09 September 2019

ACPGBI Travelling Fellowship – Visit to Western University and London Health Sciences Centre - Canadian Surgical Technologies & Advanced Robotics Centre, London, Ontario, Canada (23rd August – 30th August 2019)
Michael Kelly BA MB BCh MCh MRCS

Background I am currently a ST7 based in the Mater University Hospital, Dublin. I have an interest in the management of complex pelvic malignancies, and want more exposure in the selective use of minimally invasive platforms. The ACPGBI kindly awarded me a £2500 fellowship to visit the Western University and London Health Science Centre and the Canadian Surgical Technologies & Advanced Robotics Centre in London, Ontario, Canada. University Hospital – London, Ontario Western University and London Health Science Centre Western University and London Health Science Centre is a large hospital network based in London, Ontario. It is a merger of two major teaching hospitals (University Hospital and Victoria Hospital) and London’s Children’s Hospital. Together, these centres make up one of Canada’s largest acute-care teaching hospitals. Its legacy dates back to 1882, and is closely related to the University of Western Ontario (Now the Western University). London Health Science Centre is the largest employer in London, with over 15,000 healthcare staff providing care for over one million patients per year. Through the affiliation with Western University and the co-association with 30 other educational institutions, London Health Science Centre trains more than 1,800 medical and health care professionals per year. Canadian Surgical Technologies & Advanced Robotics Centre (CSTAR) CSTAR first opened in 2000. It is one of four Canadian Accredited Educational Institutions of the American College of Surgeons that delivers a team-based simulation program. In addition, CSTAR is a world-leading centre for research, development, testing, and delivery of simulation training for minimally invasive surgical technologies. It is the only Canadian training centre and one of eight international centres that utilizes da Vinci® Surgical to certify surgeons skills. Host: Dr. Nawar Alkhamesi MD, PhD, FRCS, FRCSC, FACS, FASCRS Dr Nawar Alkhamesi is a Colorectal Surgeon who specializes in minimally invasive colorectal and acute-care general surgery. He completed his basic surgical training at Imperial College London, UK. Subsequently, he received his PhD under the mentorship of Prof. Ara Darzi on the development of peritoneal aerosolization in minimally invasive surgery. Furthermore, he completed his higher surgical training and colorectal fellowship at St. Mark’s Hospital London. It was at this point that he initially came over to London Ontario to undertake a fellowship in minimal invasive and robotic colorectal surgery. He returned to a consultant position in Imperial College London, UK where he worked at The Royal Marsden, Chelsea & Westminster, Charing Cross and St. Mary’s Hospitals. In 2014 he was appointed an Associate Professorship in the London Health Sciences Centre, Canada as a specialist Colorectal and General Surgeon. My Experience: During this week, I was welcomed and had the opportunity to participate in several clinical and academic activities. The first day started with a meeting with Dr. Alkhamesi and an introduction to the rest of the department. Morning rounds were completed and then we proceeded to out-patient for the day It was immediately clear from the outset, that this unit provides a busy on-call service to a vast population, many of whom seek medical/surgical attention at very late stages of their diagnosis. The first few patients seen in the Monday OPD were perforated colonic tumours, all in the early stages of post-operative recovery. It was apparent that a substantial proportion of patients had extremely high body mass index, adding to the complexity of surgery. The OPD service in London was both consultant lead and driven, with Dr. Alkhamesi seeing a very large volume of patients by himself. I was impressed by the medical students attached to his service, as they were integrated into the unit, consulted patients and presented cases to the team. Their involvement in the clinical care is more active than the medical students in Ireland. The majority of Dr. Alkhamesi‘s elective practice involves advanced rectal cancer, many of whom have underwent minimal invasive surgery, even in the setting of elevated BMI. He was very open to discussing the differences between the British and Canadian system, especially regarding follow-up surveillance protocols that are heavily influenced by Canadian healthcare coverage rules. Differences in the use of mechanical bowel preparation, preoperative antibiotics, enhanced recovery protocols, and surgical approaches/techniques were other topics discussed. Powerhouse Brewery, London - Ontario The following day, I had the opportunity to observe an all-day endoscopic list. That evening over dinner and sampling of the local micro-breweries, Dr Alkhamesi and I further discussed the contrasting differences in the Irish/British and Canadian surgical training schemes. I find it interesting and encouraging to hear a colleague’s story and pathway along his surgical training. We also discussed the referral pathways for recurrent rectal cancers needing pelvic exenteration and/or cytoreductive surgery (+/-HIPEC). On Wednesday morning, there was a dedicated resident training from 7am to 8am. During this time, one resident presented recent on-call cases (two bowel obstructions – one colo-colonic intussusception and one small bowel intussusception). Then, the senior consultants extensively quizzed the viewing residents on aspects of management and surgical care to prepare the senior residents for their end of training exams (Boards). Later that day, I was given a tour of both CSTAR and Western University facilities. CSTAR has several large laboratories for high-quality training. It has resources ranging including basic medical and surgical task trainers, virtual reality simulators, and high-fidelity simulation environments. It also operates a collaborative research program between London Health Science Centre, Lawson Health Research Institute and Medical & Engineering departments at Western University providing an open environment for interaction between surgeons, engineers, and medical students, with whom I had the opportunity to discuss their research projects. Wet Lab Facilities Overall, it has a $20 million research budget to fund research on minimally invasive, image-guided and robotic-assisted technologies for surgical management and simulation training. The residents have an unique opportunity to utilize the simulation lab for training in surgery, critical care and endoscopic techniques. One full morning per week they have formal training that is mandatory in both the wet and dry labs.     Set-up for Resident Training Thursday morning started with the advanced malignances MDT (Tumour Boards). This MDT involved a teleconference between University Hospital and Victoria Hospital with 4-5 peripheral units. Advanced rectal, pancreatic, and retroperitoneal malignancies were discussed, with excellent radiological input and teaching. An obvious difference with our own MDT was the minimal involvement from the histopathology unit. I later learned that this is an issue across Canada, as there is a lack of funding for the histopathological involvement in MDT. I participated in another busy clinic with a mixture of general and complex coloproctology patients. On Friday, there was a robotic panproctocolectomy for familial adenomatous polyposis in a young female, for which Dr. Alkhamesi divided the operation into three parts for the senior resident, the fellow, and himself. Overall, the level of teaching, training and opportunity for residents and surgical fellows is excellent. Friday evening I made my way back to Toronto. I had the opportunity to stop in Sunnybrook and University of Toronto and discuss their surgical oncology program. I met with several international fellows and heard about their training and the regional service for advanced rectal cancers. I hope they will also participate with PelvEx Collaborative in future research projects. Downtown Toronto Skyline Summary: In summary, this was an invaluable experience to an excellent colorectal unit providing care to a large region in Ontario, Canada. CSTAR is an impressive unit, with extensive budget facilitating research on minimally invasive, image-guided and robotic-assisted technologies for patient treatment and simulation training. The surgical training in Canada is focused, with good academic and surgical skill acquisition. Overall, the visit provided useful exposure and discussions regarding differences in healthcare systems and training. In addition, I hope that I have built new collaborative networks. I am thankful to ACPGBI for facilitating the opportunity to travel on this trip.    

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