So, so can you see full screen? You see full screen? Yes. Yes. Great. So, so kind of I'm kind of talking in my capacity of being a lead in a cytoreductive surgery programme in the UK. And also I've just started a master's in cytoreductive surgery in the university. So there's a lot of elements that I'm going to talk about is from educational mentoring points of view. So basically, after my talk that, you know, why do you need quality indicators? So what is the evidence? What is the training perspective that you have? It is a high risk procedure. So, you know, it needs a dedicated regional service. And how do you put the quality assurance into it? Because as you can imagine, nowadays, you don't do only surgery. You need good pathology, radiology, chemotherapy, or if it's something else, sometimes radiotherapy. So everything needs to be up to a standard. You have to fire all cylinders together in order to give a good outcome. So it can't be that you are good in one thing and the others are not working together. So that kind of impacts, for example, if your chemotherapy sometimes is not that optimal or your pathology is not that optimal, then, you know, whether you would be doing really a big surgery. That is a question because you can't possibly deliver the benefit what you want to do if you just did one thing alone. And then basically, it is about combining everything, especially for fellows who are starting to do new or new consultants, to develop a practice based on evidence. And it's not on convenience because you would realize that a lot of things that we do are based on where we have it here or whether it's convenient for you, but then it doesn't necessarily match on what needs to be done. And therefore, I think training is important because you're continuously reading and you know what needs to be done. You need a benchmark. You develop an attitude towards it and then you develop an infrastructure around it. So you start with training that you know what to do. Then you develop an attitude that, well, that needs to be done and I need to get it done. And then sometimes you develop the infrastructure resource around it, like you are trying to develop your Sentinel node service because you know that needs to be done. I don't need to go about this. I think, you know, ovarian cancer is going to be our next pandemic in our gynecological cancers because cervix is coming down and endometrium is coming up as well. But this is going to be the major killer. And as you can see, I mean, even we have done all these progresses, but about 75 percent of the cases diagnosed all over the world, they're going to die. So you see new cases about, you know, 333,000, but then, you know, majority of them will still die. So this is a big problem. And some of this problem is not just due to the biology, because actually compared to many tumors, the biology of ovarian cancer is not that bad because we know from the BRCA and things. But maybe we're not treating it first very well. And there I am going to come about this, talk about the surgery. And then again, I just kind of want to put this slide, not to go through the busy bit, but it is also one of the costliest cancers to treat in terms of our scenario in low resource setting. Now, there has been three big pillars, you know, understanding disease, biology, BRCA, HRD, then the involvement of PARP inhibitors and things. And then also there has been a massive progression towards understanding the role of surgery. So maybe like people who they talk about precision medicine, but maybe we will be at a stage where we can also talk about precision surgery. Because maybe that, you know, one day these will supersede the need for doing a good, you know, like a massive surgery, but we are still not there yet. And that is very important to know as a surgeon, because when I started doing my PhD, I was involved in BRCA, HRD, PARP inhibitors. And I really thought that, you know, I don't need to maybe learn that amount of big surgeries for 10 hours, 12 hours, grueling days, you know, ruining your work-life balance. But 10 years down the line, I know that good biology does not compensate for a poor quality surgery. So four hours extra in theatre, four days extra in ICU, maybe does impact on four years of extra life. So you have this sort of data by US that each 10% increase in cytoreduction increases survival by 5%. So we in the UK, we have something called a duty of candor. That means that if you're not doing it, then you have to tell the patient explicitly that why you couldn't do it. So basically, you could either fix the goal that you want to remove all the disease, or you could fix the time that you need to finish by 5 o'clock. And then accordingly, the other variable will vary. So if you want to, for example, achieve CC0, then you might not be able to finish at 5 o'clock. Or if you have to finish at 5 o'clock, then your residual disease will vary. And that is important because it's very important in a scenario like NHS, we still have a huge battle to kind of move beyond finishing our operating time, you know, 5, 5.30, because, you know, every hour of operating is counted, costed, and then you need. So that is something in terms of capacity building. If your center is or doesn't have it, then maybe as young surgeons coming out, young gynecologists coming out, this is something on a management point of view that you need to, or maybe we call it like putting up a business case, you know, in order to achieve those sort of things. And surgery, it is the most cost-effective cancer intervention for advanced