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to welcome you to another session of back to the future. Back to the sushi is a 12 weeks teaching program designed alongside assets suited for young, budding surgeons. We'd like to thank asset for helping us design this course. Um, like to thank m d U for sponsoring us and a huge shoutout to medal to provide us with a platform to allow, you know, to allow us to provide you with certificates, uh, with necessary certificates at your After this week, the teaching webinar session will be on a softball gastric surgery given by Mr Pritam Singh, who works at the Royal Surrey County Hospital. He's and he's a consultant here at the Royal Surrey County Hospital. And, uh, this week, suture technique that we'll be showing is sub particular sutures and how to perform in Aberdeen. Not so that further a doodle. I'll show you the video that particular sutures sub particular sutures are designed to leave no suture showing over the surface of the skin. This suture runs intradermally and not in between the subcutaneous tissue. This suture technique is the most common technique used to close skin incisions. Start the sub particular suture by inserting and not at the far end of the decision, enter the skin at right angles approximately one centimeters away from the start of the decision. This first stitch is an anchor. Yeah, tie a standard reef, not and then cut the short end of suture very short in order to bury the not bring the suture underneath the reef, not over to the fore edge. As shown here. This prevents a not from protruding through the edges of the skin incision. Using the forceps. Catholic. Retract the skin edge. Enter the intradermal layer on one side, retake the wrists and ensure you remain this layer. Take a small bite and pull the suture through. Then on the opposite side of the wound, insert a similar bite in line with or just behind where you came out from. Make sure to stay in the intradermal layer and not go too deep into the tissue. Repeat this process along the length of indecision. Working your way up, each new suture must be inserted in line with or just behind the exit of the previous suture. And this ensures that as the suture material is tightened, it draws the edge wounds together almost in a manner of invisible mending. The accuracy of the placement of the suture will ensure an equal tension down the wound and neatness of the closure. All right. At the end of the incision, perform in Aberdeen, not perform your last suture who do not pull the suture all the way through. Keep the loop of the suture opened with your left hand, which reaches through to grab the long end of suture and pull the loop through this loop is pulled through untighten and And this process that repeated four times before bringing the needle underneath the Abdi not and outside in order to secure and bury the not Uh huh. Okay. So that video showed how to perform subcuticularly sutures and how to perform an Aberdeen not at the end of performing sub particular sutures. Now, without further a do, I'd like to introduce you to Mr Pritam Singh, who is a consultant. Esophagogastric surgeon at the Royal Sorry County Hospital. Uh huh. Uh, one. Yeah. Lovely. Hi there. Thanks. Dashi. Uh, for the invitation to talk to you all. Um and, uh, thank you for giving a chance to talk. So my name is pretend I'm N o g. Surgeon based at Royal Surrey County Hospital in Guilford. Um, been working as a consultant since 2019. So I'm going to try and hopefully, uh, tell you why. I think it's a great special thing. Um, So I will share my screen. Happy to take questions as we go along. Um, Dash is gonna be looking at the chat screen and charting out any questions, and I'll ask you some things as well, if that's right. Great. Okay. And good. So, um, to start off with what we're going to talk about today. Can you see that? That you give me a thumbs up if they're going through. Great. Um, So the plan today is to talk about what the software gastric surgery is, uh, what it's all about what you should expect in an everyday job. If you were to do this, um, and then talk you through. Three cases are I wouldn't say necessarily common, but classic of a soft gastric surgery, um, and how we deal with them. Um, the idea is not to go into too much detail, but happy to go into some more of people do want it. There's more to give you a flavor of what kind of things we can deal with, Um, and what kind of things we may do in the future. So as part of this one of the things to start off with us, talk about how we got here or how we get here. Um, so I understand most of you are probably at med school or in your foundation training. Um, medical these days is normally five or six years just spending whether you do an integrated degree, that's standard for everyone. Um, and for soccer gastric surgery, you do still have to go through the standard pathway for general surgery training. So that's two years foundation training, two years court surgical training and six years of higher surgical training. Um, there is a plan to move towards a competency based curricula, but I think by and large it's at least a minimum of six years higher surgical training. I don't think that will likely change any time soon. Um, that's the mandatory training um, the two have put down at the bottom are optional, but fairly common amongst the software gastric surgeon. So, uh, an MD or a P H. D. um takes either two or three years, sometimes longer, but it's fairly common place if you do o g surgery, and also because it's a fairly specialized field. A lot of people move on and do a post training fellowship for either one or two years. Uh, my own training. I did a PhD for three years, and I did a fellowship for a year as well as a couple of visiting fellowships to other units internationally. Um, but so it's a long training program, but I think you do. You do enjoy it most of the time you learn as you go along, and it's quite nice to see the progress. Um, so move onto what is o g surgery all about? There's obviously elective and emergency Ogi surgery. Elective surgery is largely looking divided into benign and cancer work. So benign surgery would include, uh, gastroesophageal reflux disease, hiatal hernias. Uh, achalasia, uh, various operations for those things, and then probably most of our workload is taken up with O G cancer work. Uh, includes esophageal