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Great pleasure to introduce our next speaker, Mr Jim Turning is from the John Gallagher Colorectal unit here in Leeds. He's a consultant surgeon in an exam surgery and he's here to talk about us to talk to us about developing your niche. I mean, everyone I'm aware it's quite late in the day. Everyone's thirsty, probably a bit hypoglycemic and we're running late, so I'll try and be quick and I'll set a time to do that. Um, so I've been asked to talk about developing a niche and avoiding burnout. Now, th this is a very, very personal topic, obviously. Um, the niche I chose is different to other niches. You can't apply the same principles necessarily, but there probably are some things to learn, er, avoiding burnout, probably can talk about a bit and there might be some parallels with some others. Um, so I'm just gonna talk about my experience, what to do, importantly, what not to do and what I wish I'd known. So I specialized in pelvic exenteration. It's something I decided I wanted to do after watching Pete Sagar in Leeds of the trainee years ago. This has been around a long time. Um we all know what it is, but it's very much evolving, particularly over the last 20 years or so. It's hugely evolved with a huge focus on our naught because we never forget clear margins. Um You can make a huge difference for patients in terms of survival. It was becoming ever more radical because of that. And all the the contraindications I learned when I was around, around MRC S time are now obsolete. So we do all these things. These used to be contraindications to surgery. There is an exaggeration scale. It's a hugely heterogeneous um term. I've just read an email which I wish I hadn't read um from our theater team whinging about how these, we write exenteration in our booking forms, which means we get a 12 hour session in the theater plus and how on Thursday, I finish too early. So it's a waste of resource. I spent the five years prior to that arguing for more resource. I don't think you can really win. But the the problem was this manager doesn't understand that an exenteration can be different to recurrent rectal cancer excision and these terms are important. So one end of the scale, you've got the supraelevator, soft tissue exempt where you go to gynecology, um You can normally bang that out in 2.5 hours. They've not had radiotherapy. It's lovely Plains Wide pelvis, very enjoyable. Um Finish early. The other end is the infra ator total exenteration with all sorts of extra bits on. It's a recurrence. The sciatic nerves involve, um, the iliacs, the bone, they've had radiotherapy plus the ones reradiate radiation and that's a whole different ball game. Um, they're very long ups, um, particularly if you're doing the high complexity ones, which is what we specialize in leads huge blood loss. Um, a normal day would be 5 L and our records, some 20 L, um, very resource intense. As you can imagine, you need a big team at the hospital for a long time. All these things mean all eyes are on you. Um And you need a big team of all these people, they're all important in different ways and it takes a long time to build that up. Er, the challenges are I joined in leeds when Pete has sort of been the father of exenteration surgery in the UK. Really? Um So he's doing this for a long time but this e evolving um practice sort of came in around the time I was appointed, I'd learnt some stuff in the States, my colleague, Aaron Quinn learnt some stuff in Australia. We started together and tried to push the envelope a bit very much with peak support. Um But the problem is these are very long lists, lots of blood, lots of it, um er use and lots of impact on other things. So personally, to the surgeon theater time, if it's running to two in the morning our records five in the morning. Um, and it affects, er, colleagues the next day. II thank Pete for his support, particularly because I operate on a Thursday evening on a Friday. When I was first doing this, it would mean his case didn't have any theater staff sometimes cos I'd kept them in until three in the morning. Um, so, although he was supportive, he was very much in, it was in his, er, interest. Um And you get questions about morbidity. These patients are very, very sick and that remember the theater teams and managers don't see them in three months time when they're cancer free and you give them a hug in clinic, they see a patient on it for weeks. Morbidity, take backs deaths occasionally. So there's a lot of challenge with this and we came into this as relatively junior consultants, albeit with Pete's support, but it was a fighting, um particularly anus to be honest on multiple fronts. So what do we do? We started by collecting loads of data. So if you're gonna do something new, um and you might be on the spotlight, make sure you collect all the data, spend that extra time when you're knackered at the end. Filling in your database. Pete always told me to do that and he did it for him. Um You need some backing again from your department. So I made sure our department did back user. There were some voices and grumbles about theater capacity, you're focusing on one patient, we could do three or four, right? Hemi and if it impacts on theater lists, but everyone did back us cos we showed them the data and the evidence. Hearts and minds is probably the term if you're gonna start something new in a hospital and it feels like it's gonna be a bit of a rocky road, that's probably the key. So we were under a lot of heat and we collected three years worth of our data, put it together and presented to our entire anesthetics and theaters um away day thing they have every year. So there were about 350 people there and we got patient stories, videos, all our results and we went overnight from being um slightly the pilloried to being the golden boys of the unit. And that made a huge difference. And that was the only advice of people like Pete Ian Jenkins at Saint Mark's had had a similar battle and he'd done the same thing and he advised us to do that and we've done that ever since. So with colleagues, we've tried to show what we're doing. Show there are positives, show in improvements over time. Um