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Keywords:

  • Gastrointestinal procedures;
  • gynaecological oncology surgery;
  • perioperative morbidity and mortality;
  • subspecialty training;
  • survival outcome

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Disclosure of interests
  8. Contribution to authorship
  9. Details of ethics approval
  10. Funding
  11. Acknowledgements
  12. References
  13. Commentary on ‘Surgical training in gastrointestinal procedures within a UK gynaecological oncology subspecialty programme’

Objective  An analysis of surgical experience in gastrointestinal procedures within a UK-based gynaecological oncology centre to which subspecialty fellows within the subject are exposed.

Design  Retrospective study.

Setting  Northern Gynaecological Oncology Centre, Gateshead, UK.

Population  All women undergoing bowel surgery over a six-year period, 1 January 2000 to 31 December 2005.

Methods  Cases were analysed by specialty and grade of surgeon performing the procedure.

Main outcome measure  Proportion of cases to which subspecialty fellows were exposed.

Results  Two hundred and sixty-two women (11.5%) underwent bowel surgery out of 2280 women undergoing major surgery for gynaecological cancer. This included ovarian/primary peritoneal cancer in 186 women (71%). Of these 262 cases, 238 operations (91%) were performed by a gynaecological oncologist, 20 (7.5%) were performed jointly with the gastrointestinal surgeons and four (1.5%) were performed solely by the gastrointestinal surgeons. A gynaecological oncology subspecialty fellow performed 21 (8%) and assisted in an additional 204 operations (78%). Perioperative morbidity and mortality statistics in addition to overall survival outcomes were comparable to the published literature.

Conclusions  A significant proportion of major surgical operations performed within a gynaecological oncology centre require gastrointestinal procedures. The majority of these procedures can be performed by gynaecological oncologists with an acceptable perioperative morbidity and mortality rate. Subspecialty training has the potential to allow trainees significant exposure to these procedures. An accredited post-Fellowship Training Programme can provide the opportunity for hands-on experience to allow gynaecological oncologists the confidence and credibility to perform these procedures independently.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Disclosure of interests
  8. Contribution to authorship
  9. Details of ethics approval
  10. Funding
  11. Acknowledgements
  12. References
  13. Commentary on ‘Surgical training in gastrointestinal procedures within a UK gynaecological oncology subspecialty programme’

The Royal College of Obstetricians and Gynaecologists (RCOG) introduced subspecialty training in Gynaecological Oncology in 1984 following recognition of the clinical expertise and associated need for specialist training in the management of gynaecological malignancies. A comprehensive syllabus of core knowledge within the subject was described and a list of modules and common surgical procedures was produced.1 Research experience and outcomes were also identified although minimum requirements for these have changed over recent years. Entry into the programme required registration with the RCOG, which was followed by a formal mid-term and end-of training RCOG visit to ensure entry of high-calibre candidates, and satisfactory progress and completion of training, including experience of an adequate range and number of surgical procedures, although this has now progressed to competency-based assessments.

Following the centralisation of gynaecological cancers to cancer centres via cancer networks and the expansion in the number of gynaecological oncologists within the UK, many gynaecological oncologists have seen a change in the case-load and case-mix presenting to them with a gradual dilution of cervix and vulva cancer cases by a significant increase in the number of ovarian cancers.

The surgical training requirements for the management of ovarian cancer are considerably different from those for other gynaecological malignancies; particularly challenging is the greater emphasis on carrying out procedures in the mid- and upper abdomen for the performance of successful debulking surgery to achieve optimal/complete cytoreduction. Despite these specific challenges in relation to ovarian cancer surgery, there have been few changes or additions to the Subspecialty Training Programme although individual trainers and training centres have made selective modifications to their training schedules to ensure that their trainees learn and develop the skills required to practise independently and safely while continuing to offer a range of procedures to women in the successful treatment of the disease.

