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CANAD IAN CANAD IAN CANAD IAN CANAD IAN CANAD IAN AS SOC IAAS SOC IAAS SOC IAAS SOC IAAS SOC IAT IONT IONT IONT IONT IONOF GENERAL SURGEONSOF GENERAL SURGEONSOF GENERAL SURGEONSOF GENERAL SURGEONSOF GENERAL SURGEONS

General Surgery Matters

774 Echo Drive

Ottawa, ON K1S 5N8

Phone: 613-730-6280

Fax: 613-730-1116

E-mail: [email protected]

INSIDE:

President’s Messagecontinued ......................... 2

CSF 2009 ...................... 3-6

Research Summary ......... 8

Canadian SurgicalResearch Fund ................ 9

Research Summary ...... 10

Development andValidation of the Goals-IHModule ........................... 11

AMAZING SurgeryStories ....................... 12-13

MSF in Kabul,Afghanistan ............. 13-14

CAGS-GuyanaCollaboration ......... 16-17

WINTER 2010

CAGS: Your Association and Your Advocate

Continued on page 2

President’s Message

CAGS was established in 1977to promote the specialty ofGeneral Surgery in Canada.The Association continues tobe the voice of the specialtyacross Canada, with one ofthe declared objectives beingto effectively advocate allissues related to GeneralSurgery.

I should like to report, andcomment, on a membershipsurvey conducted earlier thisyear to study the needs of themembers. It was clear thatmany wish CAGS to do morein its role as an advocate.Specifically, many members feltthat we have a role to ensurebetter recognition of thespecialty, and to build thevisibility of General Surgery inthe eyes of the public. Ageneral surgeon is often thebest advocate for the patientin a situation of limitedhospital resources. Generalhospitals cannot functionwithout general surgeons, andmany members felt thatsurgeons deservedappropriate remuneration fortheir essential role. Membersalso have concerns abouttheir access to hospitalresources. A common viewexpressed was that CAGS isseen by many members as thevoice of the universitysurgeon, and that it should

involve more communitysurgeons in political decisions.It was suggested that in oureducational role we shouldemphasize the training of abroad based general surgeonto serve peripheral and ruralcommunities.I feel strongly that CAGS mustadvocate on behalf of thepatient and the surgeon. Weshould speak out for ourpatients to ensure that theyget the best surgical care, andshould address issues such aswaiting times and access tosurgical care. We should bean advocate for surgeons,addressing issues such asremuneration and quality of

life. It is perceived bymembers that work hours areexcessive and in particular,that on-call demands aregreater than those faced bymost other specialties. Wemust advocate for the bestpossible delivery of care, andbe involved in the debateregarding regionalization ofhospitals, and how to providegood surgical care to patientsin rural communities.Coverage for acute surgicalcare will continue to be anissue.

There is increasing concernamongst members as to whowill provide general surgery

Dr. Chris Jamieson and Dr. Christopher M. Schlachta

GENERAL SURGERY MATTERS

Continued from page 1

CAGS: Your Association and Your Advocate cont’d

care if the future generation isless willing to work theexcessive and long hours ofthe previous generation; this iscompounded with morewomen in general surgerywho have other commitmentsin their lives, and who may notbe able to devote long hoursto clinical work. Another wellrecognized demographicchange is the aging surgeonwho will have to look after anaging population; a shortage ofgeneral surgeons in the futureis inevitable, with more than40% of general surgeonscurrently over the age of 55.In addition, there are fewerapplications for training ingeneral surgery, and aninadequate number ofresidency positions in generalsurgery.

Among the political issues thatwe are facing are the newintraprovincial licensing issuesthat would permit easiermigration of surgeons aroundthe country, and the proposalin Ontario that surgeonsshould be compelled to reporttheir HIV and hepatitisserostatus.

Many members might perceivethat CAGS has not been aseffective as it should inpolitical advocacy. However,there are a number ofexamples where CAGS has

been effective, and one suchexample is the role CAGSplayed in ensuring that generalsurgeons have access to G.I.endoscopy in hospitals.Certainly, the Board has haddifficulty identifying surgeonswho will represent theirprovince on the Board, andsome provinces do not haveactive provincial generalsurgical societies. Manypolitical issues in generalsurgery are furthercomplicated by the fact thatwe are a national societywhereas healthcare isdelivered according toprovincial rules withprovincial allocation ofresources.

So how can CAGS providebetter advocacy for ourpatients and our surgeons?First, we must define nationalissues upon which we shouldfocus our efforts. We mustnot be seen to be self-servingand will only be credible if ourmotive is seen as thepromotion of better patientcare. We are not in a positionto pay lobbyists. The mosteffective route of advocacy isto work through the CanadianMedical Association, where weare represented on theSpecialists’ Forum, whichrepresents national specialtyorganizations in Canada.CAGS has a seat on theGeneral Council of the CMA.

