7. Optimising cytoreductive surgery

In the United Kingdom, the chief medical officer, Professor Dame Sally Davies recommended that 'the Royal College of Obstetricians and Gynaecologists should make sure that subspecialist training in gynaecological oncology equips doctors to perform optimal surgery for gynaecological cancers and reduce mortality from ovarian cancer' [43].

Both modifiable (technical skills, organisation of care) and constitutional (e.g. age, biology, functional status) factors need to be addressed if we are to make incremental improvements in the outcomes for our patients.

One approach to this could frame any death from ovarian cancer as an 'error'. With such an approach one can adopt a sophisticated approach to addressing the modifiable factors [44, 45]. Vincent and colleagues articulated seven levels at which an error should be tackled. These are institutional (and national climate), organisation & management, work environment, team, individual staff member, task and patient [45]. How this model could be used for maximising optimal cytoreductive surgery is briefly illustrated here.

The statement by the CMO above creates a national sense of the overall aim. In addition, the European Society of Gynaecological Oncology (ESGO) published a benchmark regarding ovarian cancer surgery, which adds to this impetus, about the desirable end goal [46]. This expert consensus report recommends 10 indicators relating to structural, process and outcome metrics ranging from individual performance to team decision making process within a multidisciplinary setting. Such a suite of benchmarks can set the direction of travel.

Around the globe and even within the 'developed' nations the practice of patient selection, planning and delivery of upfront surgery varies a great deal. Therefore in terms of organisation and management, centralization of care delivery will help optimise outcomes [26, 47]. With regard to team and individual factors, training should target both and the end goal should be clear to both entities, that is, microscopic clearance of the disease. The delivery of surgery could be by a sufficiently trained gynaecological oncologist with the appropriate contribution from allied surgical oncologists. ESGO have organised or sponsored numerous workshops targeting technical skills and the philosophy to support primary debulking surgery. Such a concerted effort will help to redress one of the concerns about current training. The application of the current 'gold standard' evidence from two randomised controlled trials, (though heavily criticised) will adversely impact the training of the next generation of surgeons. Further, the timing of TRUST trial outcome and retirement of those trained prior to the wide acceptance of PDS, will change the landscape of practitioners.

Indeed individual and team training can be augmented by not only skills training in workshops, but through buddy operating during the transition phase. Such an endeavour could be supported by virtual platforms to maintain skills (e.g. video based feedback on specific subtasks in cytoreductive surgery) [48, 49]. This will augment task performance.

Patient selection is discussed elsewhere in this book and will not be discussed here. The factors will include demographic, biological (including molecular characteristics of the disease) and radiomics to mention a few [50].

Another important measure in improving the outcomes as part of CRS is to enhance chemotherapy with the use of Hyperthermic Intraperitoneal Chemotherapy (HIPEC). In a recent study, addition of HIPEC to CRS appears to prolong the overall survival by almost 12 months in patients undergoing interval debulking surgery [51]. This offers an exciting complement to maximal effort CRS. These findings will require independent verification prior to widespread adaptation. This topic will not be discussed further in this chapter.
