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Today, we're just waiting for the microphone so that you can hear it one for the Duke's. It's a pleasure to see you all here today. Um And um I'm, I'm, I'm very pleased that we uh we, we have the um pleasure of um our speakers joining us today. Um And on behalf of the Duke's Club, I hope that you will find that will be useful and, and we try to make it um um inclusive and diverse as well. So um without further ado introduce our chairs, um like to introduce our president and also for our research rep to start the session. Thank you, Mo. So, um first session of the day stepping outside of the Codon three fantastic talks. It gives me great pleasure to introduce Nina Randa from Newcastle. She's a consultant surgeon with a specialist interest in ID and inflammatory bowel disease. Thank you, Nina. This is gonna be awkward to hold this in my hand and talk. So you'll be hearing me breathing down this rather than talking. Uh My name's Lina. Thank you for inviting me. I've attended quite of these weekends myself as a registrar. They've all been great fun. So nothing better than starting a morning session. We're talking about nutrition, having just had your breakfast and everybody, nobody's awake. I mean, it took me three cups of tea to wake myself up. Um, I'm gonna try to keep this talk quite attractive and I would like, if everybody can participate as much as you feel like, and I would try to keep it as more exam oriented as possible because that was my purpose for going to this weekend to walk away thinking what's going to come in the exam and how can I use this? This is our team and Newcastle this and as you can tell, there are lots of blue dresses in there. I don't know if you can see and it basically shows that the whole team is dependent on the MDT. What makes the, the intestinal failure, team successful? No, perfect. We've all been through med school. Uh I know it's a room full of surgeon. So I'm just going to ask this. Anybody who volunteers, what do you understand by heart failure? This is not a trick question you're answering to a surgeon. Yes. We roughly have the same idea. I hope not say again to reduce. But um the what the what? Yeah, roughly there. What's renal failure? Your kidneys don't work. What's intestinal failure? What's that? Yeah. Or they work but just not to the point where they're useful to you. Yeah. So can you see these slides ca clearly I mean, there have been multiple attempts at trying to define what intestinal failure stands for. There have been about what 25 I think we're down to about 28 different descriptions now to what intestinal failure is. And in summary, as you said, your gut doesn't work to absorb all the essential nutrients for it to be sustainable for you to without requiring additional supplements. Classifications. We love classification and they love this in exam as well. So if you can rule out these three classifications, you're already on to a winner. Type one, every single surgical registrar consultant have seen this. You've done an anterior section, they, they just the gut just doesn't work. They sit there day three, feeling nauseated and you blame the Anestis for giving them too much PC. Actually, they're in ileus, that's the type one and the plan is to stop them progressing into type two. So type one is usually self limiting common and most of the surgical wards IES you get them G two and they get better. Type two is usually type one is self limiting. Type two is when the type one has we have failed to address the type one or there have been other complications of intraabdominal surgeries. So the which is we are needing a TPN requirement for longer than 28 days. Type three. These are usually the patients with the short gut or they have had an abdominal catastrophe where their bowel is no longer functioning and they are on a lifelong parenteral nutrition. What type of intestinal failure? Would this be hands up for? Type one? Type two? Oh, come on, come in type three. Yeah. Yeah. So this is type two and the plan is to prevent her from going into type three. This is a 22 year old lady background of Crohn's went to her local hospital with small bowel obstruction. They found intraabdominal abscesses and as we all do, we wanted to fix things. So she kept going back to the theater, kept going back to the theater. And then eventually she was referred to my unit because they couldn't look after the wound because they didn't have a bag big enough for this. They were trying to put a stoma bag on this when after about nine months of TPN when we finally took, but at the beginning when she first came, she had 16 lumens sticking out. This is the 16 small bowel lumens in there. It looks horrendous but she's home now without TPN. So this is doable, but it's scary to look at you. See this lady as in surgical regimen call, what's your first instinct? How would you manage this? Who's that? Yeah. Well, you, I'm hoping you'll take history first. Yeah, snap. So, so once you've done your basics and it does start with basics and you'll see. But every hospital we have these patients who turn up because they are visiting or they've had the operation and then down the road, but they come to your hospital, POSTOP with complication. You don't have an op note. You don't really know what the underlying problem was. You don't even have the full medication history because patients just take it for granted that it's on their record. So you should know it. So this is what you need for the exam. They love hearing about snap, but it's not just saying snap. You need to be able to talk through every bit of it. Sepsis control. You have no idea how difficult it in these patients. And actually it's like for the trauma cold where you say ABC D, you have to keep going back to your AC once you made it to D and they become D stable and same thing, same thing with these, you get these patients in, you get an up to date ct, speak to a microbiologist, speak to ir get their collections drained, et cetera. Two weeks down the line, they're spiking again. Sepsis control is the best thing you can do to get these patients better and stop them from progressing from type two to type three nutrition. I've written the gut rest. How many of them will put, how many of you will put this patient on gut, rest hands up. What do you mean by gut, rest completely nail by mouth? How many of you will put a nail by mouth? How many of you would let her eat. Say again? Ok. At least someone's committing. You've got 16 lumens of small bowel. What do you think is going to come out? Jelly babies, jelly rabies will come up. Literally, that's one, we're annoying. It, whatever they eat it does come out and the first couple of rounds of new F ones, it's quite interesting to watch your face when they see the food coming out. So, yeah, it's quite entertaining. Not for the patient, but they actually, the patients are quite obsessed with it as well. They watch how long it takes for the food to come out. But yeah, she will have high outputs. So a fistula. So you need to decide whether you are going to feed her or not. But I'll go through that in more detail in a bit. Once they are all, once you think you've reached a stage where they're nutritionally optimized, they're, you've got sepsis under control, you need to make a decision where you're going from there. So ct scan contrast studies, you identify the anatomy because the op not, you will receive, will make no sense whatsoever. You'll be lucky if somebody has been kind enough to draw a diagram for you, but that doesn't always happen. And then obviously you have to plan. Plan is probably the hardest thing you and I've learned one word from my senior colleague. It's called Muga. Make it up as you go along. This, this is a lifesaver for intestinal failure surgery, but of basics. So that's my, that's how I draw my small bowel in the notes. So starting from Judum Ileum and colon as you can, and we all know this has the nutrients get absorbed. Water follows sodium. So as it progresses from the judgment down to the colon more so the sodium water gets absorbed and you pass solid stool. So you can imagine uh once you start from either colic resection and the more proximal you get, the more sodium you lose and the more liquid the output will be. And I've got a patient with proximal jejunostomy and his stoma output is about five liters every day. That's never gonna be manageable with just his gut function. He does need TPN. So every time you want to take your patient back to the theater because they've got another collection be mindful because every, every return to theater, your risk of causing enterotomy, your risk of resecting more bowel. And you really need to ask yourself, can they manage without surgery? So, nutritional assessment, I mean, previously, it was just called a must tool. Every patient that got admitted to the hospital, the nursing staff will fill out a must tool and they will tell you the BMI. But once you get into the intestinal failure category, you need to do a detailed nutritional assessment. If you're in a dedicated intestinal failure center, you're slightly spoiled because a dietician will do that for you. But for the exam purposes, you need to read out all of this, you need to know their weight and it's not, and there's more to weight as well. Their BMI, their mid arm circumference and they're triceps full. But this is again, unless you've got a dedicated dietician who is walking around with those things with them in their hand, you're not going to get, this weight is slightly difficult to categorize