NEW TECH IN ORTHOPAEDIC SURGERY · The impact of the ten-year-old partnership between RCSI and the College of Surgeons of East, Central and Southern Africa (COSECSA), which you will

ISSUE 2 2018

MR PADHRAIG F O’LOUGHLIN DELIVERS THE MILLIN LECTURE

NEW TECH IN ORTHOPAEDIC SURGERY

CUT TO CUREMs Helen Heneghan on the benefits of Bariatric Surgery

Leading the worldto better health

SPECIALTY SPOTLIGHT: OTOLARYNGOLOGY

THE MAGAZINE EXCLUSIVELY FOR RCSI FELLOWS AND MEMBERS

KeyMed House, Unit G8, Calmount Business Park, Ballymount, Dublin 12Follow us on Twitter @OlympusMedUKIE

www.olympus.co.uk/medical

OLYMPUS IRELAND Supporting Irish Surgical Training

To register you interest in attending an Olympus Surgical Training course, speak to one of our territory managers or contact [email protected]

ASSOCIATION OF WOMEN SURGEONS (AWS) MEETING

In July this year, the Association of Women Surgeons (AWS) was warmly welcomed to Dublin for the first

Women in Surgery meeting to be held in Ireland. The meeting focused on the experience and evolution

of gender equality in surgery in the United States, Ireland and Africa, and addressed issues including

flexible working, burnout and resilience and the role of mentorship. The AWS held the first meeting in the

United States in 1981 and now has 2,000 members across 21 countries.

REGIONAL EVENTS DECEMBER 2018 Monday 10 RCSI Fellows, Members and Diplomates Conferring Ceremony, RCSI, Dublin

FEBRUARY 2019 Tuesday 5 - Saturday 9 Charter Day 2019, RCSI Dublin Wednesday 6 Emily Winifred Dickson Award: Mary Robinson, RCSI, Dublin

FEBRUARY – MARCH 2019 Thursday 28 February - Saturday 2 March 26th Sylvester O’Halloran Perioperative Symposium, Graduate Entry Medical School, University of Limerick

MARCH 2019 Wednesday 27 RCSI Fellows and Members Regional Meeting, Sligo

JULY 2019 Tuesday 9 RCSI Fellows, Members and Diplomates Conferring Ceremony, RCSI, Dublin

NOVEMBER 2019 Thursday 21 RCSI Fellows and Members Regional Meeting, Limerick

GLOBAL EVENTS DECEMBER 2018 Sunday 2 RCSI Fellows, Members and Diplomates Conferring Ceremony, Penang Medical College, Malaysia Friday 7 - Sunday 9 25th Anniversary Congress of the Hong Kong Academy of Medicine, Hong Kong

FEBRUARY 2019 Friday 15 Alumni, Fellows and Members Reception, House of Lords, London, UK

APRIL 2019 Friday 12 RCSI Reception, The University Club of Toronto, 380 University Avenue, Toronto, Canada Sunday 14 RCSI Reception, Hampshire House, 84 Beacon Street, Boston, USA

OCTOBER 2019 Monday 28 RCSI North American Chapter of Fellows, ACS Reception, San Francisco, USA

Scope

Dates for your diary

Mr Kenneth Mealy, President, RCSI, with meeting attendees

Dr Avril Hutch, Head of Equality, Diversity and Inclusion, RCSI

Ms Camilla Carroll

Mr Kenneth Mealy

Dr Patricia Numann, Professor Eilis McGovern, Past-President RCSI, Mr Kenneth Mealy, President, RCSI, and Dr Barbara Lee Bass

RCSI’s Court of Examiners was established in 2014 to acknowledge the essential contribution made by our Examiners to Fellowship and Membership examinations.

We are currently inviting applications from College Fellows who wish to become Court Members and examine in the MRCS and/ or FRCS. Membership of the Court allows our Fellows to: › Contribute to the assessment of junior colleagues› Obtain PCS Credits› Participate in Annual Meetings / Postgraduate Conferrings› Network with colleagues› Examine in Overseas Centres

SUPPORT OUR DRIVE FOR EXCELLENCE IN ASSESSMENT

To find out more about becoming a Court Member, please contact us at [email protected] rcsi.ie/coe S U R G E O N S S C O P E / 33

S U R G E O N S S C O P E / 1

Fellows and Members, welcome to the second edition of Surgeons Scope. We want to make sure that, through

this magazine, we address the issues that matter to you and connect you with the RCSI surgical community in Ireland and further afield. We were really encouraged by the positive response we got to the first edition of the new iteration of Surgeons Scope and I welcome your ongoing feedback.

GLOBAL SURGERY As one of the world’s truly international education institutions, we have a responsibility to help reduce the inequalities in health provision globally. The impact of the ten-year-old partnership between RCSI and the College of Surgeons of East, Central and Southern Africa (COSECSA), which you will read more about later in this edition, is impressive, with 261 specialist surgeons having graduated and over 600 surgeons currently in training. Our SURG-Africa research team undertook situation analyses in 85 district-level hospitals in Africa in 2017, supporting ministries of health to widen access to surgery.

Building on this experience and expertise, I am proud to say that RCSI is now ready to consolidate this work through the opening of an Institute of Global Surgery. The Institute will aim to address the findings of the 2015 Lancet Commission on Global Surgery, which advocates for universal access to safe, timely, affordable surgical and anaesthesia care. We are in the process of embarking on the recruitment of a Chair of Global Surgery to drive our efforts in research, advocacy and surgical training.

SLÁINTECARE IMPLEMENTATION It is unquestionably positive that we are now talking about the implementation of a ten-year plan for healthcare that has cross-party support. It is also very welcome to see such a diverse group of people represented on the Sláintecare Implementation Advisory Council, which includes former RCSI President Patrick Broe. Of course, the devil, as always, is in the detail, and we will continue to take a constructive approach in engaging with the Department of Health and the HSE to advocate for safe and sustainable surgical services throughout the implementation of Sláintecare.

The Minister for Health’s recent visit to a scheduled care hospital in Scotland bodes well for the introduction of a similar model in Ireland. Surgeons know all too well how vulnerable elective surgeries are in a system that cannot cope with any peaks in demand for unscheduled care. There is, in my view, an inescapable logic to the separation of acute and elective care. Putting the patient exclusively at the centre of our planning means there is no other outcome that makes sense.

Liam McMullin describes his experience of the reconfiguration of hospital services in Roscommon in an interview on page 8. We have much to learn from what happened in Roscommon about the importance of an honest conversation between healthcare professionals, politicians and the public about the type of hospital system that is needed to meet the needs of people living in rural areas. I truly hope that this conversation can be had during the implementation of Sláintecare so that we can move towards a reconfiguration of surgical services that is capable of meeting the age-related increase in demand we can already see.

QUALITY IMPROVEMENT Quality improvement and efficiency was the focus of discussion at the joint RCSI/HSE Value Improvement Programme day, which RCSI hosted in September. Efficiency is a word that has almost lost its meaning at this point but our ageing population means we simply have no choice but to focus on evening out variances in activity across the hospital system and dis-incentivising inefficient practices. The alternative is to build more hospitals and I do not think any one of us would suggest that as a sensible solution.

Currently, theatres across Ireland are probably working at 65 per cent capacity. A ten per cent improvement in terms of efficiency would halt the growth of waiting lists if enacted in 120 of our operative theatres nationally. A 15 per cent improvement would result in waiting lists starting to come down. Surgeons are healthcare leaders and we cannot lose sight of our responsibility to advocate for a system that is constantly mindful of limited resources. We must

› P re s i d e n t ’s L e t t e r

MR KENNETH MEALY

A letter from the President, RCSI

2

tackle this issue head on and deal with waiting lists now before our population ages to a point where the system grinds to a halt.

Not all of the issues that can mitigate against the efficient delivery of healthcare are, however, resource related. Many of the difficulties we face in managing patient care reflect how we work together. Current healthcare management involves teamwork by a large number of healthcare workers in treating increasingly complex medical conditions; this often results in not only patients but also all of us having difficulty in navigating our way through the healthcare process. This, I think, is typical of the organisational dysfunction that we often see in operating theatres and sometimes it would appear we are in competition rather than unified in responding to these organisational challenges.

Earlier this year, University Hospital Kerry became the first hospital in Ireland to complete the Theatre Quality Improvement Programme (TQIP), a collaboration across the HSE’s Integrated Care Programme for Patient Flow, the National Clinical Programme in Surgery, the National Clinical Programme in Anaesthesia and RCSI. The programme supported a multi-disciplinary team at the hospital on a series of patient flow and pathway redesign projects. Significant improvements in start times, and theatre usage were demonstrated, in addition to other quality measures of patient care.

The HSE has now committed to rolling TQIP out in hospitals across the country. This very welcome development will, I believe, go a long way in supporting hospitals to make better use of resources that are currently available, improve patient care and provide a more productive and fulfilling environment for staff to work in.

SCALLY REPORTThe ongoing controversy surrounding cervical screening has been exceptionally distressing for the women and families affected and concerning for all women. For clinicians, Dr Gabriel Scally’s report forces us to confront some uncomfortable issues. Many of the doctor-patient interactions called out in the report were inappropriate and ill-judged. I doubt they reflect the behaviour or attitudes of the majority of doctors in Ireland but we do have a responsibility to reflect on our communications skills as a community of clinicians.

The Code of Practice for Surgeons updated by RCSI in 2018, states clearly that

“You must listen to patients and respect their views and give them information in a way they can understand. Patients have a right to be fully involved in decisions about their care and you must respect this right”.

At RCSI, we put the concept of “professionalism” at the centre of our education and training. RCSI Chair of Medical Professionalism Professor Dubhfeasa Slattery has taken a lead in highlighting the critical importance of professionalism in improving patient

outcomes and experience. Communications is one of the core skills taught to our students from the beginning of their education at RCSI and we will shortly launch an online training programme on medical professionalism for doctors in all specialties. Developed by Professor Oscar Traynor, the programme is based on the Medical Council’s Guide to Professional Conduct and Ethics for Registered Medical Practitioners. www.rcsi.ie/professionalism

INVITATION TO CHARTER DAYCharter Day, the annual celebration of the granting of a Royal Charter to the Royal College of Surgeons in Ireland by King George III in 1784, will take place from Tuesday, 5 February to Saturday, 9 February. This year’s programme includes a conversation with physician and Canadian parliamentarian Dr Hedy Fry (Tuesday) and the NOCA Conference (Wednesday), which will focus on the importance of working collaboratively within multidisciplinary teams to enhance the patient journey, ensuring we deliver truly patient-centred care. The National Clinical Programme day (Thursday) will address the implementation of speciality models of care and the Charter Day Meeting (Friday) will focus on two difficult issues in surgery – patient and surgeon care when ‘things go wrong’ and how to support the surgeon in difficulty.

We hope you can join us at Charter Day as we address these important issues. You can find more information, below, and register to attend at www.rcsi.ie/charterday2019 n

› P re s i d e n t ’s L e t t e r

RCSI has taken a lead in putting the concept of

“professionalism” at the centre of our education and training.

Tuesday 5 February, 18.45pmIN CONVERSATION WITH… Hedy Fry (followed by a Drinks Reception) Dr Hedy Madeleine Fry PC MP is a Trinidadian-Canadian politician and physician. An alumna of RCSI, she is currently the longest-serving female Member of Parliament, winning eight consecutive elections in the constituency of Vancouver Centre since the 1993 election, when she defeated incumbent Prime Minister Kim Campbell.

Wednesday 6 February, 9.00am – 16.00pmNOCA Conference 2019: ‘Connected Healthcare’Focuses on the importance of working collaboratively

within multidisciplinary teams to enhance the patient journey, ensuring we deliver truly patient-centred care. The programme will see the launch of both the Irish National ICU Audit Preliminary Report 2017, and the Major Trauma Audit National Report 2017.

Wednesday 6 February (evening)Presentation of the Emily Winifred Dickson award to Mary Robinson, former President of Ireland. Mary Robinson, the first woman to hold the office of President in Ireland, has also served as United Nations High Commissioner for Human Rights from 1997 to 2002, and as Senator for the University of Dublin from 1969 to 1989. The award, which recognises women who have made an outstanding contribution

to their field, has been established in honour of Emily Winifred Dickson (FRCSI) who broke boundaries when she became the first female Fellow of RCSI in 1893, making her the first female Fellow of any of the surgical royal colleges in Britain and Ireland.

Thursday 7 February, 9.00am – 19.00pmNational Clinical Programme in Surgery Implementation of Specialty Models of Care

Friday 8 February, 9.00am – 17.00pm Friday Morning Plenary Session‘When Things Go Wrong: Supporting Surgeons’Parallel Specialty SessionsFriday Afternoon Plenary Session‘When Things Go Wrong: Supporting Patients’

Charter Day 2019PROGRAMME OUTLINE


THE MAGAZINE EXCLUSIVELY FOR

RCSI FELLOWS AND

MEMBERS

RCSI SURGEONS SCOPE MAGAZINE is published bi-annually by the Royal College of Surgeons in Ireland.

Issues are available online at www.rcsi.com. Your comments, ideas, updates and letters are welcome. Please contact Robyn Byrt, RCSI Development, Alumni

Relations, Fellows and Members, 123 St Stephen’s Green, Dublin 2; telephone: +353 (0) 1 402 2116; email: [email protected]. RCSI Surgeons Scope is posted biannually to our Fellows and

Members in Good Standing. To ensure you receive your copy, please send your current contact details to [email protected]. RCSI Surgeons Scope is produced by Gloss Publications Ltd,

The Courtyard, 40 Main Street, Blackrock, Co Dublin. Copyright Gloss Publications.

OUR HERITAGE

ISSUE 2 2018











ON OUR COVERMr Padhraig F O’Loughlin,

who delivered the 41st Millin Lecture at RCSI.

Photograph: Conor Healy

RCSI’s mission is to educate, nurture and discover for the benefit of human health. Founded in 1784 with Surgery at our essence, we

are an independent, not-for-profit, world leading international health sciences education and research institution, with a deep

professional responsibility to enhance human health.

Contents04 Scope News News, notices, research and training courses;

surgeons in the news

08 A Model Hospital Mr Liam McMullin has led the reconfi guration

of Roscommon University Hospital

12 Global Surgery After a decade’s involvement in global surgery,

RCSI opens a new Insitute

14 Back to the Beginning Professor Alan de Costa: from Sri Lanka to

Australia, via RCSI and other adventures

17 � e Colles Q&A Mr Trevor Thompson, consultant urologist

at Belfast City Hospital, on life, work,

medicine and rugby

18 Beyond Weight Loss Ms Helen Heneghan on how

bariatric surgery is a convincing cure

for obesity-related diseases

21 Meeting of Minds At the Millin Meeting: World War One,

technology and President Trump

24 Specialty Spotlight Otolaryngology: opportunities and challenges.

Professor Rory McConn Walsh’s perspective

27 A Surgeon In ... Donegal It’s all in a day’s work at Letterkenny Hospital

for consultant laparoscopic and bariatric

surgeon Mr Zsolt Bodnar

29 Scope Events Conferrings, Millin Meeting, Foley Lecture,

North American Chapter Event

33 Scope Diary Women in Surgery Event plus details of

upcoming Fellows and Members events at RCSI

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12

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SURGEONS

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Irish Healthcare Awards 2018:Educational Project of the YearWe congratulate RCSI Fellow and Council Member Ms Camilla Carroll for receiving an Irish Healthcare Award for the National Clinical Programme for ENT Education in Primary Care: Integration of Ear Microsuction into Primary Care, an Educational Model. The programme team also included RCSI Fellows Professor Nash Patil, Mr Martin Donnelly and Professor Michael Walsh.

