The management of urethral stricture disease in men is a relatively common issue faced by practising urologists. Urethral strictures occur for many reasons including congenital, iatrogenic, idiopathic and inflammatory causes. Stricture disease is responsible for as many as 5,000 hospitalizations and 1.5 million outpatient visits per year in the USA and has an annual cost of $200 million.
Figure 1: Incision and mobilisation of Neo-Urethra, Urethra Sutured at a wide diameter, and Closure and wound dressing. Stage two of urethroplasty.
Case Report Mr. A is a 45 year old man suffering from a long standing problem with urethral strictures, caused by the inflammatory condition Balanitis Xerotica Obliterans (BXO). This was previously treated with a topical steroid cream and several unsuccessful dilatation surgeries, home dilatation, as well as an urethrotomy. Passing urine was painful and he suffered from urinary retention, for which he had to self catheterize. As a result he underwent reconstructive surgery to relieve his strictures. This involved a two stage Urethroplasty using a buccal graft to reconstruct the urethra (fig1 &2). The two operations were 6 months apart and appear to be successful, having recently completed the second stage operation. Mr A’s urinary flow rates and Urethroscopy will be performed in outpatients every 3 months to monitor the risk of re-stricturing. He is recovering well after the surgery and is looking forward to resolving his long standing problem. Discussion This case study discusses the aetiology of urethral strictures as well as their investigation, highlighting the role of the “reconstructive ladder” in their management. It also discusses whether in more severe cases the less invasive steps of the reconstructive ladder should be bypassed in favour of the more effective and invasive urethroplasty. Figure 1: Ventral Midline Incision, Incision into urethra and Stricturotomy, all as part of a urethroplasty
Conclusion Most surgeons believe that urethroplasty should only be indicated after urethrotomy. Urethrotomy works best on small proximal strictures. Urethroplasty has a success rate as high as 96%. Repeated Urthethrotomy and Dilatation is neither clinically effective nor Cost Effective in longer strictures. For longer strictures where urethrotomy is expected to fail a primary urethroplasty is both cost effective and clinically effective. 2 References 1. Rourke. K. (2004) Urethral Stricture Disease: contemporary management; presentation at university of alberta. 2. Wright. J.L (2006); Urology 2006;67:889
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SPECIAL REPORT Rsearch
Impact of pathologic re-evaluation of core needle biopsies in patients undergoing radical prostatectomy Eoin Dinneen
Fourth Year Medical Student, University of Bristol Ed4798@bris.ac.uk doi: 10.4201/lsjm.surg.010
Objectives Gleason sum from prostate biopsy (bGS) is an important tool in classifying severity of disease, ultimately influencing clinical management. Commonly, outside laboratory pathology is reevaluated prior to surgical intervention. We evaluated agreement of bGS with prostatectomy Gleason sum (pGS) and the impact of regrading on prediction of true underlying tumor architecture. Methods A retrospective analysis was conducted of men who underwent robotic prostatectomy (RARP) by two surgeons during the period 2005-2009. Initial trans-rectal ultrasound biopsy demonstrated carcinoma by an external laboratory. Specimens were re-evaluated by our Genito-Urinary pathologists prior to surgery and biopsy data were correlated with pGS. Statistical analyses were conducted on positive core bGS and percentage carcinoma involvement to assess inter-laboratory agreement. Kappa (ะบ) statistics for agreement and linear regression analyses were used for categorical variables and coefficient of concordance used for continuous variables. This data was also correlated with the final surgical pathology Gleason Score.