cancer, especially for countries like in India. We do not have funding for PARP or BEV, you know, routinely available to our patients. And think about Befaso Zimbabwe, you know, in the best of the hands, even spending all the money, the PFS benefit was three months. If you did a very good surgery, I can assure you that even in your setup, you will match the PFS to Western standards. What you can't do is to match the overall survival sometimes, because then maybe when you are challenged economically, then after your first progression, then you don't have the opportunity to go into trials after trials or costly interventions. So the overall survival, maybe it's impacted, but if you do a good surgery, at least you can match the first progression pre-survival. But like a transplant surgery, it needs a super speciality and a dedicated service and centralization. And therefore, your training in ovarian cancer surgery also needs to be done, at least for some time in a dedicated center, which has got a very high volume of cases. And there you talk about rotation. And with that, I will come around in the next few slides about what does it mean by an ESGO quality assured center or accredited center for ovarian cancer surgery. Indications, we know that it's the primary setting. You know, whether it's a primary surgery or neoadjuvant, that's a major indication. Sometimes we do recurrent and recurrent settings, especially if you're following the desktop AGO criteria, you know, limited disease. Again, for our setting in India, it is possibly the most cost effective intervention for an oligometastatic disease because we do not have a routine access to PARP or it is so costly that the patients can't buy. And, you know, as I say, that if you have to do a surgery, there is a really nice guidance for following the quality indicators, especially for the trainees. So there are three things which are extremely important because you are doing a high risk procedure. One is that you need to assess receptability. And now after doing all these years, to me, there's only two indications where I wouldn't do an abdominal cytoreduction. And that is infiltrative disease of Porter. The superficial disease of Porter again is receptable. And then if there is disease in the root of mesentery. And although you can train your radiologists to really be very good in predicting either of them. But in my personal opinion, you really need to not even a laparoscopy is good enough, because, you know, if you have increased your skills to even remove superficial disease in the Porter, then you really need to do something tactile. You need to feel that, you know, it's infiltrated, whether both in the root of mesentery, because again, superficial disease in the mesentery, you can you can remove it. Right. So once you develop that sort of skill set, then it requires an interoperative assessment, in my view, to really say that whether this disease is infiltrative, fibrotic, that sort of disease. In that case, maybe you wouldn't be able to do a good primary surgery. But also, if you want to give neoadjuvant chemotherapy to these cases, this is not going to disappear with chemo. This is going to be more fibrotic and sclerotic in the Porter and the root of mesentery. So basically, even if you go for neoadjuvant chemotherapy in those cases, you might need to have a mindset that, OK, you're going to go for maximal effort cytoreduction. But you may be not able to remove all of that infiltration because with chemo, it's now really difficult. But then you do as much as you can do. And then you really need to fit in the patient's age, comorbidity, activities and all those factors. Because when you know that you might not be able to remove every bit of it, then would you be wanting to do a 10 hour procedure? That's another question. So again, in my series, sometimes I find that my rate of finding CC2 or CC3 disease is actually higher when I do neoadjuvant chemotherapy, because they are more because I'm selecting out really bad disease to start off with neoadjuvant chemotherapy. And I can't always remove all of it because of especially with this disease distribution. And then again, nutrition is important. But I would say if you find somebody with SITs and low nutrition and all, especially in young in India, I don't know about China and Hong Kong. But, you know, median age of ovarian cancer in UK is 65. When I used to work in Tata, where we used to have affluent patients, the median age was 52. Now that I have been working in very poor government sector, our median age for ovarian cancer is 42. Right. So even if they are, you know, nutritionally poor or they got an ascites, but because, you know, age does something, you know, they are kind of fitter in another way. So if you drain the fluid, you put them on a nutrition program, you could still do a good quality cytoreductive surgery, even in small women with, you know, BMI 1920, which are quite standard in our part of the world. So you should not sometimes you need to customize your Western guidelines and policies to customize in your woman. So do not cancel surgery. So I don't need don't need to go through this, because you all know there have been two big studies on URTC and chorus. But what you need to understand is the red bit on the top that centers, which do 70 percent neoadjuvant chemotherapy, usually don't see a benefit of doing primary surgery. Because, you know, once you are doing neoadjuvant chemotherapy day in, day out, 70 percent neoadjuvant chemotherapy means that you're invariably your length of operation is