Siwan Thomas-Gibson

Imperial College London, Londinium, England, United Kingdom

Are you Siwan Thomas-Gibson?

Claim your profile

Publications (116)900.42 Total impact

  • Mayur Garg · Ana Wilson · Simon Gabe · Brian P Saunders · Siwan Thomas-Gibson

    No preview · Article · Dec 2015 · Endoscopy
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: OBJECTIVES: The aim of this study was to identify risk factors associated with development of high-grade dysplasia (HGD) or colorectal cancer (CRC) in ulcerative colitis (UC) patients diagnosed with low-grade dysplasia (LGD). METHODS: Patients with histologically confirmed extensive UC, who were diagnosed with LGD between 1993 and 2012 at St Mark’s Hospital, were identified and followed up to 1 July 2013. Demographic, endoscopic, and histological data were collected and correlated with the development of HGD or CRC. RESULTS: A total of 172 patients were followed for a median of 48 months from the date of initial LGD diagnosis (interquartile range (IQR), 15–87 months). Overall, 33 patients developed HGD or CRC (19.1% of study population; 20 CRCs) during study period. Multivariate Cox proportional hazard analysis revealed that macroscopically non-polypoid (hazard ratio (HR), 8.6; 95% confidence interval (CI), 3.0–24.8; P<0.001) or invisible (HR, 4.1; 95% CI, 1.3–13.4; P=0.02) dysplasia, dysplastic lesions ≥1 cm in size (HR, 3.8; 95% CI, 1.5–13.4; P=0.01), and a previous history of “indefinite for dysplasia” (HR, 2.8; 95% CI, 1.2–6.5; P=0.01) were significant contributory factors for HGD or CRC development. Multifocal dysplasia (HR, 3.9; 95% CI, 1.9–7.8; P<0.001), metachronous dysplasia (HR, 3.5; 95% CI, 1.6–7.5; P=0.001), or a colonic stricture (HR, 7.4; 95% CI, 2.5–22.1; P<0.001) showed only univariate correlation to development of HGD or CRC. CONCLUSIONS: Lesions that are non-polypoid or endoscopically invisible, large (≥1 cm), or preceded by indefinite dysplasia are independent risk factors for developing HGD or CRC in UC patients diagnosed with LGD.
    Full-text · Article · Sep 2015 · The American Journal of Gastroenterology
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Introduction Due to the varying risks of residual disease that have been reported after removal of malignant polyps, clinicians rely on clinical practice guidelines (CPGs) to inform decision-making. This study qualitatively and quantitatively compared the internationally published guidelines on the management of malignant colorectal polyps. Method A systematic literature search was undertaken to identify malignant colorectal polyp CPGs. Quantitative comparison was based on the Appraisal of Guidelines Research and Evaluation (AGREE II), a validated CPG appraisal tool which assesses 6 domains: scope and purpose; stakeholder involvement; rigour of development; clarity and presentation; applicability; and editorial independence. Histopathological risk factor assessment and treatment recommendations were further analysed for supporting levels of evidence and scientific agreement. Results Eleven International malignant colorectal polyp guidance documents were included. The AGREE assessment demonstrated significant variation in all quality domains across the CPGs. The scope and purpose domain showed the highest level of quality (median: 91%, interquartile range (IQR): 86–97%). The Applicability domain showed the lowest level of quality (median: 43%, IQR: 35–55%). Risk was attributed dichotomously (low/high risk) to malignant polyps in 8/11 CPGs and in a graded fashion in the remainder. Importantly, there were disagreements regarding which histopathological findings carried risk. Significant variation was found for degree of risk between CPGs for resection margins, tumour budding and depth of invasion. No CPG was able to provide a comprehensive analysis when multiple histopathogical risk factors are present in an MCP. The indications for local excision also demonstrated considerable variation. Conclusion There is variation in evidence interpretation and recommendations between widely used malignant colorectal polyp CPGs. Improvements in the underlying evidence base, particularly defining accurate probabilities of residual disease in the presence of multiple histopathological risk factors, are required to allow clinicians to provide personalised care to this complex patient group. Disclosure of interest None Declared.
    Full-text · Conference Paper · Jun 2015
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: These guidelines provide an evidence-based framework for the management of patients with large non-pedunculated colorectal polyps (LNPCPs), in addition to identifying key performance indicators (KPIs) that permit the audit of quality outcomes. These are areas not previously covered by British Society of Gastroenterology (BSG) Guidelines.A National Institute of Health and Care Excellence (NICE) compliant BSG guideline development process was used throughout and the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool was used to structure the guideline development process. A systematic review of literature was conducted for English language articles up to May 2014 concerning the assessment and management of LNPCPs. Quality of evaluated studies was assessed using the Scottish Intercollegiate Guidelines Network (SIGN) Methodology Checklist System. Proposed recommendation statements were evaluated by each member of the Guideline Development Group (GDG) on a scale from 1 (strongly agree) to 5 (strongly disagree) with >80% agreement required for consensus to be reached. Where consensus was not reached a modified Delphi process was used to re-evaluate and modify proposed statements until consensus was reached or the statement discarded. A round table meeting was subsequently held to finalise recommendations and to evaluate the strength of evidence discussed. The GRADE tool was used to assess the strength of evidence and strength of recommendation for finalised statements.KPIs, a training framework and potential research questions for the management of LNPCPs were also developed. It is hoped that these guidelines will improve the assessment and management of LNPCPs. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
    Preview · Article · Jun 2015 · Gut