Figure 1: Trans-rectal Ultrasound Guided (TRUS)
Results 100 patients had 331 positive core needle biopsies. Agreement (ะบ) for bGS between outside laboratories and internal pathologists was 0.55 (p<0.001). Internal readings were twice as likely to upgrade vs. downgrade the original bGS (23% vs. 11%). When reevaluation resulted in a change in bGS, agreement with pGS was ะบ =0.29, vs. ะบ=0.04 for agreement of initial (external) bGS with pGS. When no change was made to bGS agreement with pGS was ะบ=0.40 (p<0.001). No effect was seen on accuracy with increased time to surgery though data suggests a relationship between increased number of biopsies and improved accuracy. Conclusions Good reproducibility of bGS seen between external laboratories and our institution. Internal pathology re-reads correlated better with pGS than original external bGS. When re-evaluations result in a change in bGS, there is a marked improvement of prediction of underlying tumour architecture
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SPECIAL REPORT
Investigation into the association of Cancer Stem Cells and chemo-resistance in breast, colon and prostate cancer cells
Research
Hardip Gendeh, BMedSch (Hons)
Fourth Year Medical Student, University of Nottingham mzyahsg@nottingham.ac.uk doi: 10.4201/lsjm.surg.011
Susan Watson PhD Professor of Pre-Clinical Oncology, Division of Pre-Clinical Oncology, University of Nottingham
Figure 2: IHC of AP5LV lung metastasis with significant expression of CD133 CSC marker (brown)
Rajendra Kumari, PhD Senior Research Fellow, Division of Pre-Clinical Oncology, University of Nottingham Background The Cancer Stem Cell (CSC) theory suggests that tumours are heterogeneous, consisting of a small proportion of highly tumourigenic cells with similar properties to normal stem cells, in terms of yielding a heterogeneous cell population and proliferation. Evidence suggests that CSCs are highly tumourigenic in mouse models, with increased metastatic potential and chemo- and radio-resistance. They are emerging as key targets for new therapies and detection providing prognostic information. CSCs express specific surface marker panels, CD44 and CD24 in breast cancer, CD133 in colon cancer and CD44 in prostate cancer. Purpose To demonstrate that CSC markers are over-expressed in human cancer cell lines, associated with chemo-resistance and enhanced metastatic potential. Methods The chemo-resistance of MCF-7 breast and C170HM2 colon cancer cell lines was assessed by a tetrazolium-based, colorimetric cell viability assay. Enhanced chemo-resistance cells were subjected to immuno-fluorescent staining for the expression of CSC markers. Breast (MCF-7 and MDA-MB-231), colon (C170HM2 and AP5LV) and prostate (PC3M) xenograft tissue from mouse models of metastasis were subjected to immunohistochemical staining for the expression of CSC markers. Figure 1: IF of MCF-7 (ADR) with significant expression of CD44 CSC marker (green) with nuclei (blue)
Results MCF-7 adriamycin- and paclitaxel-resistant human breast cancer cell lines were confirmed to be resistant and were found to express higher levels of CD44 than chemo-sensitive MCF-7 cells both in vitro and when grown as xenografts in vivo. CD133 expression was enhanced in AP5LV lung metastases compared to the primary tumour injected in the peritoneal muscle wall. Overall CD133 and CD44 expression were elevated in the poorly vascularised subcutaneous sites compared to well-vascularised sites including prostate (PC3M), peritoneal cavity (C170HM2), mammary fat pad (MCF-7) and peritoneal muscle wall (AP5LV) suggesting they may be up-regulated in response to stress. Conclusions CD44 is a robust marker of chemo-resistance in breast cancer cells in vitro and in vivo whilst CD133 is less discriminative. CLINICAL RELEVENCE & FUTURE WORK Current chemotherapeutic agents have broad and non-selective cytotoxic effects, hence killing only the proliferative cancer cells and sparing the highly tumourigenic CSC. Although tumour de-bulking is achieved, CSCs are not eradicated and may result in re-emergence. Thus future chemotherapeutic agents should concentrate on specifically targeting CSC, hence preventing the tumour to be sustained. An optimal panel of CSC markers are required for all cancer types to provide a prognostic marker, act as a biomarker of chemo-resistance and to guide new treatment specifically targeted at CSC.
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ARTICLE
Surgical training in the 21st century-should we be worried? Benjamin Shaw, BSc (Hons) Year 4 Medicine, University College London b.shaw@ucl.ac.uk For the vast majority of medical students interested in a surgical career, the closest we get to ‘actual’ surgery is holding a retractor, suctioning or if we’re lucky, tying a suture or two. It is puzzling how we can choose a career in surgery without knowing whether we have the skill, aptitude and precision to become competent and successful surgeons. This issue becomes even more pertinent when considering the relationship between the recent reforms in surgical training and the advancement in surgical technique. The European Working Time Directive restricting a doctor’s work to 48 hours a week, combined with the Modernising Medical Careers initiative to reduce the length of surgical training has meant a significant reduction in a surgical trainee’s education. Furthermore, political and economical factors including patient safety, the implementation of quality assurance targets and time demands, are also contributing to limiting a surgical trainee’s operating experience.1,2 At the same time, continual advancement in surgical techniques, such as minimal access surgery, has necessitated an increased need for skills such as enhanced hand-eye coordination and meticulous manual dexterity.3
These factors raise a number of concerns about surgical training in the twenty-first century. As surgical trainees have less time to develop the necessary skills to become competent surgeons, will ‘natural ability’ become more important in the success of a surgeon? With medical students only performing the most basic of surgical tasks how can students with a ‘naturally ability’ be selected? Additionally, will the reduction in training compromise on quality and as a consequence put future patients at risk? What can be done to prevent this bleak prospect and aid surgical training?