We should work with otherspecialty societies that havesimilar issues, examples ofwhich are the Wait TimeAlliance and the PartnershipAgainst Cancer in whichCAGS is collaborating withother specialty organizations.In addition, we shouldpublicize the life of a generalsurgeon and educate thepublic on what we do.

The CAGS Political ActionCommittee is chaired by thePresident-Elect Susan Reid([email protected]), and wewish to encourage provincialparticipation. Susan wouldbe pleased to hear frommembers with suggestions asto the issues that should beaddressed by this committee,and ideas as to how we caneffectively deal with suchissues.

The declared vision of CAGSis to ‘be the voice of thespecialty of General Surgeryin Canada’. It is mostimportant that we involve theentire community ofsurgeons from across allprovinces, in large and smallcommunities, academic andrural; and to identify andaddress the concerns wehave in common across thecountry.

Chris JamiesonPresident, CAGS

The Canadian Association of General Surgeons gratefullyacknowledges the support of this newsletter’s production by Covidien

and Ethicon Endo-Surgery Division of Johnson and Johnson.

WINTER 2010

Canadian Surgery FORUM 2009CSF Presidents’ Dinner

Continued on page 4

Canadian Surgery

canadien de chirurgie

Dr. Roger Keith, Dr. Frank Turner, Dr. Bill Mackie, Dr. Bill Pollett, Dr. Gerry Fried,Dr. Paul Belliveau, Dr. William Fitzgerald, Dr. Christopher Jamieson, Dr. ChristopherSchlachta, and Dr. René Lafrèniere Dr. Paul Belliveau and Dr. William

Fitzgerald

Dr. Bill Pollett, Mrs. George, and Dr. Ralph GeorgeDr. Sean Cleary, Dr. Ellesmere, and Dr. Pitt

Mr. Matt Horne and Mr. Mark ViminitzDr. Liane Feldman, Dr. Simon Bergman, Dr. Shannon Fraser, Dr. JonathanSpicer, Dr. Paola Fata, and Dr. Jeremy Gruschka.


Canadian Surgery FORUM 2009 cont’d Continued from page 3

Industry Partners

Canadian Surgery

canadien de chirurgie

Dr. Christopher Schlachta and Dr. Jim Watters

Winners of the CAGS/Covidien Resident Teaching Award Dr. Christopher Schlachta and Covidienrepresentative Ms. Maisie Cheung

Dr. Christopher Schlachta and Covidienrepresentatives

Dr. Christopher Schlachta and Ethicon representatives

Dr. Christopher Schlachta and Karl Storz representatives

WINTER 2010

Canadian Surgery FORUM 2009 cont’d Continued from page 4

The first annual CAGS ResidentLaparoscopic Suturing competitionwas a big success in generatingenthusiasm for simulation,laparoscopic skills, and the CanadianSurgery Forum. In all, 10 residentscompeted in the qualifying round atthe Canadian Surgery Forum inVictoria. This was a very skillful andenthusiastic group (not to mentionbrave) and included (from East toWest): Drs. Rene Boisvert(Dalhousie), Raad Fayez (McGillUniversity), Suleena Duhaime(University of Ottawa), VladislavKhokhotva (Queens University),Shady Ashamalla (University ofToronto), Joey McDonald (McMasterUniversity), Vipan Jain (UWO), RamziHelewa (University of Manitoba),Andrey Vizhul (University of Alberta)and Andrea MacNeill (UBC).

The task was performed in the FLStrainer box and required the

participants to place three suturesand tie each with an intracorporealsquare knot. The qualifying roundwas friendly but the competition wasfierce, with Chris Schlachta acting asa very exacting judge and makingsure no errors were made. The topsix times were very close to oneanother, but only four could advanceto the semis (Andrea MacNeill, RamziHelewa, Vipan Jain and ReneBoisvert). Two finalists advanced -Vipan Jain with a time of 2 minutes43 seconds and Rene Boisvert with atime of 2 minutes 28 seconds. Thefinal round was held at the openingof the exhibits and turnout to watchthe finals on two large screens wasexcellent. Although both finalistsperformed admirably in front of alarge and occasionally boisterousaudience, Rene Boisvert was thewinner and took home the trophy.His name will be engraved on a

trophy that will be seen again nextyear for the second edition of thecontest in Quebec.