The programme is designed to upskill 60 primary care professionals in the procedure of ear microsuction. These primary care practitioners will have safely treated 1,200 patients by March 2019. These patients would previously have had to attend a hospital-based ENT Surgeon for delivery of care. Initial set-up cost to the primary care practice is €1,319.89, with a €5.94 disposable equipment cost per patient. The aim is to develop a national network of practitioners, empowered to deliver an adult microsuction service for common ear conditions in a local setting.

RCSI and the 30% Club awards three scholarships to promote greater gender diversity in healthcare

Th e RCSI Institute of Leadership and the 30% Club has awarded three scholarships as part of ongoing eff orts to improve gender diversity in healthcare. Th e scholarships, each valued at ¤5,750, were awarded to three female healthcare professionals. Th e fi rst RCSI 30% Club Scholarship (MSc in Leadership) was awarded to Sarah Hume, a Senior Psychologist in the Irish Prison Service in July 2018. In September, RCSI Fellow Dr Róisín Dolan and Dr Danielle Divilly, a GP based in Co Wicklow, received their scholarships.

Dr Mary Collins, Programme Director said: “Th e programme is designed for all senior clinical staff ,

seeking to signifi cantly develop their clinical leadership capacity, increase their self-insights and maximise their impact on others in their healthcare organisations.”

Dr Róisín Dolan FRCSI, from Co Tyrone, graduated from medicine at UCD in 2007. Following completion of a two-year Doctorate in Medicine (MD) in cancer research at UCD Conway Institute of Biomolecular & Biomedical Science, she completed both basic and higher surgical training in Plastic & Reconstructive Surgery at RCSI. Dolan was awarded Fellowship of the Royal College of Surgeons in 2017 and subsequently completed clinical fellowship training in upper limb microsurgery and sarcoma reconstructive surgery at the Oxford University Hospital NHS Trust, Oxford, UK. She has recently been appointed as a consultant plastic surgeon to

the Oxford University, Hospital Group specialising in upper limb surgery, and plays a signifi cant clinical role in the renowned vascularised composite allograft (transplant) programme in addition

to the ongoing randomised-controlled trails in this fi eld.

In addition to prestigious international visiting fellowship awards, Dolan is an avid clinical researcher having authored numerous publications, book chapters, international presentations at scientifi c meetings and having been awarded funding for education, training and research.

Dolan has taken on leadership and management roles throughout her surgical training and has completed a diploma in healthcare economics and a Masters degree in healthcare management. Her goal is to be appointed as a consultant plastic surgeon in Ireland.

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GENERAL DATA PROTECTION REGULATION – A GUIDE FOR SURGEONS

The most recent General Data Protection Regulation (GDPR) came into force in May 2018, replacing the existing

data protection framework under the EU Data Protection Directive. In

general, employers will be responsible for interpreting and applying these

obligations (though there are responsibilities on individual employees)

but for those surgeons in part-time or whole-time private practice, there will be an individual obligation to ensure data is held in accordance with the regulations. RCSI has produced a guide as to how individual practitioners can ensure that their private practice is compliant with the regulations. RCSI has drawn heavily

on the work of the Data Protection Working Group of the ICGP who have

produced an excellent set of guidelines as a service to GPs and their patients. For the RCSI Surgical Affairs guide,

see www.rcsi.ie/surgeons_gdpr.

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newsRCSI RESEARCH, REVIEWS, NEWS AND TRAINING COURSES

Dr Róisín Dolan


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RCSI has developed an online course “Professionalism in 21st Century Medical Practice” which is aimed at medical doctors in all specialties. The course is based on the Medical Council’s “Guide to Professional Conduct and Ethics for Registered Medical Practitioners” and is presented in an interesting and engaging format. There are twelve online modules covering different aspects of Medical Professionalism and each module can attract five CPD credits. An online introductory video (5-7 minutes per module) is supported by a Learning Resource Area which contains carefully selected reading materials and videos related to the subject matter of the module. On completion of the reading and viewing tasks, you can take a MCQ test to earn your CPD points and even print your own certificate! The course is designed to be accessed on any mobile device, which means that it can be accessed anytime and anywhere. You may study the modules in any order and at your own pace. This online course on Professionalism will be available to all registered medical doctors in Ireland. If you wish to access this course, please email [email protected].

MODULE 1 – Relationship with Patients: CareThis module explores the complexities of the doctor-patient relationship, including empathy and compassion, power differentials, respect, trust and advocacy. Five CPD Credits

MODULE 2 – Relationship with Patients: CommunicationThis module covers important aspects of communication with patients including use of language, jargon and elements of cultural awareness. It also covers informed consent and the importance of patients becoming “partners” in their own healthcare. Five CPD Credits

MODULE 3 – Relationships with ColleaguesThis module deals with professional loyalty, collegiality and the important area of interprofessional teamworking. It also deals with raising concerns/whistleblowing and the causes and effects of disruptive behaviour. Five CPD Credits

MODULE 4 – Relationships with SocietyThe fundamental basis of a profession is our implicit contract with society to uphold basic standards of behaviour and professional performance including service to society, altruism and self-regulation. Five CPD Credits

MODULE 5 – Professional PerformanceThis module deals with issues concerning the scope of professional practice, continuous professional development, self-reflection and audit and safe introduction of new technology/new procedures into clinical practice. Five CPD Credits

MODULE 6 – Honesty & IntegrityThis module covers advertising and portrayal of services, conflicts of interest, duty of candour and the obligation to maintain adequate professional indemnity. Five CPD Credits

MODULE 7 – Confidentiality The duty to maintain patient confidentiality is

a core responsibility of all doctors. This module explores this responsibility

including elements of data protection, conversations with

relatives, electronic patient records and the use of social media. Five CPD Credits

MODULE 8 – Maintaining Health & Fitness to Practice

This module covers important issues around physician health,

burnout, substance abuse and sources of help/support for doctors with health issues. Five CPD Credits

MODULE 9 – Patient SafetyThis module highlights adverse events in healthcare, risk management and safety checklists,

infection control and medication safety. Five CPD Credits

MODULE 10 – Continuity of CareThis module deals with documentation of patient care, delegation and transfer of care and clinical handover including handover tools. Five CPD Credits

MODULE 11 – Ethical PracticeThis module describes ethical principles in modern healthcare with a particular focus on dealing with vulnerable patients, research ethics and clinical trials.Five CPD Credits

MODULE 12 – Teaching & Mentoring This module deals with the time-honoured tradition of teaching and mentoring the next generation of doctors with an emphasis on the importance of role models and the responsibilities of adequately supervising trainees. Five CPD Credits.

The winning team, with Kieran Ryan, Managing Director of Surgical Affairs and Justin Ralph, CTO RCSI.

RCSI’S NATIONAL EMERGENCY MEDICINE PROGRAMME WINS PMI AWARDRCSI’s National Emergency Medicine Programme was awarded a prestigious Global PMI Award for Project Excellence. The award recognises complex projects that deliver superior performance and positive impacts on society, and was presented at the PMI Professional Awards Gala in Los Angeles.

The RCSI project team, across IT and Surgical Affairs, developed an innovative system to manage the National Training Programme for emergency medicine training, from point of application entry through to clinical rotation and assessment.

Professor Cathal Kelly, Chief Executive, RCSI said: “RCSI is committed to investing in technologies and infrastructure to support our teaching and learning. I am immensely proud that the College has been recognised for the development of National Medicine Training Programme, which will have a significant impact on how Emergency Medicine training is delivered in Ireland, reducing complexity, reducing risk and leading to improved outcomes for trainees and patients. I congratulate all involved,” added Professor Kelly. The winning team comprises Leila Wilson (IT), Padraig Kelly (Surgical Affairs), Pedro Airo (IT), Neeraj Kumar (IT), Orla Mockler (Surgical Affairs), Eoin (Ian) Keith (IT), Gareth Quin (Surgical Affairs), Ken Purtell (IT), Fintan Guihen (IT) and Lisette Biggins (Surgical Affairs).

The online course can be accessed on mobile

Professionalism in 21st-Century Medical Practice

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The College is committed to encouraging the acquisition of additional training and skills outside the structured programmes of the College and, to this end, provides a range of scholarships and grants in postgraduate surgery to assist surgeons-in-training and recently-appointed consultant surgeons, to gain additional expertise in centres of excellence overseas. The following received awards in 2018:

THE RCSI COLLES TRAVELLING FELLOWSHIP IN SURGERY The RCSI Colles Travelling Fellowship in Surgery 2018 was awarded to Kieron Sweeney for a Fellowship in Paediatric Neurosurgery at Hospices Civils de Lyon, France. Sweeney was also awarded a surgical travel grant. A surgical travel grant was awarded to Ms Sarah Moran, towards the cost of her visit to the Fondation Optalmologique Adolphe De Rothschild, Paris, France.

A surgical travel grant was also awarded to Gregory Nason, towards a Society of Uro-Oncology Fellowship at the University of Toronto.

THE JOINT RCSI/GUSSIE MEHIGAN SCHOLARSHIP TRAVEL GRANTThe Joint RCSI/Gussie Mehigan Scholarship Travel Grant was awarded to Gregory Nason towards a Society of Uro-Oncology Fellowship at the University of Toronto.

THE JOINT ACS/RCSI RESIDENT EXCHANGE PROGRAMMERoisin Dolan was the nominated RCSI trainee for the Joint RCSI/ACS Resident Exchange Programme 2018. She attended the ACS Clinical Congress which ran from October 21-25 2018, in Boston, MA.

RCSI/ETHICON FOUNDATION TRAVEL GRANTS Ten RCSI/Ethicon Foundation Travel Grants were awarded:n Oisín Breathnach – towards

a Fellowship at the University of Toronto, Orthopedic Sports Medicine Program.

n David Coyle – towards an MIS Fellowship, Nationwide Children’s Hospital, Columbus, Ohio, USA.

n Jaime Doody – towards the Paediatric Otolaryngology Programme at the Boston Children’s Hospital, Massachusetts, USA.

n John Galbraith – towards an Orthopedic Surgery Hand Fellowship, Dandenong Hospital, Monash Health, Melbourne.

n David E Kearney – towards a Clinical Fellowship, Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio.

n Elizabeth McElnea – towards Orbital Plastic and Lacrimal (OPAL) Fellowship, Royal Victorian Eye and Ear Hospital, East Melbourne, Victoria.

n Sarah Moran – towards a Fellowship at the Foundation Optalmologique Adolphe De Rothschild, Paris, France.

n Gregory Nason – towards the University of Toronto Uro-Oncology Fellowship Program, University of Toronto.

n Kieron Sweeney – towards Fellowship in the Department of Paediatric Neurosurgery at Hospices Civils de Lyon, France.

n Peadar Waters – towards a Colorectal Fellowship at the Peter MacCallum Cancer Centre, Melbourne, Australia.

THE RCSI/IITOS TRAVELLING FELLOWSHIPSThree RCSI/IITOS Travelling fellowships were awarded:n Oisin Breathnach - towards the

University of Toronto Sports Medicine Fellowship at the

University of Toronto, Canada. n Cian Kennedy – towards his

upskill Fellowship in the UK.n Sven O’hEireamhoin - towards

a University of Toronto Trauma Fellowship Program at Sunnybrook and St Michael’s hospitals, Toronto, Canada.

THE RCSI-ANTHONY WALSH/IPSEN UROLOGY TRAVELLING FELLOWSHIPThe RCSI-Anthony Walsh/Ipsen Urology Travelling Fellowship for 2018 was awarded to Eva Bolton toward her visit to the Royal Marsden Hospital, London.

MILLIN LECTURE Padhraig O’Loughlin was awarded the Millin Lecturer for 2018. The title of his lecture was “New Technology and the Future of Orthopaedic Surgery - A Surgical Deus Ex Machina?”

DR RICHARD STEEVENS FELLOWSHIP FOR 2018A Dr Richard Steevens Fellowship for 2018 was awarded: n Eva Bolton – for a Retroperitoneal

and Pelvic Urological Oncology Fellowship at the Royal Marsden Hospital, London.

n Emmeline Nugent – for a Fellowship in Minimally Invasive Colorectal Surgery, with a special focus on Surgical Training & Simulation Technology, at the Cleveland Clinic.

n Peader Waters – for his Surgical Oncology Fellowship at the Peter McCallum Cancer Centre, Melbourne.

THE BRIAN LANE MEDAL 2017The Brian Lane Medal for 2017 was awarded to Darragh Waters.

THE PROFESSOR W.A.L. MACGOWAN MEDAL 2017The WAL MacGowan Medal 2017 was awarded to Kieron Sweeney.

RCSI President, Mr Kenneth Mealy, launched the Continuous Professional Development programme at an event atended by NCHDs in August. The seven Module Leads outlined their Module offerings and the Continuous Professional Development brochure – an interactive, online resource which outlines the courses available each month to support NCHDs in meeting their professional development and training needs – was launched. The online brochure also makes it easy for NCHDs to book courses.

Enrolment for the programme closed in early October and already 40 of the 70 dedicated CPD courses are fully subscribed. To book a place on any of the engaging courses still on offer, please visit www.rcsi.ie/cpdss. Follow the team @RCSI_CPD for updates.

Clinicians work in a challenging environment, and RCSI recognises the responsibility to help develop their resilience and interpersonal skills in order to thrive professionally and personally. Courses will be reviewed and improved to help clinicians deal with the many challenges facing them. If you have any queries, please contact [email protected] or telephone 01-402-8593.

Testimonials include:Minor Operations & Suturing Techniques 12.10.18 “Found the course very helpful!”Working in High-Performance Teams & Conflict Management 18.10.18 “Increased my sense of understanding and more efficient way of communicating” Powerpoint Skills 15.10.18 “Found it very beneficial”Surgical Emergencies 28.09.18“Excellent revision for cases not to be missed”

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RCSI POSTGRADUATE SURGICAL AWARDS FOR 2018

Continuous Professional Development Programme 2018-2019


CANCER DRUG STUDYResearchers at RCSI, with international collaborators within the ANGIOPREDICT research consortium, have discovered that chromosomal instability may predict which patients will receive most benefit from a key drug used to treat colorectal cancer (Avastin).

By knowing in advance which patients will not benefit from Avastin, patients could be spared side-effects and are more likely to receive optimal treatment with a minimum of delay, while reducing cost of care.

The study, led by researchers at RCSI and the VIB-KU Leuven Center for Cancer Biology in Belgium – is published this month in the prestigious international journal Nature Communications. According to the World Cancer Research Fund, colorectal cancer is the third most common cancer worldwide with nearly 1.4m new cases diagnosed annually. In 2014, almost 153,000 people died from colorectal cancer in the EU - equivalent to eleven per cent of all deaths from cancer. Half of colorectal cancer patients develop metastatic cancer, for which Avastin is a key component of therapy.

Professor at RCSI’s Department of Physiology and Medical Physics said: “We have demonstrated that tumours with intermediate-to-high chromosomal instability have improved outcome after Avastin treatment, whereas tumours characterised by low chromosomal instability benefit less. This work further builds on our recent Journal of Clinical Oncology study and has identified a complementary biomarker strategy that could be used by doctors in the future.”

“Our goal is to improve the standard-of-care for colorectal cancer and to ensure patients only receive drugs that will work specifically in the setting of their own disease. This will reduce side-effects, treatment costs and improve patient outcomes,” added Professor Lambrechts (VIB-KU Leuven Center for Cancer Biology).