because these patients acquire edematous. And you need to know that what you're aiming for is a dry weight and not a body weight Espin has given quite clear guidance. Well, how much nutrition you should aim for. Again, this is a, a quick, this varies from, for ethnic minorities and different um height and weight. I mean, it is, it is on average, this is the guidance. It's not an absolute must, but what you're looking for is patients weight and then you're trying to make sure that you're trying to meet the energy requirements, especially protein, et cetera. The only thing you have to be careful is try not to give them too much glucose and you need to be careful of how much lipid you are including in these, most of these patients will need most, almost daily bloods uh to begin with. So what you're looking for is you'll look for everything because at the start of if they're septic and you're starting them on TPN, you will notice that LFs will go off. So you need to make sure that they are having a regular surveillance of these. You need a dedicated team or nursing team committed who will take a strict input output chart. What I've got done is that most of these patients will be in bed all day, just feeling sorry for them. So just, I just give them a piece of paper. Like can you write and actually it one, you're empowering the patient. And two, they are entertained because they keep a much better, more accurate recording than the nursing staff can do. And the same for the fluid balance. So I've given my patients uh one of those wart balls with the markings on them to see and they, they collect their stoma and that and they keep the chart and it's a perfect and then my ones go around recording that into our paper light system. They love me for that. I found this one of the, from one of the stoma nurses. Unfortunately, it doesn't project well. But if you get my presentation, it's really useful because it's like a cheat guide that tells you how much you lose from every bit of a G I tract. And they will love that for the exam because I'd like to know how much your, your stomach is producing a year daily. How much your small bowel et cetera. So this is your cheat sheet for the exam, oral diet. So, yes, initially, I will put this lady know by mouth, but that's until we get her full nutritional assessment, her actual weight, her, what her BMI and what her up to date electrolytes a day. But the best thing you can do, which you said all along is get the gut working. That's the only way to get this gut in circulation because once you come to reversal, reversing that you don't want the half of the gut that hasn't been in use for about nine months. We usually start them on low residue diet. Small steps. We start them on corn based snacks. So, quaver, what's it? Uh, cheese and crackers. That's just, and it's a bit of a humane thing to do because it's a war bay full of other surgical patients that every three times a day, they're getting their food, the smell and et cetera. And you were just sitting there with feces pouring out your belly, unable to eat or drink. And it's the worst thing you can do for their mental wellbeing. So get them eating small things. The gelatin, you have to be slightly careful with the jelly babies. It's got sugar. So you need to maintain, make sure that they're, they're not diabetic and also gelatin tends to thicken things up a bit. So you almost don't want to give them that unless they're really having high output. Start with that. And then I always say that it's called the junk diet or the white diet. So, pizza, pasta, white bread, everything that a healthy living we tell them not to eat is actually good for them because it's a soft squidgy stuff that will pass through whatever narrowing in the small bowel is. So what we say is that try to don't drink with your food because they'll drink this, then three liters comes out of their stomach and then they feel uh thirsty again. And so they compensate by drinking more and more and more liquids. So tell them to paste. So have small portions, often have your drinks in between the meals supplements. Again, the calorie shakes, the different names for an um candy shake or um what 46 et cetera. You need to be careful how much of that you're giving because quite a lot of them are calorie dense but also quite uh sweet as well. So you need to be careful and monitor the diabetic uh control. But in patients who actually have a reasonable gut function and you're trying to wean them off TPN, they are actually quite useful. I wouldn't talk about this self reading just yet and I wouldn't mention that in your exam. It's, it's a new kid on the block. It's been around for a while, but this is not every exam they want to hear about, but I'll come back to it. So other things to consider with when it comes to nutrition with these patients is access. So she's got 16 lumens. She needs daily bloods. You're not going to keep stabbing her every single day. So, what you aim for is Hi M Line. And generally, if, uh, you, uh, got IR department friendly enough or a dedicated access team, ask for double lumen hic line. So one is dedicated just for PN and the other one can be used for blood tests and et cetera distal bowel lexis. So you've got a patient, I mean, forget mine with the 16 units. But generally you get who's, they've got a double barreled stoma and you don't really know how much his distal length is. Get your CT scan, find out how much distal bowel is. And if there is no obstruction, what we do is we actually let them have something to eat, to drink and whatever the stoma output is, you collect it and the nursing staff will put it fully down the distal limb and actually put the, whatever what we call the chi down the distal limb. And actually what we found is that keeps the distal limb active. So that when you do come to the reversal, it's an active bowel rather than something that's just been dormant for 9 to 10 months long term PN requirements. Some of these patients will go home with PN before they come back for their reversal. So you optimize them nutritionally, you get them eating as much as they can oral diet, but they still don't have enough bowel le to absorb, to be of any nutritional value to sustain without requiring supplement nutrition, they will get trained on the home PN where the patients will manage their own TPN at home and it can, the duration can vary from patient to patient. Some will need it for a couple of months and this lady needed it for about 10 months before she came back for her surgery. And after the surgery don't think that it's going to be a miracle cure and she'll be off the TPN. Once you're reversed, it's a slow wean, you slowly, slowly start them on increasing their nutritional oral diet. Before you will think of taking the withdrawing the TPN. They're different types of TPN bags. So depending on your patient's requirements, what you normally hear is if you've got a patient on ICU, they had a trauma laparotomy, they won't be eating for a while. You just get, I mean, as I read, you just go like they need TPM, but you don't really know what's in it. What you normally get is a standard bag, which is not, you can't customize it. So if the patient's a basic standard laparotomy because they're not going to be eating for a while, the standard bag is suitable that just covers for the on average 70 kg patients energy requirements according to espen guidance. But if you've got a patient who's got five liters coming out of their stoma, you need to customize a bag according to their electrolyte and multivitamin requirements. And that's where you can get the multi chamber bags. Luckily, for us, we've got a production unit in the hospital so we can customize these bags. But this is done by a dietician or a patient who's actually got reasonable amount of bowel length, but they're needing a lot more fluid requirements and you go for the compound bags and then depending on the patient's liver function, you can decide which one whether they need a lipid bag or non lipid bags. So in summary intestinal failure, patients with their nutritional requirements requires N MDT. The key is to prevent your type one intestinal failure. Patients going into type two. You see an on call patient with a complex abdomen, resist the temptation for rele laparotomies unless absolutely necessary. And as a standard we say, unless you can help it, don'tt re laparotomies between 10 days to six months, you will run into trouble, find a microbiologist, find an interventional radiologist, anything to avoid going back into the belly if you can help it and you'll be surprised how many times it will keep ringing you and going like no, they've got collection in their belly. You need to take that and you need to fight that. Actually. No, you will make this patient worse off if you go back into their belly and you'll be surprised how many times just holding your own nerves will pay off. It's not even the other teams that's actually holding your own nerves because they're surgeons, we like to fix things. But in these cases, you will break them further. Don't be in a rush to take them off. TPN. It's not coming out of your paycheck. Doesn't matter what the sister wants, it doesn't matter what anybody else wants. Patience is your virtue in these patients don't be in a rush to take them off because if you take them off too soon, they will go back into s or they will go at high output and they'll go into renal failure and you set them back again. Don't keep them nail by mouth. There is generally no indication for keeping these patients nail by mouth. You can