two to three to four hours. I mean, that's what was in the chorus of neoadjuvant and the URTC study. The median length of operation was 120 minutes in both arms. I mean, in two hours, I really don't know what you can remove in an ovarian cancer. And if you do a two hour surgery, then neoadjuvant chemotherapy is non-inferior. That is what you need to understand. Right. Never superior, though. And then if you are developing a practice, training your fellows, training your whole infrastructure, that you're going to do an operation two to three hours and doing 70 percent neoadjuvant chemotherapy, then you really don't develop the skill set and the infrastructure mechanism to do a good primary surgery. And then you feel a little bit shaky when you have to do an odd primary debulking. Everything impacts, you know, and then you start saying, oh, no, then I can't do it. Then you really leave residual disease. If you leave residual disease in primary surgery, that's never going to be superior to your neoadjuvant chemo. But what you will see is the difference in your overall survival. And you will see that in both the URTC and Chorus, the median overall survival was around 24 months or 36 months. But if you see centers which do 70 percent or 80 percent primary debulking surgery, say about the German centers, the AGO, the Lyon study, even in the standard arm. Without any additional interventions, without part, without something else, the median overall survival is 60 months. Compared to 24 or 30 months. So it is a basically it's an attitude difference. It's a it's a difference in your surgical team. And the converse is also true that if you are in a center which is doing 70 to 80 percent primary debulking surgery, that means, of course, you are doing a lot of high volume PCI scores. You're putting them to primary surgery, your anesthetist, your health worker in the theater, your nurses, your ICU, your doctors, everybody's tuned to do these big operations. You will see that even that you come, you'll find your next neoadjuvant chemotherapy patient. You are not finishing in two hours. You would put that maximal effort to even remove a big stuck pluck of diaphragm or things or others. So even your time spent in doing a good interval debulking surgery also is prolonged. So this is a kind of thing which we will get to know with the TRUST study, but for the time being as it stands and you will find in the quality criteria that to be recognized as a good center for cytoreduction of your stage three, stage four disease, almost, you know, like more than 50% of your stage three, stage four should have primary surgery. So again, I just kind of think that's what I have told that and it is even in India, when you don't have massive infrastructure, you can still, you know, improve on your criteria and your goal points in doing more and more primary surgery. When I came back from the UK, I used to see that people was just blindly following the course of neuroticity because it was very easy for many other purposes, which are not necessarily evidence-based. I mean, if you, it was just like using as, you know, like, okay, we've got a piece of literature, let's do more and more neuroadjuvant chemotherapy. You know, it's easy for everybody. I mean, now when I'm getting old, I think, well, it's a brilliant thing. I mean, you know, you know, you don't need to be in hours in theaters. You can go home on time. Your family life is not, it's not only your family life, by the way, the anesthetist, you know, the nurses and everything, if they're not costed, nobody likes to stay back, you know, long hours, day in and day out. And that's why if you don't have your hospital management buy into that and invest in long hours, you will never achieve this. But then, as I say, the duty of CANDOR, you know, we need to really tell every patient that 10% increases in the amount of cytoreduction does increase in your median survival by 5 to 5, 5.5%. And therefore, you know, if you could do more, you need to do more. And if you're not doing it, then you have to give an explanation to the patient. And that is your duty of CANDOR, so that they can't turn around and back, doctor, why didn't you do it? It's in the literature or whatever it is. But it requires a lot of counsel, counseling. And I think you can always want to achieve complete. If you can't, then optimal is okay. But nowadays, the definition of optimal is not less than one centimeter, it is less than 2.5 millimeters. So that is, again, something that you need to really understand. And that difference between less than one centimeter and less than 2.5 millimeters is addition of three hours. And that is also important because in many locations, as I'm going to show you in the next few slides, all the disease is small volume, right? But if you leave them behind, then it's not, if you may say GCIG optimal, because it's less than one centimeter residual, but actually it is not less than 2.5 millimeters, because you will find maybe 60% of your disease load is less than one centimeter, but more than 2.5 millimeters. You know, it's like milliary small, small, small, small disease, right? So basically determinants, you need to see about disease load and distribution. Distribution means root of all patient factors to select who, when is your primary or interval. Again, by whom, I think that is a very major determinant. You know, trained surgeons who are really passionate about doing it, you know, they have the time or they have made the times to want to do it. Wanting is a very important thing. The whole team wanting to