Thanks to all the programs whoparticipated by supporting theirresidents to come to the CSF and tothe local surgeons who organizedthe local rounds. Feedback was verypositive in regards to the way thesuturing competition encouragedand promoted the use of simulationand curricula such as FLS toimprove surgical skills. Thanks alsoto our corporate partners (Ethicon,Olympus, Storz and Stryker) whosesupport enabled the use of the largemonitors for the finals, as well as thepurchase of the trophies and bookprizes for all the participants. Seeyou again next year!

Liane Feldman, ChairEndoscopy and Laparoscopy

Committee

National Laparoscopic Suturing Competition

Honourary Members2009

Dr. Christopher Schlachta, Dr. Frank Turner, and Dr. BillMackie

Dr. John MacFarlane , Dr. Nis Schmidt, and Dr. ChristopherSchlachta

Dr. Christopher Schlachta, Dr. Con Rusnak, and Dr. RenéLafrèniere


Cancer metastasis is a multi-step process that is responsiblefor most cancer deaths inhumans. After systemicdissemination from primarytumors, circulating cancer cellsmust first adhere to the hepaticendothelium against a constantflow in the circulation in orderto establish liver metastasis.Emerging evidence suggests thatresection of malignant tumorsincreases circulating cancercells. If the adhesion of thesecirculating cancer cells can beselectively blocked by a givenbiologic agent preventativetreatment of cancer metastasis,especially peri-operatively, maybecome an option for cancerpatients to reduce the morbidityand mortality of cancer.

2009 CSF

webcast

Molecular mechanism of the CEACAM family genes in cancer metastasisCarcinoembryonic antigen (CEAor CEACAM5) discovered atour institution by Dr. Phil Goldhas been widely used as clinicaltumor marker since 1960. Mostclinicians think that CEA is onlya biomarker for cancerprogression. However, there areearly in vitro data suggesting thatCEA is more than a biomarker,but a direct mediator ofcancer metastasis. In addition,some clinical and experimentalevidences suggest that otherCEA-related cell adhesionmolecules, CEACAM1 andCEACAM6, are involved incancer progression.

Combination of the metastaticeffect of elevated CEACAM5level and the increase ofcirculating cancer cells during

resection of malignant tumorsis potentially a fertile groundfor the development of cancermetastases. In this project, weaim to demonstrate definitivelyCEACAM5 is an importantmolecule mediating metastasisin vivo and to dissect the exactmolecular mechanism involvedduring this process. We willalso explore the role of otherCEACAM molecules in livermetastasis. This project willprovide sufficient basis forfuture development ofCEACAM-based targetedtherapies against cancermetastasis.

Carlos HF Chan, MD, PhDGeneral Surgery PGY3

Post-doctoral Research FellowDepartment of Surgery

McGill University

Selected sessions from the CanadianSurgery Forum, held September 10-13,2009 in Victoria, are now online via theCanadian Surgery Forum Live LearningCentre! View sessions you missed during this year’saction-packed conference, or favoritesessions for the second time, including theOpening Plenary Session and all FeatureLectures. If you were unable to attend theconference, find out what the CanadianSurgery Forum is all about! The CAGS/TAC Postgraduate Course:Catastrophe Surgery for Victims of Disaster,Terrorism or War is available at a cost of$50 CAD. Attendees of this course willreceive information to login and access theinformation free of charge. All othersessions audio-recorded are available freeof charge for this second year, twenty-fourhours of content is presented in audio

Earn MOC credits via the 2009 CSF webcast!format synchronized to PowerPointslides. This content may be used forMaintenance of Certification credits. The 2009 Canadian Surgery Forum is just a click away atwww.softconference.com/csf/ Follow these easy instructions to accessthese free sessions:1) Once on the main page of the LiveLearning Centre, click on the “EducationalContent” Tab2) Select “Click here for content from theMeeting” link in the Canadian SurgeryForum 2009 Event3) Select your session of choice, and clickthe “View” button to begin We hope to see you at next year’sCanadian Surgery Forum, September 2-5,2010 in beautiful Québec City, QC! Inthe meantime, enjoy this educationalcontent from the 2009 Forum.

2009CSRFAward

2009CSRFAward

WINTER 2010


Congenital diaphragmatic hernia(CDH) affects approximately 1 in2200 total births, includingstillbirths. Despite advances inneonatal care, the mortality rateof isolated CDH remains 20 to40%. Furthermore, high-riskneonates with CDH mayexperience mortality ratesexceeding 50%. CDH isassociated with lung hypoplasia,pulmonary hypertension andsurfactant deficiency, all of whichcontribute to the acuterespiratory insufficiency observedin these neonates. Currently,most infants with CDH aremanaged with postnatal intensivecare therapy followed by delayedrepair of the defect, but prenatal

The Effect of Invitro Tracheal Occlusion on Branching Morphogenesis in FetalLung Explants from the Rat Nitrofen Model of Cngenital Diaphragmatic Hernia