Joint first authors on the paper are Dr Dominiek Smeets (VIB-KU Leuven), Dr Ian Miller (RCSI Department of Physiology and Medical Physics) and Professor Darran O’Connor (RCSI Department of Molecular and Cellular Therapeutics). The study can be accessed in full here: www.nature.com/articles41467-018-06567-6

WHAT IS THE LIFESTYLE LIKE? HOW DO YOU AND YOUR FAMILY SPEND YOUR TIME?I enjoy living and working in Bahrain. All of my family have been here at one time or another and my wife Geraldine spends most of the year here. Bahrainis are a friendly and welcoming people, very family orientated and appreciate the values of hard work so it’s been an easy culture to adapt to. I continue to teach Tae Kwon Do at RCSI and cycle a little. It’s hard to keep the weight down here but it has been one of the best moves I’ve made in my life and I’m sorry I didn’t come out earlier!

OTHER ASPECTS OF YOUR NEW LOCATION?I’ve also been able to continue my involvement in ‘Operation Childlife’ which the University and the Hospital both support. This enables me to help with surgical oncology in Vietnam and Tanzania and obviously was one of the reasons for my involvement in the successful separation of conjoined twins. RCSI Bahrain has implemented a Global Health Initiative Programme where our students get an opportunity to develop an altruistic sense and become more aware of the need to give back to society which is one of the main pillars of RCSI Bahrain.

WOULD YOU RECOMMEND THIS MOVE TO OTHERS CONSIDERING IT?I’d highly recommend it. I think everyone should work in a different environment/work outside their comfort zone at some stage of their career. I hope more will see this as the great opportunity it truly is.

Professor Martin Corbally, Professor and Chair of the Department of Surgery, RCSI Bahrain.

Based in Bahrain, Professor Martin Corbally is head of the surgery department at the local campus of the Royal College of Surgeons in Ireland (RCSI). Recently in the news for leading a team in the successful separation of conjoined twins in Tanzania, he also founded an Irish charity, Operation Childlife, that brings specialist medical skills to developing countries.

WHY DID YOU DECIDE TO MOVE TO BAHRAIN?It followed an invitation from RCSI Dublin to be part of a new hospital and to help develop the department of surgery at RCSI Medical University of Bahrain. Opportunity like that does not come around too often, the time was right and who could say no!

WHAT’S IT LIKE TO WORK HERE?It is exciting not only in the context of my clinical workload but I also have a greater administrative and teaching responsibility. There is no shortage of complex cases. I spend a lot of time on administration and I am constantly surprised how much I like it! There is ample support and a sense of being valued. I helped set up the governance structures for the hospital and serve on a variety of Hospital and University committees. There is a sense that things will get done and by and large they do. The relationship between the University and its stakeholder hospitals is very good and there is considerable official support for teaching and examinations. It is a very progressive environment and a real ambition to improve health care in the Kingdom and of course RCSI is recognised and valued for its significant role in this. I have always enjoyed teaching surgery and students and staff benefit from a process of direct engagement with academic staff. Our results compare very favourably with our sister sites which is reward in itself.

WHAT OPPORTUNITIES HAVE YOU HAD IN RELATION TO RESEARCH?There is a very significant level of co-operation between the University and clinical sites. We encourage staff and students to be actively involved in research and it has fast become a focal point both in terms of academic achievement and from the aspect of promotion. The new National Oncology Centre at KHUH promises to provide even greater access to research and we are enthusiastic about this potential especially in stem cell and translational research. We are very involved in clinical research and have contributed significantly to national journals.

Our man in ...Bahrain

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8

› H o s p i t a l S e r v i c e s

etween 2003 and 2011, either I or Mohamed Mustafa Magd-Eldin, the other consultant surgeon in Roscommon Hospital, was on call every single night. We were the only two surgeons. We were trained for it, and we got good support from Galway – we sent the really serious cases there – but it was very pressurised.”

Mr Liam McMullin is remembering what it was like before the A&E department at Roscommon Hospital closed in 2011, and the hospital was reconfigured to Model Two status. Not that being on frequent call was a new experience for him – when he was attached to University College Hospital Galway (UCHG) in the 1980s, he was

one of just three surgeons, and on call every third night. “Back then in Galway, we were on call for everything including

emergency neurosurgery and emergency vascular surgery. Once a year I’d have to do a burr hole; we were expected to be able to do it. Now, Galway has about twelve surgeons and every one of them is a specialist. General surgeons like me are a dying breed.”

McMullin qualified from UCD in 1974 and became a Fellow of RCSI in 1979. He spent the first five years of his career as a surgeon in Ireland, before moving to the UK in 1983, and then on to a research post in Canada, attached to the University of Alberta, before returning to Ireland to take up a position as a clinical lecturer in surgery at University College Hospital Galway.

“I was trying to become a consultant in Galway, but I wasn’t getting anywhere,” recalls McMullin, “so I worked overseas for a few years. When I came back to Ireland, I was appointed as a consultant in Cavan/Monaghan in 1998 and then to Roscommon in 2003.”

Mc Mullin had no previous connection with Roscommon before taking up the post at the hospital and, 15 years later, still describes himself as a ‘blow-in’.

Perhaps it is that outsider status that enabled him to take a cold hard look at the hospital and the way that it functioned – “acting as though it could fulfil a Model Four type hospital model with none of the resources to do it” – and over the years develop the pragmatic yet controversial view that it would be better for Roscommon to reconfigure itself as a Model Two hospital (mainly day-case surgeries with surgical cases only rarely staying overnight) without an A&E department, major acute surgery or critical care facility, rather than attempting to hang on to all those things.

“In order to justify having a fully-equipped 24-hour A&E department and

Model HospitalSecuring the future of a smaller hospital

“The magic numberof population to

justify that level ofinvestment, to

provide that level of cover is 300,000

to 350,000 ... and Roscommon

has 64,000.”

Mr Liam McMullin, FRCSI

Roscommon University Hospital, part of the Saolta University Health Care Group.

SURGEON LIAM MCMULLIN’S PART IN DETERMINING ROSCOMMON HOSPITAL’S SUCCESSFUL TRANSITION TO

A MODEL TWO HOSPITAL IS THE TEMPLATE FOR OTHERS…

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a surgical intensive care unit (SICU), apart from the surgeons you need an A&E consultant and an intensivist and an anaesthetist – and each one of these needs to be one of three in order to maintain a rota. You also need 24-hour nursing cover in A&E, and in SICU and in theatre. And finally you need ancillary back-up of laboratory, X ray and physiotherapy. And, by the way, this takes no account of acute emergency medicine requirements – the medical side is equally important and would have an equally comprehensive set of requirements.”

McMullin continues: “The magic number of population to justify that level of investment, to provide that level of cover is 300,000 to 350,000 ... and Roscommon has 64,000. In 2011, we had two surgeons, two anaesthetists and an A&E consultant who provided nine hours of cover during the week. You can do the maths. The choice was stark – either reconfigure or give a less than clinically acceptable service to our patients. You cannot justify being a smaller hospital doing everything when another hospital just down the road – in our case, Galway – does just that.”

McMullin reluctantly took the decision to endorse the HSE proposal to reconfigure Roscommon. He says that the position that he took was naturally unpopular locally, and “didn’t exactly make [him] flavour of the month in the area”, but he invested time and energy into making sure that the transition was as seamless and trouble-free as possible.

“In 2011, when Roscommon’s A&E department was about to close physically, we spent many weeks trying to design protocols for what would happen. In the early days, if an ambulance had a patient with serious chest or trunk injuries it was very reluctant to bypass Roscommon A&E on the way to Galway. It was clear to me that the situation could not continue. We couldn’t take those patients – they had to go to Galway.”

McMullin says that ambulance response times are still not as good as they

should be, and that more ambulances are needed to improve the situation. “That was one issue that was not thought through as well as it should have

been. The administrators saw the closure of our emergency department as a cost saving, but really it wasn’t. We needed more ambulances and staff and we didn’t get them. That created political catastrophe, and the local people were extremely upset. To them, Roscommon without an A&E department is not a hospital in the way that they think of a hospital.” (The public’s perceptions of what “hospital” means nowadays are of necessity going through somewhat of a definition change.)

McMullin says that the introduction of excellent trained paramedics who travel with ambulances, and the availability of the air ambulance helicopter in Athlone, are helping to improve matters.

As well as investment in the ambulance service, McMullin says that for the repositioning of Roscommon to be fully successful it requires a greater degree of buy-in from consultant surgeons in Galway.

“Galway – which is a Model Four hospital, even though technically it isn’t because it doesn’t have neurosurgery – now has surgeons who specialise in everything from upper and lower GI to breast, to vascular and to endocrine,” he explains. “There have been amazing developments since I worked there.

“But each one of those specialist surgeons needs time and space, both on the ward and in theatre, and they need somewhere to see their outpatients. The system gets clogged up because of constraints of space. In the old days, as a surgeon, you expected to have your own little kingdom within the hospital, but there simply isn’t enough space for that to happen now.”

McMullin says that requiring surgeons attached to Galway to do some of their elective work in Roscommon frees up space in Galway and is more efficient for patients.

“The choice wasstark – either

reconfigure or givea less than clinicallyacceptable serviceto our patients.” C

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10


“When I retire, a new general surgeon will not be appointed here. No young surgeon will be interested in this type of post – there’s no emergency work, no cancer work.” But McMullin wants Roscommon to survive. From a patient’s perspective, he says, it is both convenient and efficient. “The specialist consultants in Galway need to be convinced to do sessions in outlying hospitals such as ours for elective procedures. Roscommon is the template – the guinea pig – on which everything is being tried.”

The challenge, as McMullin sees it, is to convince these surgeons to see Roscommon as part of their own hospital. “They ask: ‘Why should we waste time driving 60 miles to and from Roscommon?’ But, is it better they get in their cars than five or six day-case surgery patients and 25 outpatients all have to make their way to Galway, perhaps trying to find parking in UCHG which is an absolute nightmare.

“This is the new paradigm: surgeons appointed at the flagship hospital must commit to doing elective work at the Model Two hospital. And the administrators have to enforce it. They have to say: ‘Your contract includes x number of sessions here and you must do them.’

“What is required is a mindset change. Both doctors and administrators must agree that Roscommon is part of the same hospital as Galway. As it stands, the HSE administrators at Merlin Park don’t see beyond the motorway; they see Roscommon as a nuisance and a drain. There has to be a realisation that the geography and population spread in the Saolta Group requires a new way of working.”

McMullin acknowledges that older consultants in particular (he being one of them) can be set in their ways. “They can be steeped in history,” he says, “regarding their beds as their little kingdom. I am starting to see more buy-in from the younger surgeons though. And that’s good. Currently we have a plastic surgeon who has bought into it and does two days a week here in Roscommon, and we also

have buy-in from urologists, maxillofacial and vascular surgeons. We have not been as successful with upper GI and lower GI surgeons and other specialities. It’s one of the reasons why it’s important that young consultants are offered a good package. If they don’t get that, they are off to Canada, Australia or Europe. It’s hard to get them to stay when they are being offered a sub-par package.”

These days, there is no surgical ward open at Roscommon at the weekend and grand talk of the A&E department being reopened is abating (“it is pie in the sky,” says McMullin.) The urgent care centre which treats injuries from the shoulder to fingertips and from the knees to the toes also closes at 8pm at night.

“Technically,” says McMullin, “I am on call every second night as before, but it does not arise other than in the very rare situation when a medical in-patient has a surgical complication.”

As a quid pro quo for the reconfiguration of Roscommon to a Model Two, the hospital got a €5.5m state-of-the-art endoscopy unit. “Elements within the HSE didn’t want to give it to us,” says McMullin, “but we went the political route and got the deal. The unit is superb but unfortunately shut one day a week because we need more nurses.”

A medical rehab unit is, according to McMullin, “in the pipeline” and, and Roscommon has also been promised a number of palliative beds.

“The final thing we are looking for is a central sterile supplies department,” he says. “All surgical instruments have to be washed, cleaned, and sterilised at the end of the day and ours is currently below par, so we have to ship our instruments to Portiuncula, which is obviously unsatisfactory and very inefficient.”

McMullin says that even though he is three years past retirement, nobody seems to be in any hurry for him to depart.

“They don’t want me to go and I am happy to stick around. It keeps me off the street and the work is very enjoyable, and it is not as pressurised as it was. It could be even better if there was more buy-in from Galway.” n

“This is the new paradigm: surgeons

appointed at the flagship hospital must commit to

doing elective work at the Model Two hospital. And the

administrators have to enforce it.”

Mr Liam McMullin in Roscommon University Hospital’s expanded endoscopy unit. C

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RCSI (Royal College of Surgeons in Ireland) is seeking to appoint an outstanding and passionate individual to the position of O’Brien Chair of Global Surgery to lead the newly established Institute of Global Surgery (IGS) in RCSI’s Dublin campus.

The Chair will have the opportunity to make a major impact working with a world class team focused on making quality surgical care available to underserved populations and will participate in generating high impact research outputs, while setting the foundation for greater growth.

The O’Brien Chair of Global Surgery is a full-time, permanent Professorial appointment.

For further details and to apply please visit www.rcsi.com/dublin/globalsurgery

Applications should be made no later than 5pm on Friday, 25 January 2019.

Informal enquiries may be made to Judy Walsh, RCSI Recruitment Lead at [email protected] or on +353 1 402 2440

Leading the worldto better healthINSTITUTE OF GLOBAL SURGERY

The RCSI Institute of Global Surgery (IGS) will implement a programme of work to achieve its strategic objectives across 3 pillars – Education and Training, Research, and Advocacy. These pillars reflect RCSI’s strengths and will enable the IGS to build on the relationships and achievements of the COSECSA collaboration, COST-Africa and SURG-Africa; as well as the global reach of RCSI’s alumni and professional networks.

O’BRIEN CHAIR OF GLOBAL SURGERY

12

› G l o b a l S u rg e r y

ABOVE LEFT TO RIGHT: Operating theatre in Africa;

instruments in theatre; COSECSA-trained Dr Bruce Bvulani and the successfully separated twins, Bupe and Mapalo Mwape, in Zambia.

THE NEW INSTITUTE OF GLOBAL SURGERY IS A KEY COMPONENT IN RCSI’S GLOBAL HEALTH STRATEGY FOR THE FUTURE … AND THE NEW CHAIR OF GLOBAL SURGERY WILL HAVE AN OPPORTUNITY TO DRIVE EFFORTS TO PROVIDE SAFE, TIMELY AND AFFORDABLE SURGICAL

TRAINING AND RESEARCH IN LOW AND MIDDLE-INCOME COUNTRIES

RCSI Opens New Institute

he newly established Institute of Global Surgery consolidates and builds on RCSI’s already impressive decade-long record training surgeons across sub-Saharan Africa. Successful programmes, including COST Africa, SURG-Africa and a collaboration with the College of Surgeons of East, Central and Southern Africa (COSECSA), has meant that RCSI has an extensive range of expertise and experience in delivering support to low-resource countries. The Institute will concentrate this expertise in one leading centre, with the intention to expand sustainable programmes into new regions.

It’s an exciting development. Thanks to philanthropic funding through the RCSI_TOMORROW campaign, academic leadership and direction for the new Institute will be provided by the RCSI O’Brien Chair of Global Surgery. RCSI is seeking to appoint an outstanding trailblazer with the ability to develop a team of international leaders in

global surgical education, training, research and advocacy. It’s an opportunity to expand on a proven model of partnership with local organisations, and to evolve new strategies in line with delivering on the findings of the 2015 Lancet Commission on Global Surgery which advocates for universal access to safe, timely, affordable, surgical and anaethesia care.