do it is another thing. And that actually determines a lot of these factors on the top and infrastructure where you're doing it. And then of course, you know, whether you've got a research parallel going on, I think unless you've got something, either it's a clinical research or a lab research, unless it's going on parallel, you never develop these standards. And again, it's very important to know, I know everybody says that if you can't achieve zero, then don't do surgery. I don't think that's right. You know, you do what is called a maximal effort cytoreduction and your chances of giving maximal effort will be maximized with good training. And that is why you have this fellowship program. You have this mentorship program so that you can maximize your effort in giving this treatment. Right. So and then, you know, we don't know this bit yet that will upfront knowledge of tumor biology help in deciding whether you do optimal or suboptimal therapy. That's still we don't know that yet. Until we know that, we are ought to do our duties as a surgeon. As I say, debunking of a neoadjuvant chemotherapy is actually more difficult than primary surgery due to scarring. I find I get more suboptimal cytoreductions with that, especially with the high volume PCI. And then when you do surgery, you don't do surgery looking at the CT after three cycles of chemotherapy. You have to do the surgery looking at what was the disease distribution before the start of chemotherapy. For example, if somebody had a lot of disease on the diaphragm, on the liver surface, and then you decided that you're going to give neoadjuvant chemotherapy, that is not going to disappear to zero after your chemotherapy. So maybe radiologically, you will see that you don't see those plaques and things. But if you do a really, really systematic way of looking into every quadrant, and that's again training your eyes, you will see the chemotherapy scars, you know, some neo vascularization, which is now, you know, now, you know, with the chemotherapy is, you know, like plaque, you will, you know, it's like flat surface, which you will not see because it's not raised. But then you would be able to look into the texture, look into like colposcopy, you see those vascularization patterns, you see the dots, you see that scars, and you know that the disease is there, you know, it has responded, but maybe there are some dormant cells. And there was an elegant study in Finland, what they did, they were actually biopsying all these neoadjuvant scarred areas, which a surgeon would normally say it's normal. And therefore, I will not do diaphragm, I will not do peritoneum, you know, all that stuff. And then in 25% of cases, you find active disease in those areas, which you as a surgeon were leaving behind, just thinking that chemotherapy has done the trick, and they look normal. So that is why look into the CT scan before the chemotherapy, and know that, well, I need to really, really look very hard in those areas. And if I find anything which doesn't look absolutely normal, I still need to remove it. So that is what I think. It's like a GnRH effect, maybe something like what you find in fibroids, you know, once your pattern, you know, GnRH effect goes after your chemo, they will bounce back in those areas. And if you follow your recurrence pattern, and I know because I did, you would find that when you start off your training, and you're removing, leaving all these disease behind in the upper abdomen, because you think it's all gone with the chemo, when your disease will come back, you would see a lot of disease coming back in diaphragm, upper abdomen, splenic hilum, lesser sac, you know, all that sort of areas. Once you start, you know, adopting a practice of whether it's primary or it's neoadjuvant, but after looking into the disease distribution, you will find your rate, and it's your heart, you know, you need to be convinced yourself, you know, you can't just fool anybody else, you fool yourself, basically. You look into your data, and you will find that you are finding less and less peritoneal recurrences. And all your duration of having your recurrences and the distribution of recurrences are different, once you start taking this approach. Planning and execution, again, as I say, it's a huge thing, you know, you've got ADAS, you need to do a lot of pre-optimization, you might need to drain ascites, pleural effusion to make them fitter. I mean, if your lungs is not great, your anesthetist can't give anesthesia for, you know, 10 hours, but you can, you can, you know, you put into like exercise, I tell my patients, this is like running a marathon, I can't do it tomorrow, right? You know, like as a marathon runner would train beforehand with exercise, diet, fitness training, so I'm going to put you in a fitness program for at least two to three weeks, sometimes even up to four, it doesn't matter, but once they're more fitter, they can tolerate it better. So that's the, that's the analogy I give to my patients. And then as I say, you have to really have a pre-operative meeting, immediate pre-surgery communication that is just before the day you group, this is what we find, this is a CT, this is what we're going to do, these are the organs which are likely to come out, this is the expected duration, these are the things that I need, calm theater environment, it's very important that people are not shouting, screaming, getting agitated, you know, you really need to have somebody who can anchor the role if somebody is getting agitated. Sometimes it's a senior nurse, they're really