Principal Applicant: Jeremy Grushka1 MDPrincipal Supervisor: Jean-Martin Laberge1, 2 MD,

Co-Supervisors: Pramod Puligandla 1, 2 MD, Feige Kaplan PhD 3

1) General Pediatric Surgery Division, Montreal Children’s Hospital, Montreal, Quebec, Canada (2) Research Institute ofMontreal Children’s Hospital, Pediatrics Department, McGill University, Montreal, Quebec, Canada (3) Department of HumanGenetics, Pavillon Stewart (biology), McGill University, Montreal, Quebec, Canada

intervention is being investigatedas a tool to improve the fate ofhigh-risk fetuses.

The concept of fetal trachealocclusion (TO) to reverse lunghypoplasia was introduced inthe early 1990’s as a potential inutero treatment for high-riskCDH. TO in utero has beenshown to accelerate lung growthand improve postnatalpulmonary function andcompliance in animal models. Itis unclear, however, whether TOstimulates mature lung growthor induces alveolarizationwithout concomitant bronchialdevelopment. This distinction hasimportant clinical ramifications,

since increased alveolarizationmay not be sufficient to restorenormal lung function.

We are currently studying lungbranching morphogenesis in anestablished, nitrofen-induced ratmodel of CDH. The aim of ourresearch is to assess the abilityof TO to promote bronchialbranching in control andnitrofen-exposed fetal rat lungexplants. In addition, we plan tostudy the effect of TO on globalgene expression in the nitrofenrat model, with the goal ofelucidating the moleculardeterminants of impaired airwaybranching in this model.

We would like to extend a warm welcome tothe 2009-2010 CAGS Executive:

PresidentDr. Christopher Jamieson President ElectDr. Susan Reid

President Elect SecundusDr. Ralph George

Past PresidentDr. Christopher Schlachta

TreasurerDr. Dave Olson

2009-2010 CAGS ExecutiveSecretaryDr. Don Buie

Thank you to our outgoing Executive BoardMembers: Dr. René Lafrenière, Past President,and Dr. Jim Watters, Secretary. We wouldalso like to welcome Dr. Paolo Fata who hasjoined the Board as Chair of thePostgraduate Education Committee. Allother members of the Board have kindlyagreed to continue serving for an additionalyear so that the governance review canmove forward.

WINTER 2010


PAGE 10

Development and Validation of the Goals-IH Module to Assess Performance ofLaparoscopc Incisional Hernia Repair

The laparoscopic approach is avaluable option in the managementof incisional hernias but has aspecific learning curve. Therecurrence rate is higher whensurgeons are less experienced andtechnically less proficient. Inaddition, the risk of enterotomy, withpotentially catastrophic outcomes, isprobably related to the learningcurve. Our previous work supportsthe role for simulation as an effectiveway to teach fundamental surgicalskills to novices and accelerate thelearning curve. However, the role ofsimulation in training moreexperienced surgeons for morecomplex minimally invasiveprocedures, such as laparoscopicincisional hernia repair , is notknown.

In order to assess whether skillslearned in a laparoscopic incisionalhernia simulator transfer to theoperating room, a method forobjective assessment of surgicalperformance, both in the simulatorand in the operating room, is firstrequired. We previously developedand validated the Global OperativeAssessment of Laparoscopic Skills

(GOALS) for assessment ofgeneric laparoscopicperformance.

The objective of the currentresearch is to develop aninstrument specific forperformance of laparoscopicincisional hernia repair(GOALS-IH Module) andvalidate its measurementproperties. This global ratingscale evaluates the technicaland cognitive competenciesrequired for effective and safelaparoscopic incisional herniarepair. To assess itsmeasurement properties, 30PGY 3 to 5 general surgeryresidents (intermediateexperienced group) andattending staff/MIS fellowsurgeons (experienced group)will be evaluated by attendingsurgeons, trained observersand self-assessmentintraoperatively and in ahernia repair simulator. Inter-rater reliability and internalconsistency will be assessedwith intraclass correlationcoefficients (ICC) and

Cronbach’s alpha respectively.Construct validity will beassessed in three ways:

(1) by comparing mean scoresfor the two experiencelevels in the operating roomand the simulator (knowngroups validity);

(2) by tracking improvement inperformance for lessexperienced surgeonsduring simulator practice (longitudinal validity); and

(3) by comparing scores on theGOALS-IH module withthose obtained usinggeneric GOALS and avisual analog scale assessingoverall competence(convergent validity).

We believe that thedevelopment of an objectivemeasure of operativeperformance will have asignificant impact on residenteducation by providingformative feedback and will bevaluable for the assessment oftechnical competence.