This retrospective study provides a descriptive analysis of the surgical experience in gastrointestinal procedures to which subspecialty fellows within the subject are exposed within a UK-based Gynaecological Oncology Centre.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Disclosure of interests
  8. Contribution to authorship
  9. Details of ethics approval
  10. Funding
  11. Acknowledgements
  12. References
  13. Commentary on ‘Surgical training in gastrointestinal procedures within a UK gynaecological oncology subspecialty programme’

All major surgical procedures carried out within the six-year period from 1 January 2000 to 31 December 2005 were identified following interrogation of a Departmental Database/Clinical Information System on which all the surgical procedures performed within the department were prospectively registered. The operation notes for all women were then inspected to determine performance of bowel-related procedures. For these women, the case-notes were then examined and information was extracted relating to patient demographics, date of procedure, indication for surgery, procedure performed, achievement of optimal/complete cytoreduction for all ovarian cancers, primary cancer site, specialist performing the procedure, grade of surgeon, presence of subspecialty training fellow, perioperative complications and outcome survival. Optimal cytoreduction was defined as <1 cm residual disease and complete cytoreduction was defined as removal of all visible disease. Standardised departmental protocols and operation notes ensured that this information was stated for all cases undergoing ovarian cancer surgery at the time of surgery and was cross-checked for completeness at the time of the post-surgery multi-disciplinary team discussions. All statistical tests were performed using spss® Version 17 (SPSS Inc, Chicago, IL, USA). Survival curves were constructed using the Kaplan–Meier method. Results relating to perioperative complication rates were compared with the published literature.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Disclosure of interests
  8. Contribution to authorship
  9. Details of ethics approval
  10. Funding
  11. Acknowledgements
  12. References
  13. Commentary on ‘Surgical training in gastrointestinal procedures within a UK gynaecological oncology subspecialty programme’

During the study period a total of 262 women (11.5%) underwent bowel surgery out of 2280 women undergoing major surgery for gynaecological cancer. The main indications for performing bowel surgery included management of primary disease, surgery for recurrent disease, management of radiotherapy complications and palliative treatment, see Table 1. The median age at the time of surgery was 62 years (range 22–99). The most common diagnosis was ovarian and primary peritoneal cancer in 186 women (71%). Twenty-four (9%) women had cervical cancer, 19 (7%) had endometrial cancer, 12 (5%) had vulval cancer and ten (4%) had vaginal cancer (Table 2).

Table 1.   Indications for bowel procedures
IndicationNumberPercentage
Primary treatment19173
Recurrent disease (active treatment)4517
Radiotherapy-related complications73
Palliative treatment197
Table 2.   Number of procedures by tumour site
Primary tumourNumberPercentage
Ovary and primary peritoneal18671
Cervix249
Endometrium197
Vulva125
Vagina104
Other114
Total262 

The optimal cytoreduction rate for women undergoing bowel surgery at primary surgery for ovarian and primary peritoneal cancers was 74%. The optimal cytoreduction rate for recurrent ovarian cancer undergoing bowel surgery was 69%.

The majority of operations were performed solely by a gynaecological oncologist (238 [91%]) in the absence of a gastrointestinal (GI) surgeon, 20 cases (7.5%) were performed jointly with the gastrointestinal surgeons and four cases (1.5%) were performed solely by the gastrointestinal surgeons. A gynaecological oncologist subspecialty fellow performed 21 (8%) and assisted in an additional 204 surgeries (78%). Details of the types of bowel procedures performed are given in Table 3.

Table 3.   Frequency of bowel procedures performed
ProcedureNumber
  1. Some women underwent more than one procedure.