good into it, that, you know, keeping the doctors on the check if somebody is losing their patience or, you know, losing control over trainees, or trainee has done something wrong, you lose patience, you know, it can't be like that, you know, mistakes will happen. You're always working on difficult, with a knife or a 200 degree blade on some difficult organs, right? Mistakes are bound to happen. But if you know how to bail them out, then you can maybe avoid that shouting, screaming, or that sort of environment. And HALT, if you're hungry, angry, lazy, and tired, HALT. That's important, you know, for surgeons, again, you know, we don't need to carry on, we can always regroup. And that's important for a surgical point of view. Postoperatively, I always tell my management that, you know, we have a tertiary center for cardiothoracic, we are a tertiary center for trauma in UK. But in spite of everything, conducting a multi-organ surgery like we do in ovarian cancer surgery is the most complex and most complicated surgery in our, and even a transplant, a liver, because a single organ, you know, they've got, when you do multi-organ resection, you know, you've got chest, you've got abdomen, you've got peritoneum, peritoneum is a massive organ, you know, gut, spleen, I mean, what not, I mean, I think I would just leave the kidneys behind sometimes. But then, you know, this is one of the most complex surgeries in your entire, in your hospital, and you need to convince your management to buy in, especially for the close vigilance. And I think I just want to maybe last, maybe five, six slides, I don't know how much time I've got left, maybe another five minutes. So, you know, just look into this distribution, that, you know, the same ascitic fluid with your tumor cells is now hitting the omentum, and it looks like a cake. It's hitting the liver, there's not no spot of disease there, it's hitting the diaphragm, you see that sort of milliary-milliary disease over there, right? So, it's a seed and soil hypothesis, that means that, you know, it also matters where the tumor is going and sitting, and the type of disease you will find is going to be different in different, different cases. Now, if you find a disease like omentum, like a big plug sitting on the diaphragm, it tells you something about the biology, and you really need to be thinking it's an infiltrative type of disease, it's a good biology, it's not going to respond very well to chemo, maybe you need to be extra aggressive in doing your surgery. We don't know the evidence yet that doing less would be better. So, that's what I think, that looking into, it's not only the where it is, but what type of tumor distribution, whether it's infiltrative or whether it's like a granular type of thing, whether it will be easily coming up with site, you know, with hydroresection, or whether you need to really, I mean, like this sort of disease on the diaphragm, I'm comfortable using diathermy. But if it had been a very difficult plug sitting on the diaphragm, I change, I don't use diathermy, I use more scissors, because, you know, if you use diathermy in that location, you're bound to make a hole in the chest. So, you know, you learn, you know, by these things and, you know, putting or applying your brain, even what instrument you need to use in which location to remove the disease. And it's similar with the bowel. So, again, I normally start, you know, quadrant by quadrant evaluation. And so, basically, because you need to, I take pictures of all the quadrants at the beginning and at the end. So, that's my quality assurance procedure to convince anybody or even myself that I have looked into all the quadrants systematically, not only to the disease distribution, but also the type of disease, whether it's infiltrative or whatever it is. And then again, taking pictures at the end of all the quadrants, so I know whether I have really done a zero job. And I usually start with the omentum, because, you know, the moment you remove the omentum, you straight away, you will see that, you know, intraoperative fluid production is getting less and less, because it's a massive, you know, the surge response, which sets in the intraoperative surge. The moment you remove the big omental cake, you will automatically find that, you know, the fluid production continuing through the operation is less, and anesthetists will be more happy because then they need to get more fluid intraoperatively. So, do the omentum first. Whatever it is, you know, you do the omentum first. Once you've done the evaluation, that you can remove the disease. Then I usually start with the upper abdomen. The reason being, the pelvis bleeds, right? So, if the upper abdomen usually doesn't bleed, the pelvis bleeds, and if you now, the ascites, you know, two, three liters is gone, then, you know, the already patient is in a trickle of noradrenaline or something or they're putting on something or the albumin or whatever, then you lose another couple of liters blood because the pelvis may bleed. Then the patient would be a little unstable. So, you would find then to make a head up. For the liver, you need the head and elevation, right? If the patient starts getting slightly unstable because of the blood loss, fluid loss and all, then you will not be able to put the head up and put your hand or press on the liver or the IVC to do the diaphragm. So, then again, you compromise on sometimes ablation but not resection. So, you know, so that's why I do the upper abdomen first when you can have the patient's head up so that you can position