RCSI’s involvement is predicated on empowering local healthcare systems and focuses on initiatives which increase surgical capacity and widen access to surgical services in rural and underserved areas; increasing the number of trained surgeons and establishing a support network for referrals between district and central hospitals. The emphasis has been on active support to help local partners achieve these aims. “The results achieved by those partner organisations with our support have exceeded anything we could have delivered had we taken a

more traditional approach,” says Eric O’Flynn, Programme Director for Education, Training and Advocacy at the RCSI Institute for Global Surgery. “It has proven to be a very successful model.”

Three key issues will be part of the RCSI Institute for Global Surgery’s remit, according to Jakub Gajewski, Programme Director for Research at the Institute: “On average, 65 per cent of populations in the countries in which we work live in rural communities, mostly far away from central hospitals so surgical solutions must reflect this fact. It is critical that we address the lack of access to surgical services for rural populations, make significant improvements to the referral system between district and central hospitals and continue to increase the number of trained surgeons.”

Applications are now open for the RCSI O’Brien Chair of Global Surgery. For more information, see www.rcsi.ie

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Global surgery


THOSE WHO DOSURVIVE THE JOURNEYFIND LIMITEDRESOURCES AT CENTRALHOSPITALS AND FEWSURGEONS, IF ANY ...

ADVERSE OUTCOMESOCCUR FROM THE LACK OF EQUIPMENT ANDLIMITED NUMBERS OF TRAINED SURGEONS IN CENTRAL HOSPITALS ...

THE FAMILIES OFTHOSE THAT ARETREATED FACESIGNIFICANT DEBTAS A RESULT ...

› G l o b a l S u rg e r y

3 INCREASING THE NUMBER OF TRAINED SURGEONSTh e RCSI COSECSA collaboration, now in its eleventh year, continues to go from strength to strength. COSECSA, supported

by the collaboration programme, now has over 600 surgeons in training and is predicted to graduate 2,500 surgeons by 2030. Importantly, data shows that 93 per cent of COSECSA-trained surgeons remain in-country aft er graduation. COSECSA now works across twelve countries with a combined population of 372m people and recently garnered international acclaim when a graduate, Dr Bruce Bvulani of Lusaka’s University Teaching Hospital, performed the fi rst-ever operation in Zambia to separate conjoined twins, a procedure that would not have been possible before the training pathway developed by the COSECSA partnership.

“We’ve come from very far ... in human resources, skills in surgery, skills in radiology, skills in the lab, and various other sectors of the health system.” Dr Robert Zulu, a lead surgeon, quoted in The Irish Times in November 2018. ■

AND IS TAKEN TO LOCAL OR RURAL HEALTHCARE ...

PATIENT SUFFERS INJURY OR ILLNESS REQUIRING SURGERY ...

WITH LITTLE EQUIPMENT AND SURGICAL TRAINING PRACTITIONERS ARE FORCED TO ...

1WIDENING ACCESS TO SURGICAL SERVICESFunded by EU Horizon 2020, SURG-Africa, a consortium headed by the RCSI Institute of Global Surgery, is a four-year project supporting ministries of health to widen access to life-saving

surgery for district and rural populations in Tanzania, Malawi and Zambia. Increased surgical capacity is achieved via a supervision model for district level surgical teams, where surgeon specialists from central hospitals provide training to district hospital staff in surgical procedures. SURG-Africa aims to increase the number and range of surgical procedures performed at district level, whilst capturing the surgical data from these centres to develop long-term surgical systems with local partners.“Universal health coverage can only be achieved if we have a surgical service everyone can access. SURG-Africa will help provide the evidence and the blueprint for Government to follow.” Dr John Kachimba, Principal Investigator, SURG-Africa, Zambia.

2 IMPROVING THE REFERRAL SYSTEMEstablishing an eff ective, real-time consultation

and support network between district and central hospitals is paramount to ensure that the right patients are referred at the optimal time with the necessary information. Using mobile phone platforms, SURG-Africa has been able to facilitate a more responsive communication and referral feedback mechanism which has decreased by half the number of unnecessary surgical referrals from the districts and eased the surgical caseload at referral hospitals.

“It is helpful in terms of giving advice. You are reaching out to a number of clinicians. So even though I am advising one person to prepare a patient in a certain way, someone else is also learning from the same group conversation.” Dr Tiyamike Chilunjika Kapalamula, Paediatric Surgeon, Queen Elizabeth Central Hospital, Malawi.

2

OR SEND THE PATIENT TO A CENTRAL HOSPITAL, BUT WITH A LIMITED REFERRAL SYSYEM PATIENTS ARE OFTEN SENT WITHOUT ESSENTIAL INFORMATION AND TREATMENT DETAILS

3

1

CARRY OUT THE PROCEDURE ANYWAY WITH OFTEN ADVERSE OUTCOMES ...

14

› L i f e S t o r y

From the beginning

Professor Alan de Costa

lan de Costa (Class of 1973) grew up in post-colonial Ceylon (now

Sri Lanka), the son of cultured, Anglophile parents. Theirs was

a wealthy family, and Alan’s childhood was a privileged

and protected one, filled with sport (cricket and

tennis; he excelled at both) literature, music and adventure. “It was

unconventional – for my 14th birthday I was given a rifle, and at that age I was driving a Land Rover, camping out in the bush and learning about wildlife. I was completely free. It’s a childhood you couldn’t conceive of now, really unbelievable.” Alan has one sister who is now in a home and whom he has looked after for many years.

His parents assumed he would go abroad for his education but expected he would go to England. He even interviewed for St Bartholomew’s in London while still in Ceylon. “The dean of St Bart’s interviewed me in the presence of my father and the Governor of Ceylon, in the capital, Colombo.” Alan’s grades were impressive, as was his sporting CV, particularly his cricket prowess, which

was widely known. “But the dean asked me if I had ever played rugby!” Alan had been busy doing other things, rugby had not been a priority. It wasn’t a deal-breaker – he actually received his place at Bart’s the following year – but it does indicate a rather different approach to college admittance than is now the case.

In any case, he had other plans. In 1967, a year after his A-levels, Alan came to Dublin. He knew about RCSI via a Jesuit connection, and as he says, “my parents probably hoped for a degree of pastoral supervision.” Alan, however was determined to plough his own furrow, which of course he did, having an eventful and sometimes challenging six years at RCSI, but without missing a beat academically. When he refers to “most of the medals I received ...” we enquire how many he was awarded. He simply can’t recall, as there were many, including several in his final year, including the Council’s Prize. “Most of the medals,” he finishes, “I pawned.” Money difficulites persisted for years as he continued his studies and started a family while at college with classmate Caroline Downes, an Australian.

“We entered RCSI in 1967, a class of 100, of whom just 20 were women. They sat at the front of lectures until about our third year, when men and women were mixed. Both our names beginning with D, Caroline and I were seated next to each other. In fact, it wasn’t unusual for people who sat next to each other to marry.” Marry they did – “we somewhat put the cart before the horse, there were children involved” – and simply got on with it, studying, looking after their two boys, living “pretty much hand to mouth”.

At RCSI, he found both support and mentorship. At a particularly challenging time in his final year, he couldn’t see a way to continue with both Caroline and himself studying and they decided he would try to defer for a year while she finished her degree. When she was qualified, she would support him. “We had hit the wall in terms of money.”

Alan had spent summers working in London as a Securicor guard, sleeping in Green Park during the day, before changing into his uniform to go to work at night. He thought he would do this again. He told Professor of Medicine, Alan Thompson –

ALAN DE COSTA, BORN IN CEYLON, MET HIS WIFE CAROLINE AT RCSI IN THE LATE 1960S AND

BEGAN A LIFE AND A SURGICAL CAREER OF UNCONVENTIONALITY AND ADVENTURE

Professor de Costa wrote a series of open letters for his children where

he described his adventures. In one, he sketched his encounter with an

elephant in Sri Lanka.

FROM THE RCSI YEARBOOK 1973

ALAN DE COSTA Superstar From the tropical wilderness of

Ceylon this unique specimen was

smuggled into Ireland with a tennis

racket, a cricket bat and a box of

white mice suffering from dissem-

inated intravascular coagulation.

He subsequently won a research

grant which enabled him to spend

three summers with Miss Hartigan

in the Richmond Hospital. Miss

Hartigan never quite recovered from the experience, but Professor Thorne’s

brilliant boy went from victory to victory in the fields of sports and academ-

ics. Through the years, Alan amassed prizes and medals of gold and silver

which has become the envy of his beautiful wife and a number of Dublin

pawnbrokers. A social reformer and a born leader, Alan was one of the

authors of the pre-clinical report and as one of the first student represen-

tatives on the College Academic Committee he lost all faith in the workings

of democracy. Together with a Norwegian genius and a couple of other

concerned exhibitionists he organised the Great Ecology Symposium that

rocked Dublin in the early 1970’s. His concern for the environment may

cause him to abandon it altogether - and for this and other reasons he may

go off to New Guinea with wife and children to immunize Papuan cannibals.

Professor Holland would be glad to pay the transport of his handsome

head if he can get it for his museum. We wish him luck.


From the beginning

to help the wounded – they were about to have a huge clan fight. A colleague had advised me that if this happened, I should counsel against the use of barbed arrows before I agreed to treat the casualties. All was agreed. There were several casualties but no barbs.” Alan also spent two weeks as the last surgeon on infamous Bougainville Island, 1,000 miles off the coast where there was a vast Australian mining operation – and later a huge mine collapse and an armed rebellion.

A three-year spell in the NHS (1977 to 1980), where Alan continued in general surgery (Caroline, now an obstetric registrar, worked in maternity hospitals), followed four years of pre-fellowship training in Dublin, after their PNG internships.

“In Dublin, I worked in A&E in the old Jervis Street Hospital, did some rotations in the old Richmond Hospital and also worked with Vincent Sheehan in Drogheda. I got my Fellowship exams in Dublin.” At this stage the de Costas had five children and Caroline was deputy master at the Coombe Hospital. “Again, it was challenging.”

One of Alan’s friendships at RCSI was with an older Norwegian student, Sven BjÖrk, an interesting, well-read man. A larger than life character, he drew Alan into a bohemian world of theatre, political activism (with the Troubles as political backdrop) and left-wing journalism, when Fulvio Grimaldi, a prominent Italian journalist, who was to record many of the events of Bloody Sunday, and give evidence in court, moved into their shared flat in Ranelagh. He and his “decorative moll” as Alan describes, cut a glamorous swathe in Dublin. Alan maintains he was in this inner circle as he used to tutor less assiduous students free of charge, but this is surely not the full picture. Alan and Sven were part of a delegation from RCSI which went to Derry in the aftermath of Bloody Sunday. “We went to show solidarity – we travelled around the Bogside and met Martin McGuinness.” These were the days of politicised students, and protest. “There were impassioned discussions: where was the left at the time, guns, politics …” Caroline

“a distinguished and gentle man”– what he was thinking. “We were at the old Richmond Hospital at the time. I remember him looking aghast at me, then bundling me into his Ford Prefect. He drove me around to Allied Irish Bank and there he asked the manager on my behalf for a loan, which he guaranteed.” He was saved.

It was an example of the great kindness and support Caroline and Alan received from staff and students alike, as they took an unconventional path. Strong relationships with mentors are a feature of a surgical training and Alan found his in consultant surgeon Harold J Browne, on whose practice, he says, he would model his own. “We kept in contact and he was always generous with his time – he was very helpful to me.” There is a lecture theatre named after Browne at RCSI.

“At all times, the children were our primary focus, their requirements our priority. I was what you might call now ‘hands-on’. There was never any question of Caroline giving up her career, rather we would work together to make it work. Caroline did the organisation and I did what I was told. I loved the children and it was not an imposition to look after them. We kind of managed – later, with well-paid jobs to sustain us, we would be able to hire a nanny.”

After graduation with flying colours (and many medals), Alan and Caroline “got on a series of planes” and finally landed in Port Moresby in Papua New Guinea for the first time. (After prefellowship training in Dublin and three years in the NHS in England, they would return to PNG as Senior Registrars in 1980, before moving to Australia permanently, first to Sydney for 17 years; then to Cairns in 2000.) “Papua New Guinea was a third world country with many challenges, but a fascinating one, where, as interns, we learned a great deal.” Alan, occasionally craving the adventure of his childhood, took off into the jungle for a couple of weeks. “I abandoned my family and went to Mount Hagen to do a locum. It was an area associated with warring tribes. I once encountered a gentleman in full war dress who asked me to agree

Papua New Guinea

Ceylon in the 1960s


16

too was a campaigner and activist, advocating for legalised and free contraception.

Sven was an extraordinary character, prone to highs and lows. “When we were graduating, he had not in fact passed the final exams. But that did not stop him from attending the ceremony, dressed as a nun.” (He had been playing in the theatre play The Nun, so the costume was to hand.) Alan remembers the scene where Sven, dressed as a nun, was wrestled down the main college stairs, an image which was reproduced on the front page of The Irish Times.

Sven did go on to qualify and practised as a pyschiatrist but later, he took his own life, which Alan found very hard. “Statistically, suicide rates are high in the medical profession. I am fortunate, I never had any particular worries about my mental health and am always able to laugh at myself. Humility is an essential requirement for the surgeon. One per cent of patients don’t survive major surgery. That is grounding.”

After six years in Dublin, the de Costas moved to Australia and both got their Australian Fellowship exams.

“I have always been a general surgeon, with an special interest in trauma, which probably began in Papua New Guinea, where we saw some very difficult cases. But in Cairns, which has a relatively small population (though we cover an area which is physically larger than the UK) you have to be an all-rounder. Brisbane is 1,500km away. So we have to go out of our comfort zone and tackle all sorts of surgery. We have a regular stream of patients, and all the acute and emergency cases, including those from PNG. It keeps us on our toes.” He mentions several RCSI-trained GPs in Queensland who became great “referring doctors” – the network is alive and strong in Australia.

Now Professor of Surgery at James Cook University Hospital in Cairns (where Caroline is Professor of Obstetrics), Alan stopped operating earlier this year – “there comes a time”– and is now focused on delivering an undergraduate and a post-graduate course in surgery, which includes a simulated programme of operative general surgery (see www.ase.training).

Surgeons, Alan volunteers, can be

“a bit odd”. In his case, work-life balance came with interests outside surgery, like his long-held love, fostered in childhood by his parents, for music and literature. “So 15 years ago, I got myself a music teacher, and I am still trying to acquire competence!” He also writes and draws. And he regularly returns to Sri Lanka, where he has a small boutique hotel. Life is less frantic now but both he and Caroline remained engaged and committed to medicine, even as they have more time to enjoy a slower pace of life in a tropical climate.

Their children, now grown up, are scattered “all over the globe”, with one daughter, a lawyer, in Cairns. They lost their eldest son when he was 17, which was “incredibly tough”. Two are medics, though they both trained as lawyers first. What advice would Alan give to young people wishing to pursue a career in surgery? “It has become very difficult – the whole selection process is so competitive. Surgery is a long, tough road but it’s right for those with the passion to sustain them through a long period of training.”

To add to his collection of medals, Alan was awarded the Order of Australia medal in 2017, for his contribution to medicine and education. “Surgical research and training has been a focus for all of my career. We face some challenges. It used to be apprenticeship based, but now it is more complicated and far more steeped in education itself.”

And having had firsthand experience of Caroline’s career, he can see that female surgeons need to be supported. “In Australia now, women are represented in surgery to the tune of 15 per cent, but there are 30 per cent in training, which is encouraging.” Alan recognises the efforts of RCSI in this area and its role as an agent of change.