Rectosigmoid colectomy54
Right hemicolectomy18
Bypass procedures5
Colostomy only31
Small bowel resection and anastomosis66
Large bowel resection and anastomosis18
Anovulvectomy and colostomy12
Ileal conduit19
Exenteration – anterior/posterior or total (cervix, endometrium)17
Reversal of ileostomy17
Reversal of colostomy5
Repair of injury to small bowel29
Repair of injury to large bowel17
Splenectomy6
Appendicectomy22
Total336

Postoperative adverse events included: 11 (4%) deaths within 30 days of surgery, four had an acute cardiovascular event (myocardial infarction), three had sepsis, two had pulmonary emboli and two had cerebrovascular accidents. Thirteen women were managed with febrile morbidity and there were three cases with anastomosis leak. Twelve women were managed for wound infections and one woman (0.4%) had wound dehiscence (Table 4). Table 4 also includes comparison with the published literature of gynaecological oncologists performing colorectal procedures on women with gynaecological cancers and of colorectal surgeons performing colorectal procedures on women with primary colorectal problems.2–13

Table 4.   Postoperative complications
VariableNumberPercentageGynaecological oncologist (ten publications) (%)Gastrointestinal surgeon (12 publications ) (%)
  1. = 262 except when indicated by an asterisk.

Haemorrhage103.84.7–6.72.2
Respiratory distress/atelectasis31120.8–7N/A
Pulmonary embolism20.70–6.4N/A
Febrile morbidity1350.3–17N/A
Sepsis31.11.2–134.6–10.5
Leakage of anastomosis33.3 (3/89)*0–5.23.2–9.8
Cardiovascular complications41.51.6–16N/A
Cerebrovascular accident20.760.8–2N/A
Bowel obstruction51.90.7–2.25.7–7.1
Wound infection124.54–21N/A
Wound dehiscence10.41.41.1–5
Ileus103.82–17N/A
Conduit necrosis15.2 (1/19)*4N/A
Fistula31.10.7–3.81.5
Postoperative death114.12.2–81–2.4

The overall postoperative median survival for women undergoing primary surgery for Stage 3 and 4 ovarian and primary peritoneal cancers was 50 months (CI 44–55). The median survival for women with recurrent ovarian cancer was 48 months from the date of surgery (CI 38–58) and the median survival for women undergoing bowel surgery for palliation was nine months (CI 5–13) (Figure 1).

image

Figure 1.  Survival curve for Stage 3 and 4 ovarian cancer and primary peritoneal cancer undergoing cytoreductive surgery and requiring bowel procedure.

Download figure to PowerPoint

For women with cervical cancer (the majority of whom had bowel surgery for recurrence or in the management of radiotherapy-related complication) the median survival was 25 months (CI 12–36). The median survival for women with endometrial cancer was 77 months (CI 63–81) and for those with vulval cancer the median survival was 49 months (CI 30–51).

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Disclosure of interests
  8. Contribution to authorship
  9. Details of ethics approval
  10. Funding
  11. Acknowledgements
  12. References
  13. Commentary on ‘Surgical training in gastrointestinal procedures within a UK gynaecological oncology subspecialty programme’

This review has shown that a significant proportion (11.5%) of major surgical operations performed within The Northern Gynaecological Oncology Centre require gastrointestinal procedures. The majority of these procedures contribute to surgical debulking of high-stage epithelial ovarian cancer and primary peritoneal cancer at primary presentation and recurrent disease. With adequate training, these procedures can be performed by gynaecological oncologists with acceptable perioperative morbidity and mortality rates. The outcomes for these women are excellent with a median survival for women with primary ovarian cancer exceeding four years.

Gynaecological oncology subspecialty fellows appear to be well exposed to these procedures having performed 8% of surgeries and been present during the procedure in an additional 78% of women. Their training is also supplemented by a four-week module in Gastrointestinal Surgery where they are formally scheduled to colorectal and upper gastrointestinal surgery; our programme includes additional training where the fellows are required to attend a recognised Anastomosis Course and the Care of the Critically Ill Surgical Patient (CCrISP®) course.

The range of procedures performed includes rectosigmoid colectomy, total colectomy, right hemicolectomy, small bowel resection, small and large bowel anastomosis, formation of end colostomy and loop ileostomy/colostomy, reversal of ileostomy/colostomy, bypass procedures, splenectomy, formation of ileal conduit and anovulvectomy.