give them something to eat and it's a human thing to do. Just let them have. So even if even the earliest patient, no high ST mouth for patients where you prevent them to go into type two, just give them Diro light but reduce the volume diur light to let them have two cups of tea a day. I mean, that's not really going to add much or cause them any harm, but they'll be thankful and actually they'll be more compliant because you are kind of on their side monitor. These patients need their weight, their BMI their blood's monitored every single day and you'll be surprised how often these patients go off so quickly. And the other thing you need to monitor because they'll have lots of lines, they get infected, line sepsis is the worst thing you can, that can happen to these patients because eventually they'll run out of anywhere. You can get a line into balance. It's, it's all about balance trying to find a balance between keeping the gut going with enteral nutrition. And parenteral nutrition is where you need your dietician, your nutrition, gastroenterologist, you work as a team, it's, it's a fine balance. So for the exam purposes, the cases you'll get is a laparotomy patient who needs a multiple re laparotomies. And the general rule is there is no indication unless they've got open abdomen. And even if they have an open abdomen, let's say you found a ischemic bowel overnight, you resect, uh you put al thea on and you left the abdomen open or was a trauma patient who was bleeding, you pass, you put up thea on and you come back 24 48 hours later, aim to close the abdomen because the what we found is that the commonest thing happens is that you take the patient back to theater. It's not the same consultant, same, not the same team. They're going to um, looks of ters, let's just put another ab the room and these patients have the highest morbidity because of open abdomen. If you can't close it because they are edematous. Do a mesh mediated traction, use a vial mesh. Don't let any theta stuff tell you and, uh, this is a protein mesh or a bit of, unless it's a pure vir don't use it. You will run into trouble and vir mesh is just like you two a vir, you use it on the bowel all the time. NDT for the exam, the, for the exam. They love hearing the MDT approach. It has to be your dieticians, your pharmacist, your nutrition. Oh, actually the new thing they love hearing about the psychologist, that's a big part of your MDT for these patients. Um, categorize them into types of I and then the aim is to prevent them going into type three. And it all depends on your nutrition and your sepsis. So going back to the snap, snap is your lifesaver here. Perfect. Thank you much. Uh, for that interesting start to our, uh, our day. Are there any questions from the room? You're right. I think it's taking a little while to get started. Oh, front row well done to find about these medications. Cause you often hear in like I BDM DTs where you've got someone that's got a fistula. And they're saying, can you operate, can you operate this patient's life is miserable to their fistula or when they come in as an emergency under the gastroenterologists with intraabdominal sepsis like that? How do you get a gastroenterologist on board with the kind of change in mentality to the timing in operations in IVD patients? I think it depends on the type of fistula. If it's an in fistula and the Crohn's patient, they're probably not going to get better without surgery, but it depends on their nutritional status. So, if they've got, let's say a Crohn's patient, Entero enteric fistula, but they are BMI 17, I will tell them. No, no. This patient is not having surgery until we get them on TPN. And most gastroenterologists will buy into because what gastroenterologists prescribe operations, how they prescribe mesalazine. So, but you're the one who's going to pick up the pieces of it. So you need to work together and say, ok, I will operate but you need to optimize them. So give them TPN. But I don't know, four weeks, six weeks, et cetera. And then I will operate and this is how I do because you're right, you get quite a lot of these patients come in. They were like, um, they're obstructed, they can't eat, they're vomiting, they need operation like tomorrow. And actually he's not eaten for the last four months. Anything I do will fall apart. And actually, that's exactly what happens. So I will get them in and I'll TP in and the gastroenterologist, they need to, they need a plan. That's all they want. They don't need anything. They're like, as long as it doesn't keep coming back to their ward, they're happy. So what usually is that I take them over? I take them on TPN and then I'll plan. But you need to have a plan in your mind as well. That what is the end game here? If it's an intracutaneous fistula, then it's not really a gastro, it's you. And actually you need to have a gastroenterologist with interest in nutrition because as a surgeon, I don't remember every single requirements of the TPN, but I'm spoiled in the sense that we have a dedicated three gastroenterologist with interest in nutrition assessment of these patients. But on a standard D, it's slightly difficult. But still the medics will be a lot more cool into the nutrition requirements than any other surgical department team will. So I think if you, it, it's a teamwork and if the most gaster should just get their shoulders up because we have them off and go like no, not operating yet. But what they need to hear is that yes, the patient does need surgery. I completely agree with you, but we need to nutritionally optimize them. And this is how I will, I will stick them on TPM and you need this for patient and your wellbeing because you're not going to do a proximal jejunostomy just because they weren't fed properly. Whereas if you give them 4 to 6 weeks of TPM, and actually you can do a limited resection in the joint, that's the best outcome for everyone involved. So we always talk about, we always talk about the importance of not going back to, sorry. I'm just asking when we always talk about not going back doing V Leroy for sepsis control. And then we think about getting IR involved, right? But quite a few hospitals won't have ir. So if that is that important, do you recommend the people should be going to the Regional Center for IR procedure rather than le Leroy patient again for just sepsis drainage? Definitely. I mean, we've always said, and I worked in D too and, and I've been know where I'm taking the patient back to the and now being in the IR Center, I, I receive those patients. And I said, I'm like, oh my God, the reality is every time you ring up your uh regional center, they never have beds. They don't wanna hear about it. They just think that you're being lazy and actually, if you ring up your regional IOP center, they, because they're about to pick up the mess of it, they will be willing to take the patient. So every time A AVG brings around my hospital, I always say don't operate, we'll find a be that's and this is almost me trying to make my life easier to help the patient in the long term. But this is the insight you get only after you go to the center. But I know it's not always practical, but generally, and what I've done to the regional hospital is that I always say to them that why don't you just speak to the IR at the tertiary center, send the patient over for the drain and then transfer them back. And actually, you'll be surprised how many ir departments will be happy to do that. As long as they know that they don't have to look for a bed afterwards because no hospital has red be safe around my area. We will tell them if in doubt, just give me a ring. Just got one question for some from people online saying um what prescribable oral protein supplements for hypo albumin diabetic vascular paths aren't sweet. Probably none. OK. But I think it all depends on what your hospital buys as well because I remember when I moved to New Castle, I was prescribed this candy shake. It took me a few months to realize I don't have that in the building. So you need to speak to your dietician that what you actually supply or there's certain flavors your hospital want. Like I've got a patient who only wants the blood current and it turns out our hospital will not buy the blood current one. OK. So great. Thank you so much again for starting our day and uh well done for equally answering our issues. Thank you. So we're going to move on to our next speaker for this morning while just ignore our A V technician. Um For those of you not in the room, he's running around doing a very good job. I'd now like to introduce Mr Denis Seo. He's a consultant, obstetrician and gynecologist at the endometriosis center here in London. And he's going to be um enlightening us on what we can do um for endometriosis as a general surgeons. Thank you very much and good morning. Um Thanks for the kind introduction and it's always AAA big honor for a gynecologist to be much of the proper surgeon. So, uh forgive me if my presentation is a little bit simplistic for you, but uh it's about endometriosis. So, just curious about myself, I am a fully robotic surgeon. Haven't done a single laparoscopy since 2021. And I lead on the robotic MDT four complex gyne and endometriosis is the Princess Grace and I'm I teach robotic surgery. E cut and Griffin. And uh so my main specialty is deep endometriosis, basically. Yeah. Oh, so if we talk about deep endometriosis, there are certain principles which are slightly different from cancer principles. So, first of all, it's excisional surgery. So it's always