The Norfolk & Norwich Oesophagogastric Cancer Centre Fellowship
Introduction
The Norfolk & Norwich University Hospital Foundation Trust (NNUH) serves a catchment area population of 1.3 million. It is one of the main tertiary oesophagogastric (OG) referral units within the East of England and provides this service to a number of smaller units around the region.
There are currently 5 Consultant Oesophagogastric Surgeons (Mr Bhaskar Kumar ( OG Cancer lead), Mr Mike Lewis, Ms Loveena Sreedharan, Mr Nick Penney, Mr Suheelan Kulasegaran) and one hepato-biliary surgeon (Mr.Simon Wemyss-Holden).
On average the unit performs 70-80 oesophagogastric cancer operations per year. All surgical results are submitted to the National Oesophagogastric Cancer Audit (NOGCA) and we have consistently demonstrated excellent surgical outcomes with the shortest length of stay in the UK, well below the national average.
Ivor Lewis oesophagectomies are carried out as both 2 stage Minimally Invasive Oesophagectomies or Hybrid (Lap assisted) operations. In addition we perform 3 stage McKewon oesophagectomies for proximal cancers. We have a close working relationship with excellent thoracic as well as head & neck surgeons with whom we perform combined complex resectional operations such as colonic conduits and sub-sternal gastric conduits. The unit has a national & international reputation for excellence within minimally invasive cancer surgery and has hosted visitors from European centres such as Utrecht medical centre, Netherlands. Mr. Bhaskar Kumar is the oesophagogastric cancer lead and has been instrumental in driving the minimally invasive surgery and research within the department. We have had an overseas fellow on a number of occasions and are well versed to accommodating their training needs. We will soon establish a training syllabus for the fellow which will allow exposure to the range of surgical pathologies relevant to specialist training in OG surgery.
The unit is supported by excellent Upper GI cancer nurse specialists as well as administration staff within the Multidisciplinary team. There are also two full time Upper GI dieticians to support both in and out patients. We also have the support of an excellent oncology team who not only deliver neoadjuvant chemotherapy but also neoadjuvant and radical chemoradiotherapy.
All cancer resectional patients are discussed in detail in the weekly Oesophagogastric Multi-disciplinary meeting (MDT) where the fellow will have an opportunity to present the case and take part in subsequent discussions. The MDT is a regional meeting in which live link transmission is gained to peripheral hospitals for case discussion.
Benign Oesophagogastric & Hepato-biliary surgery
Anti-reflux procedures and giant paraoesophageal hiatal hernia surgical operations are performed laparoscopically. Anti-reflux operations include laparoscopic Nissen as well as partial anterior fundoplications. We receive and perform a large number of laparoscopic repairs of complex paraoesophageal as well as diaphragmatic herniae. Fellows will be trained in performing both intra-corporeal as well as extra-corporeal suturing and knotting techniques.
Approximately 600 laparoscopic cholecystectomies are performed annually at NNUH. In more recent months we have commenced a regular emergency ‘hot gallbladder’ list as well as a laparoscopic common bile duct exploration service. More advanced biliary techniques are also being developed such as the use of laparoscopic ultrasound for cholecystectomies and liver surgery. There will be ample learning opportunities for all of these techniques. We also perform a number of laparoscopic hernia repairs and offer both TAPP as well as TEPP repair and lap incisional hernia repair. Bariatric operations are not performed at the NNUH and are restricted to the regional bariatric unit at the Luton & Dunstable (LDH) teaching hospitals trust. If a fellow wishes to obtain limited exposure to bariatric surgery it may be possible to organise a module in liaison with LDH.
As a tertiary referral centre NNUH receives a number of Boerhaave’s and oesophageal perforations and emergencies. We provide a 1:4 oesophageal on call and the fellow is welcome to join any such cases that require intervention. Other oesophagogastric emergencies range from complex upper GI bleeding cases to strangulated paraoesophageal hernias and endoscopic perforations.
Interventional Endoscopy
A number of advanced interventional endoscopic procedures are performed by the OG team. There is a strong emphasis and culture that trainees should be well trained in performing both diagnostic as well as therapeutic endoscopy. The endoscopy suite has full JAG accreditation as a training centre and has 5 rooms with state of the art High definition monitors. In 2019 the endoscopy department will be based at the Gut Institute at the Quadram centre and is set to be the largest endoscopy suite within Europe. There are dedicated gastroscopes available for intra-operative use within the theatre complex and these are used in conjunction with wireless HD monitors. The medical gastroenterology team provide a consultant led 24:7 endoscopic intervention on call service and the fellow would be able to gain exposure to this if considered desirable. We have access to an excellent interventional radiology service on site which also provide a 24/7 on call service.
The fellow will have an opportunity to learn and perform Endoscopic mucosal resection (EMR) as well as the more commonly performed procedure such as endoscopic balloon dilatation and enteric feeding tube insertion and balloon dilatation. We have a Barrett’s surveillance programme which is currently led by the OG surgical consultants.
Other interventional endoscopic procedures which may be of interest to the fellow include Percutaneous Feeding Gastrostomy (PEG) as well as Endoscopic Ultrasound (EUS) and EUS guided hepato-biliary interventions such as endoscopic cystgastrostomy. Fellows will also have the opportunities to work with the Thoracic team to acquire skills in minimally invasive thoracic surgery and flexible bronchoscopy. The respiratory team perform weekly Endoscopic Bronchial Ultrasound (EBUS) and are happy to accommodate the surgical fellow to gain exposure to this.
General Surgery Exposure
The NNUH has a very large and active general surgery department. Our colorectal department has the largest case volume for major open and laparoscopic colorectal resections in the UK. The department offers a wide range of laparoscopic and open general surgical procedures including lap incisional and TEPP/TAPP hernia repair. We also provide a regular emergency gallbladder service which is led by the upper GI team.
The fellow is encouraged to concentrate on OG and Upper GI surgery as much as possible and is exempt from general surgery on call commitments. However, should the fellow wish to participate in some general surgery on call then this can be incorporated into the schedule after discussion with the educational supervisor. Other surgical specialities on site include thoracic surgery, vascular and endovascular surgery, paediatric surgery all but to name a few.
Research
There is a strong culture of research within the unit and is led by Professor Andy Hart based at the NNUH and the University of East Anglia (UEA). There are currently two national trials we are leading on: STAT-ROC is a RCT looking at Statins in the Prevention of recurrence of oesophageal cancer post oesophagectomy as well as EXPO (EXercise in Preparation for Oesophagectomy). We are also contributors to national studies such as OCCAMS.
A number of other individual research projects are also available which are discussed at the monthly GI research team meeting. The fellow will be encouraged to participate and contribute towards one of the research projects.
Teaching & Education Facilities
There is in house weekly teaching attended by the OG unit on a variety of OG topics as well as a weekly journal club. The fellow will be encouraged to participate in these activities.
We run cadaveric teaching at the University of East Anglia and are in the process of setting up an upper GI module. The fellow will gain opportunities to participate in this either as a participant or to teach depending on their level of expertise. Mr Bhaskar Kumar is the Royal College of Surgeons tutor for the hospital and would be happy to support any surgical training interests the fellow wishes to develop. The department accommodates 8 specialist general surgical trainees of which two are placed within the OG department.
Further Information
For further enquires please contact Mr Kumar ([email protected]).