cancer, gastric cancer, Um, and also depending on which unit you work in, you may also deal with just which are gastrointestinal stromal tumor, which we certainly do here. Um, and actually, it's probably a very interesting part of the surgery because it's quite variable on an emergency side. What are you likely to do? Deal with and see again benign and cancer Emergency side is often more benign work. Um, strangulated hiatal hernia or have syndrome. Um, sadly, some corrosive ingestion injuries. We've seen a lot of those recently. Uh, the cancer side of things is less emergency work for for cancer. Um, but there's a lot of sort of semi emergency work. I'd say, Um, in terms of absolute dysphagia, Um, if people can't drink anything and you may need to do something about it sooner, you can't go down the standard pathways. You may need to think about feeding access or IV fluids. Um, and then there's perforated or bleeding tumor's. These are, thankfully, quite rare, but but you may have to deal with them. So I'll just go into the first case, if that's okay. Um, Mr Singh, someone's mentioned what's the benefit of doing a fellowship? So the main benefit I found for doing a fellowship is, um, I trained in West Midlands. I think I had really good mentor with really good trainers. Um felt very well supported. Um, and I came out of it feeling like I was able to do the surgery. However, I hadn't done as many cases. Perhaps I'd like to have done. And I hadn't had that experience of being a consultant. Um uh and going straight to consultant job is good if you can get it if you get it in the right environment. But actually, the fellowship often gives you that opportunity to build up some experience. So even though you're trained, you then get to extension, build up your case numbers, your experience. You gradually gain ex, um, experience of doing things independently because I was doing the same operations. But the same operation feels very different when you're doing it. Supervised by a consultant in theater, um, to doing it on your own as a fellow as a with a consultant available, but but actually doing it on your own. So I think that that was very useful for that. Um, the other thing actually is, however well trained you are, however much experience you have. Um, almost everything you do in surgery can be done in a different way. So if you go to do a fellowship in a different unit, you learn different ways to deal with the same thing, which I think is invaluable. Um, and you pick up little tips and tricks, which you can use to enhance your own practice, uh, and perhaps even do things slightly differently if if you have to encounter a different way of doing something, so I'll give you something specific. So the way you do, you join from esophagectomy, hand sewn, stapled, linear, stapled. There's various different ways of doing it, and the chances are, as a trainer, you're going to do what your trainer has taught you. Whereas if you go into a fellowship, you may then learn a different way of doing it. And then when you go into your consultant posts, you can decide how you're going to do it and which, which way felt the best for you? Um, other specifics are, if you want to specifically learn a new techniques such as minimally invasive surgery or robotic surgery is probably the most normal newest thing these days. Um, so yeah, many different reasons. I hope that answers the question. So first case, I thought keep it realistic. It's two. AM You're asleep at home, Uh, and you get a phone call and, uh, with a softer gastric surgery on calls. Quite often, the emergencies do seem to happen in the middle of the night. Uh, because it's a centralized service. Often you're taking a phone call, uh, from another unit. So you've got a call coming in from someone you haven't necessarily met before. You don't know very well. Um, and you've got to get some key details bearing mind. You've just woken up. So you've got a 68 year old man? Um, you've been told that he's presented with sudden onset onset chest pain, which was preceded by vomiting. Uh, and as he's had the basics work up, and they sensibly organized a CT and the CT scan that given you is this. So I'm going to leave it up there for about 30 seconds to actually just, uh, so that no one feels under the spotlight. Could anyone just write down on the chat? What they think they can see? Tell me what? The silences. Very condition. Yeah. I'll let you know if someone's mention anything. Anyone, maybe you'll warm up a bit later. Yeah. So, um, this is a CT scan of the chest. Obviously, a CT scan should be taken in context of the whole thing. And you normally go up and down the images, not just have one slice like this, but what can you see on this? And I'll talk you through it. So, um, you're fairly high because you can see, uh, the aorta. You can see. Um, lung nicely expanded on what is the left side? Because normally, when you look at CT scan, you're looking from the feet upwards. So what's on the screen, right? Is actually the patient's left. And on the screen, right, you see a bit of lung. But then you see a big black space. Um, that black space is air, So this patient's got a big pneumothorax. Um, let me know if anyone breaks the silence stash. If anyone's got any ideas, um, nothing. You also see some white fluid underneath that lung. Now that white fluid in the context of a CT scan, which I know has been, they've been given oral contrast. Um shows that if they've had oral contrast and there's free oral contrast now in the right chest cavity along with a lot of gas. The chances of what we're looking at here is that there's been some kind of perforation. Um, and if you scroll up and down, look at all the various images you'll find that this gentleman had a distal esophageal perforation, commonly known as a board have syndrome. Uh, the amount of gas is actually very sporting. Um, that's that's not typical, but, uh, but that's where you're at. So at this point, um, bore half syndrome, you've got taken a phone call at two. AM You've been given this information very diligently by a very thorough registrar, Another unit, and you've got to think of the logistics. Um, this gentleman does warrant transfer to a softer gastric unit. Um, but before you do that, you got to think of the logistics. How is this going to happen? So the patient needs to be stabilized. Um, and the key thing, whatever stage of