  • No preview · Article · Jun 2015 · Gut
  • [Show abstract] [Hide abstract]
    ABSTRACT: Introduction Multi-disciplinary team (MDT) working is an established part of cancer care. Limited data is available on their impact for benign complex colorectal polyps. Increased numbers of these polyps are referred to our tertiary centre for further management. Method Polyp MDT comprising of gastroenterologists, colorectal surgeons and histopathologists was established in January 2013 to discuss the management of complex polyps (large or recurrent polyps or those where endoscopic access was difficult). Cases that were referred to individual consultants and had a provisional management plan made were then discussed at the MDT and a consensus management plan was agreed. The impact of MDT management plan was then evaluated. Results 96 cases were discussed between January 2013 and October 2014. Of those 75 (78%) were tertiary referrals. The reasons for polyp complexity included large polyps 53 (55%), those with difficult access 52 (54%) and previous failed attempt 35 (36%). Majority of the polyps were in recto sigmoid, 49 (51%) or in caecum, 32 (32%). In 38 cases (40%) provisional management plan was changed after MDT discussion. This plan was then followed in 80/96 (82%) cases. Combined surgical-endoscopic approaches were proposed in 68 cases (65%). 25/96 patients had polypectomy during a single hospital visit. The remaining cases (71/96) needed further assessment before attempted polypectomy. Complete polypectomy was achieved in 85/96 (89%) of patients: endoscopically in 75/96 cases (78%): 38 by endoscopic excision alone and 37 by combined endo-surgical approaches. Ten polyps were resected surgically. Of the remaining 11 patients no polyps were found in 2 of those referred, 2 patients were referred back their local hospital for surgery, 5 were not fit for a polypectomy and are under surveillance, 1 had metastatic colorectal cancer and 1 declined any intervention. Cancer was found in 7/96 polyps and 6/7 had surgical resection (the remaining patient had metastatic disease). Conclusion The polyp MDT consensus management plan led to a change in the proposed management in almost half of the patients. This resulted in complete polypectomy for a large majority of patients referred to our service. Disclosure of interest None Declared.
    No preview · Article · Jun 2015 · Gut
  • N Ding · WM Yip · B Saunders · S Thomas-Gibson · A Humphries · A Hart
    [Show abstract] [Hide abstract]
    ABSTRACT: Introduction A clinically relevant stricture is usually defined as a luminal narrowing with pre-stenotic dilatation and obstructive symptoms. Surgical resection is an effective treatment for Crohn’s anastomotic strictures, however disease recurrence after 15 years is more than 50%, often with the need for a further resection.1The long-term outcome of endoscopic balloon dilatation is unclear as most cohorts have a follow-up time of less than 3 years. Method All endoscopic balloon dilatations performed at a single centre for patients with anastomotic Crohn’s strictures between 2004–2009 were retrospectively reviewed with the aim of collecting long-term follow up data. The stricture length, signs of disease activity and evidence of upstream dilatation were assessed from imaging. Clinical data on medical therapy and escalation to anti-TNF or thiopurines was obtained. Endoscopic data including disease activity, balloon size and therapeutic success, along with histological reports were recorded. Results A total of 54 patients were identified with a median age of 52 years (46–62). The median follow-up period was 6.48 years (5.34–7.42) with a disease duration of 28 years (19–32). Stricture length at cross-sectional imaging was described in all cases with a median of 20 mm (10–30) with features of active mucosal inflammation at the anastomosis in 38/54(70%) and upstream dilatation in 25/54(46%). At the time of endoscopy, active disease was described in 37/54(68%) of cases, a median balloon dilatation of 15 mmHg was used to achieve therapeutic success in 48/54 (89%). 