“I remember, in 1969, Sven and myself, the first student representatives, going to the Council with various ideas, and we were listened to. Institutions like RCSI, big and complex as they are, continue to change. As well as a top-tier education, he says, “that’s a characteristic of RCSI, openness to change.” n

“Surgery is a long, tough road but

it’s right for those with the passion to

sustain them through a long period of training.”


TOP: Professor Alan de Costa with his surgical team and trainees. ABOVE: James Cook University Hospital, Cairns, Australia

When and where are you happiest? I tend not to reminisce and not to take the future for granted. I am happiest in the here and now.What is your ideal evening? At home on a winter Saturday night with an open turf fire. Sitting on the sofa with my wife and our three pugs, with a glass of wine and watching subtitled Scandinavian drama on TV. If you could research and write a book on any subject, what would it be? The History of Urology in Ireland. I discussed this recently with a former boss. He was not enthusiastic as he thought it would not attract many readers!What relaxes you most? Watching rugby (Ulster and Ireland) but this is not always relaxing. Otherwise a long hot bath and listening to BBC Radio 4’s “In Our Time” with Melvyn Bragg.What is your greatest fear? Letting others down.When did you decide you wanted to become a surgeon? My father had a heart attack when I was taking my A levels. I had intended to study engineering at university, but my contact with the GP and cardiologist involved in his care made me change to study medicine. My father is still alive today thanks to the prompt and expert care he received then. He was one of the first people to receive thrombolysis in Northern Ireland for myocardial infarct. The GP gave him intravenous streptokinase in his bed at home; his

I take pride in every successful treatment for an individual patient under my care. I take pride in the success of others especially when I have been of some help to them along the way. I am proud of the urology nurses in Belfast City Hospital Ward 3 South who get amongst the best ward patient feedback results in the NHS. My proudest moment as a trainee was winning the Keith Yeates medal for outstanding performance at the FRCS

(Urol) examination many years ago at RCSI. I am proud that another Irish trainee (RCSI Fellow, Miss Anna Lucy Walsh) won this medal in 2018.How does a surgeon in 2018 cope with pressure? Ideally by working within a functioning and supportive team where all problems are solved by sharing them. I am very fortunate to work with a close-knit group of friends (nurses, doctors, secretaries, trainees etc) in Belfast City Hospital who reduce my stress, keep me right and make me laugh.Who is your hero? Nigel Owens, the Welsh international rugby referee. He overcame much in his early life to become the best referee in world rugby. His competence, communication skills, precise and rapid decision-making, wit,

enthusiasm and respect for all those on the field are an example for every surgeon. Listen to his Radio 4 Desert Island Discs programme and he will be your hero too. I am delighted he now has a successful and happy fulfilled life. What are your favorite memories? Wedding day. Birth of children and completing my first solo appendectomy in 1992!What is your spirit animal? The pug dog: a big character in a small body, beautifully ugly, full of divilment, humour, energy, and loyalty. Name your favourite popular writer. Alive – Robert Harris. Dead – Patrick O’Brien. Both create wonderful characters, gripping plots and period detail based on much research. Seamus Heaney is my favourite poet. I read one of his poems each day. I recommend the new 100 Poems anthology.Which talent would you most liked to have had? I would have loved to have been a better rugby player and captained Ireland to a world cup win with Nigel Owens refereeing the final. Ireland 62: New Zealand 7. In my dreams!What is the wisest thing you have ever said? “I do” during marriage to Mrs Thompson in 1992. She keeps me right in all things visible and invisible.Name one virtue all surgeons ought to have. Patience with others.Name one vice no surgeon should have. Arrogance to others. ^

The Colles Q&A

MR TREVOR J THOMPSON, BSC MB BCH BAO FRCS (UROL) FRCSI, FROM BELFAST, IS A CONSULTANT UROLOGIST AT BELFAST CITY HOSPITAL AND HEAD OF SCHOOL OF SURGERY, NIMDTA ...

grey face turned pink and his pain settled in front of me. A life-changing moment for my dad and for me. How do you have fun? Watching rugby again (Ulster and Ireland) but this is not always fun. My wife and I also enjoy visiting the cultural centres of Europe and beyond. A slow day in a museum of art is bliss. Our poor children were dragged around art galleries, museums and historic buildings. Now grown up, they escape these trips.Where would you be if you decided not to become a surgeon? I would probably be a civil engineer and living in England. What has been your proudest moment? I am proud of my wife and children and their achievements.

Mr Trevor J Thompson


› Q & A

18

he recent obesity pandemic has been paralleled by an equally dramatic rise in the prevalence of obesity complications, particularly Type 2 Diabetes Mellitus (T2DM), cardiovascular disease and obstructive

sleep apnea. This is of major concern to healthcare providers globally. In Ireland, where 23 per cent of the adult population is obese, it is estimated that there are over 200,000 adults with T2DM at present. More alarmingly, according to the Healthy Ireland survey, there are 1,158,547 adults in Ireland at risk of developing T2DM.

BARIATRIC (METABOLIC) SURGERY Bariatric/Metabolic surgery has revolutionised the management of severe obesity and obesity-related diseases such as T2DM in recent years. In addition to substantial weight loss, it leads to dramatic improvements in glycemic control, insulin sensitivity, and cardiovascular disease risk. Over the last decade, bariatric surgical techniques have evolved and advanced. Recent data examining the utilisation of laparoscopic bariatric procedures at academic medical centres in the United States reflects changing trends. Vertical banded gastroplasty was the prototype-restrictive operation for many years until acknowledgment of its high failure rates and long-term complications resulted in it

being largely abandoned. Sleeve gastrectomy was initially utilised as the first component of a two-stage procedure in high-risk patients, but has since been demonstrated to be effective as a standalone bariatric procedure, and has now become the most commonly performed procedure in the US where it accounts for 54 per cent of all bariatric operations. Gastric bypass is the second most commonly performed procedure at present (23 per cent), and gastric banding is much less commonly performed than previously (six per cent of all procedures). Malabsorptive procedures such as biliopancreatic diversion (BPD) and duodenal switch are infrequently performed (<1%) and revisional procedures are becoming increasingly common (13 per cent).

Novel endoscopic procedures are proposed alternatives to bariatric surgery, and include intragastric balloons, duodenojejunal bypass liners such as the EndoBarrier, and endoscopic suturing platforms. They are associated with a mean weight loss of ten–20 per cent in the short-term, and a complication rate of up to 20 per cent. Complications include device migration and bowel obstruction. Given the lack of long-term data at present, the role for such devices remains to be determined.

OUTCOMES OF BARIATRIC SURGERY: BENEFITS Weight Loss The primary goal of bariatric

MS HELEN HENEGHAN, MB BCH BAO, PHD, FRCS, SPECIALIST IN BARIATRIC SURGERY AND GASTROINTESTINAL MALIGNANCIES, GAVE A RECENT LECTURE AT RCSI WHERE SHE EXPLAINED HOW BARIATRIC SURGERY IS THE ULTIMATE CUT TO CURE FOR OBESITY-RELATED DISEASES …

› B a r i a t r i c S u rg e r y

procedures remains weight loss in most cases. While the various procedures achieve this to different extents, the overall percentage weight loss is reported to be as high as 20-30 per cent in the long-term. Malabsorptive procedures such as biliopancreatic diversion and duodenal switch attain the greatest weight loss, but at the expense of higher morbidity. Weight loss after gastric bypass and sleeve gastrectomy is comparable (25-30 per cent at 24-48 months) but there is a higher risk of weight regain after sleeve gastrectomy.

Impact on Comorbidities In addition to substantial weight loss, bariatric surgery is known to have profound metabolic effects, the most striking of which are the marked resolution of diabetes, hypertension and dyslipidemia. The various procedures differ in the degree of improvement they impart on an obese individual’s state of metabolic disarray, with malabsorptive procedures demonstrating greatest benefit in this regard overall. A substantial body of evidence, including data from 16 randomised controlled trials, demonstrates that bariatric/metabolic surgery achieves superior glycemic control and reduction of cardiovascular risk factors in obese patients with Type 2 diabetes (T2DM) compared with various medical and lifestyle interventions. A meta-analysis of the data from eleven of these RCTs indicates that weight loss was significantly greater in the surgical

SURGEON’S FILEMs Helen Heneghan is a

Consultant Bariatric Surgeon at

St Vincent’s University Hospital,

Dublin. A graduate of NUI

Galway, she completed basic

surgical training at Galway

University Hospital. In 2012,

she was awarded a PhD in the

molecular expression of breast

cancer and obesity from NUI

Galway. She then completed the

RCSI Higher Surgical Training

scheme in General Surgery in

2016. During her training, she

spent two years in the Bariatric

Metabolic Institute in Cleveland

Clinic, Ohio. She then completed

her training with a Bariatric

Fellowship in the UK (Chester,

Liverpool). She has co-authored

60 publications in peer-reviewed

journals and has written five book

chapters on the topics of bariatric

and endocrine surgery.

Cut to cure


Impact on other Weight-related ComorbiditiesBariatric surgery positively affects many other weight-related conditions including obstructive sleep apnea, non-alcoholic fatty liver disease, gastroesophageal reflux, arthritis and back pain, urinary incontinence, gout, thyroid and parathyroid function, subfertility, asthma and others. There is emerging evidence that bariatric surgery may reduce the incidence of cancer, with a stronger protective effect reported in women than men.

Impact on Mortality Several studies have demonstrated that bariatric surgery significantly reduces mortality. The Swedish obese subjects study showed a three per cent decrease in mortality rates after ten years of follow-up, mainly from decreases in deaths due to cancer and myocardial infarction. Similar results were reported by Adams et al, showing a 40 per cent reduction in mortality rates, particularly from diabetes, cancer and cardiovascular disease. A recent systematic review and meta-analysis has identified eight studies which reported on long-term mortality, involving 23,647 operated patients and 89,628 non-operated obese controls. This data showed a reduction of 41 per cent in all-cause mortality after bariatric surgery.

HOW BARIATRIC SURGERY WORKS: Mechanistic InsightsWhilst weight loss certainly plays a major role in the metabolic benefits of bariatric surgery, it appears that there are other weight-independent mechanisms at play. Evidence to support this assertion includes the fact that leaner patients with T2DM experience similar anti-diabetic effects without significant weight loss, and most patients’ glucose control improves or normalises almost immediately after surgery, well before

groups, and bariatric surgery patients had higher remission rates of type 2 diabetes (relative risk 22.1 (3.2-154.3)) and metabolic syndrome (relative risk 2.4 (1.6 to 3.6)), greater improvements in quality of life, and reductions in medicine use. Other notable benefits in the surgical arms of these trials included significant decrease in triglyceride concentrations, and increase in HDL cholesterol 6. Although not included in this meta-analysis because it was not a randomised trial, the noteworthy Swedish Obese Subjects (SOS) case-control study demonstrated a hazard ratio of 0.17 for diabetes incidence following assorted bariatric surgical interventions illustrating how effectively bariatric surgery reduces progression from the pre-diabetic state. The SOS studies have also shown that bariatric surgery is associated with a decreased incidence of diabetic microvascular complications (HR 0.44; 95% CI, 0.34-0.56; P < 0.001) and macrovascular

any significant weight loss takes place. Many patients with T2DM are able to decrease, or even discontinue, insulin and oral hypoglycemic drugs just hours after undergoing RYGB. Furthermore, it has been observed that malabsorptive procedures in which gastrointestinal anatomy has been altered result in significantly greater remission of metabolic comorbidities such as T2DM, compared to other interventions with equivalent weight loss.

The various weight-independent mechanisms proposed to induce diabetes remission after bariatric/metabolic surgery include:• Exclusion of the proximal duodenum and small intestine from nutrient flow, possibly downregulating unidentified anti-incretin factor(s)• Increased postprandial secretion of distal gut hormones such as GLP-1 and peptide YY, from enhanced and expedited distal intestinal nutrient delivery• Changes in intestinal nutrient-sensing mechanisms that affect insulin sensitivity• Impaired ghrelin secretion• Bile acid alterations• Changes in the gut microbiome

In light of such evidence, a joint statement by several international diabetes organisations was published in May 2016, stating that metabolic surgery should be recommended or considered as a treatment option for certain categories of people with T2DM. Specifically, these guidelines state that metabolic surgery should be recommended to treat T2DM in patients with class III obesity (BMI ≥40 kg/m2) and in those with class II obesity (BMI 35.0–39.9 kg/m2) when hyperglycemia is inadequately controlled by lifestyle and optimal medical therapy. Surgery should also be considered for patients with T2DM and BMI 30.0–34.9 kg/m2 if hyperglycemia is inadequately

complications (HR 0.68; 95% CI, 0.54-0.85; P = 0.001).

Impact on Cardiovascular (CV) Risk Profile Bariatric surgery has been shown to significantly decrease CV risk, by inducing resolution or improvement in CV disease risk factors including T2DM, hypertension and dyslipidemia. Indeed, a systematic review of 52 studies involving 16,867 patients who have undergone bariatric surgery demonstrated a reduction of 40 per cent in Framingham risk (ten-year cardiovascular disease risk score) following bariatric surgery, resolution or improvement of 60–75 per cent in traditional cardiovascular risk factors (T2DM, hypertension and dyslipidemia) and significant reduction in novel risk factors such as C-reactive protein and endothelial function. No pharmacological treatment has been shown to have such a marked positive impact on CV risk profile.

› B a r i a t r i c S u rg e r y

20

controlled despite optimal treatment with either oral or injectable medications. This statement has since been endorsed by 52 international professional organisations, including Diabetes Ireland and Royal College of Physicians Ireland.

RISKS OF BARIATRIC SURGERY: Perioperative Mortality and MorbidityOver the last two decades, the safety of bariatric surgery has been greatly improved and well-documented. Developments in surgical innovations, in the medical device industry, coupled with increased experience in minimally invasive surgery have enabled this. Additionally, advances in surgical technique and implementation of enhanced recovery after surgery (ERAS) programmes have contributed to reduced operative time, length of stay, and complications. The rate of conversion to open surgery is now one per cent, occurring most often in the setting of revisional surgery or for complex malabsorptive procedures. Short-term mortality after bariatric surgery is low, ranging from 0.04 to 0.3 per cent. A recent population-based, nationwide study from Finland reported 30-day, 90-day, and one-year mortality rates following bariatric surgery compared to mortality rates after other common operations (cholecystectomy, hysterectomy, prostatectomy, knee and hip arthroplasty, colorectal and gastric resections, coronary artery bypass graft). This study demonstrated that mortality within the first year after surgery was lowest for bariatric surgery in comparison to these other procedures.

It was found that early and long-term complications after bariatric surgery are lower than might be expected for this medically comorbid population; the LABS consortium reported a 4.3 per cent incidence of major adverse events in the early postoperative period. Although these reports are encouraging, a few complications associated with bariatric surgery are potentially fatal

and merit careful consideration. These include sepsis from an anastomotic dehiscence, shock secondary to post-operative haemorrhage, or cardiopulmonary events in this high-risk group. The leading cause of death after bariatric surgery is thromboembolic disease, with an incidence of 0.34 per cent. Perhaps the most dreaded complication is sepsis secondary to an anastomotic or staple line leak, with rates ranging from 1-2 per cent for primary gastric bypass and sleeve gastrectomy. Early identification and an aggressive approach to management of leaks improves the outcome. Early postoperative bleeding complicates 1-4 per cent of bariatric surgeries. Several risk factors for postoperative morbidity and mortality have been identified; these include male gender, age >50 years, congestive heart failure, peripheral vascular disease and renal impairment. While these factors may increase risk, they do not necessarily preclude an individual from bariatric surgery and need to be considered in the individual clinical context.