training you're at, always think of airway breathing circulation. You'll never go wrong if you think of that first. So you need to stabilize this patient airway being and breathing being the main things for this chap in that he's got a huge pneumothorax. He needs to have a chest train to try and decompress that, um interestingly, that CT scan was with the chest strain in. So there's a There's a complex story to this, but, uh, I won't go into that today, But ordinarily, if you put a chest rain in the lung should re expand pretty well. Um, circulation you want? You want to find out how sick this chap is? Is he awake and talking to you? Is he actually on? I t you already on? I know tropes already. Tube vented. Um, and you need to think about how fit he potentially can be. Um, and will he be able to withstand, um, surgery for this? Because you can't treat this without an operation, but the surgery is going to be required for this. Um, and then you've got to arrange a transfer over to you. Um, it's 2 a.m. Do you Do you want to wait till the morning? Probably not for this guy. He's sick. You need to get in touch with your intensive care team. You need to speak to the team that are referring to you and ask for them to arrange a suitable transfer. Probably. I t you to I t u You want to inform your theaters that you're gonna have to take the chap straight to theater? Um, and then have a plan? Um, images are often elsewhere, so you need to get them linked on. So I won't bore you with all the details, but essentially got to think of a lot of, um, pragmatic and logistical thoughts. And then you get to what should really be The easy part is you take them to theater. Um, to treat this, you have to open up the side of the chest. That's contaminated. Um, wash it all out, and and then the traditional way to repair this is to put in what we call a T tube. Now, I don't know if you can see my arrow on here, but within that CT scan on that image, can you see my arrow dashing? Yeah, I can. Yeah. Where that is there. There's that white line within the esophagus. Um, that's actually a t shaped tube. And then this bit here actually comes out through the chest as a tube. Now, the purpose of this is that it allows the tissues to heal with a root of drainage, because if you just try and close it, it may heal. But there's a fair chance it will carry on leaking because they're not healthy tissues. Um, it's not like incising this esophagus. This is normally do to, um, or classically associated with a heavy night out. Heavy drinking, perhaps, uh, forceful vomiting. So it's a tear, so the edges of that tissue may not be very healthy. So when you go in and you wash out and you repair, you do try and freshen those edges, you cut, Um, some of the unhealthy tissue away you put in a teach you, uh and then you've dealt with a problem from a surgical point of view, you then got to think about the recovery. So this this gentleman definitely going to have to go to I t u he's gonna need some chest drainage. Um, and then you got to think about medium term, how you're going to get him better, because he would have probably been. And he was for this chap. He was very sick when he arrived. Uh, it's gonna be a prolonged recovery. You're gonna need your physios to get him mobilizing. You're gonna need your dieticians to think carefully. Nutrition team about How are you going to feed this gentleman? So do you feed him through this standard central route from the mouth? Probably not. If he's asleep on I t u for a couple of days. Um, you can think about TPN. The other thing you can think about is a feeding jejunostomy, um, where you put a feeding tube into the small bell? Um, this sort of gets him out of trouble. And it means that you can give him nutrition without actually having to go past the whole That may carry on, uh, taking some time to heal. Okay. Any questions about that? Does you, um, any questions, guys at all? If there's any questions that come up Mrs saying, I'll let you know. Sure. Great. So I'll go on to the next case, then. Um, it's a bit kinder. It's 10 a.m. this time, and you get a telephone call. Uh, this time you're in hospital already. You're in the middle of something. Um, an m d t. Uh, and you get a call from another very diligent, very thorough registrar from one of the regional units and saying they've got a 72 year old female who's presented, um uh, as an emergency with vomiting and chest pain. So this could be obviously, many things. Um, but once again, they've been very thorough. Um, they've assessed the patient, they stabilize the patient, and they have got, um, a CT scan. Again, I'll put up there 30 seconds to see if anyone has any ideas or thoughts. Okay. Any ideas, guys, if you have any ideas, do let us know in the chap. Um, some people have mentioned perforation again. Um, someone else has mentioned this. That that the stomach has been pulled up into the chest. Yeah. Good thoughts. There's certainly something in the chest. Um, there was not a perforation for this, but there was an imminent perforation. Give you another 30 seconds. It sounds Sounds like people are warming up a little bit. They might have some thoughts. It doesn't matter. Guys just give a shout. And so someone's mentioned it. Diaphragmatic hernia to have right. Well done. Yeah, that is what this is. So, um, on that thing on these pictures the left hand side of the screen is there? Is there just general scouting type A gram almost like an X ray that yet with the CT, I just thought put it up there because it gives you an idea. Um, that essentially the plain radiograph would have shown you that there is something in the right side of the chest. Um, stomach is a good thought, because actually, hiatal hernia is something that we deal with a lot. But actually, in this case, that's Colon. Um, the picture on the right is a snapshot there, and you can see the defect in the diaphragm there on the right hand side. And you can see that there's colon occupying most of the right side of the chest. And actually, if you strolled up and down, you realize that the colon is going right up to the apex of the right chest. Um, I mean, this patient's sick very unwell. There's definitely an I t you to I t u transfer. Um, Fortunately for her, the colon hadn't perforated. Um, but it was certainly there, and it was certainly about to perforate. So again, um, logistics, how you're gonna