10/54(18%) subsequently required surgical resection. The median number of dilatations was 2(1–9) with a time to repeat dilatation of 23 months (7.2–56.9) with 31/44 (70%) of patients being managed endoscopically requiring repeat dilatations. There was one perforation which resulted in a resection of the anastomosis and temporary ileostomy. Active disease at time of first endoscopy (p = 0.049) and stricture length >20 mm (p = 0.015) predicted need for repeat dilatations (Table 1). Furthermore, escalation of medical therapy to either azathioprine or anti-TNF appeared to delay time to further dilatation. Conclusion At long term follow-up, 18% of patients required surgical resection. 32% of patients were well with no further endoscopic intervention required. 68% required intercurrent endoscopic dilatations. This is the longest follow-up period in the literature and demonstrates that the effects can be durable if patients have escalation in medical therapy to thiopurine or anti-TNF and avoidance of surgery is possible in a group of patients with anastomotic strictures. Disclosure of interest None Declared. Reference
    No preview · Article · Jun 2015 · Gut
  • [Show abstract] [Hide abstract]
    ABSTRACT: Introduction Colonoscopy is widely practised to reduce rates of colorectal cancer, although it does not confer absolute protection. The most hazardous part of colonoscopy is polypectomy, accounting for the majority of serious complications. It is unclear whether countries around the world have highlighted polypectomy as a specific skill that needs to be taught. The objective of the study was to assess both trainees’ and trainers’ experience of polypectomy training in countries around the world. Method Colonoscopy trainers from 19 countries worldwide (Figure 1)were asked to provide access to local trainers and trainees who would be invited to participate in a survey. An online survey was created asking about trainees’ experience of instruction and trainers’ experience of teaching polypectomy skills. Results Data were obtained from 610 colonoscopists- 348 (57.0%) trainers and 262 (43.0%) trainees. Most (79.6%) of the trainers surveyed were involved in polypectomy assessment weekly. 51.4% of those surveyed said that they used a specific framework when assessing polypectomy. 90.5% of trainees had a primary specialty of medical gastroenterology. The trainees had a breadth of colonoscopic experience, 31.7% having completed more than 500 colonoscopies and 38.2% fewer than 200 procedures. 51.1% stated that the principles of polypectomy had only been taught intermittently. Most (64.1%, 168 respondents) trainees had never been taught the principles of EMR. Only 53.1% of trainees had ever had their polypectomy technique formally assessed by any trainer. Of the 177 trainees who stated that they were competent at polypectomy, 70 (39.5%) had never had a formal evaluation of their polypectomy technique. Conclusion This study, the only in the literature, shows that polypectomy training is variable worldwide with low prevalence of formal competency assessment. There is a need to a) understand the learning curve for polypectomy, b) develop an international consensus defining optimal training methods and c) develop a framework of competency assessment. This should improve the safety of polypectomy and the effectiveness of colonoscopy in preventing colorectal cancer. Disclosure of interest None Declared. Reference
    No preview · Article · Jun 2015 · Gut
  • Source
    MK Matharoo · R Baldwin · A Haycock · J Jenkins · D Burling · N Sevdalis · S Thomas-Gibson
    [Show abstract] [Hide abstract]
    ABSTRACT: Introduction The colorectal cancer multidisciplinary team (CRC MDT) provides a common pathway for patients from Bowel Cancer Screening (BCS), symptomatic (SYM), 2-week wait (2WW) and tertiary (TER) pathways. These pathways are complex and variable and hence error prone. Improved endoscopic techniques have transformed CRC management but little is known about improvements required for the MDT. Enhancing MDT quality by addressing errors can raise quality assurance at the bridge between diagnostic and therapeutic pathways. Objectives: To prospectively record Patient Safety Incidents (PSIs) identified at CRC MDT across different patient pathways. Method Two independent clinical observers prospectively evaluated CRC MDTs in real time. Patients were subcategorised by clinical pathway: BCS, 2WW, SYM and TER. PSIs were noted qualitatively for each patient and subsequently categorised. PSIs were defined as near misses, adverse events and sub-optimal clinical processes negatively impacting the patient’s cancer care. Results 412 MDT patient discussions (SYM n = 165, 2WW n = 97, TER n = 97 BCS n = 53) over 27 meetings were prospectively analysed. Medical notes were unavailable for 73 (21%) patients. 