I'm pretty sure our clinical director came to Pelvic with us in Amsterdam a few years ago, not just for the drink, um but just to make sure we weren't being totally crazy and he sat there and listened to some Dutch guys who were crazy at us and he came back, feeling better and continued to back us. We had to go to the executive board, which in Leeds is a huge, quite scary place and present our argument for why we should be doing this. Because in the NHS, when there's a huge waiting list, post COVID, you can see how it would be easier to do smaller cases. And then you need to identify enthusiasts in each area. Cos they're gonna do it for free. When you start a service and push it, you're gonna have to do it for free. Prove it works and then argue for funding. So you find a radiologist, a pathologist, a physiotherapist, et cetera to help you of things we did. We got dedicated theater days. We adjusted our job plans. It doesn't mean we got paid to do this, but it means that we moved things around so that I was free on Aaron's List and he was free when I was operating on a Thursday. We do all our own stuff now. So we realized that one of our biggest stresses was having the urologist um or the plastic surgeon ringing theaters at 4 p.m. saying I've got to pick the kids up. What time are you gonna be? And you're currently dealing with a 6 L bleed. So we got, we did five conduits with some renal transplant surgeons, cos the urologist refused to help us. And then we done our own, we've now done 85 as of yesterday. Um, between us and we do oral own gynecology, bone and vascular resections. So we only rely on someone else if we need a complex flap. So what she gonna say, er, a complex flap or, um, if we need a fecal sac tying off, other than that, we do it all ourselves and it's far less stressful, it's a longer day but it's far less stressful. Er, the anesthetic support has been very, very key. I think that's probably the difference between death and not in some of these patients. And we're trying to get funding for radiology, time and um, pathology time, cos obviously, these are big cases. So that's the, the tough bit. Um, this is sort of stuff we do just because we need some pictures, don't we? That thing looks like a Demi gorgon. It's actually a recurrent SCC um, that came out in a huge operation. Um, a lot of the, the recurrences these days as you probably know, due to neoadjuvant treatment changes, MRI improvements and standardization of TME surgery mean that recurrences are now very much in the pelvic side wall or in the bone, whereas in days gone by, they're very central. Um, and this is tricky cos it's a hard place to work. There's not much space, it's complex anatomy. Um, all these, that's a side wall lymphadenectomy. So everything's preserved. But when there's a tumor going up to that and you've got to take it all out. You've got even less space. Yeah, we all aorto cable stripping. Now, there's some evidence for that. We've had some success in that. Um, we use the robot for Pelvic sidewalls. Um, we're still trying to build that its usual access problem that everyone has, uh, laparoscopic sidewalls. If it's a nice pelvis, that's, um, a lap per dissection I did for, um, a solitary node in a recurrent sec. That's the IVC and the aorta sciatic nerve. We're seeing a lot of this. Um, we've perfected this quite a lot over the last few years. So that's taking out the sciatic nerve if it's, if it's on the inside. Um, and it's just touching, we can normally shave it off from there. If it's through the sciatic notch, then we'd go from the back. Um That's the femoral nerve I've taken all the iliac out there. You can see the empty blue sloop. That's cos we've done a recon afterwards. So that's right down to the bone. So there's no blood flow to or from that left leg on that patient. They're the sacral nerves going through to for notch. So we've peeled the tumor off. But if we're going posteriorly, we make a parasacral or take the sacrum with it. Identify the nerve. That's the, it's slung, that's the sacrum and it comes off with a tumor which we push back in the sciatic notch. Uh This is a patient walking after a full sciatic nerve resection on one side, that's about three months later. So the nervous, the neuro is witchcraft as far as I can tell, she couldn't move her leg at all for two weeks and suddenly it started coming back. Um This is a patient. We've done three nerve grafts with the plastic surgeons when we can face using them. Um We've published these results but it, it's tricky but there does seem to be a benefit. We're gonna continue doing that. So he's had a s so I think never affected and he is walking unaided. The highest secret means we're getting a lot of referrals for these. These are huge operations mainly because of the amount of soft tissue loss. I take a ton of planning. So that was a plan I did for an s naught 0.5 to the highest I've done which I did this summer. Um So the stability of that pelvis is debatable. Um But it's a 41 year old ODP um who was prepared to take the risk. And this orthopedics I had chats with stammer. They wouldn't put metalwork in there in this case. So we went for it and she did OK. But every millimeter counts in this cos you can see the shape of the part the sacral was taking out and how little was left. Um I've got a video of it. It's not quite, I was hoping to have edited it by now. But I haven't had time. Um You have to adjust the angle of that and just bang and hope for the best. Sometimes you come out in the bed. It is possible. We try and plan it and the measurements so that you don't. But that can be harder than um it plans and you get a big lump out. That's the posterior approach for the tumor just come out. You can see it's a huge soft tissue, um, lump of meat. Um, and that causes the huge physiological um alteration that you see on itu for three weeks. And that's the bow you can see inside a lot of tissue. Not, not much of that is tumor. Uh This is that lady that I did on s naught 0.5 walking in a POSTOP visit. She's very determined. She's ex army and an ODP. So she's got realistic expectations, but we were pretty happy with that. We got another naught by naught 0.1 millimeters. The fecal sac is an issue. Uh