CONCLUSION In addition to achieving substantial and durable weight loss, bariatric surgery can achieve remarkable benefits for many obesity-related complications. There is now substantial evidence supporting durable remission of T2DM, decreases in cardiovascular risk and actual medium-term cardiovascular outcomes, and a mortality benefit. Mechanistic studies have elucidated various weight-independent mechanisms responsible for such outcomes. Research to further elucidate these weight-independent antidiabetic mechanisms of bariatric surgery promises to identify targets for new pharmaceuticals that might replicate some of the dramatic effects of these operations medically. The current extensive evidence demonstrating the safety and efficacy of bariatric surgery supports it as the current standard of care for treatment of severe obesity and its metabolic complications. ^

› B a r i a t r i c s u rg e r y

In November, nine-year-old Sudanese national Bana Nizar Hassan was the recipient of a cadaver kidney during surgery performed by a joint medical team from Al Jalila Children’s hospital, and Mohammad Bin Rashid University of Medicine and Health Sciences (MBRU). Hassan was born with just one kidney, with a condition called renal agenesis, which affects around one in 1,000 children. The team was led by MBRU’s prominent transplant surgeons Dr David Hickey, Professor of Surgery and RCSI alumnus Dr Farhad Kheradmand Al Janahi, Assistant Professor of Surgery. The lead surgeon, Dr Hickey, former director of the National Kidney and Pancreas Transplant Programme in Ireland, has performed over 2,000 transplants, trained transplant surgeons from around the world, and published over 130 peer reviewed scientific papers.

Ten government health entities in Dubai and Abu Dhabi worked together to ensure that the kidney from a deceased donor in Abu Dhabi was transplanted within the critical twelve-hour window. The UAE’s Organ Transplantation Law allows for deceased and living donors. Commenting on the deceased organ transplant, Dr Ali Obaidly, Director of UAE’s National Organ Transplant Committee, told Gulf News: “So far, nine cases of deceased organ transplants have taken place in the UAE. The nine deceased donors from Mafraq Hospital Abu Dhabi, donated various organs such as lungs, livers, kidneys, heart, tissue, bone marrow etc. Of these organs, four kidneys went to children. Three of the kidney recipients were

from Abu Dhabi. Bana Nizar, who received the deceased donor’s kidney was the fourth child in UAE and the first in Dubai to receive the organ.”

Hassan was born with just one kidney, with the condition of renal agenesis, which affects around one in 1,000 children. She has since been discharged from hospital.

Dr Al Janahi, who in the past has collaborated with RCSI to initiate the establishment of a kidney transplant programme at Dubai Hospital, explained the significance of the surgery: “Our team has carried out five kidney transplants and this is the first time a child has been the recipient of a kidney transplant in Dubai. This indicates that the deceased organ transplantation programme is progressing well in Dubai.” n

RCSI ALUMNUS, FELLOW AND FORMER SURGICAL TRAINEE MR FARHAD KEHADMAND ASSISTED

WITH THE FIRST EVER PAEDIATRIC KIDNEY TRANSPLANT IN DUBAI

A first for Dubai

Professor of Surgery and RCSI alumnus Dr Farhad Kheradmand Al

Janahi, Assistant Professor of Surgery at Mohammad bin Rashid University of

Medicine and Health Sciences.


Meeting of Minds

› M i l l i n M e e t i n g

The RCSI Roll of Honour was produced

to remember and celebrate the

compassion, medical skills and unselfish

nature of those staff and students, some of whom were never to

return home.

RCSI HELD THE 41ST ANNUAL MILLIN MEETING IN NOVEMBER 2018 WITH A NUMBER OF KEYNOTE SPEAKERS LOOKING TO THE FUTURE OF SURGERY ...

WELCOME BY MR KENNETH MEALY, PRESIDENT, RCSIPresident of RCSI, Mr Kenneth Mealy welcomed attendees and led a moment’s silence for those RCSI staff, students and faculty who served and lost their lives in the First World War. According to RCSI former Council member, Mr Joe Duignan, 1,266 graduates, Fellows, staff and students joined the Armed forces. Of these, 176 were mentioned in dispatches, 148 were honoured and 44 died. The RCSI Roll of Honour was produced to remember and celebrate the compassion, medical skills and unselfish nature of those staff and students, some of whom were never to return home. A project to digitalise The Roll of Honour was led by Susan Leyden, RCSI archivist, and completed

Mr Kenneth Mealy, President, RCSI

in time for the centenary of the end of WW1, and screened at the Millin Meeting.

THE SHAPE OF SURGERY 2030The theme of the contribution by Professor Deborah McNamara, Fellow and Council Member, RCSI and consultant colorectal surgeon at Beaumont Hospital, was “What Surgery Services in Ireland Might Look Like”. Professor McNamara addressed a number of topics related to surgery. She said that, at a time when some might view the democratisation of knowledge as heralding the end of the expert, surgeons must stay strong in the belief that this is not the case. She addressed the “new normal” of comorbidity, informing us that “a third of patients undergoing hip surgery also have cognitive impairment” and that the issue of surgical capacity is one not just of availability of beds but “about decision makers and risk-takers”.

Still on the theme of “The Shape of Surgery 2030”, Mr Richard Kerr, Chair of the Commission on the Future of Surgery UK and Consultant Neurosurgeon at John Radcliffe Hospital, Oxford, UK explained that the Commission was established in late 2017 to predict what the next five to 20 years would look like in terms of surgery. Using the example of cataract surgery in the context of an ageing population, he explained how increased demand for this and many other similar age-related procedures would shape the future need for resources. Mr Kerr underlined the importance of facilities such as those

at 26 York Street in preparing surgeons of the future, when simulation-based training would become the norm due to pressures on theatre access.

Using data from ESRI 2018, Professor Jan Sorensen, Director of the Health Outcomes Research Centre, RCSI predicted considerable increased demand in both public and private bed days and inpatient admissions, longterm care places and GP services. He put forward some ideas for better use of hospital resources including the introduction of a decentralised management structure, stronger incentive structure and a stronger focus on patient-related outcomes.

On the subject of surgical cancer services in 2030, Professor Arnold Hill, Head of School of Medicine, Professor of Surgery at RCSI and general breast and endocrine surgeon at Beaumont Hospital, Dublin took the opportunity to look back at a decade of decentralisation and what happened to what cancers and why. Thanks to funding and political support, breast cancer is now completely centralised as is lung cancer. Professor Hill also outlined the changes that have happened over the last ten years in terms of oesophageal, pancreatic, rectal, colon and prostate cancers.

CAITRIONA PERRY DELIVERS 26TH CARMICHAEL LECTURERCSI was delighted to welcome award-winning journalist, broadcaster and author Caitriona Perry to RCSI and the Millin Meeting where she delivered the 26th Carmichael Lecture: “The Place of Truth in a ‘Fake News’ World:

22

Reporting from the Divided United States of America”. The timing was apposite – with the mid-term elections and the Trump administration in full-throttle mode, Perry described the experience of being a journalist in the press corps attached to the Trump White House: “He likes to have journalists in a tailspin,” she said, “ensuring there’s little time for the press to take a deep dive into anything.” She recounted the summer of 2016 and how the press corps was anticipating a badly needed break for August, the month when traditionally everything shuts down in Washington and everyone gets a break. Not so for the Trump administration. She listed a dizzying number of chaotic Trump initiatives that ruled out a vacation of any sort, among them the departure of press secretary Sean Spicer, the arrival and rapid departure of Anthony Scaramucci, the exit of Reince Priebus, the firing of the attorney general. Trump almost went to war with North Korea and banned transgender people from the US military; his reaction to the race events in Charlottesville was to say the least controversial, and he

DEFINING COMPETENCE FOR THE FUTURE SURGEONThis session was co-chaired by Professor Laura Viani, Council Member, RCSI and Consultant Otolaryngologist and Neurologist at Beaumont Hospital, Dublin and Director of National Hearing Implant Research Centre, and Professor Oliver J McAnena, gastrointestinal surgeon, National University of Ireland, Galway. There were contributions on “Confirmation of Competence” by Mr Gareth Griffiths, Chair of the Joint Committee on Surgical Training and Consultant Vascular Surgeon, and on “Leadership: The Future Challenge” by Professor Ciaran O’Boyle, Director, Institute of Leadership, RCSI and on “Professionalism: Problem and Solution” by Professor Dubhfeasa Slattery, Professor and Chair of Medical Professionalism, RCSI and Bons Secours Health System before the presentation of medals and awards.

PRESENTATION OF MEDALS AND AWARDSThis year’s recipient of the ACS & RCSI Exchange Fellow Award is Dr Ryan

Caitriona Perry

› M i l l i n M e e t i n g

Ellis, who was presented the award by Mr Kenneth Mealy, President, RCSI. Mr Brian Lane presented the Brian Lane Medal to Dr Richard Carr and Dr Rory O’Neill. Professor WAL MacGowan presented the Professor WAL McGowan Medal to Miss Anna Lucy Walsh. The December 2017 winner of the Professor Gerald C O’Sullivan Medal was Dr Mbonisi Malaba from Zimbabwe who was presented with the medal by Mrs Breda O’Sullivan.

PROFESSIONALISM IN 21ST CENTURY MEDICAL PRACTICE: LAUNCH OF ONLINE COURSEProfessor Oscar Traynor, Professor of Postgraduate Surgical Education, RCSI has developed an online course “Professionalism in 21st Century Medical Practice” aimed at medical doctors in all specialties. The course is based on the Medical Council’s “Guide to Professional Conduct and Ethics for Registered Medical Practitioners” and is presented in an interesting and engaging format. There are twelve online modules covering different aspects of Medical Professionalism and each module can attract five CPD credits. An online introductory video (seven-eight minutes per module) is supported by a Learning Resource Area which contains carefully selected reading materials and videos related to the subject matter of the module. On completion of the reading and viewing tasks, you can take a MCQ test to earn your CPD points and even print your own certificate. The course is designed to be accessed on any mobile device (see page 5 for module outline and course details). You may study the modules in any order and at your own pace. This online course on Professionalism will be available to all registered medical doctors in Ireland.

PRODUCING SURGEONS FIT FOR PRACTICE The final session of the Millin Meeting was co-chaired by

called Rex Tillerson a moron. A quiet month … But, by any measure, Perry acknowledged, the Trump presidency has been deemed a successful one, delivering what his voter base wants, although the biggest questions still on everyone’s lips are how did he do it, how did he get elected, who voted for him? These questions are the key to how he rules and makes decisions, and the key to how Irish business can engage with the US in the future. And the race is on for 2020. Perry was presented with the Carmichael Medal by Mr Kenneth Mealy, President, RCSI.

“He [Donald Trump]likes to have

journalists in atailspin ...ensuring there’s little time

for the press to takea deep dive into

anything.”


Ms Bridget Egan, Council Member RCSI and Consultant Vascular Surgeon, Tallaght University Hospital, and Ms Ailín Rogers, Chair of Irish Surgical Training Group.

Dr Bas PL Wijnhoven, Gastrointestinal Surgeon & Programme Director Surgical Training at the Erasmus University Medical Centre, Rotterdam, Netherlands, gave a presentation on the “Structure and Governance of General Surgical Training In The Netherlands”. This was followed by “The Role of Research in the Future of Surgery” presented by Professor Michael Kerin, Council Member RCSI; Professor & Head of Department of Surgery, NUI Galway and Mr Kieran Ryan, Managing Director of Surgical Affairs, RCSI on the subject of “Evolution of the Training Model – Are We There Yet”. Two trainees, Core Trainee Dr Robert Michael O’Connell, SpR General/Breast Surgery, University Hospital Limerick and Higher Surgical Trainee, Miss Anna Lucy Walsh, Urology, Cork University Hospital, Cork presented their contribution entitled “Trainee Expections: Reflections on Training and Career Aspirations”.

41ST MILLIN LECTURE: DELIVERED BY MR PADHRAIG F O’LOUGHLIN, MB BCH MD FRCSI (TR & ORTH) The Millin Lecture is a prestigious award and open to all surgical specialties. The subject chosen is always one of clinical interest embodying original research. The 41st Millin Lecture, entitled “New Technology in Orthopaedic Surgery: A Surgical Deus Ex Machina” was delivered by self-confessed technophile orthopaedic surgeon Mr Padhraig F O’Loughlin. His was a fascinating account of how he, throughout his career, embraced new technology, exploring the opportunities it presented. He explained how we need to get better at recognising good

(now home to 116 orthopaedic consultants) and where many Irish Fellows and surgeons had already, in his words, “blazed a trail”. O’Loughlin was thrown in “the deep end”, immersed in the use of the latest devices, tablets and robots. This was his first experience of the robotic arm developed at the Kawasaki motorcycle plant and adapted to assist with treatment of ankle sprains. He noted that while computer-assisted navigation helped in surgery, it also lengthened the operations – so not always in the best interest of the patient. After Barack Obama was elected president of the United States, “a huge tranche of research funding was released” which allowed research into increasing precision of surgeries and reducing the time spent in surgery. O’Loughlin admitted to the audience he has often queried the evolution of tech “for tech’s sake”. Does it improve patient outcomes? He explained that if a company invests huge sums in developing a technology, they are under pressure to make it work, to prove it works. While studies have shown in the past that there may be little difference in functional results of between non-tech and tech-assisted surgery, his later experience in a large

He explained how weneed to get better at

recognising goodtechnology, proving itand improving it, andquicker at discardingthe technology that

does not deliverimprovement to

patient outcomes.

Mr David Moore, Council Member, RCSI, Mr Padhraig F O’Loughlin MB BCh MD FRCSI (Tr & Orth) and Professor John O’Byrne

technology, proving it and improving it, and quicker at discarding the technology that does not deliver improvement to patient outcomes. Mr O’Loughlin began by looking at processes and systems and what can be gleaned from the process even if goals are not met. He gave examples from his own journey in orthopaedics, first as a medical student at UCD, and as a trainee at the Mater Hospital, before he moved to the United States to the Hospital for Special Surgery in the Upper East Side, New York

trauma hospital in Glasgow where tech was used in very innovative ways and later still in Lyons where tech applications resulted in customised implants, reinforced his faith in good tech. Before his return to Ireland, and to the Mater Private Hospital, Cork, he spent time in Belgium where a young hip surgeon was being “forensic about the process” of replacements, involving all staff at every step in the process to streamline every aspect. This “efficient surgery concept” resulted in greater productivity and the surgeon being able to complete between eleven to 13 hips in a day. While O’Loughlin’s international experience consolidated his respect for tech as a valuable tool, he says “a fool with a tool is still a fool”, he believes in the low-tech revolution (improving the tibial nail being one example) and, most importantly, the human side, the importance of intuition and empathy, the bedside chat and the hands-on, old-fashioned physical exam. Mr O’Loughlin was presented with the Millin Medal by Mr Kenneth Mealy, President, RCSI. As official proceedings drew to a close, Fellows, Members and guests were invited to gather for a reception in the College Hall. n

24

OVERVIEW OF THE SPECIALTYThe specialty is known by different titles including ENT (Ear Nose & Throat Surgery), Otolaryngology (official RCSI title), Otorhinolaryngology Head & Neck Surgery and ORL-HNS. Most departments in this country, the UK, Europe and North America use the title Otolaryngology Head & Neck Surgery as it more accurately reflects the wide breadth of the specialty.