excision, it's never ablation. So, ablation is not used. It should be criminalized the nerve sparing. Yes, nerve sparing is very important because not only we remove the disease, we're trying to preserve the inferior hypogastric plexus. We try to preserve the hypogastric nerve. Therefore, we try to preserve the uh bladder function, the bowel function, sexual function. And it's quite important MDT approach is absolutely critical. So, my MDT consists of 15 people, three colorectal surgeons, two gynecologists, three urologists, psychosexual counselor, pain specialist radiologist, psychiatrist, gastroenterologist, and you, you have an endless amount of specialists involved in endometriosis care. So, uh the principles of conservative radical, what it means we should be conservative to these patients because most of them would like to preserve the fertility, preserve sexual function, preserve the hormonal function. But at the same time, we should be very radical to the disease and the choice of instruments. And I'll talk about robotic surgery a little bit is I think the best instrument you can find for endometriosis treatment. So, what endometriosis surgery is all about? So, it's a very high risk challenging surgery and we often deal with previous, incomplete and incorrectly done surgery. So it's just a scenario where a gynecologist says let's do endometriosis surgery. They enter the abdomen. Oh my God, let's not do it. Or let's just massage it or let's just remove a little bit of it. You know, and that's how we end up with the patients who had 12 laparoscopies for endometriosis. And you open the pelvic side. Nobody's been there before. What have we done 12 times there? You know, it's like this and um it's scarring, it's active infiltrating disease. It's out the tissue planes and it's involvement of ureters, nerves, everything. So it's a bit of a nightmare. And why did they switch, switch completely to robotic surgery? Because it's ergonomics precision target access, image quality and simplification of complex tasks because I, I forgot what the back pain is all about because I don't have back pain anymore because the uh severe endometriosis surgery can last 6 to 9 hours. And if you stay as a laparoscopic surgeon with assistant who loses interest maybe at two hours after the start of surgery and your horizon goes up and down and said, oh my God, why me? You know, and you want to quit medicine instantly. But um, yeah, so robotics is, is actually better and my surgical outcome is actually better robotically comparing to my laparoscopic outcomes. So, instruments are simple but not simple, of course. So we use monopolar and scissors really and uh monopolar and bipolar and we don't really use um advanced energy robotic instruments for endometriosis because they're a bit bulky. Apart from the cases where we do bowel resection, we need to do mesorectum quickly and that, that's quite good. So uh for bowel deep endometriosis, uh the commonly, most commonly affected organ is rectal sigmoid Coulon. So 90% of bowel endometriosis will be rectal sigmoid. And uh so the the deep infiltrating endometriosis is uh about 12% of all endometriosis cases. And um but like I said, mostly erect, the sigmoid colon, the symptoms they present with are quite marked. So it's menstrual. If you take any symptom, you can find and add menstrual to it. Yes, we have it. Ok. So, severe menstrual pain which become non cyclical at some point. Uh dyspepsia, dyspareunia, bowel dysfunction, constipation, urgency, frequency incontinence bleeding, you name it. So, endometriosis patient can present like this. Some of them will be totally asymptomatic with stenosing bowel nodules, which is a mystery. But we see that once or twice a year. Ok. And the dilemma is, what type of surgery to choose for bowel endometriosis are we going to be radical? Are we going to be conservative? What strategy, what tactics do we need to use? So important dilemma is uh to understand that endometriosis is not cancer. So you don't have to do huge anterior resection for bowel endometriosis. From the other hand, this been an excuse not to touch it at all because it's not cancer, it's not going to kill the patient and why we're doing this big operation if it's not cancer, you know, but leaving endometriosis behind will probably leave your patient, which are most of them are young, young women in years and years of severe pain and severe dysfunction. So, and that's where it comes. Again, the principle of conservative radical. So we need to be to be radical to the disease and conservative to other functions and organs. So again, what type of surgery to go for? To answer this question, we need to fulfill few tasks. So first of all, we need to assess the pelvic pain. We need to assess the bowel function. We need to understand exactly what patient comes with and then we need to map the lesions. So we need a very good map of a disease before considering surgery. And that will answer us a lot of questions. And then we discuss it on the MDT MDT CO MDT is radiologist, urologist, gynecologist Colorectal. And then we formulate the plan and discuss it with the patient and see if the patient he's in agreement with what we need to do. So it comes in the end to three possible bowel scenarios, rectal shaving, discoid, bowel resection, and segmental bowel resection. So, segmental bow resection is the name for economical anterior resection. So, and map of the disease uh uh allows us to avoid surprises. Surprises in surgery are not nice, normally not nice surprises. And therefore we try and avoid them and we for any symptomatic patients, uh sorry for any symptomatic patients. We would uh do MRI scan with Buscopan and contrast. We not only do the pelvis, we do abdomen pelvis very often. We do diaphragm and chest as well if they're symptomatic. And uh more importantly, this uh MRI is reported by a specialist radiologist who specializes in uh gynecology and endometriosis because for normal radiologists, he says, yeah, I don't see any signs of cancer. It's pretty normal. No, but we need more detailed description in particular. We want to know how many nodules in the bowel because we know that bowel nodules can be multifocal. In 40% of cases. We want to know size of the bowel nodules if it's more than 2.5 centimeters or less than 0.2 0.5 centimeters. Why 2.5? Because for a discoid for, for stapler, discoid resection 2.5 for us is a cut off because the bigger nodule will not fit into the CDH stapler. We know we want to know the distance to the anal verge because I is it gonna be ultra low resection, ultra low anastomosis or not? We want to know the depth of infiltration of the bowel wall because uh superficial infiltrating nodules can be shaved. If it goes down to mucosa, it probably cannot be shaved because uh because technically not possible, we want to know the degree of bowel stenosis and that can be done again with the MRI or ultrasound scan. We don't normally use colonoscopy uh before surgery because I don't think it has any, any, any sort of diagnostic value in in this particular case. So, apart from the cases where the patient has bleeding, and we like to, to rule out some other causes of bleeding apart from endometriosis. So which surgery type? So MDT of course allows the shared responsibility and decision making and the CO M DT is presented by a few specialties. And uh we also do MDT surgery. We have the vici dual console and we can operate together with colorectal gynecology and urologist. So we can change our seats or the controls to each other on the robot and it works very well. So the most commonly used procedure is rectal shaving. It's less traumatic because you don't have to, you don't open the bowel lumen. But then it raises the question, is it radical enough? And there was about 1% risk of perforating into the bowel and about 10% risk of recurrence of endometriosis. So, shaving is done. We, we do it with monopolar cut. You can see there is a nodule which we know is superficial infiltrating and we can use um, monopolar scissors to shave into the bowel like this and laparoscopically, it would be difficult because laparoscopically you need to do with the cold scissors, which is um, becoming quite unpleasant because the rectum starts to bleed. And, but with the robotic monopoly, you can easily go predictably three, maybe 34 millimeters into the bowel wall and still not perforate. So that's um, shaving. We can even shave the thinner part of the bowel like rectal sigmoid. You can see there is a nodule on the bowel. And again, and this procedure is done by a gynecologist. So we have colorectal surgeon on a standby. But this procedure is done by gynecologist because it's so reproducible and, and we can easily do that. You always need, need to know what to do when you perforate the bowel. But that's another story. And yeah. So this is the sigmoid colon. Again, we can shave from the sigmoid with just monopolar cut. And then if we enter the muscularis, we then have to put a few vital stitches to protect the bowel wall. But you can see it's quite predictably going 12 millimeters into the bowel wall without any unpredictable moves into the lumen. So if the nodule is bigger or deeper than shaving can get, so we can use discoid bowel resection. So basically, the idea is to remove the disc of the diseased bowel. So the nodule infiltrating full thickness muscularis uh down to the mucosa. And we can do it with either CDH stapler uh or in a, in a sort of open way. So it has to be single nodule. It has to be less than 2.5 centimeters and it has to be non ST nosy nodule and not