My heart sinks if the fecal sac extends by the sacrectomy line on planning cos it involves the neurosurgeons. Um, and they'll come in normally about midnight when we're ready to flip, um, talk to this bit of tubing for a long time stroke. It use some funny tools and finally put a couple of vitrs on it. Um, at which point we've all lost the will to live. Um, they'll tie it off and then we'll take the sacrum where we need to, with a big defect to the front and the back. And then for that sort of thing, we do use plastics to do in advance from flap. And that's that guy sat there so he can sit with no sacrum. And, um, um, he was actually pretty healed pretty well. A sciatic nerve. So we use a seral nerve or perineal nerve to do that. You can just about see it in the middle of the screen there we're still experiencing from that. We do pubic bone resections. They sound horrendous. They're not actually as challenging, although you remove all the adductive muscles. So when you think you've often lost some of your nerves, obturating nerve and others on the way, again, the recovery from that is big. Um That's a pubic shave on the um ramus at the top left of that image. You see that's where I've cut it with an Os. So, and you can see it's there on the specimen and you can take the whole pubic simps sound. We've done one of those er, so long ops. Um that was my fellow who's now a consultant in Leicester. And this time on that stamp on that photograph of my phone, which I look was about 2:15 a.m. You would wonder is this worth it or is it just madness? Um It's very resource intense. But if you look at the outcomes, the survival is pretty good. So our overall five year survival all comers is 63% which I think is pretty good. Um And if you look at the ones we've got r naught, um, it's much higher than that. So it's 85%. And when our r naught rate is about 83% including recurrences. So the highs of all this are, it's immensely good job satisfaction, but that probably goes hand in hand with the risks involved and the personal toll and the stress at the time. But if you like that sort of thing, um and every niche has a different advantage and that's good, you definitely get a sense of fulfillment and sense of good. And I quite like the idea of a continued challenge. Some people like to conquer something and make it perfect. I like to keep doing something new with some unpredictability. That's just I think personal. Um but there are some lows, the hours are, are immense. The, the amount of planning that goes into these cases. It's an hour and a half of the radiologist doing an MRI the op itself takes ages, they're in for weeks. And if it's a take back on these only, I'd only let me Aaron or Pete take it back. Um And the three of us are often away or doing all busy, our own stuff. So you're on standby quite a lot. It's our responsibility. Most people don't get it and my colleagues don't really get it what we're doing. They don't come in and watch us try and peel off an internal iliac vein that's been, that's fibrotic and how stressful that is. And they just think of an extent as an ex. Um, and it's a lot of pressure and some fear. You often wake up like this in the night thinking. Did I do this? Did I do that? You can imagine after 12 hours there's lots of parts of the operation that you can easily just forget to do, believe it or not. Um There's a lot of politics. I'm gonna reply. I've written the email first draft which is angry now on my phone, I'll get home, I'll edit it and I'll send it tomorrow on the third edit it. When I've removed the swear words, you've gotta be careful with that and the goodwill fatigue goes cos I must be doing 15 pa si don't get paid for that. Um So it sounds pretty crap. Um And then you add, add on the on call and get treated like any other colleague on the same job plan and this can lead to burnout, I guess cos you can't do everything. And I looked back at the other roles. I did my first few years and they were all and I think I've missed some of that. I did put clinical future on. I mean, that's just madness. Um You can't do everything but you, you come into your consultant job, I think as you just heard, um, that full of enthusiasm wants to everything but you just have to accept you can. Um, but that was a huge academic topic. You could spend a day on it. Um, there's different definitions. Um, but for me the things that improve was giving up stuff, er, reflecting what you enjoy and what makes you happy and what doesn't, because if it makes you happy it doesn't matter if you're getting paid for it, you'll come and do it again anyway. You've got to try and protect some family time. I've taken up some hobbies in the last few years that I actually leave work for and that's been hugely beneficial. But the key moment when I sort of just lost all the bitterness, um, that I'd sort of grown in the last few years, just about all the extra stuff I do was giving a student talk for the Royal College. So they asked to give me at, for me to give a talk in leeds. So, a load of, um, college students from deprived areas who want to do medicine and particularly want to do surgeries. They, they join this club and they expressed interest and I talked about what I do and the life and I, and I thought I don't want to scare them off cos it sounds horrendous. So I said, well, when I was at school, the things I wanted to be were a mechanic work for Aston Martin, um an F one driver or a fighter pilot. And if you could, when I was writing, I realized if, if I could go back and do any of those, I wouldn't, I do what I'm doing now. So that probably answers the question, doesn't it? Um And I think if you work out your own mentality and what makes you happy, all the other things slide off a bit and you can then try and control the things you can control. So thanks to Pete A and my colleague, Damien's, our radiologist who's um really fought for us. Rich Baker's, my CD who came to Amsterdam with us and let us carry on being mad and the whole ex empty. Thank you. Thank you so much for that. Um Mr Turner is not staying for dinner because he's got to take the kids for a movie night. So if anyone's got a burning question, the new minions film, I thank you so much, Mister.