get this patient Cross what you're going to do. What may you need to do? Um, I'll just talk you through briefly. So stabilized patient again. Airway breathing circulation. The referring team had done an excellent job of that. In fact, they already got this patient into I t u. She was very stable. Um, despite the fact we later found that she had dead gut in her chest. She was actually doing quite well, but she was tubed. Invented. You got to think about conversations you're gonna have with the family, or she can't have a conversation with a patient because she's already intubated and ventilated. Um, but you want to let the family know that this is a a life threatening event, but there is potentially something you can do about it. Um, again, you've got to think about how you're going to get her across. Um, need to let your theater team know that you're gonna again have to take her to theater. Um, fine treating the problem. So, for this, we actually did this through a laparotomy. Midline laparotomy. Um, in order to get all the contents down from the chest, we have to extend the diaphragmatic defect because it was too tight. Um two. So actually make the defect bigger. We don't pulled all the bowel contents down, dissected it out, thankfully, because it was fairly acute. Um, the lung expanded very nicely. Uh, very quickly. If it's a chronic problem, sometimes the lungs actually almost kind of atrophied or shrunk down. But this was actually fairly acute. Event so long. Picked up nicely. And then you got to think about closing that defect. Um, are you trying to say something that, actually I've just seen a hand up? Yeah. So someone just mentioned Is this what we call chili Dottie syndrome? Uh, no. This is this is actually just a straightforward diaphragmatic hernia. Um, but this is, um, good thought anyway, but But for this, then you got to think about how you're gonna close the defect. Um, and whether you're going to use mesh or not, Um, and then you get back to general surgery. So you've got some dead gut. In this case, it was the transverse colon. And the question was whether or not we need to, uh, resect and rejoin or whether we just take out the transverse colon, bring up stoners uh, or do we bring out the right side of the colon and think about rejoining at a later date? Um, and you got to think of all of this in the context of the fact that, as I said, she was very sick when she arrived. So whilst right Hemicolectomy, um, in a clean setting, I there's no perforation is a sensible option sometimes. But when the patient's already dosed up on high dose of inotropes and is already very sick, the chances of them having that joint survive Well, um are lower than in a standard elective setting. So you need to think about what? What's going to be the safest option for you here and then recovery again. Think about nutrition. Think about having to get the patient early mobilization. You're going to need I to involvement. You're gonna need a lot of, um support for this patient because they're not going to get over this very quickly. Okay, so these are two emergencies and, uh, sort of strange hours of the night and early morning. Okay, now, to this is a much more common, uh, sorry. That's the picture, actually, after this diaphragmatic hernia is reduced you can see patient's right long has expanded nicely, uh, the diaphragm and is now intact, Mr Singh? Yep. Someone just asked, Why can't we just push the gut back to where it belongs and close the defect? Sort of. How it sort of like how we would get rid of a hernia without any reception? Yeah, it's a very good question. Um, there's no reason why you can't do that If the bowel is healthy, so similar to an inguinal hernia. If the bowel is healthy, you reduce it, and you repair the hernia. In this case, the bowel was not healthy because although it hadn't perforated, it was a scheme ick, uh, and was imminently going to perforate. But a very good question. Um, if it's healthy, there's no reason why you can't do that. And we have done that many times in the past. No further questions at the moment. Okay, great. So that's the picture of her after. And as you can see, if you see the sort of, um, I'll just quickly flick back and forth. So if you see her there and then you see her there, you can see that she's already become bigger in size. And that's due to fluid retention. Low albumin state. You know, this patient was very unwell, but thankfully, uh, recovered. Well, right, So I go to a more standard upper gi day. Those are emergencies that we do see, But still, uh, probably not your everyday work, but two week great referrals from a GP or from, uh, and even sometimes it may upgrade someone to a two week great referrals they present with a problem that they think doesn't need an emergency but needs to be seen relatively quickly for fear of cancer. Um, so you've got an 83 year old man who present with dysphagia and weight loss, so this chap is otherwise fit and well, but over the last couple of weeks to months, he's noticed he's lost about 6 kg and weight. Uh, and he's unable to swallow food as well as he used to be able to. So any thoughts on what we do next? Pop your answers, guys. So someone's mentioned an o g d. Yep. Very good. Anything else? Anyone want to do? A CT? Yeah. So I think that's fair. I'm I think, um, for attenuate referral. Anyone with dysphagia. It's one of the nice criteria for an urgent O g d. Very sensible. Um, barium swallow. Yeah, barium swallow is is an option. Um, it used to be, uh, potentially favored. Um, but in modern practice, people normally go from O g D. Um, occasionally use a barium swallow for patient's who perhaps can't tolerate an o g d. But then, um, with the caveat that it may miss things, but I guess if they can't tolerate an O. G. D. Because they're too frail, then they may not be someone who's going to have major interventions anyway. But for diagnostic purposes, it may be useful. Um, the reason I had a CT for this patient is because of the weight loss, because even if there is no nothing found on o g d u someone who's lost, you know, half a stone in weight who's otherwise fitting while and eating well, you got to worry about an occult malignancy elsewhere. So although we are a software gastric surgeons, we still want to make sure that the patient's holistically looked after good. So o g d do an o g d. And what you see any suggestions guys. I