too low uh down down the rectum. So the idea is to shave the nodule first and then invaginated it into the CDH stabler and then it will remove the disc of the disease bowel. So the complications is uh fistula, especially when you open the vagina at the same time, like for Hysterectomy or if you want to excise vaginal nodule. Um And obviously, um the, the, the risk of for shaving and segmental resection as well and omentoplasty doesn't seem to be, I think my microphone is dead. Hello. No, it's not working. Yeah. Yeah. Hello, everyone at the back of the room to step up without his microphone. OK. I'll shout. OK. So, uh risk of fistula and um it's about 3.6%. So, and uh recurrence is pretty low. So about 2% over the five years time according to the research of Horis Roman, which is the uh do center for deep endometriosis. So the way we do it, so there is a nodule which so you can see the higher up the nodule was shaved because it was too superficial. The, the, this one, we put a marker if we put the CD stapler and invaginated the nodule into the stapler and fire. The stapler. Again, this is a joint procedure between gynecologist who is leading the surgery and colorectal surgeon who is having GTN spray, uh nearby see the building beds around the room. OK. So this is the flex sigmoidoscopy. After this discoid resection, you can see there is a full circle. It's like a proper anastomosis, but it's not because we know there's only top part. The, the upper part is the muscularis staple. The bottom is a little bit mucosa cold into the staple, which can be avoided by lifting the CD stapler a little bit higher up. But that, that's not a problem that that is not a full circle anastomosis. You can also do it. It's supposed to start. Yeah, you can also do it with a vessel sealer. Now, this is a, a video from my American colleague. So you can just cut into the bowel like this. Obviously, you need to prepare the bile. So we normally use moviprep for this kind of job. And then uh you put a V lock 30 and the second layer would be interrupted viral. So for gynecologist is quite simple procedure, you can see. And uh so, and if you want to go cheaper, then you can just do it with scissors. And that's uh that's again done by gynecologist with the colorectal surgeon supporting. And uh you can remove the disk of bile like this and then put um sound vir interrupted. Uh you can see the, the robotic monopole that doesn't really charcoal the tissue. So it's like fresh bleeding edges of the, of the rectum. And therefore, it's uh it's different because if you do it with laparoscopic monopole ssss of barbecue, you have to use cold scissors for this job. But uh with robotics, I think it's much better. OK. OK. So as a result, we can remove 2.5 centimeter infiltrating nodules. So here, previously, we just did, did the segmental bowel resection. Now, we can do discoid resection. That means we're not going to open lateral spaces, we're not going to open uh the tiger territory of hypogastric ne inferior hypogastric plexus. And the result is the same, we remove the same size nodule with much less invasive technique. And so we had a few complications of this technique. The most common complication is bleeding. So this is the flexi which we did um straight away. And then after half an hour, the patient was still on the table and she started losing from the rectum. So we put a flexi again and there was a bleeding. Thank you. And there was, oh, fantastic. And there was a bleeding from the staple line which was um managed with um sigmoidoscopy clips and the bleeding stopped. You can also put some extra stitches on the suture line. Like here you see, we already undocked the robot. Uh and then uh we decided just to put a little needle holder and just do the couple of stitches which stop the bleeding. Uh and bubble test. We always do the bubble test and sometimes it comes as, as a little bubbly. In this case, we look for the way it's bubbling from and then uh put extra stitches on where it's where it's not perfect. So uh there is a warning because it will be temp, you will be tempted to do a discoid bowel resection rather than segmental resection, but you need to really assess the size of the nodule. So this is uh a video from a different unit and they said let, let's do the discoid resection, but the nodule was actually four centimeters. So they use the CDH uh 29 and the, the stapler fired on the nodule. So three days later, the whole thing leaked out and she ended up with Hartman's procedure. So if we go for segmental bar resection, it's done for the bigger nodules, it's done for the multiple nodules or for the high nodules which you can reach with a circular stapler and anastomosis leakage is the main problem. It's about 2% comparing to different literature sources and functional. Uh so, urinary and sexual function uh can suffer in about 17% of cases. So, um the recurrence of the segmental bowel resection for endometriosis is extremely low. So it's very radical but it's very traumatic at the same time. So, and we have several options for bowel resection. So conventional and then natural orifice and anastomosis can be handmade or staple made and staple me can be double staple technique, single staple technique. So I'll just very briefly talk to you about the options that we have. So this is the the traditional um uh sort of sigmoid, the uh segmentary resection and we use the form stapler, it's articulated robotic stapler. So it's uh the standard technique. And you can see the, the problem is getting the staple staple angle right. So try to minimize the amount of stapling that we have to do. So. In this case, we do two firings. And then after the uh stapling is done, the traditional way is to put the bowel externally and uh remove the disease part of the bowel, put on wheel and and then complete the anastomosis. So we used to do this for many years, but now we moved away from this technique and because the higher leakage is associated with double staple technique because of the staple conflict, because you have staples on one side, staples on the other side, maybe 23 stapling. And that creates a dog's ears and, um, therefore increase the risk of anastomosis leakage. So the dog's ears if, when you have anastomosis, but you have still excessive part of the bowel, which is stapled and that's a potential leakage problem. So we want to minimize that. And if you see this laparoscopic picture, once that's day four after segmental bowel resection for endometriosis. So it's quite a lot of uh evidence that the, the anastomosis didn't work. And obviously, we're trying to minimize this. And one of the ways to minimize it is used to end to side anastomosis to minimize the staple line involvement and also uh remove the dog's ears either overlapping them or stitching them together. But we uh now move to the uh in int corporeal single staple anastomosis. So we, we can do it in two ways. So first is uh we staple the bowel, use a linear stapler and then we don't do the external part of the operation because we make a cut in the proximal part of the rectal sigmoid. OK. OK. And then insert the veel from the 15 millimeter port from the side. So do a little hole for the spike. Yeah. No. And uh then we, once the ovule is in, we can support it with uh P DS sutures. So it doesn't go traveling up the sigmoid, which has happened by the way and then do another stapling and then do end to side anastomosis, which is better anastomosis comparing to uh end to end in this case. So here we can use a linear staple twice and then a circular stapler. Yeah. So that doesn't really uh avoid the dog's ears, but it does avoid the external part of surgery. But then we modify this technique even further and we decided not to use uh linear stapler at all. So that will be the next uh video which we have done. I think we've done five procedures uh with a new technique. I, I'll show you in a second. What, what I what I mean? So uh we do the mesorectum as usual. Again, this is done by gynecologist with uh assistance of colorectal surgeon on the dual con consult and the, the mesorectum is done in the usual fashion. Yeah. Mhm. And then we put um a Meslin tape below the nodule and basically occlude the bowel like this. And then we wash the rectum with Betadine few times and once the rectum is washed, we can then without needing to use the linear staple, we can just open the rectum there name and then we can do the same on the proximal part of the rectal sigmoid. So the bowel preparation for this case is a standard moviprep with a low residue diet for, for one week. And then the rectum is removed, trans rectally and then all will is passed into the rectum and for bowel preparation, we also use, um, Ciprofloxacin and metroNIDAZOLE for one day prior to surgery and then both ends of the bowel. We have first string suture. Yeah. Yeah. Mhm. Ok. So once the ve is stabilized, we then put a couple of envelopes for further stability like this. Ok. And it's important to keep the bowel upright. So the, the proximal bowel doesn't discharge because the distal bowel we washed. So it's, it's quite good, but the proximal bowel can still leak a little bit. But um the good bowel preparation is quite important here. So another sort of double string here and then we put ac DH circular stapler inside and basically tighten up uh around the spike again with P DS and some envelopes. And we are ready for anastomosis. You can see the advantages here. So we don't have a staple conflict at all. There's no staples involved until we actually fire the circular stapler. So no staple conflict, no dog's