146 PSIs were identified: SYM n = 62 (42%), 2WW n = 37 (25%), TER n = 31 (21%), BCS n = 16 (11%). There was a trend towards more errors in the SYM group and fewer in BCS, although there was no significant difference between groups (p = 0.39). Table 1illustrates examples of severe PSIs. Many PSIs related to miscommunication, incomplete clinical data and poor non-technical skills such as leadership and inclusive team discussion. Although many PSIs did not have direct patient consequences they represent areas for improvement to avoid future significant errors. Conclusion Multiple errors were observed across the CRC MDT irrespective of patient subgroups. We propose a minimum patient data set and MDT team training in non-technical skills. Further work is underway to categorise PSIs by expert consensus, identify strategies to prevent avoidable error and ensure accountability for correcting errors. Examining PSIs arising outside the MDT provides a valuable opportunity to correct errors in other parts of the cancer pathway that may otherwise go un-noticed. Disclosure of interest None Declared.
    Full-text · Article · Jun 2015 · Gut
  • MK Matharoo · R Baldwin · J Jenkins · D Burling · A Haycock · N Sevdalis · S Thomas-Gibson
    [Show abstract] [Hide abstract]
    ABSTRACT: Introduction Significant improvements in the quality assurance of endoscopy have occurred driven partly by Bowel Cancer Screening. The same focus on quality however, has not been applied to the Colorectal Cancer (CRC) MDT process where key management decisions are made for patients diagnosed with CRC. Objectives: 1. Quantify quality of clinical information at MDT 2. Quantify core specialty contribution to MDT. Method Two independent clinical evaluators prospectively rated CRC MDTs. A previously validated MDT team evaluation tool1was adapted following tiered focus groups with core members. This tool objectively measures quality of clinical data, relative contribution and quality of discussion by core specialities and case note availability for each patient. Results 412 MDT patient discussions over 27 meetings were prospectively analysed (216 pre and 196 post-treatment). 217 (53%) patients were double-rated. Inter-rater reliability was acceptable with weighted kappa coefficients of 0.52 for information and 0.37 for specialty input scores. The mean scores are presented in Table 1for information and Table 2 for specialty input. Patient-focussed information (i.e. patient preferences and background) was poorly presented whilst clinical data (e.g. Radiology) scored higher. The quality of MDT discussion and decision-making from core members was highly variable with surgeons scoring highly compared to specialist nurses. Mean time per patient discussion was 4.46 min (range 1–18 min). Medical notes were unavailable for 73 (21%) of patients. Conclusion This study demonstrated variability in information provision and discussion from contributing team members. However, a limitation of the rating tool is that a low score is assigned (no contribution) even when no specialty specific contribution is required. This may explain the low scores for Endoscopists and Liver Surgeons, as their expertise was not required for all cases. The MDT tends to focus on 'clinical' discussions and may neglect relevant patient-focussed information. Optimal MDT decision-making requires attention to technical factors (e.g. availability of key information) and non-technical factors such as inclusive discussion, leadership and teamwork skills. Disclosure of interest None Declared. Reference
    No preview · Article · Jun 2015 · Gut