the patient to do the liver mobilization, diaphragm, you can press your hand on the liver because that will cause hypotension and that patient can tolerate at that point of time. So, I start with the upper abdomen, lesser blood loss, all these locations, then you lesser ventral, then the spleen if you need and all that stuff. Then I will do the pelvis because pelvis is always receptible. And a rule, I mean, when you are starting, when you are really 10 years, 20 years, you're doing this job, your speed comes up. But then guidance is for every PCI, usually about three hours. So, if you've got a PCI of 27, then you know it's going to take possibly eight to nine hours, so basically you can intimate the whole team. And I know I'm stepping into this, this is going to be a lengthy procedure, then you set up, okay, I'm going to do the first upper abdomen because this is region, reason, then you do the lower pelvis, I leave at the end, because that's always doable. If there are two exceptions, if I think for some reason, whether the patient does not fit or the patient has got hypertensive or the disease is such that I think I cannot do a zero site reduction, in that case, then I would remove the pelvic first. So you start, then your principle changes, then you do the maximum debulking of the big ovaries and blah, blah, blah first, then you go, then you go, then you start ablating rather than resecting. But when you think that you can resect, then you go for this algorithm. That's what I practice, usually. Again, this paper, again, I look back, we published in 2018, a large, larger series of looking into disease in the lesser sac, and I, we systematically developed an algorithm of looking into supragastric lesser sac, and all these areas, lesser momentum, upper recess, caudate lobe, again anterior-posterior surface, groove of ligament and venosum floor, subpyloric medial site of foramen of Winslow and the lateral site of foramen of Winslow is later on, and celiac node and all. So if you start looking at systematically, then you start looking, actually, there is a percentage of disease, you know, like 24% of cases are the disease you find in the upper recess, 20 to 20% of cases, there is in the caudate lobe, anterior-posterior. So you really need to look, search for the disease, what your eyes, you know, if your mind doesn't know, your eyes cannot see. So you really, and these diseases are all small, all volume, 2.5 millimetre, 5 millimetre. I mean, if you leave all this behind, you can achieve less than one centimetre residual, but never less than 2.5 millimetre residual. And then, according to your new criteria, it will be classed as suboptimal site reduction. So it's important to look into, you know, lesser sac, lesser momentum, all these occult places where you would find small volume disease, and you can refer to this publication. Again, as I say, it's very important, you know, the peritoneal current moves from right to left, right? So, you know, it hits the appendix area first, you would find disease, then the hepatorinal pouch of Morison, then it will find the liver. So you have more disease on the right half of your abdomen compared to your left half of the abdomen, you know, means the left diaphragm. You will always find more disease on the right diaphragm than the left diaphragm. And then the disease from the hepatorinal pouch will find the foramen of Winslow, right? So it goes into the lesser sac, and then also you will find disease on the splenic hilum. You really don't have much disease on the outer side of the spleen. So, you know, that's again another observation, if you start doing more and more, you would find majority of the time your disease is actually near the splenic hilum, but not on the outer surface of the spleen. Even your histological specimens, when you start looking into them in Grossing and your pathologists, of all the splenectomy specimens, you would find you can correlate your finding that which is the side where you find more disease attached to the spleen. Because I'm trying to now see if I can spare the spleen by removing the disease, but not removing the spleen. But then, you know, as I say, outer surface of the spleen, again, would be the rarity. If you started doing thoracoscopy for your chest disease, again, you will find maximum amount of disease is actually on the diaphragmatic surface of the pleura and sometimes on your lower right back. You know, when you stand, when you lie down, you know, wherever your fluid, ascitic fluid with the cells with gravitate, you find disease there. You don't find disease on the upper side of your pleural cavity. So that does that. That's why I say ovarian cancer is mainly a disease of stasis. It's not like in true sense, a metastasis. And that is why it's our saving grace that in our stage for disease, people can still live to 10 years. Again, pleural disease you can manage. And as I say, I just got a few slides that, you know, I think this is a guidance that you really need to know by heart. It's really good, the ESGO guidance on what are the areas you can resect and what you can't. And when you do primary, when you do interval debulking surgery. And I mean, you know, even examples of potentially resectable extra abdominal disease is nodes, retroplural panacardiac nodes, focal parietal pleural involvement, isolated parenchymal lung myths. What does it tell you? That means you really need to pick up your skills. Or if you can't, then you get other people who can do it for you. But that is not an indication for saying, I'm not going to operate on those