Italy

MILAN  May 2022

This, our second ever visit to Milan, was secured at the third attempt, Covid-19 having scuppered our first two (2020 was in lockdown and 2021 nearly so, with global travel plans uncertain and changing). Our Secretary Graham Sunderland rose to the challenge on all three occasions1. As in recent years, the finer arrangements were in the hands of Jon Baines Tours who arranged our stay at the UNA Hotel Century, near the Stazione Centrale. However, these were uncertain times with Russia invading its Russian-speaking neighbour Ukraine in late February, and a worldwide economic crisis precipitated by fuel and food shortages due to Russia’s actions and the sanctions imposed in consequence. The cost of our visits has soared and our very existence seemed precarious.

Our President Linda de Cossart was unable to attend for personal reasons, so Tim Williams was invited on arrival to step into the breach (though it felt more like stepping into the breech). The Price Thomas Bursary had attracted good applicants and Daniel Leff and Meara Dean joined the 23 TSS members.

PROGRAMME

Monday 9 May 2022 – Ospedale Policlinico; Museum of Ca’ Grande

A smart limousine coach took sixteen surgeons from the Poldi Pezzoli Museum to the Policlinic Hospital of Milan where we arrived in time to enjoy our packed lunches in the nearby park. At the Ospedale Policlinico the elderly façade belied the large modern reception atrium where we waited before crossing the road to the site of the mediaeval hospital for a tour of the Museum.

In the Museum at 1 o’clock we were guided by the smartly dressed Curator Paolo Galimberti whose English was a little difficult to follow. Nonetheless we dutifully followed him, past many benefactors of the hospital gazing down on us from large portraits painted in different styles. There was another brief foray down memory lane as we inspected early 20th century medical equipment then trooped into the rooms of a magnificent panelled library where a great many manuscripts were stored, dating back to the thirteenth century. Unlocking a cupboard in the next room he retrieved a carton secured with ribbon to produce such a document, handling its yellowing crinkly pages with loving but bare hands then replacing it in the carton tying the ribbon with seemingly surgical precision.

We were eventually led into the basement, a cool catacomb of archaeological artefacts that had been unearthed since 2018, including the remains of 60,000 skeletons from the early years of this ancient hospital, providing material for study (including DNA) of the early patients of Ca’ Granda2. Botanists are studying the remains of plant leaves and branches found in these chambers. The starch granules trapped in the teeth of the deceased provided information about their diet (durum wheat, corn and barley, and even legumes such as lentils and peas). The research was ongoing. We also glimpsed the ancient hospital itself.

We returned over the road to the present Policlinic hospital where at 2 pm we met Professor Luigi Boni and a couple of his staff, including a Resident, Ludovica Baldari. The meeting was recorded by our Secretary who also transmitted it on Zoom – another first! Professor Boni, Chief of General and Emergency Surgery here for the past five years (and a protégé of Professor Cuschieri in Dundee), said he had come from a smaller Italian hospital. Using PowerPoint he talked informally about his current hospital and the plans for the new one, to be open by 2024 and built at a cost of 50 million euros of which 95% would come from the hospital’s own assets – a first for Italy! It would have 912 beds, a reduction from the present 950. The tender to build it was won by a Spanish company.

The new single site would also cater for emergencies (A&E – Pronto Socorro) and obstetrics and gynaecology. His own state-of-the-art department was on the second floor and devoted to innovative technology, which was his special interest, together with education and research though the latter was not a requirement of trainees for advancement. He was in overall charge of 36 doctors, overseeing his team of ‘Consultants’ (effectively on-going trainees) and residents. He was answerable to the University of Milan rather than the Director of his hospital. There was a shortage of surgeons, causing some to enter formal surgical training before the end of their residency. Many came from abroad, especially Asia but not the USA. Cancer surgery was undertaken in less than a month from diagnosis but elective surgery might have to wait up to a year, due to Covid. Questions elicited that day surgery (with occasional overnight stay) accounted for 40% of surgical practice. Healthcare was free, and with pensions it consumed 40% of the social budget. Our Secretary Graham Sunderland presented Professor Boni with our standard memento, a TSS desk clock.