Dr. Liane Feldman

SurgicalHeights

That’s exactly what Paul Hardy, generalsurgeon from Red Deer, has done. Bycompiling many years of cases and combiningthem into a fiction, the result is the soon to

Have you ever thought your best (and worst) cases should be written down?be released novel, Surgical Heights. If you areinterested in this project of one of yoursurgical colleagues, please visit his website atwww.surgicalheights.com

WINTER 2010

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PAGE 12

By Scott Felker

It started with a seeminglybenign case of Chicken Pox forfive-year-old Carolyn. She had arelatively mild case with fewerspots than her older sister butwas sicker and very lethargic.Christie, her older sisterrecovered quickly and was noworse for wear. Carolyncontinued to “fail”; the onlyword that accurately describedher decline. A mother’s intuitiontold Lynn that it was somethingmuch more serious. She andCarolyn made several trips tothe emergency department ofthe local Pediatric Hospital.During one of the initial trips, alarge mass was detected on theleft side of Carolyn’s abdomen,which was interpreted to beSplenomegaly. We were assuredthat this was a knowncomplication associated withChicken Pox and that it wouldresolve itself over time. Butthings continued to declinerapidly; to the point whereCarolyn needed to be carried upand down stairs. She had noappetite and was completelyinactive. Finally, during thefourth visit to Emergency in asmany weeks and no sign of theSplenomegaly resolving itself, itwas decided to do an ultra-sound. By the tech’s response tothe images, and by her questionsas to which “surgeon” hadrequested the ultra-sound, it wasclear to me that surgery wasrequired. (The EmergencyDoctor had a name very similarto one of the surgeons at thehospital) As Lynn hadsuspected, things were veryserious, but we had no idea howserious and we wouldn’t knowfor about another 12 hours.

AMAZING Surgery Stories

Carolyn’s StoryWhat followed was a parent’snightmare.

• Approximately 12 hoursfollowing an abrupt admissionto the hospital, we sat downwith a several doctors todiscuss the urgent need forsurgery because of Wilm’sTumor. It was during thismidnight meeting we learnedthat Wilm’s Tumor is Cancer.

• Surgery to remove Carolyn’sleft kidney, stage the diseaseand place a port for chemohappened withinapproximately 36 hours.

• Three to four days later abowel intussusceptionoccurred requiring a secondsurgery to correct it.Immediately before this surgery,Carolyn asked me, a littlefearfully if they were going to“cut her in half again”. (Theinitial surgery required a largeincision to ensure that theright kidney was not involved).

• Radiation and a six-monthChemo protocol for Stage 3Wilm’s were initiated whenCarolyn had recoveredsufficiently from the surgeries.

• Another lesion was detectedin the Hilum of her right lungduring follow up scans aboutthe time of the second to lastchemo treatment (believed tobe a recurrence of theprimary).

• A Biopsy of the lesion wasdone the results of which werenot definitive but “were notinconsistent with recurrentWilm’s”.

• It was determined to placeCook catheter to harvest stemcells “just in case” (radiationduring initial protocol madeiliac crest harvest impossible)This harvest had to be doneat another hospital.

• Three months later - StemCell harvest andcommencement of 24-monthrecurrent Wilm’s protocol.

• Over the course of the twotreatment protocols Carolynendured:

o Finger and other needle“pokes” for on-going bloodtests. She eventuallyrequired GCSF and Heparin.GCSF to help blood countsrebound, and Heparinbecause she turned out tohave Factor V Leiden –inherited from her father

o Multiple transfusions

o Eventually the Chemobecame too toxic andCarolyn’s blood countsstopped bouncing backquickly enough even withthe help of GCSF. No realnumbers existed todetermine the risksassociated with earlydiscontinuation of theprotocol. It was decided todiscontinue the treatmentafter 18 of 24 months

• The initial attempt to removethe Cook Catheter wasaborted– trans esophagealecho showed a pedunculatedclot attached to the rear wallof the atrium and wrapped

Continued on page 13

WINTER 2010

around the catheter which waslarge enough to occlude thepulmonary artery if dislodged.

• Of the three options – a) donothing, b) attempt to dissolvethe clot, or c) surgically removeit, only the surgical optionseemed viable.

• A Subtotal Sternotomy and openheart surgery were performedfollowing an ambulance ride toanother city (and a thirdhospital). The catheter wasremoved and the rear wall ofthe atrium, from which a veryorganized clot needed to bescrapped, was patched (initiallyit was thought that the clot was

a tumour – It was a holidayweekend so pathology wasseveral days in coming).

• Placement of another port forthe continuation of thetreatment was discussed andrejected.