  • No preview · Article · May 2015 · Gastrointestinal Endoscopy
  • [Show abstract] [Hide abstract]
    ABSTRACT: Introduction Although colonoscopy is considered the optimal procedure for bowel cancer screening, it remains an imperfect tool for cancer prevention, due to missed adenomas and early cancers. The Endocuff is a simple device attached at the end of the colonoscope that opens up the field of view by retracting folds during withdrawal. Little is known regarding the Endocuff’s impact on a colonoscopist’s performance. Method The aim of this study was to evaluate the impact of the Endocuff-visionTM(ARC Design Ltd, UK) on the quality indicators for each operator. A prospective observational evaluation study was performed from April 2013 to September 2014, divided in three consecutive periods: pre-cuff (no device used), during-cuff (device used) and post-cuff (no device used). Four screening endoscopists (BPS, STG, NS, AH) utilised the Endocuff-visionTMat their own discretion when device was available to them. Quality colonoscopy indicators {(Adenoma Detection Rate (ADR), Mean number of adenomas per procedure (MAP), Caecal intubation time (CIT)} were analysed (t-test two sample assuming equal variances) in equivalent number of procedures. The total number of procedures performed was 399, 133 per period (BPS/26, STG/53, NS/31, AH/23). Results The mean ADR was 55.13% in the pre-cuff period, 68.98% in the during-cuff period and 61.74% in the post-cuff period. All four operators showed significant improvement in detection when using the device, which resulted in an overall increased ADR of 13.8% (p < 0.05). During the post-cuff period, the detection performance of the three endoscopists declined while maintaining a high detection rate. The mean MAP was 1.2 in the pre-cuff period, 2.2 in the during-cuff period and 1.55 in the post-cuff period. The mean MAP increased significantly in all four operators at the during-cuff period (83%, p < 0.05). During the post-cuff, 3 endoscopists returned almost to the baseline MAP pre-cuff level. The mean CIT was 9.66min in the pre-cuff period, 7.5min in the during-cuff period and 9.54min in the post-cuff period. A decrease in mean CIT was featured (22.36%, p < 0.005) to all operators when using the device, returning to about the pre-cuff levels afterwards. No complications were reported from the use of the Endocuff-vision although it was electively removed in 4 cases with severe sigmoid colon diverticulosis and one case due to anal discomfort. Conclusion In this study, use of the Endocuff-visionTMimproved overall performance by making colonoscopy a quicker (CIT) and more efficient (MAP/ADR) procedure. Further randomised evaluation of this simple novel device is warranted. Disclosure of interest None Declared.
    No preview · Article · May 2015 · Gastrointestinal Endoscopy

