10 September 2018

Presentation Given: “Mechanisms of Resistance Following Neo-adjuvant Chemotherapy for Colorectal Liver Metastasis”, ACPGBI, Birmingham

I was fortunate to be awarded the ACPGBI travelling fellowship for 2018. I am very grateful to both the ACPGBI and the CSSANZ for the fantastic experience. The fellowship gave me the opportunity to visit 5 different colorectal units within the UK and to attend and present at the ACPGBI conference. My programme was arranged by Karen Nugent and Anne O’Mara. I really appreciate the time they spent organising my visit given all of their other commitments. It was great to observe 3 of the CSSANZ trainees currently undertaking fellowships in the UK. ACPGBI Conference, Birmingham. My travelling fellowship began with the annual ACPGBI conference in Birmingham. My husband actually went to university in Birmingham so it was quite interesting to visit the town where he studied! Prior to the main conference, I attended an ultrasound workshop for pelvic floor run by Andrew Williams of Guy’s and St Thomas’ hospital. The 3-hour course included lectures that covered the anatomy of the pelvic floor followed by a systematic approach to diagnosing sphincter injuries on ultrasound. Following the lectures, there was a hands-on session using 3D data cubes on BK Ultrasound Consoles. It was a fantastic course. The level and breadth of research presented at the ACPGBI conference were astounding. Some of the highlights from the conference were the trials update such as from the ROCCS trial, the FIAT, the SCOT trial, ELF and the FoxTROT trial. It was amazing to see so many surgeons leading multicentre randomised trials. Dion Morton gave a stimulating lecture on the future of surgical research including incorporation of genomics into patient treatment decision-making, future improvements in imaging and development of new surgical techniques. Neil Mortensen gave a captivating presentation of the “Anatomy of disaster and how to cope when things go badly wrong” including his own personal experience and insights into how to psychologically deal with complications. The “Mesh Controversy” chaired by Nicola Fearnhead was another very interesting session given the issues with mesh that have emerged following gynaecological procedures. The importance of a pelvic floor MDT meeting and the need to ensure maximal conservative management prior to operating and placing mesh was highlighted. In light of the Montgomery Case findings, a number of sessions discussed the need for a shift to ensuring an informed patient, rather than simply informed consent. The ACPGBI conference gave me a renewed sense of motivation for my current PhD with a number of presentations on the importance of understanding the genomics of colorectal cancer to improve and personalise patient treatment, in particular, Malcolm Dunlop’s presentation on “How is all this genomic nonsense relevant to me as a surgeon”. Queen Elizabeth Hospital, Birmingham Following the conference, I spent time with the colorectal unit at the Queen Elizabeth Hospital in Birmingham.  The unit is so impressive with the number of clinical trials that they are leading. I attended an IBD multidisciplinary meeting where I learnt about the ACCURE trial, a randomised multicentre trial looking at the relapse rate of UC following appendicectomy. The primary outcome measure is the one year cumulative UC relapse rate. I then attended an endoscopy list with Simon Bach. Some of the patients attending the list had been enrolled in the STAR-TREC trial, an organ-preserving trial, a multicentre 3 arm, phase II feasibility study in biopsy-proven adenocarcinoma of the rectum and the ARISTOTLE trial looking at the addition of irinotecan to the standard chemo-radiotherapy regimen in locally advanced rectal cancer. The following day I attended the cancer MDT meeting and later went to theatre where I saw a complex abdominal closure following repair/excision of an enterocutaneous fistula. The team were following the STITCH protocol of 5mm bites every 5mm with 2.0 prolene published in the Lancet 2015. I spent a couple of days at the St James’s University Hospital where our own CSSANZ trainee Tamara Mullaney looked me after. Unfortunately, Professor Sagar was on leave. I was able to attend ward rounds with Tamara and later theatre to observe Tamara and Aaron Quyn undertake an exenteration with sacrectomy for locally advanced rectal cancer followed by a bilateral IGAM flap with vaginal reconstruction by the plastics team. I then stayed overnight with Tamara who cooked up an amazing dish from the New Zealand MasterChef cookbook! The following morning I visited the paediatric colorectal theatre at the Royal Infirmary to observe a robotic ventral mesh rectopexy by Julian Hance and consultant paediatric surgeon Jonathan Sutcliffe. Basingstoke Hospital, Basingstoke Following my visit to Leeds I went on to Basingstoke hospital hosted by Brendan Moran. Interestingly