All told, Carolyn endured ninesurgeries, three of which could beconsidered major. Approximpately500 finger pokes and needle sticks,and 39 transfusions. Some timelater, 5 spots were detected on herright lung during routine followup scans. Both the oncologist andradiologist were 99% sure it wasanother recurrence. This left uswith nothing but experimental

treatments and possibly moving inorder to qualify. We took a briefvacation to consider these thingsand to maybe get in a series of“lasts”. We returned fromvacation and had another set ofscans done whichshowed...nothing! It was all gone!Unexplained to this day.

That was six years ago. Today,Carolyn is a happy, healthy 14-year-old grade nine student takingflute and piano lessons.If you or someone you know has anamazing surgery story that you wouldlike to share, please send it [email protected] and we will publishit in General Surgery Matters. Allsubmissions are welcome!


Carolyn’s Story cont’d

MEDECINS SANS FRONTIERESDOCTORS WITHOUT BORDERS

Tuesday, 7 October 2009.

By 11: 30 am most patients inAhmed Shah Baba district hospital,in eastern Kabul have been seen.They tend to arrive early in themorning, queue up forconsultations and treatment, andare back home before the hottestpart of the day begins. Just beforethe staff take their lunch break,there is only one patient left in theemergency room, and twopregnant women in the maternityward. Only the vaccination roomand its waiting area are stillbustling with women in bright blueburkas and their young children.The register shows that the staffhave already vaccinated 150children today. Continued on page 14

MSF in Kabul, AfghanistanNo Guns, No Fees in Ahmed Shah Baba Hospital

Ahmed Shah Baba is a sprawlingneighbourhood and it’s growingquickly. In 2004, when MSFstopped working here, itspopulation was around 80,000;today nobody knows, but even themost conservative commentatorsestimate that the figure hasdoubled or tripled. People comefrom Jalalabad, and from furtheraway across the border refugeesare returning from Pakistan. Mosthope to find work in Kabul,especially with all the foreign aidpouring into Afghanistan, but manyare disappointed and jobless ratesare high.

The emergency room reveals theseproblems. The doctor on dutyexplains that they see many people

with injuries. A fair number are theresult of road accidents; AhmedShah Baba lies between the twovery busy roads that connectKabul and Jalalabad. But anequally large number of injuries,mainly knife wounds but also theoccasional bullet.The fightingensues over land, for instance, orsometimes because people simplycannot deal with being withoutwork.

The clinic is becoming a districthospital. MSF has come in to makeit function as an emergencyhospital; until today, many of thepatients need to be transported toother health centers, at least one


PAGE 14

hour away, for emergency care.MSF will boost the currentfacilities, add an operatingtheatre as well as an in-patientdepartment where people stayovernight under medicalobservation, andgenerally work onimproving the quality ofthe care given anddrugs administered.

The support is only juststarting. Yesterday forthe first time, an MSFdoctor diagnosed andtreated a patient. Thewoman had come in toemergency with burnsall over her face, armsand legs, after a gascooker exploded in herkitchen. Maria was theonly female doctoraround and therefore the onlyone who could check underthe woman’s burka. She foundfurther severe burns across thewoman’s chest and dressedthem, and today a MSF nursewas called in to assist with adelivery. Leen says the babycame out quickly and withoutany problem; a healthy girl wasborn.

“We are absolutely notplanning to jump in and takeover. It is amazing to see howthe clinic has continuedfunctioning without support,”says Project Coordinator, SylvieKaczmarczyk, referring to thewithdrawal of an NGO three

months ago that had taken overmanagement of the hospital afterMSF’s previous involvement hadended. “We are starting withrepairs to some of the buildingand construction of new areas, sothat in the future the hospital will

also have all the facilitiesneeded for a range ofemergency medical careand can function fully as adistrict hospital.”

A ‘no weapons allowed’policy has beenintroduced, but thismorning a policeman wasin emergency carrying hisgun and had to beinformed of the policy byDr. Sattar. Nine guards arereceiving their firstinstruction today,including on how toconvince every

visitor to leave theirweapons behind at theentrance. “That rule appliesto policemen and military,but equally to members ofISAF,” explains Sylvie to theguards, referring to theinternational security forcein Afghanistan.

Another priority is to makesure that nobody is payingfor consultations ortreatment. The hospitaldirector, Dr. Sattar proudlypoints at a new sign at theentrance of the delivery ward.“No one is allowed to givepresents or pay money to the staffof the policlinic,” it reads. “If

someone sees this happen, pleasecall the director of the AhmedShah Baba on the followingnumber:….”