  • No preview · Article · May 2015 · Gastrointestinal Endoscopy

  • No preview · Article · Apr 2015 · Gastroenterology

  • No preview · Article · Apr 2015 · Gastroenterology
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Introduction This study provides an overview of the longest-running colonoscopic surveillance programs for colorectal cancer (CRC) in patients with ulcerative colitis (UC). Methods Data were obtained from medical records, endoscopy and histology reports. Primary end points were defined as death, colectomy, withdrawal from surveillance, or censor date (January 1, 2013). Results A total of 1,375 patients were followed-up for 15,234 patient-years (median, 11 years per-patient). Cancer was detected in 72 patients (incidence rate (IR), 4.7 per 1,000 patient-years). Time-trend analysis revealed that while there was significant decrease in incidence of colectomy for dysplasia (linear regression, R= -0.43; P=0.007), IR of advanced CRC and interval CRC have steadily decreased over last four decades (Pearson’s correlation, -0.99; P=0.01 for both trends). The IR of early CRC has increased 2.5-fold in the current decade compared with last decade (Chi-squared, P=0.05), however, its 10-year survival rate was high (79.6%). The IR of dysplasia has similarly increased (P=0.01), potentially attributable to recent use of chromoendoscopy, which was twice more effective at detecting dysplasia compared with white-light endoscopy (P<0.001). CRCs were frequently accompanied by synchronous CRC or spatially distinct dysplasia (37.5%). Finally, the risk of CRC was not significantly different between “indefinite” or low-grade dysplasia (log-rank, P= 0.78). Conclusion Colonoscopic surveillance may have a significant role in reducing the risk of advanced and interval CRC while allowing patients to retain their colon. Given the ongoing risk of early CRC, patients with any grade of dysplasia who are managed endoscopically should be monitored closely with advanced techniques.
    Full-text · Article · Mar 2015 · The American Journal of Gastroenterology
  • [Show abstract] [Hide abstract]
    ABSTRACT: National bowel cancer screening programmes have resulted in a significant shift to earlier stage colonic malignancy at diagnosis. Yet the primary treatment, colectomy, is morbid with complications in up to 40% of patients. New minimally invasive local excision techniques are being developed, but methods to assess local lymphatic staging more accurately, such as sentinel lymph node mapping, will be needed. In this video vignette we detail the use of near-infrared (NIR) laparoscopic sentinel lymph mapping in two patients with early colon cancer. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.
    No preview · Article · Mar 2015 · Colorectal Disease
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Suboptimal adenoma detection rate (ADR) at colonoscopy is associated with increased risk of interval colorectal cancer. It is uncertain how ADR might be improved. We compared the effect of leadership training versus feedback only on colonoscopy quality in a countrywide randomised trial. 40 colonoscopy screening centres with suboptimal performance in the Polish screening programme (centre leader ADR ≤25% during preintervention phase January to December 2011) were randomised to either a Train-Colonoscopy-Leaders (TCLs) programme (assessment, hands-on training, post-training feedback) or feedback only (individual quality measures). Colonoscopies performed June to December 2012 (early postintervention) and January to December 2013 (late postintervention) were used to calculate changes in quality measures. Primary outcome was change in leaders' ADR. Mixed effect models using ORs and 95% CIs were computed. The study included 24 582 colonoscopies performed by 38 leaders and 56 617 colonoscopies performed by 138 endoscopists at the participating centres. The absolute difference between the TCL and feedback groups in mean ADR improvement of leaders was 7.1% and 4.2% in early and late postintervention phases, respectively. The TCL group had larger improvement in ADR in early (OR 1.61; 95% CI 1.29 to 2.01; p<0.001) and late (OR 1.35; 95% CI 1.10 to 1.66; p=0.004) postintervention phases. In the late postintervention phase, the absolute difference between the TCL and feedback groups in mean ADR improvement of entire centres was 3.9% (OR 1.25; 95% CI 1.04 to 1.50; p=0.017). Teaching centre leaders in colonoscopy training improved important quality measures in screening colonoscopy. NCT01667198. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
    Preview · Article · Feb 2015 · Gut
  • Laura J Neilson · Roisin Bevan · Simon Panter · Siwan Thomas-Gibson · Colin J Rees
    [Show abstract] [Hide abstract]
    ABSTRACT: This special report focuses on the current literature regarding the utility of terminal ileal (TI) intubation and biopsy. The authors reviewed the literature regarding the clinical benefit of TI intubation at the time of colonoscopy and also the evidence for TI intubation as a colonoscopy quality indicator. TI intubation is useful to identify ileal diseases such as Crohn's disease and additionally as a means of confirming colonoscopy completion when classical caecal landmarks are not confidently seen. Previous studies have demonstrated that TI intubation has variable yield but may be more useful in patients presenting with diarrhea. Reported rates of TI intubation at colonoscopy vary. The authors demonstrate that terminal ileoscopy is feasible in clinical practice and sometimes yields additional clinical information. Additionally it may be used as an indicator of colonoscopy completion. It may be particularly helpful when investigating patients with diarrhea, abnormalities seen on other imaging modalities and patients with suspected Crohn's disease. TIs reported as normal at endoscopy have a low yield when biopsied; however, biopsies from abnormal-looking TIs demonstrate a higher yield and have greater diagnostic value.
    No preview · Article · Jan 2015 · Expert Review of Gastroenterology and Hepatology
  • NS Ding · W Yip · M Hanna · B Saunders · S Thomas-Gibson · A Humphries · A Hart

    No preview · Conference Paper · Jan 2015

Publication Stats

967 Citations
900.42 Total Impact Points

Institutions

  • 2008-2015
    • Imperial College London
      • Section of Biosurgery and Surgical Technology
      Londinium, England, United Kingdom
  • 2002-2015
    • St. Mark's Hospital
      Harrow, England, United Kingdom
  • 2009
    • WWF United Kingdom
      Londinium, England, United Kingdom
  • 2004-2009
    • St. Mark's Hospital
      • Surgery
      Salt Lake City, Utah, United States