Transcript General Surgery of Childhood (GPS)

Timing of Orchidopexy
Keeping General Paediatric Surgery in DGH
Su-Anna Boddy, FRCS
Chair, Children’s Surgical Forum, RCS
Consultant Paediatric Urologist,
St George’s Hospital
19 Nov 2014
Timing for Orchidopexy
• National Screening Committee
• East Midlands Specialised Commissioning
Group
• British Association of Paediatric Urologists
Consensus Document
• APA + RCPCH
• Clinical & Training Standards Manager RCS
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National Screening Committee
• Bilateral UDT on NNU refer to Paediatrician
• Single UDT examined by GP at 6 weeks, 3
months and 5-6 months of age
• If still UDT then refer to paediatric/adult
urologist/surgeon around 1yr of age
• Operation currently planned to be done
around 2 yrs of age
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East Midlands Specialist Commissioning Group
• The work of the review group resulted in
regionally agreed model of care and clinical
standards for GPS in the East Midlands
• Managed Clinical Networks
• One outcome measure was age at
orchidopexy – questioning the National
Screening Committee current standard
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Consensus Document
Germ cells
differentiation into adult
dark spermatogonia
occurs at 3-6 months.
Due to morphology,
biopsy and ultrasound
changes at 3 to 6
months, early operation
may optimise potential
fertility outcome and
may reduce malignancy
•Orchidopexy can occur
within 3-6 months
though surgery
occurring between 6
and 12 months is
acceptable.
Association of Paediatric Anaesthetists - APA
• General anaesthetics and the developing
brain – rat studies 2 years ago suggesting
anaesthetic agents themselves cause harm
to neurodevelopement under 1 yr of age but
artificially high doses in rats ( Flack and
Soriano ) not supported by FDA
• If surgery to under 1yr olds ? Higher mortality
and morbidity and ? In tertiary centre
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Commissioning Guide for orchidopexy for UDT needs
to be aligned to UK National Screening Standards
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Richard Stewart , & Sharon Verne, East Midlands SCN
Bob Bingham, President APA
Feilim Murphy, Secretary BAPU
Jane Howdon, RCPCH
Su-Anna Boddy, Chair CSF at RCS
David Elliman, National Screening Committee
Hugh Davies and John Marshall, Public Health England
Emma Fernandez, Commissioning guides RCS
Apologies Rick Turnock Past President BAPS
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Teleconference – History of UDT
• 1970 - operation 4-6 yrs morphology showed
testicular atrophy
• 1990 – operation 2 yrs before germ cell
depletion
• 2000 – operation under 1 yr - the sooner the
testis located outside the body greater
reduction in changes that could impact on
sperm cell production
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Hadziselimovic and John Hutson
• Germ cell differentiation into adult
spermatagonia occurs at 3-6 months
• 3-6 months temperature affects testis
development (children undergo a mini
puberty) this causes failure of transformation
of the cells leading to abnormal cell
developement
• UDT at 3 months will remain UDT in 98%
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Morphology and later functional change
• Data not currently available
• Evidence is available from 1970’s shows this
is the case but surgery too late
• Proxy measures of fertility ie sperm analysis
flawed do not predict long term likelihood of
parent hood
• 2 papers show earlier surgery reduces
malignancy
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Questions from National Screening Committee
• Evidence would preferably be by controlled
trial and the link between morphological
changes and the ability to father children
need to be firmly linked.
• Are children being operated on within the
current time frame?
• Large number of boys referred later than
current guidelines
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Recommendation from National Screening
Committee after review of ‘evidence’
• GP review at 3 months
• If still UDT refer to surgeon
• Operation recommended on or around one
year of age
• This can be incorporated into National
Screening committee Guidance without a
major change
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Problems for keeping General Paediatric
Surgery in DGHs
• How does an agreed age for orchidopexy of
around 1 yr of age help this?!
• SAC in General Surgery currently only has
an optional module for elective General
Surgery of Childhood
• Trusts do not advertise jobs for General
Surgeons with an commitment in General
Paediatric Surgery
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Must keep GPS in DGH
• Trusts must advertise General/Urological
Surgery + commitment to GPS
• Surgeon/anaesthetist to do UDT around 1yr
• BAUS obligatory module/25% of exam in
Paediatric Urology good succession planning
• Shape of Training?
