2018 ACPGBI Travelling Fellowship Report by Claire Warden – Colorectal Surgeon, Cape Town, South Africa

Posted 10 September 2018 in

South Africa is a nation currently reviewing and drawing up new policy on developing an equitable national health system. Our current system has significant disparities in access and delivery of surgical care. We are particularly short of general surgeons and specialist colorectal surgeons.

From left to right: Brendan Moran, Claire Warden and Cori Behrenbruch (Australian travelling fellow)
From left to right: Brendan Moran, Claire Warden and Cori Behrenbruch (Australian travelling fellow)

The colorectal surgical community in South Africa is small but growing in strength and number. A collaboration between the Association of Coloproctology Great Britain and Ireland (ACPGBI) and the South African Colorectal Society (SACRS) has created a unique opportunity to develop and share surgical knowledge and skill. I am particularly grateful to both these societies for allowing me this incredible opportunity.

The main aim of my visit was to develop my laparoscopic colorectal surgical skills. This opportunity far exceeded my expectations.

The trip began with the ACPGBI congress in Birmingham. I was honoured to be invited to the president’s welcome dinner. A special mention of thanks must go to Professor James Hill for allowing me to share a table with many of the colorectal experts in the field. There were many present that evening who had spent a great deal of time assisting and putting together an outstanding academic programme for the 2018 meeting.

The quality of the presentations over the next three days was of a high standard. It was encouraging to see the level of collaboration in various research endeavours. The National Health System (NHS) is a useful platform for collective, multisite and multidisciplinary research. The parastomal hernia session left me with many questions but I was encouraged to see a core group of surgeons keen to do research in this area. The pelvic floor mesh controversy is still ongoing and it will be important to watch the outcome of various patient-driven inquests. The various video and top-tips sessions were excellent with much advice to heed.

It was great to have dinner with old friends from Southampton and new friends from Plymouth hospitals. It is amazing what research collaborative ideas can be dreamed up over dinner. I learnt from the “Movers and Shakers” session that, despite stellar academic careers, colorectal surgeons are able to maintain their sense of humour (ask anyone who saw the session about “star jumps” and “the red chair”).

The rest of my stay involved spending time in theatres at Cambridge, Basingstoke and Plymouth. Each theatre was a melting pot of international team members who had perfected the art of teamwork.

I was privileged to spend two days in theatre at Addenbrookes, Cambridge. Nicola Fearnhead, Michael Powar and James Wheeler very kindly welcomed me into their operating theatres. I was able to observe cases of sacral nerve stimulation and learn more about the current trials in this area. It was excellent to watch the surgeons talk their trainees through laparoscopic cases. Although there is much to learn from published data, there is still much to gain from chatting through individual surgeon experiences with complex surgical cases.

Basingstoke is an amazing hospital with an incredible colorectal surgical history. Brendan Moran leads an enthusiastic team of surgeons that has developed on the legacy of Bill Heald and the total mesorectal excision. There is sound institutional knowledge in dealing with complex colorectal cases. I felt very privileged to join the teams in multidisciplinary meetings and in theatre. I learnt so much from the discussion of cases before surgery and in the operating theatre. Both about surgical and hyperthermic intraperitoneal chemotherapy techniques. A special thanks to Tom Cecil, Sanjeev Dayal and Alex Tzivanakis. Brendan Moran is an excellent host and kindly gifted me a signed copy of the ‘Manual of Total Mesorectal Excision’.

The last part of my journey took me to Plymouth. Walter Douie went out of his way to ensure that I was made to feel welcome and part of the surgical team for a month. I had an incredibly productive time in the operating theatre. I was welcomed into theatre with Mark Coleman, Walter Douie, Chris Gandy, Rajesh Thengungal Kochupapy, Chris Oppong and Sebastian Smolarek. They all never seemed to get tired of discussing cases and surgical technique. Spending between four and five days a week in the operating room was exhilarating and time very well spent. I’m quite sure I was witness to every single type of colorectal operation that could and ever will be done laparoscopically.

I got to observe just how seriously the ACPGBI/NHS takes surgical training. The Plymouth colorectal team had been chosen as one of the first five pilot centres to be trained in the art of Transanal Total Mesorectal Excision (TaTME). This is a thorough process of teaching modules, cadaveric workshops, clinical mentorship, clinical outcomes data and objective assessments (12-month process). I was very impressed with Steve Arnold, from Basingstoke, proctoring Mark Coleman through his fifth and final TaTME training case. This seems worlds away from the old system of “see one, do one, teach one”.

There is much that we can learn and adapt to our South African setting. The TaTME, colonoscopy bowel screening and laparoscopic colorectal training programmes are fine examples.

I must extend a very special thank you to the stellar “Derriford theatre two surgical team”. This team were exemplary from the early morning team brief right through to the debrief at the end of a surgical day. One could tell that each member felt valued and thus contributed to patients feeling and being safe in the theatre.

I would highly recommend this opportunity to South African colorectal surgeons. There is much to gain from visiting these high-volume centres of excellence. Seeing the NHS at work gives me much hope that a similar system can be developed in South Africa that offers the same level of quality care to all South Africans.