won't insult your intelligence by making you say what you see there. So there's there's a there's a There's obviously an obvious cancer there. Um, it's in the esophagus. You can see a mass. Um, what should we do? I will ask you that way. So someone's mentioned Biopsy. Excellent. Very good idea, because it may look like I mean, that's pretty barn door. But sometimes if there's something more subtle, you may not know whether it's a cancer or not. The other thing is, um, uh, if there, uh, is a cancer, you want to know what type of cancer there is. Uh, there are two main sort of cancer, and I'll leave that out there, see if anyone can think of what they are for esophagus. Someone's mentioned squamous cell carcinoma. And, uh, I got it so internationally. Squamous cell carcinoma is the most common in the UK population. I don't know carcinoma is what we most commonly see, but that's very important. That has very different management or potentially very different management pathways. Um, so Bharti's very good. You don't want to just take one. You want to take a minimum of six. If you've got something big like that. I'd normally take at least 10 biopsies, because you what you don't want is a false negative. There's clearly something there. If the biopsy comes back negative, you're just gonna have to put them through another, uh, endoscopy. Um, anything else you would do for this patient? Any ideas? We mentioned the CT. Would you still do a CT and all the families? Yes. So someone's mentioned for staging to look for meds? Absolutely. So you want to stage this cancer? It's It's almost certainly a cancer. You want to know whether this cancer is something that's potentially curable or whether it's something that has already spread beyond the means of cure. Then equally, we can sort of offer them other treatments. But we need to think about that. Um, would I do it straightaway? Would I wait for the biopsies? Thoughts on that, uh, someone said straight away. Yeah, I agree. So you want to get your nurse specialist involved? Uh, someone like this. I would speak to them at the end of the list, hopefully ideally in non covid times of one of their family members present with and a nurse specialist with me, so I can explain to them that I'm almost certain that we found a cancer. Um, the reason for the CT scan. I would try and get it arranged on the same day. Ideally or if not very rapidly, is to try and get some answers as quickly as possible. So very good. We've got a diagnosis. We're thinking about staging it. Does anyone know what else we would want to do As part of the staging process? You've had an O. G. D. You've taken biopsies. The biopsies confirm an adenocarcinoma, and you've had a CT scan, which shows no metastases, any ideas of what else we would do. Someone's mentioned MRI. Good thought. It doesn't have a primary role in a softer Juul cancer. Um, but it does have in terms of it's not. It's not mandatory for everyone, but we do use it selectively. So if there's anything suspicious on the liver, we would tend to get an MRI scan of the liver or, if we're looking any specific order but liver being the most common Anything else? Um, no one's got an answer. Okay, race. That's very good. That's cable tape. What do we want to do. The first picture is a CT scan again, the scout image. Obviously, the images will be very different and very detailed. You wouldn't just do the chest, even though it's a softer your cancer. You want to do chest, abdomen and pelvis because you want to see if there's any evidence of metastases elsewhere. Um, Adenocarcinomas in particular do metastasize to the abdomen and pelvis. The image to the right of the first one is a pet scan. I'm not sure if anyone knows what a pet scan is, but essentially, it's a scan where you give a type of dye that is taken up selectively by certain types of tumors. Um, the type of dye you give is dependent on the tumor type you're trying to stage. Uh, we would use fdg. Avid pet scans, um, most to soften your cancers are pet avid, um, and then you can again look for a cult metastases elsewhere, so small metastases that you may not otherwise pick up. Um, rarely you find them somewhere, even like in the bone or in the axilla. So it's worth doing. Um, e U S. That's the image on the right. That's an endoscopic ultrasound scan. Um, here at Guilford, we do do a us for all our soft your cancer's. Um uh, it's optional in the nice guidelines. Um, uh, it is very useful for local regional staging of nodes on that picture. You can see that there's some green dotted lines and around structure, which is actually a lymph node. Uh, the tumor is actually surrounding the central probe. Um, the image on the rights a bit abstract, But essentially, we're looking at the patient's fitness. Um, I mentioned he's 83. Um, soft. Your cancer is known to be fairly aggressive. Um, and we've got to think, Can we actually do anything for this patient in terms of curative treatment now, I always have this chat with patient's, um, for the pathway to continue on the curative pathway. It's not just the biology and the tumor biology. It's also the patient biology and the patient's wishes. Um, and part of that will be seeing how fit they are and how likely they are to withstand aggressive therapies for, uh, esophageal cancer treatment. So we put them on a CPX test. Which does anyone know what see Pecs test is anyone a clean cyclist. So essentially that we hook you up. I say we it's not. It's not myself. One of our intensive care doctors who is an expert in this, um he hooks them up to an exercise bike along with an E C G, along with Barometry, and he gets some very detailed output. And actually, it's the same kind of concept as professional athletes use. Um, particularly cyclists. Obviously, uh, endurance stuff is to see where someone's, uh, anaerobic threshold is I How how far can they go before? Because someone can seem quite fit at rest. But when you push them hard, which you're going to do when you put them through major surgery or if you put them through major surgery, you want to see how their heart and lungs are going to be able to cope with that. And if they can, Uh, and it gives us some objective measure, um, we find a very useful tool again. Not mandatory, but very useful, particularly for someone like this who's 83. Although he sounds fit in well, you want to get some objective evidence that he is as