• ASGBI, BAUS, BAPS, + SAC Gen Surg
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CSF Guidance to Commissioners
and Service Planners
• Provides guidance for
the development of
managed clinical
networks
• CSF - July 2010
Endorsed by:
RCS, RCPCH, RCoA, APS, APA,
ASGBI, BAUS
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Survey on GPS Service Provision
• Published in December 2010
• Delivered by CSF – Funded by DH
England
• A map of GPS service across all
hospitals in England
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Numbers of ENT, plastic, Orthopaed,
Dental, across all hospitals in England
• Available online at:
www.rcseng.ac.uk
• Planned update 2015
Children’s Surgical Forum (CSF)
• Advisory Multidisciplinary Panel
• Setting and monitoring standards
• Collaborating with external bodies
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CSF Membership
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Department of Health
Care Quality Commission
Patient Liaison Group
Surgical Specialty Associations
Association of Paediatric
Anaesthetists
• Association of Surgeons of Great
Britain and Ireland
• Federation of Dental Surgery
• Royal College of Surgeons
• Royal College of Paediatrics and
Child Health
• Royal College of Anaesthetists
• Royal College of Nursing
• Royal College of Obstetricians and
Gynaecologists
• Royal College of Ophthalmologists
• Royal College of Pathologists
• Royal College of Radiologists
• College of Emergency Medicine
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Managed Clinical Networks
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Interconnected system of providers
Not limited by boundaries
Multidirectional flow (not hub & spoke)
Contractual agreements specifying service requirements
and outcomes
Benefits:
•Common standards
•Integrated service
•Service planning
•Workforce planning
•Training
•Audit
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What are the barriers to Managed
Paediatric Surgical Networks?
• Competitive environment
• Lack of financial support
• Rigid contractual arrangements
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NHS Passport – Facilitating Cross-site work
• Flexible movement between hospitals
• Confirmation that all necessary requirements for safe
practice have been carried out in home Trust
• Delivery through Appraisal and Revalidation – ‘Certificate’
• Administered via Academy of Royal Colleges – Alastair
Henderson
NHS Passport – Facilitating Cross-site work
Certificate of Fitness for Honorary Practice
• Flexible movement of Consultants between hospitals for
short-term work and support of colleagues
• Cover for emergencies and absences in short notice
• Support for clinicians to extend and reinforce their skills
 Provide and receive short-term specialist training
 Take advantage of CPD opportunities in innovative techniques and
technology
Certificate of Fitness for Honorary Practice –
Content and Delivery
• Information currently included in the Honorary Contract
• Confirmation that all necessary requirements for safe
practice have been carried out in the home Trust.
• No additional paperwork
• Delivery through Appraisal and Revalidation
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Managed local provider
Paediatric Surgical Networks
• Support surgeons,
anaesthetists, nurses, and
whole MDT to ensure children
can receive surgical care, in a
safe and appropriate
environment, which is as close
to their home as possible.
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Configuration of Services
• Agreed guidelines and protocols for
managing the service in place covering the
full patient pathway
• Regular assessment of performance
• Forum for sharing best practice including all
contributors
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Governance and leadership
• Written policy regarding age range of children
anaesthetised and operated upon within the
hospital (and for out-of-hours period if level of
paediatric anaesthetic competences is
different)
• Evaluated with audit of outcomes, transfers
and untoward incidents
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Education and training
• Consultants work within limits of their
professional competence
• All surgeons and anaesthetists operating on
and anaesthetising children, regularly
undertake paediatric life support training and
safe guarding.
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Delivery and environment
• Care is delivered in a child and family-friendly
environment with registered children’s nurses
• At any time the emergency department
includes sufficient cover for emergencies in
children
• Surgeons and anaesthetists providing this
cover have appropriate training, competence
and CPD
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Keeping GPS in DGH
• Managed Clinical Networks
• Trusts to appropriately advertise
• Shape of Training? A General Surgeon who
can deliver elective and emergency surgery
in children ( and adults?)
• Paediatric surgeons from Tertiary centre?
• Anaesthetists keeping appropriate skills for
young children
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Commissioning Guidance by
all 10 Specialty Associations
at RCS, badged by NICE
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SCNs need to establish
Managed Paediatric Surgical
Networks
for all of Children’s Surgery
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Let’s Network!
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