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Clinical Review

Objective assessment of technical skills in surgery

BMJ 2003; 327 doi: https://doi.org/10.1136/bmj.327.7422.1032 (Published 30 October 2003) Cite this as: BMJ 2003;327:1032

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Is this contribution to surgical training worth the effort?

The only end-point worthy of consideration is clinical outcome and
this has not been considered in this review. It is difficult for me to
believe that the approach outlined in this review will address any of the
deficiencies in the NHS. It might be of some value but is it worth the
effort, time and expense? Consider the history of the evolution of
excellence in gastric surgery at Groote Schuur.

When the late Professor Louw, chairman of surgery at Groote Schuur
for decades, realised he needed a gastrectomy for his duodenal ulcer,
standard treatment in those days, he came to London on the pretext of
learning gastric surgery to find the best surgeon. He chose Norman Tanner
after watching a series of surgeons and spent a significant part of his
remaining surgical career accumulating his own impressive series of
gastrectomies.

His disciples, including Professor Dent, learned much of their
surgery by assisting him doing his gastrectomies and caring for his
patients. It is a fitting tribute to Professor Louw training program that
the best results for gastrectomies performed in prospective randomised
studies for gastric cancer were reported by Dent et al at Groote Schuur.

In their relatrively small study of some 50 patients there were no
operative deaths and five year survival rates projected, by Murray
Brennan at Sloane Kettering in New York from their three year survival
rates, were 78% and 76% for D1 and D2 lymph node clearances respectively
(1,2). In comparison the Dutch group reported operative mortalities of
4% and 10% for D1 and D2 dissections respectively and five-year survival
rates 45% and 47% in a well known and much larger multicenter study (3).
In an equally large and well known study in the UK the operative
mortalities were 6.5% and 13% for D1 and D2 dissections respectively and
the five year survivals 35% and 33% (4). These are huge differences in
outcome not only in terms of operative mortality but also in long term
survival in those who survided their operations.

I was trained by Professor Louw and his team of ward B1 and B4
consultants, the same people that had drained Professor Dent. I worked
with Dent and operated with him on occasions and am very familar with the
high standards of care he delivers and demands from his juniors. The
operations in his study would all have been perfomed skin-to-skin in one
to two hours without the use of staplers, significant blood loss, shock
and/or the the need for blood transfusions. I accept without question the
accuracy of the Groote Schuur data knowing how compulsive and honest Dent
is. The patients would have been largely "Cape Coloured", many binge
drinkers, many smokers and/or most thin and poorly nourished by Dutch and
UK standards. Few if any would have had enteral or parenteral feeding.
None would have had a jejunostomy tube placed during the course of
surgery. All would have had a single-lumen nasogastric tube with a segment
of rubber tubing to milk it from time to time rather than a Salem sump
tube on continuous suction. Suctioning would have been qachieved by
siphonage. That was the standard of care at Groote Schuur as I knew it and
I doubt that it has changed for there was no need to change it, the
standard of gastric surgery having been excellent for decades.

The most striking difference between the Groote Schuur and Dutch and
UK studies was that the latter patients were performed by a larger
variety of surgeons possibly with greater differences in training and
experience (1), presumably the norm in these healthcare services. All
are effectively social healthcare systems, the only difference at Groote
Schuur possibly being a relative absence of politically correct
interferences. The differences in outcomes are, therefore, almost
certainly due to differences in the standard of gastric surgery,
anaesthesia and perioperative management.

At Groote Schuue that involves consultants seeng their postoperative
patients at least twice a day in the week and once a day in most
weekends. It also means them being called by their residents every night
after their evening ward round, their third in the day, and them coming
in at night to examine their patients if they felt it was necessary. None
of these cases would have been registrar cases, but few ever were for I
for one was required to assist in 50 cases before I was eventually given
my first carefully selected case to do on my own.

A particularly interesting difference in these studies is in the five
-year survival rates. The projected five-year survival rate in the Groote
Schuur study was double that in the other two studies. Assuming that it is
appropriate to project five year survival rates from three year survival
rates as Brennan has done (1) why the difference in those who survived
their operations? Almost certainly because of the immunological
compromise known to be caused by blood loss, blood transfusions and/or
shock which, I suspect given the very high operative mortalities, were
infintely more common events in the Dutch and UK studies than in the
Groote Schuur study.

Blood loss, shock and/or blood transfusions and deaths are measures
of technical and management failures which are known to halve long term
outcomes in many cancer patients (5). As this important fact appears to
have been overlooked in every prospective randomised study evaluating
radiotherapy and/or chemotherapy the evidence-base upon which evidence-
based management of solid tumours of the gut and many other solid tumours
are based is seriously if not fatally flawed.

Have the authors of this review considered these important measures
of surgical skills? What of the effects of trauma revealed later as
haematomas, tissue oedema and infections or of intestinal obstructions
which, in my view, are also the product of technical deficiencies?
Clinical outcomes, short and long term are the only relevant measures of
performance.

I very much doubt that methods considered in this article are going
to address the fundamental problem, the poor outcomes being achieved from
surgery in the NHS as in some European countries. Those responsible for
training surgeons and for allocating resourses for oncological programs
need to deal with these issues by appointing surgical leaders capable of
introducing the cultures necessary to achieve outcomes such as those
consistently achieved in gastric surgery at Groote Schuur for many
decades.

1. Kim HJ, Karpeth MS Jr, Brennaan MF. Standardizing the extentr of
lymphadenectomy for gastric cancer: impact on survival. In Advances in
Surgery, Cameron JL et al eds., Mossby Inc, St Louis, 2001.

2. Dent DM, Madden MV, Price SK. Randomized comparison of R1 and R2
gastrectomy for gastric carcinoma.
Br J Surg. 1988 Feb;75(2):110-2.

3. Bonenkamp JJ, Hermans J, Sasako M, van de Velde CJ. Extended lymph
-node dissection for gastric cancer. Dutch Gastric Cancer Group. Engl J
Med. 1999 Mar 25;340(12):908-14.

4. Cuschieri A, Weeden S, Fielding J, Bancewicz J, Craven J, Joypaul V,
Sydes M, Fayers P. Patient survival after D1 and D2 resections for gastric
cancer: long-term results of the MRC randomized surgical trial. Surgical
Co-operative Group.
Br J Cancer. 1999 Mar;79(9-10):1522-30.

5. Fiddian-Green RG. Open versus laparoscopy assisted colectomy.
Lancet. 2003 Jan 4;361(9351):74; author reply 75-6.

Competing interests:
None declared

Competing interests: No competing interests

10 March 2004
Richard G Fiddian-Green
None
None