Surgical professionalism in the 21st century.
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Clinical Competence↗
Biomedical subjects
Peter McCulloch
Publications and source records attributed to Peter McCulloch.
The role of surgery in patients with advanced gastric cancer.
Surgery remains the mainstay of treatment with curative intent for established gastric cancer. Patient selection is critical to achieving satisfactory outcomes, and involves careful assessment of both patient fitness and disease stage. Staging techniques have multiplied and become much more sensitive in recent years. Current best practice involves a combination of spiral CT scan, Endoscopic ultrasound, PET scanning and laparoscopy. Only a minority of patients progress to potentially curative surgery after staging and fitness assessment in Western centres. Conventional treatment involves a distal subtotal gastrectomy or total gastrectomy depending on the site of the lesion. Innovative techniques include the Merendino operation, and pylorus and nerve sparing gastrectomies for earlier stage disease in the proximal and distal stomach, respectively. There is evidence of nutritional and quality of life benefit in the first 2 years after surgery from formation of a gastric substitute reservoir. Laparoscopic resection is well established in Japan and is developing rapidly elsewhere but its role and outcomes are not yet well defined. Radical lymph node dissection remains controversial: randomised trial evidence of overall benefit is lacking, but expert series have produced excellent results, and there are indications of a sub-group benefit for patients with stage II and III disease. The increased morbidity and mortality associated with radical dissection appear to be largely attributable to pancreatic and splenic resection together with limitations in Unit expertise. Surgical palliation has become less important in recent years as interventional radiology and endoscopy techniques have been developed for the same purposes. Overall mortality and survival results have improved dramatically over the last 20 years, but interpretation of these figures is made difficult by major changes in staging and case selection. The chances of long-term survival are, however, clearly much greater, and those of peri-operative death much less for an individual patient accepted for surgery in 2006 than they would have been in 1986.
Gastrectomy↗
Teaching evidence-based decision-making.
Evidence-based decision-making is important in surgery, but the nature of the work makes it difficult. Teaching it requires an interactive approach with a clinical team willing to consider it seriously,and to derive practical solutions. Decision-making and its influences must be understood, so that surgeons have a realistic idea of the role of evidence. Cognitive factors are particularly important.Strategies developed in the context of this knowledge are more likely to be adopted and used. Experts must be involved in searching for evidence and members of the management team in the learning process, the former to provide expertise on searching,the latter to ensure that the reasons for proposed changes are understood and treated sympathetically by those with financial control.
Attitude of Health Personnel↗
Finding and appraising evidence.
Surgeons have tended to regard evidence-based medicine with a degree of skepticism. A variety of reasons for this have been proposed,ranging from the surgical personality to the nature of the research questions that occur when studying surgical treatment. The relative paucity of randomized trials of surgical treatment has been noted by many investigators, and there has been considerable debate about whether this reflects poorly on the scientific education of the surgical community or points to special problems in applying this methodology in this discipline. This debate has matured over the last 10 years, and there is now greater understanding of the factors that make surgical operations difficult subjects for randomized trials; on the other hand, such trials are being done now more than ever before.
Evidence-Based Medicine↗
Optimal method for isolation of human peritoneal mesothelial cells from clinical samples of omentum.
INTRODUCTION: Human peritoneal mesothelial cells (HPMC) are a valuable research tool for understanding the molecular biology of several pathologies, in both monolayer and three dimensional models. We compared different methods of HPMC isolation and assessed their outcome as well as fibroblast contamination, a common problem encountered during isolation. METHODS: 1-3cm(3) samples of omentum were collected from 40 consenting patients undergoing elective gastrointestinal surgery. A total of 11 samples were incubated in 0.05% trypsin solution for 20 minutes at 37 degrees C (group A) and 29 in 0.25% trypsin (15 samples for 10 minutes (group B) and 14 for 20 minutes (group C)). Following digestion cells were re-suspended and cultured in supplemented Ham's F-12 medium containing 10% foetal calf serum (FCS), penicillin-streptomycin, glutamine, insulin, transferrin and hydrocortisone. Positive outcomes were absence of fibroblast contamination and satisfactory HPMC growth to confluence in a characteristic cobblestone pattern. Cytokeratins 5, 8, 18, Vimentin, Ber-Ep4 and Factor VIII were used to characterise HPMC and fibroblasts by immunohistochemistry. RESULTS: None of the 11 samples in group A yielded HPMC. 14 of 29 samples digested with 0.25% trypsin yielded HPMC: 10 of 14 yielded HPMC in group C versus four of 15 samples in group B (p = 0.02). Fibroblast contamination occurred in eight samples in group B versus three in group C. CONCLUSION: Optimal results are achieved with a 20 minute digestion in 0.25% trypsin. Fibroblast contamination could not be avoided completely. Other factors may minimise fibroblast contamination such as minimal tissue manipulation and early collection during surgery.
Cell Culture Techniques↗
The laws of diminishing objectivity.
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Attitude of Health Personnel↗
Gentronix.
Gentronix is an innovative biotechnology company with the aim of providing cell-based assays and systems to ease or remove some of the current bottlenecks in preclinical drug discovery and development. Gentronix's first product, GreenScreen trade mark GC, is a combined genotoxicity and cytotoxicity test designed for high-throughput screening of new pharmaceutical lead compounds, giving drug development scientists a cost-effective preview of the battery of mandatory regulatory genotoxicity tests. Future products based on the company's extensive intellectual property rights portfolio will combine the company's expertise in cellular biosensor systems with novel optical detection technology to deliver a range of products for other applications within drug discovery, as well as industrial and environmental monitoring of toxic chemicals.