Tim Williams, acting President, gave a brief illustrated overview of the origins of the TSS, stressing the roles of Lord Moynihan and Sir Clement Price Thomas. Price Thomas Fellow Meara Dean (surgical trainee at the Royal Marsden, currently applying for consultant posts) presented her experience of molecular pathways in polyp development, concluding that those at greatest risk of developing all three polyp types (serrated/adenoma/hyperplastic) were male, smokers, and more likely to have a personal history of malignancy. Questions elicited the study covered data from 2007-2014, did not include data on NSAID usage and that the most aggressive lesions were mainly left sided, whereas serrated lesions were more right sided making completion colonoscopy crucial (as in former US President Ronald Reagan).

Do you Write better after Whisky? asked Stephen Chadwick. He had on a previous occasion presented his findings, that experienced whisky drinkers could not distinguish blended from single malt whiskies any better than the rest of us (at least in the academic Department of Surgery at St Mary’s Hospital, Paddington). He advised that his mentor Professor Hugh Dudley (1925-2011) had a prodigious output of publications of all sorts and was a true essayist, whereas current doctors often lacked the ability to write good English: some journals dispensed with Editorials, and the plethora of publications (over 600 new journals became available since 2011, 95 free of charge) encouraged a culture of Surgical Twitterati. He deplored the decline in well-written articles which ‘might rob us of the traditions inspired by Italian medical schools’ such as Salerno.

Dr Ludovica Baldari comprehensively reviewed the clinical applications of fluorescence-guided surgery, using indigo-carmine green (ICG) injected intravenously 24 hours before or at operation (for instance, during breast surgery). She concluded its use could reduce various complications (such as gut ischaemia and anastomotic leaks), more than off-setting the costs of the equipment. It was ‘the dream of the surgeon – to see the invisible’.

Our second Price-Thomas Fellow, consultant breast surgeon Dan Leff from Imperial, tackled the thorny question of how axillary clearance could be taught to trainee surgeons when the operation was rarely performed (much like open cholecystectomy in this laparoscopic era) now that sentinel lymph node biopsy is established. He presented a convincing physical simulator of the operative field in a synthetic torso which realistically allowed the skin to be incised, fat explored, nodes removed and neurovascular structures to be displayed. The technique of dissection could be monitored and assessed, on several criteria. Simulators like this could be used for various procedures (even on a single model), and widely marketed. The cost was not yet known.

The meeting ended by 4.30 pm. There were no ‘Registrar Prize Presentations’ as junior staff were said to be too busy.

Tuesday 10 May 2022 morning – ’March or die‘ (a military maxim)

The visit to the IEO (Istituto Europea di Oncologia) was cancelled as the venue was closed to us under Covid restrictions, so the morning was free. It was spent usefully in the hotel, an opportunity to have an informal two hour discussion about the future of the TSS by all the visiting surgeons – including the two Price Thomas Fellows – now numbering twelve. First, though, a little history:-

The TSS began as an organisation (the Travelling Surgical Club) allowing British surgeons to watch their European counterparts operating; they suspected during WW1 deployment that they might be trailing them in surgical experience. Lord Moynihan, the first President of the TSC (though he never travelled with it) facilitated European visits in which operations were watched and critiqued, and an annual Report produced. This has continued for nearly a century with only the occasional hiatus, mainly due to major conflict and now Covid.

During the latter half of the twentieth century the visits often included tours of several of the host hospital’s facilities. They also began to embrace presentations of scientific work of surgical relevance, technology facilitating this with slide projection and then computerisation, culminating in PowerPoint presentations, often with videos. Closed circuit television allowed operating to be observed in the comfort of an amphitheatre and some meetings can now be held virtually, using Zoom, Teams or similar. The annual Reports provided a detailed record of what was seen and discussed on our hospital visits and included wider observations about the places visited and their history, often toured with a guide.

The annual week abroad and the three days at a home centre created a family atmosphere, with younger surgeons welcomed into the TSS whilst retired surgeons and their spouses stayed on after retirement (even after the death of their partner). The Price Thomas Fellowships were established to honour the memory of our most illustrious travelling President, to bring young blood and research findings to our meetings, and to encourage dialogue between surgeons at or near the start of their consultant careers on the one hand and those who have been established a while or even retired, on the other.

All the above is now under threat on several fronts, not least from the global pandemic and lockdowns which curtailed international travel for two years, and from the shift in the way many meetings in various spheres have been conducted using modern technology, whether virtual or hybrid. There have also been stresses on hospitals at home and abroad, Covid in particular having curtailed operating and reduced the availability of staff. At the present time these problems are ongoing and almost certainly impacted on our reception in Milan.