Sir William Wilde (b.1815, Roscommon), father of Oscar Wilde, is regarded by many as being the “father” of Irish Otolaryngology. Not only an ear and eye surgeon, he was also a statistician, naturalist, historian, archaeologist and biographer. He wrote the reputedly first clinical textbook on ear disease, Practical Observations on Aural Surgery, in 1853 and founded St Marks Hospital in Lincoln Place, Dublin, a precursor to Dublin’s Eye and Ear Hospital.

The specialty is the joint third

› S p e c i a l t y S p o t l i g h t

largest surgical specialty after general surgery and orthopaedics in Ireland. Unlike most other specialties, most consultants in otolaryngology in Ireland have both an adult and paediatric otolaryngology practice.

CONSULTANT STAFFING IN OTOLARYNGOLOGYConsultants in public practice: 53 (one consultant per 85,000 population) Consultants in private practice only: 9 Total: 62 (one consultant per 72,600).

The specialty is very keen for significant consultant expansion to deal with the considerable service and training demands and has lobbied for it for many years. This needs to be expanded to approximately one consultant per 40,000 population and this in turn will necessitate expansion of trainee numbers. The lowest ratio in Europe is in Greece at one per 8,000 population and the average in the EU is approximately one per 12,000 population. Thus there is a considerable gap between the number of consultants in the specialty in Ireland and the number required. The UK has a similar problem to us with a ratio of only one consultant per 85,000 population.

IRISH SPECIALTY TRAINING PROGRAMME IN OTOLARYNGOLOGYHistorical AspectsThe Irish specialty training programme in Otolaryngology is co-ordinated through RCSI.

Specialty Spotlight Otolaryngology

BIOGRAPHY NATIONAL• Consultant Otolaryngologist & Neuro-Otologist, Beaumont Hospital, Dublin• Clinical Associate Professor, Royal College of Surgeons in Ireland, Dublin ([email protected])• Head of Department, Department of Otolaryngology, Beaumont Hospital, Dublin• Chairman, Irish Specialty Training Programme in Otolaryngology, Royal College of Surgeons in Ireland• Secretary, Irish Otolaryngological Society • Specialty Representative, Academic Board of the Faculty of Postgraduate Surgical Educators, Royal College of Surgeons in Ireland, Dublin• Specialty Representative, Committee for Surgical Affairs, RCSI • President, RCSI Student Surgical Society, Dublin• Graduate of Trinity College, Dublin

INTERNATIONAL• Intercollegiate Fellowship Examiner in Otolaryngology, JCIE, UK • RCSI Representative, Union of European Medical Specialists (UEMS) - ORL Section (due to be hosted in RCSI, October 2019)• Faculty Member, Combined British Universities Advanced Otology Course, UK, hosted in RCSI, 2015• Council Member, British Skull Base Society UK (2013-16)

Specialty Chair:Professor Rory McConn Walsh

MA, MD, FRCSI, FRCS (ORL-HNS), FFSEM

Mr Hugh Burns (formerly Royal Victoria Eye and Ear Hospital) and Professor Michael Walsh (formerly Beaumont Hospital and RCSI) are credited as establishing the current structure of the programme (c.1979).

The programme became a seamless or continuous programme in July 2013 with the merger of the ‘old’ registrar and senior registrar grades and removal of the intervening gap year. Around the same time, the programme agreed to become part of the surgical training pathway at RCSI. The net effect of these changes was that specialty training in otolaryngology was reduced to six years and this in turn made the specialty more attractive as a career. Trainee StatisticsThere are currently 19 specialty trainees (STs) in post on the programme with a total capacity of 27 trainees, including a six-month residency post at Boston Childrens Hospital. The trainees rotate every twelve months through ten training units throughout the country. On average three to five trainees graduate from the programme every year, with a large number having graduated recently. There are approximately four to five entrants to the programme at ST3 level per year from the core surgical training programme. The exact number of entrants is variable, depending on the numbers graduating and the needs of the specialty. The specialty is currently proving very popular as a career choice at ST3 level.


Trainees are expected to deliver presentations at the annual Irish Otolaryngological Society meeting. This is a North-South ENT body which was set up in 1961 and meets North and South of the border on alternate years. This promotes co-operation between consultants and trainees across the island of Ireland. An international speaker is invited to deliver the prestigious Wilde discourse. Trainees are also expected to present at the RAMI ORL-HNS section meetings outside of Dublin in April and in Dublin in December. These meetings give trainees ample opportunity to present to the specialty.Fellowship TrainingOn completion of training, most trainees will then undertake a one-two year clinical fellowship abroad in their preferred subspecialty area(s). There are strong links between otolaryngology departments in Ireland and centres in Toronto, New York, Australia and the UK, amongst others. These centres have been very supportive of trainees from Ireland over the past 30 years and these friendships have endured. There are also clinical fellowship and tutor posts available in Ireland if the trainee prefers to stay at home. These fellowships are undertaken after training is completed i.e. after passing the Intercollegiate exam and post-CST as the trainee gains much more experience from the fellowship in that situation.

The success of our training programme is undoubtedly down to the time and effort that individual trainers and assigned educational supervisors in the various training units put into training, gratis, at the same time dealing with a very significant service commitment. I would also like to acknowledge the current TPD (Professor Helena Rowley), the previous TPD (Mr Martin Donnelly), the Core Surgical

The Six-Year Training ProgrammeThe trainees spend four years in “general” otolaryngology training with exposure to all of the subspecialties (ST3-6) and two years with an emphasis on subspecialty training (ST), if that is their wish. The training programme has adopted the same curriculum as the intercollegiate surgical curriculum programme (ISCP) in the UK.

It has been proposed that there is also a role for specialty trainees with a special interest in general otolaryngology as a significant proportion of the service demand in the specialty is for general otolaryngology. The “hub and spoke” model is regarded as the ideal for the future provision of otolaryngology services in each hospital region. The subspecialist otolaryngology services would be provided in the central or hub hospitals and the general otolaryngology services in thespoke hospitals.Teaching & Skills CoursesDuring their training, trainees are required to attend the weekly otolaryngology grand rounds based at RCSI and teleconferenced to all units around the country. This occurs every Friday morning with structured consultant delivered teaching between 7-7.30am and a grand rounds case presentation with literature review, usually delivered by a trainee on behalf of a specific consultant, between 7.30-8am.

Trainees are also required to attend the five annual mandatory surgical skills courses run by the specialty, most of which are undertaken at the National Surgical & Clinical Skills Centre, RCSI. These include the RCSI temporal bone and mastoid surgery dissection course, RCSI head & neck surgical anatomy course, RCSI facial plastic surgery dissection course, functional endoscopic sinus surgery dissection course and the RCSI - Boston Children’s Hospital paediatric

TPD (Professor Nash Patil) and our Specialty Administrator.

We have found RCSI to be very supportive and progressive in our dealings with them at all times and we have successfully worked together through numerous challenges.

SUBSPECIALISATION IN OTOLARYNGOLOGY IN IRELANDThere is a diverse range of subspecialties provided within the specialty of otolaryngology in Ireland now including: otology, rhinology, head & neck surgery (benign and malignant), paediatric otolaryngology, neuro-otology and lateral skull base surgery, anterior skull base surgery, facial plastic surgery, laryngology, and allergy. Most consultants have a subspecialty interest and patients do not need to travel abroad, with rare exceptions. Most training units will have a consultant with a subspecialty interest in each of otology, rhinology and head & neck surgery.

The specialty works closely with other surgical, medical, anaesthesiology and laboratory-based specialties in a multidisciplinary team (MDT) approach. The specialty also works closely with allied paramedical specialties such as clinical nurse specialists, audio-vestibular departments, speech and language therapy, swallow therapy, vestibular and facial physiotherapy, and dietetics in MDTs.

airway simulation course. Prizes are awarded for the best dissections. There is also a tracheostomy and upper airway course which trainees are expected to attend several times during their training. Trainees are also required to attend one mandatory human factors study day every six months at RCSI, specifically designed to cater for otolaryngology trainees.Exams & Programme AccreditationTrainees are also required to undertake an annual three-hour MCQ exam at RCSI and a clinical/viva exam at RCSI Education and Research Centre, Beaumont Hospital. These exams are modelled on the Intercollegiate Fellowship exam in otolaryngology. They give trainees an idea of the standard required of them and prepare them for it.

The Irish programme was formally accredited by the Surgical Advisory Committee (SAC-UK) in 2013 and this is due to take place again in 2019. The liaison SAC-UK member also reports back after the biannual CAPA/ARCP assessments held at RCSI. With Brexit looming, this may have significant implications for future external accreditation and perhaps there is a greater role for Europe to play in this regard, ie the Union of European Medical Specialists (UEMS-ORL section).Research & Presentation OpportunitiesClinical and basic science research is strongly encouraged during training. Trainees are required to produce at least one publication every twelve months, although most produce more. Facilities exist at various centres around the country for trainees to undertake high-quality research leading to a higher degree, although this is not mandatory. Most graduates from the programme in recent years have undertaken research degrees, such is the competition for consultant positions.


The specialty is very keen for significant consultant

expansion to deal with the considerable service and training demands.

26

Subspecialty services are being increasingly centralised. The NCCP is in discussion with the specialty, and other related specialties, about where future head & neck cancer centres should be located. Other tertiary referral subspecialty pathways e.g. cochlear implant, skull base surgery, paediatric otolaryngology are already well established. Future sub-specialty expansion is required in head & neck cancer services, paediatric otolaryngology and skull base surgery.

CHALLENGES FACING THE SPECIALTY AND TRAININGThere are many challenges facing the specialty. The National Clinical Advisor in Otolaryngology, Professor Michael Walsh is devising a model of care document for ENT surgery. In this the clinical challenges are addressed. Some of these include: Lengthy Outpatient Waiting ListsThe specialty has some of the longest waiting lists in the country for patients with “routine” ENT conditions awaiting outpatient consultations, with many having to wait years. This applies to both children and adults. Patients with “urgent” conditions or cancer are seen and managed very promptly and efficiently. Currently many ENT clinics are over-booked with unsafe numbers of patients attending. The specialty is recommending the ENT-UK guidelines for the number of patients seen. As previously discussed, the “hub and spoke” model of care for each hospital region is recommended such that subspecialty otolaryngology services e.g. cancer services are provided in the central or “hub” hospitals and the general otolaryngology services in the “spoke” hospitals. Significant consultant expansion is a necessary part of the solution also and more control needs to be given to the specialty in deciding these numbers. However, it must be emphasised that the main

backlog for current otolaryngology services in Ireland is for patients with routine otolaryngology conditions and therefore there is a need for more consultant general otolaryngologists. Physician associates have been introduced in Beaumont Hospital/RCSI and they appear to have a promising future.

There is also a need for involving the allied paramedical services. For example, advanced nurse practitioners/clinical nurse specialists providing ear microsuction clinics, virtual reality telephone clinics to provide patients with test results, thus avoiding a hospital visit, vestibular physiotherapists providing “dizzy” clinics, SALT therapists providing “swallow” clinics, audio-vestibular departments providing direct access hearing tests. These type of initiatives would free up clinicians. Lengthy Waiting Lists for SurgeryThe specialty also has very long waiting lists for patients awaiting “routine” in-patient and “routine” day-case surgery e.g. tonsillectomy, nasal septal and sinus surgery. Once again, patients requiring cancer surgery, surgery for serious conditions and subspecialty surgery are usually treated urgently. Currently there are insufficient in-patient and day-case beds. Standalone elective facilities with protected beds and greater access to operating theatres would help significantly. Once again separating the service into a hub and spoke model in each hospital region is recommended. More surgery could be undertaken as day-cases but it is essential that this is carried out in standalone day-care facilities with the necessary arrangements in place if emergency re-admission is required.Training ChallengesThere are also challenges facing training. In times gone by, it has not always been possible to guarantee trainees a consultant post in their subspecialty area and in their

ideal location immediately upon completion of their specialty and fellowship training. More control needs to be given to the specialty in terms of consultant numbers required.As a result, the training programme could then match the number of trainees graduating to the number of consultant posts available/required.

The implication of Brexit on specialty training is uncertain in terms of future external accreditation of specialty training, which curriculum is followed (currently the intercollegiate surgical curriculum programme) and which final exam is undertaken on completion of training (currently the Intercollegiate exam in otolaryngology). The Union of European Medical Specialists (UEMS-ORL section) may have a greater role to play in the future.

OBJECTIVES & PRIORITIESThe primary clinical objective is for the HSE and hospital regions to put into practice the completed model of care document for ENT surgery so as to deal with the lengthy waiting lists for routine inpatient and day-case surgery, the lengthy waiting times for routine outpatient appointments, the relative scarcity of beds and the relative difficulty in accessing operating theatres. Significant consultant expansion is a very necessary part of the solution also and more control needs to be

given to the specialty in terms of the consultant numbers required, where they are required and whether they are in sub-specialty areas or in general otolaryngology.

The specialty is very keen to establish an office base/hub in RCSI, managed by a full-time secretary/administrator. This office would take care of all matters concerning specialty training, the Irish Otolaryngological Society, the RAMI (ORL-HNS section), and professional issues relating to the Irish Institute of Otorhinolaryngology Head & Neck Surgery, RCSI, medical council, HSE and the media. The office would be able to pass any query on to the relevant representative of the specialty to be dealt with as a matter of urgency. I am happy to say that negotiations have reached an advanced stage.

WHY A CAREER IN OTOLARYNGOLOGY?Our specialty has a reputation for being a friendly and sociable one with most trainees and trainers having a very good relationship and a real sense of collegiality. The training is highly structured and accredited and there is ample opportunity to undertake high quality research here. It is highly likely that there will be a suitable consultant position for you in Ireland, on completion of your training, as there is expected to be significant consultant expansion here in the future. The diverse range of subspecialties within the specialty and the fact that most consultants work with both children and adults makes it very attractive. The on call is not particularly onerous. The specialty has also proved very popular with female trainees in recent years. If you are hard-working, ambitious, highly motivated and you would like a very fulfilling surgical career then you are very welcome to join us and pursue a career in our specialty. n


The specialty has some of the longest waiting lists in the country for patients with “routine”

ENT conditions awaiting outpatient

consultations.


SURGEONS SCOPE EXPLORES THE EXPERIENCES OF SURGEONS AROUND THE COUNTRY AS THEY DESCRIBE

THEIR WORK. WE TALK TO MR ZSOLT BODNAR, CONSULTANT LAPAROSCOPIC AND BARIATRIC SURGEON,

ABOUT HIS PROFESSIONAL LIFE IN DONEGAL ...

› I n t e r v i e w

solt Bodnar grew up in a small village in eastern Hungary called Korosszakal and now lives and works as a consultant general surgeon in Letterkenny University Hospital in Co Donegal. A laparoscopic, bariatric and upper gastro-intestinal specialist, Bodnar introduced the Metabolic Surgery programme in Donegal in 2016, and carried out the fi rst Metabolic Surgery Pilot Study (surgical treatment of Type 2 diabetes mellitus) in Ireland.

Bodnar founded and organised the fi rst Irish Metabolic Surgery Conference in 2017. Th e second will be held in April 2019 at RCSI.

Th e reasons for Bodnar’s move to Ireland in 2016 were both personal and professional. In 2015, while working in Spain, he brought his family for a holiday to Ireland, combining a visit to Dublin and RCSI to explore potential career opportunities, with a trip to the west coast. A number of years previously, one of Bodnar’s twin daughters had been diagnosed with upper respiratory problems which, aft er exhaustive testing, were attributed to an allergy to the olive tree. On the second day of the holiday in Ireland, Petra’s allergic symptoms seemed to vanish, and she could breathe without medication. He and his wife Edit, also a medic, were overjoyed

A surgeon in ... Donegal

“The change in climate and the environmental conditions here

were the solution.”

to witness the transformation. “Th e change in climate and the environmental conditions here were the solution,” says Bodnar.