Biosensing Techniques↗
Mortality and morbidity in gastro-oesophageal cancer surgery: initial results of ASCOT multicentre prospective cohort study.
OBJECTIVE: To evaluate the effect of comorbidity and other risk factors on postoperative mortality and morbidity in patients undergoing major oesophageal and gastric surgery. DESIGN: Multicentre cohort study with data on postoperative mortality and morbidity in hospital. DATA SOURCE AND METHODS: The ASCOT prospective database, comprising 2087 patients with newly diagnosed oesophageal and gastric cancer in 24 hospitals in England and Wales between 1 January 1999 and 31 December 2002. Multivariate logistic regression analysis was used to model the risk of death and postoperative complications. RESULTS: 955 patients underwent oesophagectomy or gastrectomy. Of these, 253 (27%) were graded ASA III or IV, and 187 (20%) had a high physiological POSSUM score (>or= 20). Operative mortality was 12% (111/955). Physiological POSSUM score, surgeon's assessment, type of operation, hospital case volume, and tumour stage independently predicted operative mortality. Medical complications were associated with higher physiological POSSUM scores and ASA grade, oesophagectomy or total gastrectomy, thoracotomy, and radical nodal dissection. Stage and additional organ resection predicted surgical (technical) complications. CONCLUSIONS: Many patients undergoing surgery for gastro-oesophageal cancer have major comorbid disease, which strongly influences their risk of postoperative death. Technical complications do not seem to be influenced by preoperative factors but reflect the extent of surgery and perhaps surgical judgment. Detailed prospective multicentre cooperative audit, with appropriate risk adjustment, is fundamental in the evaluation of cancer care and must be properly resourced.
Adult↗
Mortality control charts for comparing performance of surgical units: validation study using hospital mortality data.
OBJECTIVE: To design and validate a statistical method for evaluating the performance of surgical units that adjusts for case volume and case mix. DESIGN: Validation study using routinely collected data on in-hospital mortality. DATA SOURCES: Two UK databases, the ASCOT prospective database and the risk scoring collaborative (RISC) database, covering 1042 patients undergoing surgery in 29 hospitals for gastro-oesophageal cancer between 1995 and 2000. STATISTICAL ANALYSIS: A two level hierarchical logistic regression model was used to adjust each unit's operative mortality for case mix. Crude or adjusted operative mortality was plotted on mortality control charts (a graphical representation of surgical performance) as a function of number of operations. Control limits defined as 90%, 95%, and 99% confidence intervals identified units whose performance diverged significantly from the mean. RESULTS: The mean in-hospital mortality was 12% (range 0% to 50%). The case volume of the units ranged from one to 55 cases a year. When crude figures were plotted on the mortality control chart, four units lay outside the 90% control limit, including two outside the 95% limit. When operative mortality was adjusted for risk, three units lay outside the 90% limit and one outside the 95% limit. The model fitted the data well and had adequate discrimination (area under the receiver operating characteristics curve 0.78). CONCLUSIONS: The mortality control chart is an accurate, risk adjusted means of identifying units whose surgical performance, in terms of operative mortality, diverges significantly from the population mean. It gives an early warning of divergent performance. It could be adapted to monitor performance across various specialties.
Hospital Mortality↗
The effects of an awareness-raising program for patients and primary care physicians on the early detection of gastro-oesophageal cancer.
OBJECTIVE: To test the efficacy of education by home letter, together with improved specialist/GP liaison, in promoting the detection of treatable gastro-oesophageal cancer in patients over 40. DESIGN: Prospective non-randomized trial with matched control group. PARTICIPANTS: 37,500 individuals over 40, registered with 12 general practices, were sent yearly letters for 3 consecutive years, advising them to consult a doctor with 4 specific symptoms. A matched control population of 60,500 received no intervention. MAIN OUTCOME MEASURES: Cancer cases were identified from cancer registry data, and the stage distribution and operability rates calculated from review of hospital case notes. RESULTS: Twenty of 59 cancer patients in the study group (34%) and 42 of 125 in the control group (34%) underwent resections; 24% (14/59) of study group and 18% (23/125) of control patients had "curable" disease (odds ratio [OR]= 1.51 [95%CI 0.71-3.23], X(2) = 1.164, P = 0.28). In year 1 of the study, 11 of 20 (55%) study group patients underwent resection compared to P 10 of 38 (26%) control group patients (P = 0.045, Fisher's exact test, OR = 3.4 [95% CI 1.09-0.7]). In year 1, 8 of 20 study patients (40%) had "curable" disease compared to 10.5% (4/38) control patients (P = 0.0128 Fisher's exact test, OR = 5.67 [95% CI 1.44 - 22.3]). There was no difference in survival between the groups overall or on comparing each year of study. CONCLUSION: This intervention caused a transient marked improvement in resection rate and curability, but the longer term impact on stage and resection rate was nonsignificant, and survival was not affected. Improving the detection of curable upper GI cancer is likely to require more complex and intensive interventions.
Adult↗
Randomised trials in surgery: problems and possible solutions.
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Humans↗
Stomach cancer.
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Chemotherapy, Adjuvant↗
Stomach cancer.
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Chemotherapy, Adjuvant↗