It is important that MSF is back inAfghanistan, concludes Sylvie. “Atfirst glance, this is just a good MSFproject – rapid urbanization withservices that cannot keep up,distance from the city where youfind more health facilities,difficulties for the population toaccess medical care -, but thatdoes not necessarily make itspecific for Afghanistan. What iscrucial is that we use ourpresence here to get a clearerview of what is happening in thecountry. From the bit that weknow today, we can only concludethat things are getting worse.

Insecurity increases,health care is faltering,and as always, it’s theordinary people who paythe price.”

The support to AhmedShah Baba marks thereturn of MSF toAfghanistan after fiveyears of absence, followingthe murder of fivecolleagues in 2004.

Within weeks, MSF willalso start boosting thehospital in Lashkargah, thecapital of Helmand

province, which is at the heart ofthe fighting between ISAF forcesand the Afghan army on the onehand and the armed oppositionon the other.

MSF in Kabul, Afghanistan cont’d Continued from page 13

A ‘no weaponsallowed’policy hasbeenintroduced –That ruleapplies topolicemen andmilitary, butequally tomembers ofISAF...

A new sign atthe entrance ofthe deliveryward reads...“No one isallowed togive presentsor pay moneyto the staff ofthepoliclinic...”

WINTER 2010

Save this date!

First Canadian Summit

on Surgery for T2DM –

hosted by McGill

University

When: May 6-7, 2010

Where: Montreal, Quebec

Le Centre Sheraton Hotel

A scientific gathering of surgeons, endocrinologists,

cardiologists, healthcare professionals for diabetes care,

public policy makers and patient advocacy groups for

the purpose of examining and discussing the use of

metabolic surgery as an effective treatment of Type II

diabetes mellitus.

Summit Chairman: Dr. Nicolas Christou

Summit Co-Chairman: Dr. Francesco Rubino


PAGE 16

Dear Colleagues,

The CAGS-Guyanacollaboration, in establishing anascent Surgical TrainingProgramme, has been anamazing success story to date,graduating young surgeons well-prepared for the DistrictHospital setting initiallyenvisioned at the foundation ofthis Surgical Programme. Mytwo week review of the workbeing done at the districthospitals by Drs. Prashad,Motilall, Sukhraj, and Mahadeoreveals competent surgeonsworking within theconstraints of newlyreorganized surgicaldepartments, at each oftheir respective sites.During my travels inGuyana in October 2009,I visited three districthospitals (Suddie, NewAmsterdam & Linden),and aided endoscopicteaching at the teachinghospital, GPHC.

As a rule, the traineesdemonstrate a greatwillingness to identifybarriers and overcomethem to the best of their ability.They are not so much limited bytheir own ability, but by the lackof local support services ormaterial. They recognize theirsurgical limitations, and refer toGPHC appropriately. Of thethree regional hospitals I visited,all had reasonably busy surgicalservices, except at Suddie. Withits remote geographic position,and catchment area of 45 000,there is potential for more inSuddie. New Amsterdam andLinden have more mature

CAGS-Guyana collaborationsurgical services, and arerelieving GPHC of significantpressure.

What is most striking at allDistrict Hospitals is thealteration in culture, from adeclining institution with poorpublic acceptance and littleimpact on acute illness, topositive institutions withinterested nursing staff,educational ventures both tocommunity members and healthcare workers, and cooperativeengagement of Cuban-trainedGuyanese physicians. The

surgeons are impactingindividual lives, with life-saving trauma care, andearlier treatment ofsurgical conditions (e.g.hernias andhemorrhoids) whichdisable patients.

The Programme has nowreached a stage in itsevolution where itstrainees reasonably canask: Where are we goingfrom here? The originalgoal of producingdistrict hospital capablesurgeons has been

reached, but complacencycannot overtake us. The traineesevaluated may well not berepresentative of futurecandidates as the pool ofapplicants is likely to changesubstantially in the next fewyears, with the influx of Cuban-trained Guyanese MHO’s. Thecurrent graduates faceuncertainty as the next step intheir training, achieving a formalM.S. in Surgery from theUniversity of Guyana, needs finalapproval. They will have a

degree of independence indetermining their scope ofpractice based on the clinicalexposures they’ve had to date,and the upcoming externships inCanada several trainees haveplanned.

Leadership of the Programme hasbeen strong, and opportunities fordevelopment of residents havebeen sought out. Dr. Rambaran isto be commended for his vision,his persistence, and his support ofthe residents. One man, however,cannot sustain this Programmealone, and constant input fromCAGS is needed on an ongoingbasis.

The role of CAGS in lendinglegitimacy to the Programme, inexternal review, and input isgreatly appreciated by GuyaneseMDs.

Future Directions:1. Define entry criteria to the

Surgical Programme; given itsshort exposure, previousSurgical & ICU experiencewould be stronglyrecommended. A standardentry assessment tool may benecessary.

