|Penman Lecture 2012|
|Tuesday, 26 February 2013|
Professor Michael Griffin reports on his Frank Penman Memorial Visiting Professorship to the University of Cape Town, 14-26 July 2012
I arrived a day early from a wet UK to a warm but overcast Cape Town. This was my second visit to Cape Town, my last being in 1983 in the apartheid era. I felt exhilarated at the prospect of the coming couple of weeks.
On my first day at work, I was collected by Professor Andy Nicol, who runs the trauma unit at Groote Schuur Hospital. This unit has made major contributions to trauma care over the last 15 years. The stark differences between South Africa and the UK were evident on the acute admission ward round where I met three gunshot victims from the night before.
I was later shown round the transplant museum. We were transported back to the operating theatres of 1967 where Professor Christiaan Barnard performed the first cardiac transplant. I remember the day of the first heart transplant and discussing it at length with my father, who was a practising cardiac surgeon at the time.
The afternoon involved teaching medical students and general surgical registrars before I delivered my first lecture Current Approaches to the Management of Oesophageal Carcinoma. Dinner followed in Bantry Bay with the trainees where stories and insights were swapped about training in our respective countries.
The following day, the upper GI and HPB firms’ meeting concerned several complicated HPB cases including a young man with countless hydatid collections within the liver. I departed to teach sixth year medical students on upper GI disease before sharing stories with Professor Sandie Thomson over lunch. Professor Thomson took up the Chair of Medical Gastroenterology in Cape Town and also operates one day a week. He was trained in Aberdeen, visited Durban and never went home! The afternoon was spent discussing complex oesophago-gastric cases and culminated with registrar teaching on achalasia and spontaneous oesophageal perforation.
The first part of Wednesday morning was hosted by Dr Nad Naidoo on behalf of the Department of Vascular Surgery. Endovascular stenting was being performed more frequently but resource issues perhaps slowed the evolution of vascular practice. I next met with Professor Anwar Mall, who has worked with Adrian Allan, Professor of Physiology at Newcastle University, with whom I had undertaken some collaborative research.
After further postgraduate seminar teaching, the afternoon culminated in my delivery of the Frank Penman Memorial Lecture, Centralisation of Services for the Treatment of Oesophago-gastric Malignancy – How it Worked in the UK; a title selected by Professors Krige and Kahn. I concluded with evidence from our national audit of the improvement in outcomes and we discussed the applicability to South Africa.
Thursday began with a combined ward round led by Professors Eugenio Panieri and Paul Goldberg. This included the breast, endocrine, gastric (a surgical oncology team) and coloproctology teams. Fascinating cases as diverse as tuberculosis, Crohn’s disease, ulcerative colitis and advanced malignancy were presented. The ward round continued into the University of Cape Town’s impressive Private Hospital. I later attended an excellent oesophageal physiology and motility conference.
The afternoon session involved more teaching before the evening’s talk on the comparison of outcomes of endoscopic therapy for early oesophageal and stomach cancer with radical surgical intervention. I presented our experience in Newcastle of over 100 endoscopic mucosal resections. The discussion surrounding lymph node metastasis in early oesophageal and stomach cancer generated much interest. More discussions took place regarding surgical training in South Africa and opportunities for academic appointments.
I was invited to deliver a morning lecture on Friday 20 July at Kingsbury private hospital, where my surgical friend, Bob Baigrie, who also operates and conducts ward rounds at the Groote Schuur Hospital, works. I chose as my title Oesophageal Cancer in the North East of England. I discussed the demise of coal and shipbuilding and the increase in obesity, sedentary jobs, development of gastro-oesophageal reflux disease, Barrett’s oesophagus and of course adenocarcinoma.
My next appointment was at the Red Cross Hospital, which housed paediatrics and paediatric surgery. I was met by Professor Alp Numanoglu, who gave me a tour of the hospital and the outstanding paediatric surgical skills laboratory. I met with Professor Alastair Millar, holder of the Charles Saint Chair of Paediatric Surgery, and discussed the transition from paediatric surgical care to adult treatment and my own experience with oesophageal problems.
Back at the Groote Schuur Hospital, I met with Professor Rossouw in the oesophageal oncology clinic and discussed four cases of squamous carcinoma of the oesophagus, all of whom, depressingly, were under the age of 50 with incurable disease. They came from up to 800km away. Patients with invariably advanced disease sometimes got on a bus and simply turned up in the emergency department. Dr Barbara Robertson, head of clinical oncology, discussed the difficulties of administering long courses of infusional chemotherapy to patients who come from far away.