areas or just put neoadjuvant chemotherapy and turn a blind eye because, OK, now then it's all going to disappear. It doesn't. That's why you see the survival difference in different, different countries. Even the ESGO Resource Stratified Guidelines talks about CC0, like complete site reduction, and then how you achieve it. If you've got only one center in your country which can do it, then send it to them rather you trying to do in a center which can't maybe cater to it. Quality of life. Again, we have a very bad notion that if you do big, big surgeries, you know, then your quality of life is poor. But it's not the case. If you again, as I say, if you look into an evidence based practice rather than a convenience based practice, you would find that the quality of life is not different, even if you are doing very high volume, complex site reductive surgeries. That's why you need a quality improvement program. I'm sure you're doing it. You start from data, database, MDT protocol. Every week you do a reflection risk management like in aviation, like they do, you know, like a risk management, continuous medical audit, education, research. You really need to have that old platform built in. And that's what we did in Kolkata. We started to change our paradigm from IDS to PDS, from optimal to complete, but use the quality indicators for ESGO to continuously guide us through this procedure. And I'm not going to do, but, you know, initially complications will increase, but then you learn how to manage the complications. And then you start seeing the separation of the curves that your survival is increasing, but you have to, you know, go through this process where your complications is high, and then you start shaking. Oh, I'm not going to do it. You have to just, you have to just go past that tip. And then you start seeing that separation of your curves. And as you see your complications will gradually, six months, if you're keeping your data, you see your complication levels are going lower and lower and your survival or your, even your platinum free interval or platinum resistance will get better and better over the time. And I'm not going to go through the slides, but again, an infection, gut microbiome, we have E. coli in 90% of our individuals because everybody has been having antibiotics from childhood, incessant use of antibiotics. So we have a very big problem in having E. coli, Klebsiella, even in preoperative stool samples. So I'm very much cognizant of the fact that the moment I touch the bowel, there's going to be a massive surge response with the gram negative organisms, you know, especially when you have removed all the peritoneum, your barrier, your immune, you know, your immunological barrier in the body is gone. So straight away, your bowel pathogens, if you're not careful, will get into your circulation, right? So you really need to be careful in, you know, making a very good aseptic procedure of handling the bowel. If you see your blood pressure is dropping during operations and all, I don't mind stepping up into the antibiotics because we know that, you know, because of the E. coli and all, we know our antibiogram and when to step. I do not, in India, in my setup, when I don't have the facility to, you know, like take every individual who is leaking or potentially to theater within six to eight hours, I need to be proactive. So, you know, so, you know, in gram negative septicemia, six to eight hours is enough to kill a patient. So, you know, so you have to be sometimes, you know, my antibiotic policy in India is different to my antibiotic policy in the UK because in the UK, I can sit tight, you know, you know, to when the culture comes, blah, blah, blah. But in India, I can't, the patient will die within that window. So I need, I have different strategies. And then you keep on publishing your own data. Otherwise, you know, reading Western data and then applying into your practice or something. But then, you know, once starting, you do your own data, you know how to tweak around it. And that's an essential part. And that's, again, the audit standard of ELCO. And I think it's very useful for fellows to even start doing audit every six months at rate of complex cytoreduction, the number of cytoreductive surgeries, how many have done primary, primary debunking, you know, have you doing frozen section? Have you got MDC? Have you had a research program? Have you, there are 10 quality indicators, right? And you could do it, you know, even the fellows, every month you do your own audit and you would see by the end of two, three years, you are much more better than you start. You don't need to convince the world. If you convince yourself, I think that's good enough. And so that's what I'm going to say. Our patients in my part of the world in India, 10 to 15 years younger. So I really need to be cognizant of the fact I don't have 80, 90 years of old patients like I see in the UK and India. So I need to think differently on how I counsel, how I do things. And then I'm not going to talk about it, but as I say, integrating research is very important to convince even your, so everything you do, if you have a parallel research going on with that, even with CRS4, you know, you look into something different. It just trains your mind better. I think, you know, as a trainee or a young surgeon, I'm not going to go all these things, but just kind of show that, you know, that's where, you know, every patient should have a clinical MDT, a trial MDT, and a precision medicine MDT. That's where we are going into, you know, your