Previous publications from various countries, including the USA, Australia, Japan, France, Italy, South Africa, Singapore, China and Turkey, show similar rates of performance of gastrointestinal procedures in the management of gynaecological malignancies with similar complication rates.3–21 However, as far as we are aware, this is the first publication from a recognised UK Gynaecological Oncology Centre.

The majority of the procedures within this review were performed primarily by a gynaecological oncologist. We believe there is great value in this because it is through their knowledge and understanding of the disease that they are best able to decide on the appropriateness of performing such procedures on an individual woman by woman basis. Whether the indication be surgical cytoreduction and the achievement of optimal/complete cytoreduction, management of bowel obstruction, correction of disease-related fistulae or radiotherapy-related complications, it is an understanding of the disease-specific behaviour of gynaecological malignancies, the relevance of the procedure in relation to further treatment and use of chemotherapy or radiotherapy, and the overall prognosis for the patient that provide the best strategy for surgical management at the time of laparotomy. This strategy is also best determined by a thorough knowledge and understanding of gastrointestinal surgical procedures and their potential benefits and risks.

Certain gastrointestinal procedures are unique to gynaecological oncology including the en-bloc resection of the rectosigmoid in continuity with the uterus, fallopian tubes and ovaries in addition to the removal of the mass of tumour encompassing all of the resected organs and tissues. Such procedures are invaluable in the achievement of clearance of ovarian cancer and the removal of all visible disease, in addition to the surgical management of disease-related rectovaginal fistulae.

In contrast, there are gastrointestinal procedures with which most gynaecological oncologists are unfamiliar, in particular, procedures requiring surgery in the upper abdomen including proximal bypass procedures. Although these procedures can be learnt through attendance at cadaver courses, some cases continue to require the need for collaboration with upper gastrointestinal surgeons.

This series is a reflection of our current surgical philosophy of managing women presenting with gynaecological malignancies and in particular ovarian cancer. It is also a reflection of the changing surgical practise in the management of ovarian cancer as a result of greater evidence in support of optimal/complete cytoreduction.22–25

Despite an intensive exposure to gastrointestinal procedures as part of a subspecialty training programme, it is our view that much of the hands-on experience required in carrying out the above procedures is obtained during an extended post-fellowship period. There are few publications on surgical training in gynaecological oncology, although Web and Weaver in 1987 stated that surgeons operating on gynaecological malignancies should be capable of dealing with intestinal surgical procedures.26 In 2004, Taylor and Hammond advocated the use of freshly killed pigs to aid surgical training and Barton et al., in 2009, advocated the use of soft-preserved cadavers.27,28 Eisenkop and Spirtos first proposed the introduction of post-fellowship training following a survey of candidate and full members of the Society of Gynecologic Oncologists.29,30 Three hundred and seventeen (83.9%) of 378 respondents favoured development of post-fellowship training and this was particularly among recently graduated fellows (P = 0.01).

We believe there is great value in the introduction of a formal post-fellowship training programme for gynaecological oncology subspecialty fellows containing clear and concise curricula and objectives. Such training would allow subspecialty fellows access to centres where there is a greater emphasis on the value of such procedures and allow them to gain sufficient confidence in carrying out these procedures independently and then build on their experiences during the subsequent years. Accreditation of such programmes would provide credibility to the skills achieved and, importantly, professional support following the development of surgical complications. Such accreditation could be provided jointly between the RCOG, British Gynaecological Cancer Society and the Royal College of Surgeons.

In conclusion, a significant proportion of major surgical operations performed within a Gynaecological Oncology Centre require gastrointestinal procedures. The majority of these procedures can be performed by gynaecological oncologists with acceptable perioperative morbidity and mortality rates. Subspecialty training has the potential to allow trainees significant exposure to these procedures. An accredited post-fellowship training programme can provide the opportunity for hands-on experience to allow gynaecological oncologists the confidence and credibility to perform these procedures independently.