2. Formalize the training periodinto blocks, with an entry andexit interview and astandardized assessment toolto be reviewed face to facewith the resident.

3. Ensure any “mini-fellowship”exposures are well-advertised, made available toall, and if several candidatesdesire to pursue these mini-

Continued on page 17

The role ofCAGS inlendinglegitimacy totheProgramme,in externalreview, andinput is greatlyappreciated byGuyaneseMDs...

WINTER 2010


CAGS-Guyana collaboration cont’d

fellowships, that a screeningprocess is in place that is fair,transparent, and reviewablepost hoc.

4. Develop a formal relationshipwith an external, accreditedSurgical Programme to permitentry of Guyanese SurgicalGraduates, and completion ofan FRCS/FACS equivalentspecialty certificate.

5. Clarify the requirements for aconsultant position within thenation.

6. Encourage betterremuneration for surgicalspecialists.

We want your cases andvideos!

The Endoscopic andLaparoscopic SurgeryCommittee is planning apostgraduate course at theCanadian Surgical Forum on“Laparoscopy and Endoscopy inthe Acute Setting”. This willinclude treatment of GI bleeding,perforation, obstruction, sepsis

and postoperative complications.A case presentation will frameeach talk, which will emphasizeoperative strategies andtechniques for “keeping itminimal”. We are interested inusing your cases. Any casewhere a laparoscopic orendoscopic approach may haveplayed a role or could haveplayed a role is requested, andwill be used as much as possible

in the course to challenge theaudience and the presenters andstimulate discussion. Anyavailable images or video of thecase will be very welcome ofcourse.

Please contact Liane Feldman([email protected])for further information or tosubmit your case.

Thanks.

Message from the CAGS Endoscopic and Laparoscopic SurgeryCommittee

7. Encourage development of thePathology & Radiologyspecialties in Guyana, and aninterim step of rotating foreignspecialist advisors at GPHC.

8. Guidelines (for the SurgicalProgramme Curriculum) usedinitially in Guyana can serveas a template.

9. A CAGS International Surgeryreview board is to be created,with the specific goal ofreviewing Programmes’compliance with guidelines,and tailoring guidelines to thenation.

For the short-term, there is a needto expand the externshipsavailable to Guyanese surgicaltrainees. Currently, PlasticSurgery, Urology, and Endoscopyare being offered. Surgeons ableto provide three months or longerexternships in complementaryareas (e.g. Colorectal, Trauma,Surgical Oncology, PediatricSurgery) would be encouraged tocommunicate with Dr. BrianCameron, in Canada, or Dr. M.Rambaran in Guyana.

Submitted by Dr. P. Willard,FRCS©

Chief of Surgery, Welland Site,Niagara Health System

WINTER 2010

CANADIAN ASSOCIATIONOF GENERAL SURGEONS

RESEARCH FUNDCANADIAN ASSOCIATIONOF GENERAL SURGEONS

OPERATING GRANT COMPETITION 2010

The Canadian Surgery Research Fund was founded in the early1980’s to promote research performed by general surgeonsand general surgery residents in both clinical and basicscience. The CSRF currently funds two research projects peryear as well as sponsoring a Resident Research Retreat.

Applications are requested for Operating Grants from theCanadian Surgical Research Fund. These can be submitted bye-mail to: [email protected]

1. The deadline for receipt is June 1, 2010.2. There are three operating grants of $10,000 each.3. Applicants must be CAGS members.4. Residents are encouraged to apply with a CAGS member

as supervisor

The application should include (Microsoft Word 12point font):

1. A title page with information regarding all co-applicantsand contact information for correspondent

2. A summary of the application (max. 1 page)3. A detailed description of the proposed research including

references and a detailed budget (max. 6 pages)4. A curriculum vitae of the principal applicant (max. 3

pages)5. A letter of support from the Head of the Department of

Surgery

For further information please contact:

Dr. Oliver BatheResearch Committee Chairman:Tom Baker Cancer Centre1331 20th St NWCalgary, AB T2N 4N2Tel: (403) [email protected]

SSSSSeason’eason’eason’eason’eason’sssss

GreetingsGreetingsGreetingsGreetingsGreetings

&&&&&

BestBestBestBestBest

Wishes Wishes Wishes Wishes Wishes

for 2010 for 2010 for 2010 for 2010 for 2010

Meeting

May 13-15, 20102nd Joint Meeting

The BC Surgical Society &the Alberta Association

of General SurgeonsGrand Okanagan Lakefront Resort &

Conference Centre in Kelowna.

Information will be posted on thewebsite when it becomes available.

www.bcss.ca

general surgery matters - canadian association of...

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