ears because the whole thing is central because we suture it around the ve and around the spike. And always we do ICG um to check the, the quality of blood supply for anastomosis. So that that's worked for us quite well. And so in conclusion, stabilize, intersection are weak points in and treat with decreased vascularity and increased possibility of leakage and higher number of stapling associated with anastomosis leakage and the use of single stale technique for bow anastomosis is actually beneficial and cheaper comparing to double staple technique. So this is our work in progress and it's um myself and Jim from Portsmouth, my colleague. So we did 68 colorectal excisions with only one ileostomy, no return theater, no conversion, no fistula and with a marked improvement of dyke and quality of life six months after surgery. So just to summarize multidisciplinary approach is absolute key precision speed and um simplification is robotic surgery and standardizing the surgery is very important. We have to have clear entity, fast ways for endometriosis patients and gynecology. Colorectal urology is a core for the surgical for endometriosis. Thank you very much. Um Thank you for that. Um a little less familiar with, but um certainly something that has crept into the F OS. Yes, in recent years. Uh As far as I'm aware, um we've got time for that one question due to due to time constraints. Um Yes, just what was those for? Sorry. Thank, thank you. Is there any road for medical treatment? I mean, when will we decide to do surgery for end? So important to understand there is currently, there is no medical treatment available to make endometriosis go away. Ok. There are few options to either stop the progression or decrease the progression or slow down the progression or avoid or minimize the risk of recurrence. Ok. So, uh for example, GNRH analogs before surgery. We don't use any anymore. We use them, uh, a lot. Uh, when our waiting list for endometrial surgery was three years. Ok. So you cannot leave patients for three years without no, without, with the, with the pain. So we use generation analogs. Now, we don't have this problem because our waiting list is like four weeks. But we can use either hormonal suppression like, uh, dienogest or zam, uh, after surgery if the pregnancy is not planned immediately, or we can use Guzan if the patient doesn't want to have surgery immediately. So there are options but they are, they are more suppressive rather than curable. Here it is. Yeah. Thank you. Thank you. I think we'll have to end. Thank you. Um, so I'd like to introduce our third speaker, Professor Andrew Hayes from the Royal Marsden consultant surgeon with a specialist interest in soft tissue sarcoma. Um, talk to us about retroperitoneal sarcoma. All right. Is that, is that, uh, this is for the online one? Yeah. So I've got to use this as well. Can have hearing. Yeah, that's good. It's two weeks away. Thank you very much for the invite. I see lots of people taking notes for the exams and you can all relax. I think there's going to be very small chance of someone who's an examiner having a significant problem, volume of retroperitoneal. And I can think of probably one take home message that you need to do. So, which will remind you at the end. So I don't think you need to be taking lots of notes. Um This progressive. So it's really difficult for people to interrupt talks. What I thought I'd do is I'd break it down into three sections uh at the end of it. If anyone's got any questions at the three sections, just put your hand up then or you have to try and answer them and we'll move on to the next one. So I'm going to start with a bit of background about soft tissue sarcoma pathology, how to make the diagnosis, which is crucial a bit about radiology. Can someone just first just give me a definition of what a sarcoma is? Anyone? Put their hand up and say it nice and quickly? Good. Thank you. Absolutely. So, they are non organ based structures. Um um And there are 60 of them, maybe more. Actually, they're getting increased all the time, although their behavior is very similar. But that makes the surgery a bit very interesting. But in the retroperitoneum, I'm not, I I operate on the limbs as well, but in the retroperitoneum, there's basically three that you five that you need to think about, which is liposarcoma, which is either dedifferentiation or well differentiated leiomyosarcoma, which you've all heard of, which is a smooth muscle, a rare tumor called solitary fibrous tumor. And tumor is ari from nerves called malignant peripheral nerve sheath tumor. There are others as well in fact, many others, we see them all in the abdomen and you've all heard of gastrointestinal stromal tumor, which I'll talk about, but that's not actually a retroperitoneal tumor, but we do see it masquerading as such. Ok. So how do they present often? Incredibly late. I've cribbed this talk from a talk I gave to orth pods a year ago. So, everything I'm saying here was a year ago, I'm afraid I've not updated. It saw this guy about a year ago, no symptoms whatsoever. Just early society and his abdomen increasing in size. Um Occasionally they can have some debilitating symptoms, some weight loss. It's all very vague. Um, gastrointestinal obstruction, you would think someone with something like this would have some G I symptoms, incredibly rare. Usually eating normally very early, they just feel full early at the time. Uh This was when I was a registrar on my fellowship at the Royal Mars and 55 lbs is the largest one that I've ever been involved in which was 28.7 kg. Um uh he was, he was um basically just told he'd just been gaining weight. He been, he's told to stop going down the pub. This was before surgery and after surgery. Um, occasionally there'll be tumors which have got specific effects because they block things. So this patient here with the um um presented with bilateral DVTs, right? Vascular surgeon decided they were going to stent the small IVC leiomyosarcoma So we then had to take that out, take out the IVC and staple across the stent, which was there. This patient uh had a malignant peripheral nerve tumor and presented with symptoms in the leg. So she lost uh lost symptoms in her leg and the tumor was in the back of the abdomen um diagnosis. So there's the one take home message is about biopsy at the end here. Um Cross section imaging is mandatory, but actually the basic test is just a CT scan MRI I don't think adds much over it. It's certainly not going to give you the diagnosis and I think pet scans are rubbish. They don't tell you much. So you don't need to have them, but core biopsy is crucial. So none of you would operate on a colorectal cancer without knowing what you're doing, what, what it is and that is exactly the same. Um uh for soft tissue malignancies. I'm aware that I have a gynecologist still in the room or is he still here? Maybe not. I may be safe, definitely not. So some specialities believe that this is a dangerous technique and you will upstage malignancies. This is wrong. You know, it is absolutely wrong not to operate on something without knowing what you, you, you are operating on. Um It will tell you which patients uh uh um might not need surgery. It will tell you about the grade and the size. It will tell you about chemo sensitivity. So I've mentioned gist and I'll show you some slide chemo sensitivity is hugely important for a few patients and it will identify whether something is not a sarcoma at all, like a different type of malignancy, a lymphoma. So, if I give you these remarkably similar looking tumors, you, I want to have a guess what any of those are, you would say soft tissue sarcoma. I don't know a gist actually what you have for. This is, this one's an entirely benign Schwannoma. This one's a sarcoma hugely chemo sensitive. This one's a lymphoma doesn't have surgery at all. And this one's fibromatosis does have surgery but completely different without a core biopsy. You have no idea what you're doing. I mentioned gist. This was the very first report of uh uh of um the drug which was first used for the treatment of G, which is a drug called imatinib. We've now got three or four drugs which we've done for it. Absolutely transformed the management of this condition. This patient in this new England journal paper had widespread metastases completely disappeared. Um um This patient presented with this tumor here and you know, no one would fancy the operating on that. That was two years of just treatments and it's difficult to see the tumor now, but it's, it's that thing there. So incredible response. A core biopsy tells you what you might need to do. Um And also for liposarcoma, which is the mainstay of our work, it will tell you whether definitively whether it is a lipos soma coma or not because there is a gene in liposarcoma called the MDM two gene, which will be amplified. So, these are all fatty tumors, fatty tumor there, fatty tumor there, fatty tumor, there, fatty tumor there. Uh they all look like fat. I'm not quite sure what they are. But if you look at them, this is benign, This is benign. This is benign and this is a sarcoma. So three patients who might not need an operation. One that does, is it safe? This was our unit publishing on this a few years ago. This is a Toronto Unit and the answer is it's completely safe. Um You do occasionally, occasionally see an implantation. I probably have seen one may 2, we can deal with them, you can operate on them, but the benefits and proving, you know what you do completely outweigh that minimal risk. And in this big