Surgery in 21st century
Currently there are a variety of training techniques that have been introduced to combat the reduction in surgical education allowing trainees to gain experience outside the operating theatre (Figure 1). These techniques include static bench models whereby trainees can practise basic procedures such as suturing and tissue dissection, live animal models enabling trainees to operate on ‘real’ tissue, video box trainers and virtual reality (VR) simulators where trainees can develop laparoscopic surgical skills.4 This year I was fortunate enough to be given the opportunity to use LAP mentorTM (Figure 2), a laparoscopic VR simulator by
Figure 1. Surgical training adjuncts currently in use 4,5
Skill Training Model Bench models
Video box trainers Animal models
Virtual reality simulators
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Advantages
Readily available Suitable for basic skills training Inexpensive Use of real surgical instruments Moderately inexpensive High fidelity Physiological tissue response to surgical manipulation Similar anatomy High fidelity Physiological response to surgical manipulation Suitable for procedural training and selfpaced learning Objective assessment Evidence of skills transfer
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Disadvantages
Low fidelity Models not available for all procedures No feedback to the trainee from model Low fidelity Limited feedback to trainee from model Limited availability High costs Infection concerns Moral and ethical issues High costs Limited availability Simulators not available for all procedures Not all simulators provide tactile feedback
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ARTICLE of training such as video box trainer training, no training and standard laparoscopic training in surgical trainees with little or no prior experience in laparoscopic surgery. Although many of the included trials had a high risk of bias, the review demonstrated that those trainees who trained with VR simulators showed superior performance with increased accuracy and completed tasks in a shorter period of time compared to the other groups.6 So can VR simulators resolve the concerns listed above?
Image: Simbionix.com
Due to the demonstration of skills transfer resulting in superior performance compared to standard training6 it is likely that in the near future more surgical trainees will have access to VR simulators. This can only be beneficial in combating the reduction in surgical education. Although VR simulators cannot completely replace the experience obtained on ‘actual’ patients, by utilising VR simulators as a training adjunct, trainees can develop many of the skills necessary for surgery outside of the operating theatre and therefore make the most of their precious time in theatre. In addition, as VR simulators facilitate self-paced learning, surgical trainees of all ‘natural’ abilities can develop the required skills at their own pace and practise on the simulator as much as they require to achieve proficiency. This will ensure the next generation of surgeons have the necessary skills and experience to provide the best care possible for patients. Figure 2: The LAP mentorTM Simbionix (http://www.simbionix.com/LAP_Mentor.html). During my session on the machine I worked through a series of basic laparoscopic surgical skills such as cutting, clip applying, camera manipulation and object translocation. I then finished off my session by performing part of a simulated laparoscopic cholecystectomy. Getting first hand experience on a VR simulator illustrated to me the benefits of these machines compared to the other forms of supplementary training in surgical education. VR simulators provide normal physiological tissue response to surgical manipulation e.g. the VR ‘tissue’ bleeds when cut. In addition, the simulator I used provided tactile feedback by utilising haptic systems thereby imitating real life. VR simulators also facilitate self-paced learning and assessment by measuring objective data on specific tasks such as time taken to complete the task, instrument path lengths and economy of hand motion. I found this feature particularly useful as a way of improving my usage of the instruments and monitoring my progress. It should be noted that VR simulators are not without limitations. Although there are simulators for a wide variety of laparoscopic operations there are not simulators available for all surgical procedures. Furthermore, due to the high cost involved in acquisition and maintenance, there are a limited number of these machines in the UK. Not all VR simulators have tactile feedback and as a consequence some surgeons have questioned their ability to replicate reality, with some describing their function as primarily visual rather than motor training.4,5 Despite reservations from some camps, there is encouraging evidence in the literature demonstrating skill transfer from simulator to the operating theatre, particularly so with laparoscopic surgical skills. A recent Cochrane review of twenty-three randomised clinical trials compared VR training to other forms
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Using simulation-based training, such as VR simulators, to ensure safer care for patients has been endorsed by the Chief Medical Officer, Sir Liam Donaldson. In his 2008 annual report, he highlighted the success of utilising simulation-based training as a surgical training adjunct and its potential use as a valuable method of filling the skills gap resulting from the recent reforms to surgical education. He recommended that “simulation-based training should be fully integrated and funded within training programmes for clinicians at all stages”.7 In an ideal world VR simulators would also be available to medical students. This would enable students to begin to develop the skills essential for surgery and help to ascertain whether they feel they have the aptitude to pursue a career in surgery. Unfortunately, the prospect that all medical schools will make VR simulators available to students remains doubtful due to economic confines. Furthermore, even those institutions with VR machines will have to give priority to surgical trainees and so access to medical students will be limited. I feel privileged to have been given the opportunity of experiencing a VR simulator first hand. I thoroughly enjoyed my session on LAP mentorTM and the experience reinforced my aspiration of becoming a surgeon. If given the chance, I would highly recommend that other medical students make use of VR simulators. Apart from the enjoyment of ‘operating’ it gives deeper insight into what surgery actually entails.
Acknowledgements The author would like to thank the Department of Obstetrics & Gynaecology and the Screen-Based Medical Simulation Centre of the Royal Free Hospital for giving the opportunity to access the laparoscopic simulators.
For full references see thelsjm.co.uk.
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