Added to this was a compelling professional reason for considering a move to Ireland. Bodnar’s role

as Co-ordinator of Bariatric and Upper Gastro-Intestinal Surgery at Torrevieja University Hospital in Alicante (he was responsible for establishing a very busy bariatric unit) meant that every second patient he encountered seemed to be from the UK or Ireland. While bariatric surgery was predominantly being carried out on these patients for general lifestyle and cosmetic reasons as a means of promoting weight-loss and better cardiovascular and general health, Bodnar was convinced of the growing evidence that this

type of surgery improves Type 2 diabetes. “Given its role in metabolic regulation, the gastro-intestinal tract constitutes an obvious target to manage Type 2 diabetes.” With obesity and diabetes a worldwide problem, and acutely so in Ireland, he realised there was an opportunity here to improve the quality of life for overweight patients and those with Type 2 diabetes.

Following his appointment as a general surgeon to Letterkenny University Hospital in 2016, in May 2017, he and a multi-disciplinary team conducted the fi rst laparoscopic bariatric bypass on a diabetic patient. “For this patient, this was a life-changing intervention: she lost a signifi cant amount of weight, and could come off insulin and other medications. “Th e clinical outcome for the patient and for many since – excellent glycemic control and reduced cardiovascular risk – demonstrates the evidence to support inclusion of metabolic surgery amongst the anti-diabetes interventions for people with Type 2 diabetes and obesity. “Th e eff ects are rapid and long-lasting,” says Bodnar.

Th e clinic has been very successful but if there is one aspect that could be improved, says Bodnar, it would be to have greater access to theatre time. With his experience of three

“Given its role in metabolic regulation, the gastro-intestinal

tract constitutes an obvious target to manage Type 2

diabetes.”

28 / S U R G E O N S S C O P E

SURGEON’S FILEProfessor Zsolt Bodnar, MD, PhD,

FRCSI, FICS qualified as MD from

University of Debrecen, Hungary

and worked in the Kenezy University

Hospital, completing his specialist

traineeship National Board Exam

in General Surgery. ● In 2009 he

moved to Spain, and became

Coordinator of Bariatric and Upper-

GI Surgery in Torrevieja University

Hospital. ● He is Secretary of

WSACS (Abdominal Compartment

Society) and Associate Professor

of Maastricht University. ● He is a

specialist in laparoscopic surgery

(University of Strasbourg, 2011) and

bariatric surgery (SECO, Madrid).

● In 2015 he received the Special

Award of Professor Regoly-Merei

Foundation of Semmelweis

University Budapest, Hungary. ● He

is an Honorary Citizen in Hungary.

healthcare systems – Hungary, Spain and Ireland – he has observed that while junior doctors in the Irish system have excellent theoretical knowledge, they just do not get sufficient practice in theatre. In Hungary, he explains, intensive mentoring of young surgeons is the norm. “As a trainee, I would have performed appendectomies with the same experienced surgeon more than 200 times. He literally held my hand. Here, junior doctors move around in three to six month stints, where different surgeons might show them different solutions for the same problems but they gain expertise in none. This presents a big problem for those in training, not to mention the implications for patient outcomes.”

There is also a need for solutions in relation to his metabolic surgery clinic where patient waiting lists are long due to the lack of theatre access (Bodnar has just one main theatre list every second Monday and one day-surgery list every second

Downtime in Donegal: Zsolt Bodnar with an example of precision stone

balancing in Airds National Park.

Letterkenny Hospital, an acute and maternity campus, serves 150,000 patients in the Donegal region.

Monday alternating with the main theatre), but also long waiting lists for patients to see psychologists and endocrinologists. “In an ideal world, we should have a one-stop clinic where efficiencies for both patient and medic apply. One space where all the

appointments to see various specialties could be facilitated within a short timeframe. There is no reason why it can’t happen.” It is clear that efforts are required to fill and fund recruitment. The ongoing problem with availability of beds is also an issue.

Bodnar and his family live in a rural village not far from Letterkenny where the beautiful green landscape reminds him of his native Hungary – minus the harsh winters. He is clearly smitten with the setting, taking long walks, enjoying the peace. “I have received something back from my past, I find it all very familiar,” he says. ”We are very happy here.” A triathlete, he runs every evening in Glenveagh National Park. His other hobby is more esoteric. He practices stone-balancing. “It’s both an art and a discipline. It is a form of mindfulness, of total concentration. I feel it is of benefit to me as a surgeon – it involves well-planned small and gentle movements, each judged and tailored precisely.”

His wife Edit, formerly an emergency specialist, works as a GP locum, and daughters, Petra and Csenge, now fully adapted to the Irish school system, enjoy the outdoors, riding and walking the dog.

Following on the success of his first metabolic surgery conference in 2017, Bodnar is looking forward to the next. Due to be held in April at RCSI, he explains it is being convened to encourage and develop global discourse on the topic and to inform clinicians and policymakers about the benefits and limitations of metabolic surgery on patients with obesity and Type 2 diabetes. He is excited about the future:

“The main topic of this meeting is the metabolic surgery-related recent advances in Ireland. I would like to get closer to Irish bariatric surgeons. The meeting covers all aspects of the metabolic surgery (surgery of Type 2 diabetes, non-alcohol related fatty liver disease, polycystic ovary syndrome, obesity and cancer, perioperative care) that is why it is open to NCHDs and aligned specialists as well. There will be a “Court in Theatre” session and a one-day laparoscopic training centre. Among other expert speakers, Professor Prager from Vienna (President of IFSO), Professor Torres from Madrid (Past President of IFSO) and Mr Khammas from Dubai (President of Emirates Society of Metabolic Surgery) will be attending. Everybody is very welcome!” ^

› I n t e r v i e w

“... we should have a one-stop clinic where efficiencies for both patient and medic

apply ... where all the appointments to see

various specialties could be facilitated within a

short timeframe.”


› E v e n t s

Scope

eventsCONFERRINGS, CHAPTER MEETINGS AND LECTURES

DUBLIN CONFERRINGS

More than 100 Fellows and Members were conferred in July at RCSI Dublin. In surgery, the awards conferred included Fellowships of

RCSI in General Surgery; Neurosurgery; Ophthalmology; Otolaryngology; Plastic Surgery; Trauma and Orthopaedic

Surgery; Urology; Vascular Surgery; and Fellowships Ad Eundem. Memberships of RCSI, including Memberships in ENT and

Ophthalmology, and Diplomas in Otolaryngology – Head & Neck Surgery, were also awarded. The recipients of Honorary Fellowships

in Dublin in July were: Dr Barbara Lee Bass, President of the American College of Surgeons and John F and Carolyn Bookout

Distinguished Chair of Surgery at Houston Methodist Hospital, Texas, USA; Professor Frank A Frizelle, Head of Department of Surgery at the University of Otago, New Zealand; and Professor Gerard M

O’Donoghue, Department of Otolaryngology and NIHR Biomedical Research Centre, Queen’s Medical Centre, Nottingham, UK.

.

Ms Camilla Carroll, RCSI Council Member; Professor Gerard O’Donoghue, RCSI Honorary Fellowship recipient, and Professor Laura Viani, RCSI Council Member

Dr Joanne Devlin, Dr Adam Bjourson and Dr Daryl Blades

Dr Khan and family

Professor Eilis McGovern, Past-President of RCSI and Dr Barbara Lee Bass, President of the American College of Surgeons and RCSI Honorary Fellowship recipient

Dr Aijaz Ali Shaikh, Dr Ciaran Stanley and Dr Michael Kelly

Professor Gerard O’Donoghue, RCSI Honorary Fellowship recipient, and RCSI President Mr Kenneth Mealy

Dr Lorraine Scanlon and Dr Michael Devine

Ms Caroline Baily and Ms Evelyn O’Neill

Ms Louise McLoughlin, Mr Kieran Breen and Ms Anna Lucy Walsh

30

MILLIN MEETINGThe 41st RCSI Millin Meeting took place in

November and this year, the theme of the Meeting was ‘The Shape of Surgery 2030’. This annual surgical meeting is held every November in

memory of Terence Millin, a famous President of RCSI in the 20th century. Some of the most challenging contemporary issues facing Irish

surgeons and trainees are explored through a series of presentations throughout the day followed by the Millin Lecture. On this occasion, sessions included ‘Defining Competence for the Future Surgeon’ and

the 26th Carmichael Lecture, delivered by Caitriona Perry and the 41st Millin Lecture by

Mr Padhraig F O’Loughlin.

› E v e n t s

Professor Austin Leahy, Ms Ailin Rogers and Professor Seán Tierney

Mr Kenneth Mealy, President, RCSI, Caitriona Perry and Professor Ronan

O’Connell, Vice-President, RCSI

Professor Dubhfeasa Slattery, Mr Kenneth Mealy, President RCSI and Professor Oscar Traynor

Mr Peter Lonergan and Dr Aoife Kiernan

Dr Jessica Ryan and Dr Arielle CoomaraDr Daniel Ahern and Dr Kin Cheung Ng

Mr Padhraig F O’Loughlin

Mr Peter Naughton and Gemma Salon

Dr Syed Noor Hassain Shah, MrZeeshan Razzaq, Dr Shar Jeel Hussain Paul and Dr Muhammad Akif


› E v e n t s

Professor Carol S Dweck

Dr Gozie Offiah, Ibukun Oyedelle, and Ebun Josephs

Dr Crona Gallagher, Ms Margaret O’Donnell, Mr Brian Kneafsey, Dr Ingrid Browne

Professor Carol S Dweck

Emily Boylet and Dr Juliah Tbarani O’Shea

FOLEY LECTURERCSI welcomed Professor Carol S Dweck, Stanford University Psychology Professor

and author of the bestselling Mindset, to deliver the third Foley Lecture in

September this year. Professor Dweck, world-renowned

pioneer of the ‘growth mindset’, explained to a packed auditorium how a growth

mindset is crucial for all education, and focused on its application for the

education of medical and other healthcare professionals in her talk: ‘Medical Minds:

Growth for Healthcare Professionals’. The RCSI Foley Lecture is a biannual lecture supported by a bequest from Dr Michael Foley, an RCSI graduate of the Class of 1950. Its purpose is to feature eminent individuals globally renowned as educators, leaders and pioneers to enrich RCSI’s extensive

community of healthcare professionals.

Mark Millett and Professor Mary Aiken

Emily Grennan, James Duncan and Joshua Lavelle

32

› E v e n t s

NORTH AMERICAN CHAPTER OF FELLOWS

The Chapter of Fellows Meeting is an annual event which takes place in conjunction with the American College of Surgeons (ACS) Clinical

Congress.The purpose of the event is to promote and foster relationships between the College

and its Fellows, Members and alumni in North America. These meetings provide social and

professional networking opportunities as well as an opportunity to strengthen ties with RCSI.

More than 50 Fellows, Members and alumni attended an evening reception in October at the Seaport Hotel in Boston. This annual reception

was held as part of the American College of Surgeons Congress, and we were delighted to welcome Vice Consul Aoife Budd, along with

guests from both sides of the Atlantic.

Dr Margaret Nicholson and Mr Matthew Murphy

Dr Ranjit and Gillian Baboolal

Dr Wissam Raad, Dr Mohammed Al-Zoubaidi and Dr Nicolas Mouawad

Professor William Joyce, Jacqueline Joyce and Mr Michael Sugrue

Dr Trevor McGill and Professor Thomas Walsh

Dr Christina Whyte, Ms Camilla Carroll and Dr Fletcher Starnes

Mr Fergal Fleming, Ms Natasha O’Malley and Dr Charles McAllister

Dr Ian Maxwell, Dr Richard Tanner, Dr Emer O’Connell and Margaret Maxwell

Dr Are Chandrakanth and Mr Oduche Onwuanyi

Mr Anthony Charles and Dr Robert Gallagher

Professor Laura Viani, Professor Deborah McNamara, Dr Emer O’Connell, Professor Cliona O’Farrelly

Professor Cliona O’Farrelly, Professor Conor Delaney, Clare Delaney, Aoife Budd and Dr Trevor McGill

ASSOCIATION OF WOMEN SURGEONS (AWS) MEETING

In July this year, the Association of Women Surgeons (AWS) was warmly welcomed to Dublin for the first

Women in Surgery meeting to be held in Ireland. The meeting focused on the experience and evolution

of gender equality in surgery in the United States, Ireland and Africa, and addressed issues including

flexible working, burnout and resilience and the role of mentorship. The AWS held the first meeting in the

United States in 1981 and now has 2,000 members across 21 countries.

REGIONAL EVENTS DECEMBER 2018 Monday 10 RCSI Fellows, Members and Diplomates Conferring Ceremony, RCSI, Dublin

FEBRUARY 2019 Tuesday 5 - Saturday 9 Charter Day 2019, RCSI Dublin Wednesday 6 Emily Winifred Dickson Award: Mary Robinson, RCSI, Dublin

FEBRUARY – MARCH 2019 Thursday 28 February - Saturday 2 March 26th Sylvester O’Halloran Perioperative Symposium, Graduate Entry Medical School, University of Limerick

MARCH 2019 Wednesday 27 RCSI Fellows and Members Regional Meeting, Sligo

JULY 2019 Tuesday 9 RCSI Fellows, Members and Diplomates Conferring Ceremony, RCSI, Dublin

NOVEMBER 2019 Thursday 21 RCSI Fellows and Members Regional Meeting, Limerick

GLOBAL EVENTS DECEMBER 2018 Sunday 2 RCSI Fellows, Members and Diplomates Conferring Ceremony, Penang Medical College, Malaysia Friday 7 - Sunday 9 25th Anniversary Congress of the Hong Kong Academy of Medicine, Hong Kong

FEBRUARY 2019 Friday 15 Alumni, Fellows and Members Reception, House of Lords, London, UK

APRIL 2019 Friday 12 RCSI Reception, The University Club of Toronto, 380 University Avenue, Toronto, Canada Sunday 14 RCSI Reception, Hampshire House, 84 Beacon Street, Boston, USA

OCTOBER 2019 Monday 28 RCSI North American Chapter of Fellows, ACS Reception, San Francisco, USA

Scope

Dates for your diary

Mr Kenneth Mealy, President, RCSI, with meeting attendees

Dr Avril Hutch, Head of Equality, Diversity and Inclusion, RCSI

Ms Camilla Carroll

Mr Kenneth Mealy

Dr Patricia Numann, Professor Eilis McGovern, Past-President RCSI, Mr Kenneth Mealy, President, RCSI, and Dr Barbara Lee Bass

RCSI’s Court of Examiners was established in 2014 to acknowledge the essential contribution made by our Examiners to Fellowship and Membership examinations.

We are currently inviting applications from College Fellows who wish to become Court Members and examine in the MRCS and/ or FRCS. Membership of the Court allows our Fellows to: › Contribute to the assessment of junior colleagues› Obtain PCS Credits› Participate in Annual Meetings / Postgraduate Conferrings› Network with colleagues› Examine in Overseas Centres

SUPPORT OUR DRIVE FOR EXCELLENCE IN ASSESSMENT

To find out more about becoming a Court Member, please contact us at [email protected] rcsi.ie/coe S U R G E O N S S C O P E / 33

ISSUE 2 2018











Documents

NEW TECH IN ORTHOPAEDIC SURGERY · The impact of the ten-year-old partnership between RCSI and the College of Surgeons of East, Central and Southern Africa (COSECSA), which you will