at the same time, there was a visiting fellow from South Africa Claire Warden, who was the first female colorectal surgeon to qualify in South Africa. The visit started with a peritoneal malignancy MDT meeting. This was an extremely efficient meeting particularly given the sheer volume of referrals that the unit receives. I particularly liked the real-time dictation by the consultant in charge of the case following each case discussion to ensure that the outcome of the meeting was accurately and immediately documented and sent to the referring team without delay. Following the meeting, I went to theatre where another of the CSSANZ trainees Louise Clark was working with consultant Alex Tzivanikis. It was really great to see such a cohesive surgical unit. All of the surgeons in the unit perform the cases in the same order/method and after a period of time, to ensure they are not fatigued, are relieved by other consultants who are able then to carry on with the operation. Following theatre, I attended the private hospital peritoneal malignancy MDT meeting. Again, the sheer volume of referrals was amazing including from a number of overseas countries. I was then able to see a couple of post-operative patients on the ward with Brenda Moran. It was great to see how well patients were progressing even day 1, given the nature of the surgery. In the evening Brendan and his wife Karina very kindly invited me along with the other colorectal fellows to their house for a drink and then to a local pub for dinner. The countryside in Basingstoke was just beautiful. The following morning, I attended the colorectal MDT and then to theatre. Two theatres were running concurrently. I observed a right hemicolectomy with peritonectomy for LGAM. Following theatre, I attended the consultant outpatient clinic with Brendan Moran.  The cases were very interesting and varied including a patient referred for management of benign mesothelioma and a patient with pseudomyxoma following an appendicectomy with LGAM many years prior. The consults ended with dictating a letter in front of the patient, with a copy cc’d to the patient. This gave the opportunity for the patient to sit and listen to the synopsis of their case and it was completely transparent. St Mark’s Hospital, London From Basingstoke, I travelled back to London to visit St Mark’s Hospital. I had worked at Northwick Park Hospital as a pharmacist over 15 years ago and had actually dispensed medications for St Mark’s! The day began with the grand round/research meeting where Stella Dilke presented her work on anterior resection syndrome as part of her PhD which was very interesting. I then went to an IBD multidisciplinary meeting and then to theatre. Jamish Gandhi, another of the CSSANZ trainees with Danilo Miskovic was performing a robotic anterior resection with Danilo Miskovic. I was also able to observe a novel method of treating rectovaginal fistulas with Janindra Warusavitarne Rectovaginal fistula (DCR - Dis Colon Rectum. 2018 Jan;61(1):140-143). The following week I came back to St Mark’s to visit Jeff Moore and Sue Clark’s organoid laboratory. I gave a presentation about my PhD project at a lab meeting and was able to hear about the exciting work that they are doing with organoids in FAP patients. The Royal Marsden Hospital, London My final visit was with the both the Sarcoma unit at the Royal Marsden Hospital and briefly with the colorectal unit. It was a great experience with the sarcoma unit to discuss the complex management of cases such as anorectal melanoma, locally advanced rectal GIST tumours and retroperitoneal sarcomas. I attended a ward round with Myles Smith and Andrew Hayes and followed by an outpatient clinic where I was able to observe a number of interesting consults with sarcoma patients. Following clinic, I spent some time in theatre with the colorectal team along with 2 observers from John Hopkins. We observed an exenteration by Christos Kontovounisios and high sacrectomy by Paris Tekkis. The following day I attended a see and treat skin clinic followed by their multidisciplinary meeting and pathology meeting, which again had diverse and interesting sarcoma cases. Finally, just prior to leaving the UK I was involved in a teleconference for the Tripartite 2020 Vision Steering Group. This initiative is so exciting with the goal of developing a mutual and internationally relevant research agenda in colorectal surgery, based on shared professional and patient priorities (https://www.surveymonkey.co.uk/r/Tripartite2020Vision - please enter your research questions!). The chance to visit 5 colorectal units, attend the ACPGBI and involvement in the Tripartite 2020 Vision Steering group has made me look forward with great excitement at the prospect of a fellowship in the UK, and on completion of my colorectal training being part of the global community of colorectal surgeons.

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