fit and well as he seems to be, um, the standard pathway for a soft stool Adenocarcinoma would be to give neo adjuvant chemotherapy. Um, does anyone know what Neo adjuvant means? Um um, so based someone's mentioned before surgery? Absolutely. Exactly. So for Asafa Juul cancer in this country, there are different ways of managing this. In the Europe, they do things differently. But in this country, we tend to give peri operative chemotherapy. So we would give anyone who's not a very early cancer we would give them neo adjuvant chemotherapy, which means chemotherapy upfront. Um, that's normally four cycles of two weeks. We then wait another six weeks restage them. We then if they're fit enough to go ahead with their surgery and they've not progressed and then after the surgery would then give them adjuvant chemotherapy, which means chemotherapy after the surgery. So this gentleman was fit? Um, he was keen to proceed. He understood the risks involved. Um, and he did very well on his chemotherapy up front, um, and remain fit. And his cancer did not progress. So we did get to progress through his surgery. Um, so, uh, salpingectomy there's there's various different ways of doing it. As I said, There's various different ways of doing Almost everything is surgery. Um, but, um, probably the most common way in the UK to do a two phase esophagectomy with an abdominal phase, Uh, where you mobilize the stomach. Um, so on that picture there, you can see that the stomach is mobilized preserving that vessel at the bottom of the stomach. Uh, which is the right gastroepiploic artery. You also preserve the right gastric. Uh, and and then you divide everything else. All the vessels that come between, uh, stomach and the spleen, the short gastric six left gastric artery. You divide all of those and you free the stomach awards attachments so that you can then deliver it into the chest. In this picture, they're making the conduit, which is tubal arising the stomach in the abdominal phase. Um, the abdominal phase can be done open. Um, it can also be done laparoscopically. Keyhole surgery. Um, our default, up until recently, was to be doing it laparoscopically for the abdomen. Just recently started to do abdomens robotically, which is the same concept, but using a robot to give you a bit of extra, um, angles. Really? Um and and then the chest phase on the right. You see a picture of the chest? Um uh, at the end, essentially, when the stomach has been to Bill Arised, it's been used to replace the esophagus. Um uh, and the patient is now in continuity and can eat and drink. But as you can imagine, looking at that picture just by eyeballing it. You can see that whilst the esophagus now appears to be replaced with the stomach, you have now lost your stomach effectively because that's now been tubular rised. So you lose the reservoir, and these patient's have long term changes to their eating, so they will no longer be able to eat large meals. They'll have to eat smaller meals, but more regularly to get the same volume. So just a couple of pictures. Uh, those are pictures of the chest. I think laproscopic surgery and stomach mobilizations. Probably relatively, um, more familiar to most people. What we do in the chest can sometimes seem a bit of a dark art, particularly the general surgeon. Um, but essentially, we do a right thoracotomy through the fifth intercostal space, same space that you would normally put in a chest rain um and and then use some various retractors to open up that space various different ways of moving those ribs apart. You can either excise part of a rib or you can dislocate them. Um, and then you can see that in the zoomed in picture, there's a little metal thing inside, and that's that's actually a circular stapler anvil that's within the esophagus and the esophagus has been removed. The next phase of this operation is to do the joint together. Um, as you can see, it's a fairly large operation. It's a big hole. It's requires a lung to be deflated. You can see behind that spatula. Looking thing is the lung that's completely collapsed because, uh, the nieces kindly put down a double Lumen uh, trickle tube, which blocks off one of the lungs so that we have space to do our operation. Um, the hope is, uh, in the near future for us to move towards robotic chest phases, which I've got a picture of there on the right, which may reduce some of the morbidity. But you will still need some kind of hole in order to remove the specimen. Um, so, um, that's hence the reason why we want to make sure that our patient's are very fit. So at the end of this provided to make a good recovery, you let them get better. Um, and then you give them adjuvant chemotherapy. Okay, So you did when you gave asked me to give this talk to Ashley to tell. Talk to me about the my favorite kind of surgery. I'd probably say that for me is subject to me. I mean, that's that's the kind of operation that you go into this fall. Really? And there are lots of exciting things, but in terms of operative, uh, cases, that's the thing I think is probably the most interesting. So why choose this specialty? Um, for me, Uh, I think if you look at it in terms of a general surgery, I was always interest in general surgery, and when I wanted to sub specialize, Um, I always like to minimal invasive surgery. I also like to open surgery. Um, I think with upper gi, you also get a variety in terms of endoscopic. Uh, not so much surgery, but endoscopic procedures. So diagnostics, therapeutics. I didn't talk about it today, but we do do a soft your stent placements in the palliative setting to help with dysphasia. We do, uh, NJ choose to do dilatations. These things are quite interesting. Um, but I think as a general surgeon there there are few specialties or even as a any surgeon. I think the few specialties where you're comfortable in both the abdomen and the chest. I know the cardiothoracic surgeons are very comfortable in the chest, perhaps less so in the abdomen. Um, but I think with the software gastric surgery, it is quite a nice, um, skill to or experience to be able to say that you're comfortable in both settings. Um, that's what makes you prepared to take on those kind of complex emergency cases where you are potentially going to have to go into the chest and all the abdomen. Um, I think the fact that there are minimal invasive approaches keeps it interesting. It