After lunch we returned to Dr Robertson and her team to discuss oesophageal and gastric cancer patients. We talked about managing advanced oesophageal and gastric cancer and our experience with the MAGIC chemotherapy regimen. The oral form of 5-FU had not been available to Groote Schuur until recently. They had mostly treated both gastric and oesophageal cancer with chemo-radiation. The seminar concluded with my discussion of current strategies in managing gastric cancer.
Professor Krige had planned the inaugural Charles F M Saint Dinner for that evening during the week of my Penman Professorship. Charles Saint trained in Newcastle under the auspices of Professor James Rutherford Morison and won every academic award during his undergraduate and postgraduate career. My after-dinner speech focused on international surgical fellowship and some Geordie stories!
My second week commenced with a transplant ward round with Professor Del Kahn and his deputy, Dr Elmi Muller. The Cape Town unit leads the world in HIV-to-HIV renal transplants and we discussed the considerable ethical issues that it had faced when starting the programme.
The following day started with the HPB and upper GI ward rounds. Ian Marr, the private surgeon who did sessions within the unit, presented a difficult case of achalasia. We discussed the difficulties in making a diagnosis and the rarity of the presentations in the black community. The afternoon ended with my lecture on the role of sentinel node biopsy in the management and treatment of oesophageal adenocarcinoma.
The following day I was picked up by Andreas Grootte, a consultant at the nearby G F Jooste Hospital. This is a community hospital serving a large township. While I was there, three stabbings were brought in. The ‘front room’ was heaving and it was a fascinating experience. There are virtually no community-based resources for patients who go home after major surgery. Amputations were common and patients left to spend their lives on crutches or in wheelchairs. There was a huge experience of cardiac trauma and their only facility for investigation was a CT scanner with a quite extraordinary commitment from Dr Ash, the one radiologist. Sadly, there was no out-of-hours radiological service and so surgical decisions were very much based on clinical grounds.
The remainder of the day was hosted by Professor Brian Warren at Tygerberg Hospital, which is associated with the University of Stellenbosch to the north west of the city. Historically there was a building for whites and another for non-whites. I took the year-five registrars for a tutorial which culminated in a lecture on how to perform an endoscopic mucosal resection for both oesophageal and gastric cancer.
Back at the Groote Schuur Hospital,
The Groote Schuur Hospital’s facilities and standards were high with surgical and ward care being delivered in a similar way to the UK. The hierarchy and training programme were very different and the junior (sub) consultant grade was introduced several years ago to try to keep the outstanding talent that South African surgery was producing. Much of the early training of the junior surgeons occurred in the trauma units. I have never visited a team around the world where the trainees did not hunger for more work! Groote Schuur Hospital was no exception. The trainees were bright, enthusiastic and very hardworking. Most of them expressed a wish to travel to broaden their experience educationally and technically. My personal view was that they were generally better than their British counterparts, probably a result of longer working hours and a greater involvement in the firm structure.
The resources necessary to cope with the huge cancer and trauma volumes were large. There had been little investment until relatively recently from central government. The provincial health minister recently appointed is medically qualified and things have started to improve. South Africa’s healthcare system is burdened by HIV and by patients from neighbouring countries crossing the border to seek medical care. The interaction between the state system and the considerable private sector was interesting. Although private surgeons were less involved in state delivered teaching than before, those who were involved were highly regarded and highly valued.
My final thoughts and discussions with Professor Kahn focused on the prospect of developing a further firm within the department of general surgery. Oesophageal work is very fragmented at the Groote Schuur Hospital. Oesophageal cancer is largely dealt with in the thoracic department, whereas benign work is concentrated in the HPB unit under Flip Bornman. Professor Panieri managed the gastric cancer and much of the benign work. Physiology was overseen by Professor Sandie Thomson. I discussed with Professor Kahn the opportunity that this provided. He was excited and interested in the idea and agreed that, with a new health minister in place, now was a great opportunity for development.
The Frank Penman Visiting Professorship provided me with an extraordinary insight into a quite different healthcare system. How surgical services were set up and delivered to a developing country is very interesting to see and fascinating to be a part of. In the private sector, a very educated and wealthy group of patients was served to the highest level, certainly to British and European standards. In the state system, patients were poorly educated with little money and were served by a healthcare system that was at best in a developing environment. The commitment of the staff was absolute and compelling
There can be no doubt that I have learned far more from my South African experience than my counterparts did from me! It was a wonderful experience and I cannot thank enough Professors Jake Krige, Flip Bornman, Sandie Thomson and Del Kahn for the extraordinary friendship and hospitality afforded me. They are truly friends for life. I am also deeply grateful to the Frank Penman Trustees for having given me the opportunity of the most illuminating and insightful experience of my surgical life.
S Michael Griffin
Professor of Gastrointestinal Surgery