publication, local relapse with co needle biopsy versus no core needle biopsy essentially identical. So it's safe. Um Occasionally in our unit, we don't do it. So this tumor is a dedifferentiation liposarcoma because there's a tumor here and there's abnormal fat there, tumor there and there's an abnormal fat there. And in our unit, we sometimes take these patients straight to this because we know it's a liposarcoma. Take a message for the exam and even if they say it's wrong it's dangerous. They're wrong. Tell them. I said, so stand up to your examiner and say you are incorrect. One of my fellows did this, one of my fellows did this. He was in the exam. They said the examiner said there was a big tumor in the abdomen. I can't remember it was big tumor in the abdomen. Tim Pen. Now working in Guildford, the examiner said, what are you going to do about that? And he said, he said, well, I'm going to do an MRI and a core biopsy. He said, no, no, no, you're just going to get on and take it off. And he said, well, I've just come from the regional sarcoma unit and they would have certainly done an MRI and a core biopsy and he passed by the way. Um So, uh so final thing, don't think of them one disease, they're not one disease. So, um um they're five or six or different types. So if you look at local relapse of all, all lipos, all retroperitoneal sarcomas, that's your figure. But if you break them down by subtype liposarcomas have actually got a very large risk of local relapse. Whereas leiomyosarcoma generally don't. If you look at the same figure for distant metastases, again, all comers that's a distant metastases rate looking at uh when you break them down by subtype, leiomyosarcoma is highly metastatic liposarcoma is not metastatic. So, it's not one disease, preoperative workup. It's basically just for any major surgery. The one thing that I would say is you have to, many of our patients will require nephrectomies if you've got a liposarcoma, because liposarcoma is a disease of perirenal fat, um who's going to do nephrectomy on this patient. Hopefully not because that's the solitary kidney on that side, which has been gone since birth. So, you've got to think about renal dysfunction and do renal assessment because patients may well lose the kidney but not in this case. So that's section one, any pressing questions about diagnosis? Yep, box. Excellent question. So the MDM two gene in lipos is demonstrated anywhere. It's an early genetic mutation. So if you take some fatty areas, uh and you have some solid area, it will be completely representative grade will not be. So you can absolutely see low grade and high grade. But generally speaking, because as I'll show you, we don't have an awful lot of things to help us in terms of adjuvant therapies. It doesn't really change your management because the book for All Lipo all retroperitoneal sarcomas, it stops with the surgeon because so it doesn't change it. So yes, it can be non representative of grade, but it probably doesn't matter any other questions on this early stage. Ok, let's move on. Um So the bit we were talking about is how do we do the operations? So none of you will ever do it. But if any of you did want to come and spend a year with us. You will see anatomy which you don't normally see because I'm used to operating in the back of the abdomen that in all these rec peritoneal structures, which is complex. But actually, once you get to know it, I'm quite comfortable in this region. But you are faced with operating a lot around the major vascular structures and the major nervous structures. The reality matter for the major nervous structures is actually all we really need to look out for is the femoral nerve you hardly ever come across the obturator nerve and all of the cutaneous nerves, like obviously, you try and keep them. But if people get cutaneous loss as part of taking out a big tumor, they they live with that. Um The important thing to remember is that your anatomy is going to be distorted by your tumor. So in this case, the right colon which is going to come is on the left side of the abdomen. Uh This kidney here which is is displaced between a lump of tumor here and a lump of tumor here and a lump of tumor there there. And this kidney here is completely the wrong place. So the renal vessels which need to be taken when you get, it would be going in a completely different direction to where they would normally be going. The question I'm often asked by registrars, usually plastic surgical registrars drives me up the wall is how wide a margin should I take around the sarcoma? Because they always want me to say one centimeter or two centimeters, which is completely ridiculous. You can't say to a gastric surgeon just take two centimeters around the stomach. It's just meaningless, isn't it? This is one slide. This isn't even a sarcoma. This is AAA benign sultry fibrous tumor. We, we've got one slide in the whole unit which we can say is, oh, you might be able to do a centimeter around it and that's a drawing of what in the limb, you just might be able to do, preserving the vessels. But the reality is actually this, you can have a great tumor like this, which is hard against the bone, which has got to stay hard against the blood vessels, you got to stay. So your, your anatomy is defined by your, your margins are defined by your anatomy as I keep trying to say them. So in this leg tumor, I have the luxury of being able to operate in the leg. You know your anatomy here is going to be defined by the femoral vessels and the nerve which you're going to keep or us. It's no use keeping the leg now in the abdomen. Therefore, what we want to do is have a complete resection. Er and you want to get a macroscopic re resection with a single specimen and taking involved or contiguous organs. And this is where there's a bit of debate between the USA and, and the, and Europe. Really, this guy called Alex, who's a very powerful, er, Italian speaker, very charismatic, who did a presentation me a paper many years ago where it was basically life before Alex and life after Alex and life before Alex was when people didn't do um took continuous organs and life after Alex was when contiguous organs were taken. And basically, he said local recurrence better, five year survival better. Um And to be fair to him, his team then went on analyzed and it um why that might be. And they did a very good study looking at what organs were infiltrated by tumor. And the answer was the organs were infiltrated by tumor. So whilst it may not be the whole cause for the improvement, removing contiguous organs probably is an important thing to do in soccer. So the compartment in the abdomen, no one thinks of an abdomen compartment would be very complex at the front. It would be colon meso colon, but a pancreas liver put back psoas quad, the lots of muscles basically really, really complicated. There's very little which can be resected, but there are things which are. So we almost always do a clonic resection, right sided for a right sided tumor left for a left. If it's right up against the diaphragm, you might have to take it. The tumor involves an ipsilateral uh kidney and ureter uh kidney and colon. Again, diaphragm is mentioned and sometimes ilio sous muscle or at least fascia, I'll just run you through a few pictures to show you what that means. So, this tumor here is going to need a clonic resection. And on the lateral aspect, you can see the colon, the top mes a colon here, it doesn't show very well. This is peritoneum here and this is the tumor bed afterwards. Doesn't come up very well. Medially, it's going to be aorta and crus here where we're going to be operating against. So that's the crus. Mhm Yeah, that's the OTA at the back. The pso S muscle is here. So you're at least going to take the covering of the psoas muscle. So that's your psoas muscle and your aorta. And in this patient, the psoas muscle here is involved by a tumor. So in this case, the psoas muscle has to go, that's the femoral nerve and the thing. Uh and that's more of the femoral nerve just being showed there. And on the right hand side, your cava is usually dissected all the way along because you can see the cava right against the tumor there. So that's what your caver should look at, sort of, you know, sorry to be rude. How big is my penis type conversation in sarcoma worlds is how blue can you make the caver? You know. And so people would say I know it needs to be absolutely completely blue. Not too blue because that means you're in the middle of it. We should do that, but you know, it's meant to be dissected really clean. Sorry about that, completely inappropriate comment earlier on my apologies for that um direct infiltration. Um uh uh Generally speaking, this is a bad sign. You would only resect things like stomach, head of pants, liver. If tumors have gone into them, this is really rare and it is actually an indication probably not to be doing this surgery. So this patient had the tumor gone into the stomach. We did do a partial gastrectomy on this patient, but it's usually a bad sign of infiltrative disease. Um vascular reconstructions only if the tumor is involving a vessel. So this tumor here, this isn't an implantation, by the way, this is a massive hematoma from the biopsy. So you do get that occasionally but you know, um but it showed us this, it was a vascular sarcoma. It's arising from the external vein and it's encasing the external iliac, sorry, the common iliac artery there. So in this rare case, we had to replace both. But actually more commonly, this is an IVC