doi:10.1111/codi.12785
Editorial
Implementation of new technologies Perhaps thanks to its detractors, active and passive, laparoscopic colorectal surgery now has the best-validated evidence base, including randomized trials, of any minimally invasive approach for abdominal and gastrointestinal malignancy [1]. Despite clear and consistent proof of short-term benefit and intermediate and long-term oncological safety in a variety of settings, its implementation remains low globally. While the LAPCO programme has had an impressive impact in England [2], where, interestingly, laparoscopic colonic resection has yet to reach ‘standard of care’ case usage nationally in excess of 50%, what hope have other countries and health-care systems of significantly increasing the implementation in the absence of such a centralized, government- and administration-supported multimillion pound investment programme? What hope, too, do next-generation techniques and technological advances have when at present most colorectal resections continue to be performed by laparotomy even though we know without doubt that it causes more pain, wound problems and blood loss than its minimal access counterpart without any oncological advantage? Indeed the inertia in uptake of minimal access surgery, makes it seem slightly unbalanced that our specialty journals and meetings throw the spotlight on novel adaptations such as single-access laparoscopy and transanal minimal access surgery and all their variants, when only a small proportion of surgeons use these techniques. Surgeons and hospital administrators have of course become very cost-conscious, especially in recent years. Hardware costs, whether trocar or energy device or stack price, particularly when combined with operation time and clinical pressure from waiting list and activity targets, are frequently discussed in coffee-rooms, corridors, tradeshows, scientific meetings and publications. In reality, however, these aspects are often only raised superficially and divert attention from the need for clearer questioning of the more complex multifactorial components that make up the practice style and performance of each individual, department and institution. The ‘price tag’ of a new device is therefore often considered in isolation without detailed assessment of the potential use and depreciation values or calculation of the cost of the numerous components of the entire procedure from gloves, drapes and skin preparation formulations through to staff and infrastructure costs. Procedure time is often flagged up as a crucial barrier to the introduction of new technologies, even though we know that theatre efficiency is very often suboptimal, and simply
ending an operation slightly earlier does not automatically translate into added elective work being accomplished, because other factors such as bed availability and emergency case pressures may prevent the optimal use of time to increase the throughput of patients. ‘Training’ issues are often also used to dismiss the effort that may be needed to embed a new technique, although it is of course vitally important that trainees and students are themselves immersed in an environment of surgery as an evolutionary rather than a by-rote process and that they learn first-hand that their practice will need constant adaptation in an open-minded fashion so that the care they offer to patients is as good as it possibly can be over their future decades of practice. Opportunity cost, with all its implications, is often missing from the formula, mostly because it seems harder to quantify [3]. On the other hand, generational isolation and/or rivalry, clinical over-commitment, institutional over-loyalty, the private/public practice balance, technical confidence and security are all factors in service delivery that we often do not discuss explicitly. Indeed all too often we lack the language and trust needed to explore these in better detail to help address comprehensively the root issues behind why and when a new technique or technology should or should not be introduced. These stresses need to be managed in a way that makes for better implementation of current and future advances. Clinical directors here have a real role in ensuring that their departments and institutions understand that the future patient is as important as the current one, and must ensure a balance between the easier managerial functions of cost control and activity measurement and that of specialty development. They need to develop the language that allows fostering of clinical excellence rather than the default focus on simple administration. Academic surgeons too need to ensure they remain in the real world and return the efforts and investment in laboratory and intellectual research to the clinical care of patients. Older consultants need to ensure that their younger colleagues work in a collegiate atmosphere which allows development of the service broadly. In return, more recently appointed colleagues need to understand that their skill and expertise owe a large debt to the service and speciality developments created by those who preceded them. The ethical and moral balances between making sure a new approach is warranted need objective determination to identify the correct point between ‘cutting-edge’ pioneering work and ‘bleeding-edge’ experimentation [4]. More effort is
Colorectal Disease ª 2014 The Association of Coloproctology of Great Britain and Ireland. 16, 845–846
845
Editorial
required to analyse and clarify the implementation of new techniques for which follow-through is needed to reduce any laggardly tendency to disregard proven technique advancement [5].
Ronan Cahill Supplements Editor Department of Surgery, The Mater Hospital, Dublin, Ireland
References 1 Tanis PJ, Buskens CJ, Bemelman WA. Laparoscopy for colorectal cancer. Best Pract Res Clin Gastroenterol 2014; 28: 29–39.
846
2 Coleman MG, Hanna GB, Kennedy R; National Training Programme Lapco. The National Training Programme for Laparoscopic Colorectal Surgery in England: a new training paradigm. Colorectal Dis 2011; 13: 614–6. 3 Chatterjee A, Payette MJ, Demas CP, Finlayson SR. Opportunity cost: a systematic application to surgery. Surgery 2009; 146: 18–22. 4 Strong VE, Forde KA, MacFadyen BV, Mellinger JD, Crookes PF, Sillin LF, Shadduck PP. Ethical considerations regarding the implementation of new technologies and techniques in surgery. Surg Endosc 2014; 28: 2272–6. 5 McCulloch P, Nagendran M, Campbell WB et al. Strategies to reduce variation in the use of surgery. Lancet 2013; 382: 1130–9.