In discussion, TSS members raised numerous points, including:

•   ‘The culture has changed’ – with host units often not interested in having visiting surgeons unless such visits served a useful purpose to their own ends. Communications frequently went unanswered.
•   Saturday meetings are often preferred by foreign units (as in Malta) over the busy five day working week
•   UK Surgeons in active practice have difficulty in getting away, due to their own clinical and family commitments and restrictions on study leave
•   The format of our one week meetings is not always congenial to surgeons in practice (‘Friday to Friday is dreadful’)
•   Many surgical specialties and subspecialties have their own groupings
•   One surgical travelling group (the Surgical 60 Club?) has already foldedand the future of others is not known but could be established
•   The offer of a competitive Registrar’s Prize has stimulated presentationsbut may no longer be an incentive on busy units (in Milan especially).

•   The TSS President should be in clinical practice, and thus in a stronger position to have contacts abroad
•   Visits are getting expensive, especially if they involve distant air travel
•   The future of the Society needs to be decided before there is a seriousattempt at further recruiting, which might include established surgeons on

  the verge of retirement, who perhaps should be targeted

•   Much of current meetings could be ‘attended’ in different ways, not merelyby traditional face-to-face contact but also virtually using Zoom or similar

  techniques, perhaps hybrid (as our Secretary explored in Milan)

•   Many organisations, specialties and subspecialties have their ownconferences and piggy-backing such meetings might be a way forward
•   The views of spouses/partners need recognition
•   All issues raised might be worthy of wider debate, perhaps in The Bulletin.Action points

1. It was agreed that the TSS should continue as it is, at least until the Centenary in 2024 (possibly in Paris) which should be celebrated well
2. Avenue abroad needs to be agreed for 2023 (KualaLumpur?)
3. It needs to be decided whether the TSS should be disbanded after theCentenary or run in some other manner

Tuesday 10 May 2022 afternoon – San Raffaele Hospital

We reached the hospital campus as intended by 3 pm but circled it a couple of times in our luxury mini-coach as we were unable to find ‘The Iceberg’, eventually locating this striking structure (with 20 theatres in its two storey basement) next to Accident and Emergency (Pronto Socorro) in a complex of modern buildings (A B C D G and Q – the latter being the private wing). San Raffaele is part of the 19-hospital chain founded in 1969 by the priest don Luigi Maria Verzé, President of the San Raffaele del Monte Tabor Foundation. Most of its healthcare is free.

The large modern 1990s auditorium in Building B seemed to have every facility (apart from somewhere to rest one’s papers), but there was neither a printed programme nor any suggestion as to how the meeting would be chaired – all very informal. It took a local group (of four) half an hour to load the in–house computer. Half a dozen local trainees were present, and 16 TSS surgeons. We all wore masks. Our host, Professor Riccardo Rosati (Head of GI Surgery) in theatre gear, presented an impressive medal of Vitruvian Man to the TSS which our stand-in President Tim Williams accepted, commenting we had been very impressed by Milan’s Leonardo exhibition. He gave a brief introduction about the TSS without projection (another speaker’s slides were being displayed) and explained he was normally Editor responsible for reporting the proceedings. He would welcome written information about the hospital which the Professor said he would forward (later disparaging the hospital’s website, www.hsr.it).

Price-Thomas Fellow Meara Dean then discussed a novel grading system for diverticular disease based on retrospective data (1985-2014), concluding that this could predict the possibility of complications warranting surgical intervention.

Daniel Leff promoted an intelligent scalpel for breast cancer that could distinguish breast cancer from healthy breast tissues towards oncological resection margin control, given that reoperation was a significant factor in the management of breast cancer patients and incurred significant costs. As it cuts, the scalpel harvested cells for mass spectroscopy and could identify malignant ones so the resection could proceed more precisely.