Contribution to authorship

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Disclosure of interests
  8. Contribution to authorship
  9. Details of ethics approval
  10. Funding
  11. Acknowledgements
  12. References
  13. Commentary on ‘Surgical training in gastrointestinal procedures within a UK gynaecological oncology subspecialty programme’

R.N. designed the study and wrote the manuscript, B.A. collected the data and K.G. analysed the data and prepared the tables. M.K., M.M.J. and R.F. contributed to the discussions.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Disclosure of interests
  8. Contribution to authorship
  9. Details of ethics approval
  10. Funding
  11. Acknowledgements
  12. References
  13. Commentary on ‘Surgical training in gastrointestinal procedures within a UK gynaecological oncology subspecialty programme’

Commentary on ‘Surgical training in gastrointestinal procedures within a UK gynaecological oncology subspecialty programme’

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Disclosure of interests
  8. Contribution to authorship
  9. Details of ethics approval
  10. Funding
  11. Acknowledgements
  12. References
  13. Commentary on ‘Surgical training in gastrointestinal procedures within a UK gynaecological oncology subspecialty programme’

Naik et al. (on p. 26) have found that in their service, 11.5% of gynaecological oncology operations involved gastrointestinal procedures. The fact that 91% of such procedures were performed by a gynaecological oncologist in the absence of a gastrointestinal surgeon highlights the importance of training gynaecological oncologists in such procedures. It is therefore reassuring that they also found that there was adequate opportunity to involve their training Fellows in these procedures. They document that a training Fellow performed 21 operations (8%) but it is important to remember that they may not have carried out 100% of the operative procedures themselves (either manually, or mentally in terms of deciding exactly how to tackle the procedures). Nonetheless, hands-on involvement in such procedures still contributes substantially to the ‘learning curve’. Hopefully, the training Fellows were also involved in a substantial number of the other 92% of cases and therefore learnt by observation even if they did not physically carry out the procedure. However, one limitation that is not discussed is that additional important but relatively uncommon gastrointestinal procedures, such as distal pancreatectomy or hepatic resection, which are at times essential, will be challenging for training Fellows to master because they will have had little exposure to these procedures. Not only is their opportunity to learn limited, but during the time that they are out of service undertaking activities such as laboratory research (considered by some to be essential for training but viewed to be of questionable value at best by many others), procedures and adjunctive therapies evolve, so that upon their return to active training the trainees’ experience is already somewhat out of date (Eisenkop and Spirtos, Int J Gynecol Cancer 2004;14:23–34). Minimally invasive surgery for endometrial, cervical, and early-stage ovarian cancer is evolving rapidly and even for those in active practise keeping up with the changes is a challenge (Mabrouk et al. Gynecol Oncol 2009;112:501–5). An important randomised trial of laparoscopy versus laparotomy for comprehensive surgical staging of uterine cancer will soon be published, and this may well accelerate the trend towards the use of laparoscopy (Walker et al. J Clin Oncol 2009, forthcoming). Accordingly, training Fellows should at least be exposed to, and preferably should acquire, laparoscopic skills. The issue of robotics is more complicated. Although it has been reported to have some advantages, there are currently no planned randomised studies of laparoscopy versus robotics, and therefore at the present time the choice is likely to be based upon operator preference. Nonetheless, I consider it advisable that training programmes should at least expose training Fellows to the use of robotics as well as laparoscopy, and should document their experience prospectively, as in the study by Naik et al. This will enable us to establish in future whether their training experience is satisfactory, and allow us to continue developing their programme. Future oncologists will need to develop skills not only to operate, but also to maintain their knowledge and to develop clear thought processes for formulating treatment strategy. All training programmes should document the experience of their trainees and analyse it at regular intervals, as has been done so helpfully in this paper by Naik et al.

S Eisenkop 4835 Van Nuys Boulevard, Sherman Oaks, CA 91403, USA Email dobsncats@aol.com