keeps it challenging. It means that you don't get bored because you can always improve on what you're doing. There's always a new technique to learn. There's always a technique to refine, uh, and with a new platform with robots, I think even very experienced. So now learning completely new thing. I think that's that's interesting. I think it depends what kind of person you are. But if you want lifelong learning and you don't want to just do the same thing for the rest of your career, then, um I think it was one of the appealing things to me. Also, if you like multidisciplinary team working, I mentioned for all of our cases, Really? Nutrition is key. Physiotherapy is key. So you're gonna work with dieticians? You're gonna work with nutrition experts. You're gonna work with physiotherapists. Um, you're gonna work with intensive care doctors and east tests. Um, you can see it's a very complex pathway. Um, in terms of the staging, the fitness assessment, you do build up a very, um, uh, you do build up quite a relationship with your patient, you get to know them very well. Um, which means that, uh, there's a real sense of satisfaction when you see them doing well afterwards. Uh, equally. You know, when things don't go so well, you do feel, uh, not that satisfaction, but thankfully, that's as rarer as long as you do. You do choose the right patient. What kind of person suits it. I think if I if I were to say for any specialty, whether it's a software, gastric surgery or any surgery, I've mentioned this to you, dashi. Um, people often talk about what's competitive, what's not competitive, whether our numbers, what kind of lifestyle you're gonna lead, how much money you're gonna make, etcetera, etcetera. But I I think the key to choosing a specialty absolutely, is whether you enjoy it. Do you enjoy the work you're going to do on a daily basis? Because all the other things are going to be irrelevant unless you enjoy what you're doing. So it goes without saying that you have to be enthusiastic where you have to be enthusiastic about esophagogastric surgery. If you look at these slides and you get excited by if you're interested in it, if you want to know more about it, that's the kind of then you're willing to work hard for it. Then then then you'll succeed it. There's nothing particularly challenging and what we do it's just wanting to do it and persevering, and it's the same with whatever specialty you go for. But you have to really enjoy. You have to look at what you're going to be doing as a consultant for the next 20 years and think, Is that something that I can see myself doing? Am I gonna enjoy going into work? And I still do? Um, more specifically, um, what kind of person suits it? I think there are lots of technical challenges to Osaka gastric surgery, but as I've just tried to allude to anyway, um, it isn't just complex in terms of technical decision. It's also about the non technical decision making. Choosing the right patient, these patient's can get unwell, and you may have to think about how you're going to get them better again. And you got to think about more than just the operating, which most surgeons probably find the most stimulating part. But, uh, if you surely like the technical aspects of surgery, there are probably other specialties that are better suited to you if you like the non technical and medical aspects of surgery, if you like problem solving. Um, if you like that concept of medicine acute care, Um, then I think you're you're well suited to it. Happy to take any questions. I hope that's given you a flavor for what we do. So someone just mentioned with regards to the stuff. Ejecta me. Um, Is the gastroduodenal a artery preserved? Yes. Another person asked, What's the work? Life balance like? Um, uh, it's a tricky question. I mean, I'm still in scrubs because I'm so at work that said, I have a very, uh I think I've got a nice work life balance. Um, uh, others may disagree, but I I enjoy it. Um, I think it's certainly hard work. Um, but I think it's made a lot easier if you've got a good team that help each other out. That's the key. Really? Um, uh, you want when you're in and you're doing the operations, they can be long operations. They can be challenging operations. Um, but at the same time, they're very rewarding. Um, being a theater is fun. Uh, if you work with with a fun team, um, then it's quite enjoyable. You do need to make sure that you balance it out by making sure you've made time for your family, your friends, your general well being. Um but yeah. I mean, I think the work life balance is there, but you have to work hard at achieving it. Um, if I'm being completely honest, the fact that most people do fellowships, the fact that most people do PhDs does mean that that can be challenging. Um, but at the same time, each of those opportunities or things are are opportunities to make more friends to try out new things. And plenty of people go abroad for a fellowship. Often people take their families with them. It's it's really fun. You learn to complete new culture. Um, I had a great time doing my PhD. I really enjoyed it. I made, um, some lifelong friends. I've learned a lot about academic research. Uh, part the reason I chose to work in this units because I met people from this unit during my research. So, um, yeah, I I think the work life balance is fine, but you do have to make sure work harder to, but it's one of the things that people often talk you out of it. I don't let people talk you out of it. If you enjoy the surgery, it all it all falls into place. Uh, and you just got to make sure that you work in a supportive team and you take the slack off each other. Um, someone else has mentioned What's your device for international medical graduates? Uh, about how to go about in esophagogastric surgery as a specialty training. So I think if you if you saw from my first slide the the key to soft gastric surgery is the basics to start with, It's general surgical training. Um, I think you may have an inclination that you're interested in soft gastric surgery, but you still got to get through the basic general surgery. It may be that you find something else is more interesting. Um, I don't think you will, but I'm biased. But I think the key is just get yourself some basic general surgical training depending on where you are in your training, uh, experience. Um, in most places, um, o g