case you discussed in the meeting, you have a clinical MDT. You're also doing a precision medicine MDT because you are doing MMR. And then maybe you are thinking whether you would give immunotherapy or not or lynch. And also if you've got a parallel trial going on, which you should have, you know, maybe then you should straight away think, oh, right, this patient should go into this trial. The moment you start doing all three MDTs in a single place, you would elevate your level up to there. So that's, again, important. And as I say, you know, a patient has a right to choose. Implementation step, again, it's the implementation research methodology. I'm not going to do, but just to show that every patient, if you start prospective data collection, you know, that's key. And then analyze. That's what I say that I, during the steps of operation, I always get a small cut. I don't do laparoscopy. I call it hand-assisted evaluation, right? Or mini-laparotomy. Because to me, to find disease in the portal and root of mesentery, I've got very small hands. And I'm sure you guys also have small hands like me, right? So, you know, just within a five, you know, small incision, you put your small hand in, you pick up a loop of bowel, of your small bowel, run through it, you can feel the mesentery. And with that straight supramedical region, you could also feel the portal. And that's good enough. Once I've done this, it takes about 15 minutes straight away from ZIFI to pubic symphysis. I don't spend, I don't waste time. This bit is slow. The next bit is fast. Again, you need to, you know, you need to balance the fast bit and slow bits in your operation because it's a lengthy operation. And then, as you see, your systematic evaluation, look at this plaque in the diaphragm. This is a case of neoadjuvant chemotherapy, right? You know, the lower right hand, left hand side, this is a big plaque. I mean, this you can't ablate, right? Or you can't ignore. You have to resect. And this needs a diaphragmatic resection for this one. You know, otherwise, you will not be able to remove the disease. So again, if you see at the beginning, once I started looking at it, you don't see much on the, if you see the left, the second upper picture, you know, the diaphragm looking like that. Sometimes you do neoadjuvant chemotherapy, look like that. You would just say, oh, I'm just going to just mobilize, you know, just ablate the disease maybe because the rest of it doesn't look that bad. But then once you do a complete mobilization of the liver, then only you start seeing this big plaque. And how do I know? Because I knew from my pre-operative or pre-chemotherapy scan that I had a large volume of disease sitting in the plaque. So that's why I would bother to mobilize the whole diaphragm to even look into that. And you look, well, you see this, right? So that's why, again, don't leave this bit at the end of the day. If it's at six o'clock in the evening, if you now done the whole bit and then you start, this is a big plaque of diaphragm, you won't find colleagues to help you out sometimes. So do this bit first. Again, floor of lettuce sack. I mean, we find disease on the deposits in the groove in the ligament of venosum, caudate lobe. I mean, this, you really need to search for it and then you find. And then, as I say, you could do ZD disease zero. I always put this line that, you know, it's what I say. When I work in UK, which is six months, high resource setting, then my patient will go through this journey. Good site reduction, chemotherapy, intraperitoneal, maybe if it's a trial, BRCA, HRD, PARP, blah, blah, recurrence, morbidity, survivorship. And it all looks seamless. But when I come to a low resource setting, which is my other six months in India and everything in every step of the journey, there is something or the other which is an hindrance. And that's why you really need to have an alternative strategy, a backup strategy. How do you customize that? And most of these cases, you need to have a trial or your own study. And the first bit, as you see, to do a surgery is your IGCS fellowship or training. That's what you need. And I'm not going to do it because I call it an easy strategy that, you know, you need to use the implementation research method. But the key is that involves everybody to evolve. And that's what I say is always a problem. But if you develop the problems or you dissect the problems into skills and operations, and then within skills, there is technical and non-technical. Within operations, again, there is technical and non-technical. You would normally find it's the greatest barrier is actually the non-technical one in the operations is the human attitude. If your attitude is right, you can pick up skills, you can build up everything, you can be humble, and then you pick up on everything. So that's my conclusion, really, that complete cytoreduction, it is the main stage or stay of treatment. It is one of the most complex surgeries in cancer treatment, in your own hospital, maybe. It's a super specialized service. It needs a trained and dedicated team who is highly skilled, precise, has got knowledge, is committed. You need your brain, heart, and hands all working together. And a good outcome can only be achieved if you refer early, if you don't half-operate, if you don't disseminate during operation, and check credentials of the center. So that's the last slide, and thank you for listening.

cytoreductive surgery

ovarian cancer

quality indicators

regional service

pathology

radiology

chemotherapy

multidisciplinary approach