Senior member Stephen Chadwick discussed the results of a survey of non- technical skills training in TSS members and their response to the stresses of surgical activity (such as the emotional demands, peer and other pressures, abuse from patients, lack of resources, bullying, sleep deprivation and loss of the ‘firm’ structure in hospital practice). He applied his analysis to working on an ITU during the Covid pandemic. At the start of his career in 1970, the night before he started medical school he been motivated by M*A*S*H* and Hawkeye (played by Donald Sutherland in the film). He pondered the personality attributes of surgeons (agreeable, conscientious, neuro-divergence, extraversion, open to experience) touching on the variants of normal. By contrast, there is what is now called Autism Spectrum Disorder (the new nomenclature including what was previously classified as Asperger’s and High Functioning Autism), now considered consistent with being a variant of normal rather than pathological. He explored all this in relation to surgeons’ behaviour, whether they be a Hawkeye or a Sir Lancelot Spratt (of Doctor in the House fame).

There were two lengthy presentations on oesophageal resection of which Professor Rosati’s department (his staff wore T-shirts inscribed Chirurgia Gastro) does a hundred a year, being one of five high-volume such units in northern Italy.

The two consecutive local speakers – Valentina Andreassi and Davide Socci – detailed the management (particularly the ERAS3 recommendations of 2019 and the role of the MDT) that ensured excellent results from oesophagectomy with reduced pulmonary complications and a shorter length of stay. A tubularised gastric conduit was preferred, with delayed gastric emptying pre-empted or managed by pyloromyotomy or pyloroplasty. Early enteral feeding, trans-hiatal Jackson-Pratt drains and prompt detection and management of chylothorax were advised. ITU was not usually needed. Trainee Davide Socci demonstrated the minimally invasive approach with videos, and how it had evolved from the original Ivor Lewis oesophagectomy: thoracotomy was abandoned in favour of five then just three ports. Discussion confirmed the excellent results with only two recent deaths, one an frail elderly lady who insisted on having the operation which she tolerated well but succumbed to Covid without leaving hospital.

There had been no Registrar Prize Presentations. Finally stand-in President Tim Williams stated that the TSS had been founded (as the Travelling Surgical Club) to enable British surgeons who had been active in World War One to watch Continental surgeons of repute at work and that “today we had again seen evidence of this”. He thanked Professor Rosati for the meeting and presented him with the gift of a TSS desk clock, thankfully in working order to the delight of our host and the relief of our Secretary. The meeting ended by 5.30 pm and we made a brief visit to the latest building in the complex which had a striking atrium with illuminated stained glass panel behind a towering sculpture of a DNA helix.

Our coach arrived promptly at 6 pm but our return to the hotel was delayed by a police road block. After ten minutes, flashing blue lights heralded a maintenance vehicle which disgorged workmen who began to fill in a deep pothole which our skillful driver gingerly passed. Soon after, at red traffic lights we watched a street entertainer on a monocycle in the middle of the road juggling three skittles then his bowler hat, which he flipped around dexterously, all the while mono-cycling. It was entrancing, and ended with a broad smile and no request for money though one had to wonder if such leger-de-main was also the reason some Italians (young girls especially) seemed such successful pickpockets.

Thursday 12 May – AGM, President’s and In–house Presentations

The AGM was held on the first floor in the Pirelli room of our Una Hotel Century. Discussion was wide-ranging and included potential future visits and new members, revising the website, the healthy TSS bank balance (£18,104.91), and a meeting debrief by Barry Powell. This was all interactive, our President Linda de Cossart participating via Zoom (and the Secretary’s intelligent camera) after her welcome video had been displayed. She shared her thoughts on Current Issues in Practice not often discussed, and Stephen Chadwick reviewed the Positives of a Surgical Career. The P-T Fellows were invited to join us and share their thoughts, freely offered. The membership would be polled as to whether the expense of a flight to Kuala Lumpur for 2023 justified a visit to that country.

At the 2022 autumn meeting in Blackburn Linda’s successor as President would be appointed. The current meeting had started at 9.30 am and closed by noon after the Secretary and P-T Fellows had exchanged private mutual feedback.

Milan attendees

Tim Williams Editor

Stephen and Margaret Chadwick
(Linda de Cossart ; President) – unable to attend
Meara Dean (Price Thomas Fellow)
Andrew and Kathryn Evans
Dimitri and Catherine Hadjiminas
Rachel Hargest
(Andrew Healey – one day)
Joe and Pamela Horner
Daniel Leff (Price Thomas Fellow)
Simon and Alex Mellor
Barry and Jill Powell
David and Diana Ralphs
Graham and Anne Sunderland (Honorary Secretary)
James and Kate Thomson (Past Secretary and Past President)
David and Louise Ward
Tim and Gail Williams (Editor; Past President and stand-in President)