surgery is centralized now, even if not officially, but it is becoming so unofficially. So you need to think about where they offer it. What your um but I mean specifically for international graduates here. What? What is your caseload in your country? Um, you know, is it is it a common disease? Is it a disease? Not only that combat Do people have the facilities? Um, to offer, uh, software, gastric surgery there. Um, you know very much Depends on the socioeconomic groups. What What's the healthcare system like? I mean, if you're relying on a private healthcare system, it's it's phenomenally expensive, and and many patients may not be able to afford it. If you're relying, relying on a insurance based healthcare system or a national insurance based healthcare system like ourselves, then you're lucky. And hopefully your your insurance will cover it, so you may have the scope to do it. You got to think about how many I t. U beds you have in your country, you know? Is this feasible? Um, if you ask, talking specifically about where to get trained, um, contact people. Um, the social media has made the world a very small place these days. Um, look at who's active. Look at go to talks, go to conferences, speak to people, tell them you're interested. Um, I did a, uh, like, sort of brief fellowship. I went out to Japan, um uh to visit because it's it's it's one of the places with it was actually for a soft your surgery for gastric cancer surgery. Um, they've got one of the largest experiences in the world. Really? I knew someone who knew someone there. I got in touch. I arranged it. It was a great experience. I loved it. Um, so, uh, but But they didn't know me before hand. And I think if you if you want to get trained, you want to go speak to someone, get in touch with them. Um, and if they don't have opportunities in their own institution that people are often very helpful in trying to put you in touch with others, someone's mentioned from your work experience. Have you ever used a colon to substitute the esophagus? It's funny. You should say that. Uh, so we had two parallel list running today, and one of our list was doing just that. Uh, the other list was doing a robotic, um, subject to me. Um, yeah, we do. There's two settings, actually, and, uh, setting we were using today, which is frankly rarer, but is when you've got a very extensive tumor where you don't think there's enough soft stomach? Um, that is free of cancer to make a conduit. So that was the case today, Um, that's quite a very nice operation. That's probably the most fun operation because it's it's taking out. It's huge surgery, a huge dissection, but actually the patient's controlled well, very well selected. You wouldn't offer that to someone who's not really fit, because it's such a big physiological insult. Um, the other scenario is, if you've got an emergency, and these are slightly sadder cases where historically, um, used to be more common when patient's had anastomotic leak, people often disconnected and their stomach would not be used again. Um, we tend to manage esophagectomy leaks more conservatively now without disconnecting them, so we don't have to do many colon interposition for that. But we do have corrosive injuries where people have, sadly, either by mistake or intentionally, uh, ingested corrosive substances and taken out their esophagus and stomach so they don't have a stomach too used to replace their esophagus. Um uh, and that's actually where we've probably had our greatest experience of, oddly, in the last sort of, um, 18 months. We've seen a big uptick in them, and hopefully that goes down. It's fun surgery, but not not for that indication. Um, it's It's quite sad because whilst you can replace the esophagus with colon, Um, uh, the functional outcome is is a lot less a lot worse than, uh, with the stomach and and someone's mentioned, What portion of the colon would you use? Good question again. So traditionally we used to use the left colon. Um, more recently, we have used the right colon on a couple of cases because, uh, interesting, because they were emergency cases by emergency. What I mean is, they've come in with an emergency. We've had to take out their esophagus and or stomach at the time at the first sitting because of because they were very unwell. And then six months down the line or three months down the line, you you're looking to reconstruct them. But because of the damage that was done at the first, um, insult the colon or left was not as healthy looking as the one on the right. So we choose to use the right. Um, often, what we do is mobilize the whole colon and actually choose what looks best on table like, um, sort of temporarily clamping the vessels and seeing which bit of colon looks the best perfused when we are going to divide their, uh, said vessels, and then someone's mentioned. How would you advise someone to go about doing an elective in this specialty? Say that again. Sorry. How would you advise someone to go about doing elective in the specialty? Uh, again, I would say, uh, contact a unit that you're interested in going to visit. Uh, people are normally pretty receptive. Uh, elected of time to have fun as well, though, remember? I mean, I think you have a lot of funding a soft gastric surgery, but yeah. I mean, see, see. See where you want to go. Um, see who offers it. Um, Maybe pay them a visit. Um, drop them a line. Uh, get in touch. Um, some of those things we've talked about the emergencies in particular are they come in fits and ways. You know, you'll have two months where you've had three or four of them, and then you have two months where you don't get any, so you may not necessarily see that in an elective, But software your cancer surgery esophagectomy are fairly routine practice in most software gastric cancer centers. So you will. You will get to see them. Gastrectomy as well. You'll see. Um, you know, when I was in Japan in about 2 to 3 weeks, I saw almost 30. Gastrectomy is the volume. There was an event. Uh, it kind of depends on where you're going. Any other questions? Guys, I think that's about it. Mr. Sink, I'd like to say a huge thank you for giving an amazing presentation today. Uh, no, It's my pleasure, Mr Singh. And guys, please do fill out the feedback links to get your certificates. Uh, thank you for joining us today, and yeah, Enjoy your evening, guys. Good luck. Thank you, Mr Singh.