leiomyosarcoma. Here. More commonly, we just divide the IVC. Uh and II, I don't do a lot of reconstructions. I get a vascular surgeon to do it. So in this case, we just divided it. This patient's creatinine peaked at 117 and went back to normal. So the body can survive without an IVC um incisions, uh no laparoscopy, no robotics, none of that. It doesn't work with these tumors generally down the midline. Um for obvious reasons, no robotics doesn't really make sense. You can sorry, you can extend laterally if you need to. So we sometimes have to do that side or that side really both sides to get better access. Um lots of other incisions, you know, you can do things like that. Tumors go elsewhere. They go funny places so they can go down in the leg or up into the chest. So you may have to extend there. Um So this is a tumor spanning the inguinal ligament. It's a retro tumor which you bulge out through in the femoral canal. So you've got to do that and then reconstruct the inguinal ligament there. It's all very exciting surgery for anyone who wants to come and spend a bit of year with us. You get to do this stuff. It's good. Um really useful approach. A retroperitoneal approach through here. You can do this tumor by reflecting the whole of the retroperitoneum and don't even go into the abdomen. And this tumor and this tumor we have both taken out without exposing the peritoneum, um toys and tools. Uh we that 55 kg tumor um we did without any of this stuff, but this has really transformed our abilities, retractors, uh ligasure, you will use a lot. We've moved from G I staplers to Endo GS which are really great and we use them a lot. Not for bowel work actually for just control of blood vessels usually. Um, but the most important it is actually your assistant, two consultants, Dick Strauss and myself, usually for big complex work, two consultants, it makes a huge difference. Um So this is, everyone talks about multi routines. It's really important, you know, your medical oncologist, your radiation oncologist, your pathologist. Yeah, absolutely. Really? Me? good for the exam. Uh Same for the retroperitoneal. Your multi British routine is your other surgeons in your team and your Anestis? And that is it. I'm afraid to say because the truth of the matter is that our oncology colleagues haven't got a lot to give. Um and if you got the right team um for we published our 281 patients a while ago, overall mortality less than 1% greater than 65 years. It was still only 1.8%. Median number of organs resection was two because it's usually kidney and colon which normally go um 10 day stay in hospital, eight day stay in hospital. Ca new morbidity over 65 is high. So 30 28.3% versus 10% younger because it's a big surgery. But actually they get them through that. OK. So uh that is that OK. Questions on techniques and I think, oh, I done your thumb. I take that as so we'll move on. Why did I say that adjuvant therapy is no good. It's a bit of a shame really. Um Radiotherapy works in Sarcoma and this was a randomized trial which took us years to do randomizing patients to preoperative radiotherapy versus surgery alone. In all comers for intra-abdominal high grade sarcomas, all those five groups and these were the survival curves and they were identical. So this was reported in Lancet oncology that radiotherapy does not work as a preoperative strategy in Sarcoma. Unfortunately, this is a a lesson in trial design. In the trial, we included leiomyosarcoma, which as you know, don't relapse. So we underpowered the trial. And the other crucial mistake we made is we said that if you progressed on radiotherapy, that was an event as favor. So that was a negative event in the radiotherapy arm, but it didn't mean you couldn't have an operation. And if you said, took that event out, actually, if you looked at liposarcoma alone, this was preoperative radiotherapy, local relapse and this was surgery alone and it's significantly different. But because this was a secondary endpoint and a post talk analysis, it was not allowed to lance oncology to report it in the abstract or anything like that. And so this has been the ta home message, not this. So it hasn't changed practice, at least not in the UK. So we do not give any adjuvant preoperative radiotherapy. Other than in very rare circumstances, we are going through the same process of asking the process of chemotherapy. This question has been asked in limb sarcomas and the answer was it didn't work. And liposarcoma is a particularly chemo insensitive tumor. And we are using drugs which is Adriamycin or DOXOrubicin, which you've been around for 50 years. I think this is going to be another negative study. So I think we're still not going to have any preoperative chemotherapy. So the buck will remain with the surgeon for management of this disease. Um How many should we be doing? And this is why I'm saying that, that this is a rare disease, 6% of all sarcomas. This study estimated uh in the UK 100 and 40 cases, there's 100 and 70 hospital with A&E S in England. So if we didn't specialize, that would be one case per hospital per year. Um It's been recommended that we do, these are in treatments with specialist centers and the number which has been suggested there are 15 sarcoma N DTs around the world, around our country. But that would um equate to about somewhere between 10 cases a year. Um If you look at what the difference between high and low volume is, this is our unit. We moved from about 20 cases a year when I started to about 50 to 60 over the last decade. And the National Special Service Specification says we should be doing 24 a year, which is only one every, only two A month for the whole unit. The French group looked at whether outcome was improved and this is in small unit with whether you outcome was improved. The answer was yes, it was. And we looked at this, this is public health in England data. So this is whether you get your retroperitoneal Sarcoma operated on in a specialist center with an MDT or not. And the answer is big difference in survival. And what was very provocative was what happens if you were operated on in a high volume center carrying 24. And whilst people have criticized the sticks stats about this. And this is very provocative data. The outcome in this slide was that if you're in a high volume center, it was 71% survive five year survival, whereas a low volume center 59%. So if that is correct, that's a 10% survival difference based on volume outcomes. Um And the thing which was even more provocative was that when you looked at the hospitals which were doing high volume. So this is over five years. R. Mh was doing about 300 to 350. Every other unit in the country was doing less down here. And what's the argument which we are trying to win but failing to win that actually, the Oranges or the Sarcoma BTS. So actually we move all these patients here and put them into a small number up here so that all the numbers go up just the way we did in pancreas and in esophagus. But that is an argument that is going on in the Sarcoma community and you guys don't have to worry about. So, what does high volume mean? Well, for me, uh this is actually last year, I haven't reupdate it. But if I'd have shown you the cases over this month, it would be the same. This is what we have to operate on at three in the last three weeks. They're not all my cases. So in this slide, this one was mine. I think this one was mine. I think this one was Dirk, but I operated on all three of those with him in those three weeks. And in the next eight days we have this one and this one and this one. So you get to live and breathe the disease because the disease is what you do. And it's very interesting, but you have to come to a high volume center. So as I say, if any of you are interested in taking a year out and it is a year out, you get to see completely different surgery, it won't replace your own fellowships. But it's really interesting. Most of our fellows are from abroad because they still enjoy doing these things and want to come to the UK. It's a while since I've had a UK senior fellow, but it's always out there. Um And that's all I need to say. But talk this morning and you've all had multiple uh in invitations. So uh please do touch base. Are there any questions from the room? Yes, I just going to bring them right to you about the measurement of desmoid tumor about the desmoid tumor. The desmoid desmoid desmoid desmoid? Yeah. Yeah. Um Is it any different or just muscle resection? Because for question. So you probably all hear desmoid because of FA P and you're told don't operate desmoid is desmoid can also be sporadic. And now this can be defined on a genetic mutation cause it, it is a ct one gene which will tell you whether you've got a sporadic, non FA P or an FA P. If you have a sporadic uh uh desmoid, actually, the outcome from surgery is really, really good. There's a 5% local relapse rate compared to FP figures. So Su Clark who has proc retired yet or is she still? But anyway, she published extensively on this showing that patients do very badly. So the management for desmoid tumors still is principally surgery. There's some bigger desmoid. They actually do respond to chemotherapy occasionally, but the management for sporadic desmoid is still surgery. Ok. Thank you. Any other questions from the floor? Enjoy your coffee break. Thanks so much. Um We are running slightly behind so we're going to reconvene at 11 o'clock. Thank you to all of this morning speakers, including Nina Rawa, er Mister Se and prophase. Thank you again. I thank you because you had surgery.