Colorectal Disease ª 2014 The Association of Coloproctology of Great Britain and Ireland. 16, 845–846
Copyright of Colorectal Disease is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Editorial
Implementation of new technologies Perhaps thanks to its detractors, active and passive, laparoscopic colorectal surgery now has the best-validated evidence base, including randomized trials, of any minimally invasive approach for abdominal and gastrointestinal malignancy [1]. Despite clear and consistent proof of short-term benefit and intermediate and long-term oncological safety in a variety of settings, its implementation remains low globally. While the LAPCO programme has had an impressive impact in England [2], where, interestingly, laparoscopic colonic resection has yet to reach ‘standard of care’ case usage nationally in excess of 50%, what hope have other countries and health-care systems of significantly increasing the implementation in the absence of such a centralized, government- and administration-supported multimillion pound investment programme? What hope, too, do next-generation techniques and technological advances have when at present most colorectal resections continue to be performed by laparotomy even though we know without doubt that it causes more pain, wound problems and blood loss than its minimal access counterpart without any oncological advantage? Indeed the inertia in uptake of minimal access surgery, makes it seem slightly unbalanced that our specialty journals and meetings throw the spotlight on novel adaptations such as single-access laparoscopy and transanal minimal access surgery and all their variants, when only a small proportion of surgeons use these techniques. Surgeons and hospital administrators have of course become very cost-conscious, especially in recent years. Hardware costs, whether trocar or energy device or stack price, particularly when combined with operation time and clinical pressure from waiting list and activity targets, are frequently discussed in coffee-rooms, corridors, tradeshows, scientific meetings and publications. In reality, however, these aspects are often only raised superficially and divert attention from the need for clearer questioning of the more complex multifactorial components that make up the practice style and performance of each individual, department and institution. The ‘price tag’ of a new device is therefore often considered in isolation without detailed assessment of the potential use and depreciation values or calculation of the cost of the numerous components of the entire procedure from gloves, drapes and skin preparation formulations through to staff and infrastructure costs. Procedure time is often flagged up as a crucial barrier to the introduction of new technologies, even though we know that theatre efficiency is very often suboptimal, and simply
ending an operation slightly earlier does not automatically translate into added elective work being accomplished, because other factors such as bed availability and emergency case pressures may prevent the optimal use of time to increase the throughput of patients. ‘Training’ issues are often also used to dismiss the effort that may be needed to embed a new technique, although it is of course vitally important that trainees and students are themselves immersed in an environment of surgery as an evolutionary rather than a by-rote process and that they learn first-hand that their practice will need constant adaptation in an open-minded fashion so that the care they offer to patients is as good as it possibly can be over their future decades of practice. Opportunity cost, with all its implications, is often missing from the formula, mostly because it seems harder to quantify [3]. On the other hand, generational isolation and/or rivalry, clinical over-commitment, institutional over-loyalty, the private/public practice balance, technical confidence and security are all factors in service delivery that we often do not discuss explicitly. Indeed all too often we lack the language and trust needed to explore these in better detail to help address comprehensively the root issues behind why and when a new technique or technology should or should not be introduced. These stresses need to be managed in a way that makes for better implementation of current and future advances. Clinical directors here have a real role in ensuring that their departments and institutions understand that the future patient is as important as the current one, and must ensure a balance between the easier managerial functions of cost control and activity measurement and that of specialty development. They need to develop the language that allows fostering of clinical excellence rather than the default focus on simple administration. Academic surgeons too need to ensure they remain in the real world and return the efforts and investment in laboratory and intellectual research to the clinical care of patients. Older consultants need to ensure that their younger colleagues work in a collegiate atmosphere which allows development of the service broadly. In return, more recently appointed colleagues need to understand that their skill and expertise owe a large debt to the service and speciality developments created by those who preceded them. The ethical and moral balances between making sure a new approach is warranted need objective determination to identify the correct point between ‘cutting-edge’ pioneering work and ‘bleeding-edge’ experimentation [4]. More effort is
Colorectal Disease ª 2014 The Association of Coloproctology of Great Britain and Ireland. 16, 845–846
845
Editorial
required to analyse and clarify the implementation of new techniques for which follow-through is needed to reduce any laggardly tendency to disregard proven technique advancement [5].
Ronan Cahill Supplements Editor Department of Surgery, The Mater Hospital, Dublin, Ireland
References 1 Tanis PJ, Buskens CJ, Bemelman WA. Laparoscopy for colorectal cancer. Best Pract Res Clin Gastroenterol 2014; 28: 29–39.
846
2 Coleman MG, Hanna GB, Kennedy R; National Training Programme Lapco. The National Training Programme for Laparoscopic Colorectal Surgery in England: a new training paradigm. Colorectal Dis 2011; 13: 614–6. 3 Chatterjee A, Payette MJ, Demas CP, Finlayson SR. Opportunity cost: a systematic application to surgery. Surgery 2009; 146: 18–22. 4 Strong VE, Forde KA, MacFadyen BV, Mellinger JD, Crookes PF, Sillin LF, Shadduck PP. Ethical considerations regarding the implementation of new technologies and techniques in surgery. Surg Endosc 2014; 28: 2272–6. 5 McCulloch P, Nagendran M, Campbell WB et al. Strategies to reduce variation in the use of surgery. Lancet 2013; 382: 1130–9.
Colorectal Disease ª 2014 The Association of Coloproctology of Great Britain and Ireland. 16, 845–846
Copyright of Colorectal Disease is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
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