liverpool 2012 report

DDF 2012 |
17-20 June 2012 | Liverpool

The 16th AUGIS Annual Scientific Meeting 2012, Liverpool, was held as part of the Digestive Disorders Federation and was a resounding success with presentations from speakers of international renown and highly informative talks by specialists from across the UK.

The parallel sessions for oesophago-gastric, hepato-pancreato-biliary and bariatric surgery were all well-attended and there was a full house for the AUGIS Plenary session.

The Meeting was preceded by a successful teaching day for trainees and young consultants.
Partners in industry supported the Meeting with a very busy trade exhibition.

The Annual Dinner was held in the Pan Am Restaurant in the historic Albert Dock  and was a great success with dancing to a live band into the early hours.

Training Day:

An Upper GI training day preceded the annual meeting.

The session formed part of a combined postgraduate training day at the 2012 Digestive Diseases Federation. The morning saw a combined gastroenterology and surgical lecture session, where trainees from a number of disciplines enjoyed a true multidisciplinary training experience. In the afternoon, trainees broke out into specialty specific groups.

AUGISt-2012-2

An intensive afternoon saw 25 trainees enjoy a combination of practical and theoretical training sessions supervised by a faculty of 22 consultant upper GI specialists, many of whom were recognised world leaders.
The traditional viva stations saw some sporting discussion between trainees and examiners, and provided useful preparation for those approaching the exit exam.

Virtual MDT stations included surgeons, oncologists and radiologists with access to full real time imaging to allow virtual case management to unfold in a realistic fashion. This provided a useful insight into the oncologic rationale for treatment which is sometimes not immediately obvious during a more formal MDT setting.
The skills stations saw trainees perform a variety of practical procedures on tissue including bowel anastomoses, gastric bypass, HPB dissection and laparoscopic suturing. Using unfamiliar technologies on tissue was a real bonus and provided a fantastic opportunity for trainees to practice these techniques in a safe environment.

AUGISt-2012-1

The afternoon was rounded off by two excellent lectures. Professor David Kerrigan delivered a compelling presentation on the rationale for anti-obesity surgery, whilst Mr Chris Halloran delivered a masterclass on Surgical Management of Acute & Chronic Pancreatitis.

The traditional post-course dinner was held at Gusto on the Albert Dock, with trainees able to relax and enjoy the end of an intense but very rewarding day.

We are indebted to our sponsors Covidien and Ethicon for the success of the day, as well as all the faculty who gave up their Sunday afternoon (on Fathers Day no less!) to provide support.

Rob Jones, Local Organiser, AUGISt
Declan Dunne, Local Organiser, AUGISt
John Hammond, President, AUGISt

 

AUGIS / BOMSS Symposium: Bariatric Surgery
Session 1 chaired by Mr Roger Ackroyd and Professor Yuri Yashkov,

Gastric bypass: laparoscopic gastric bypass controversies
Mr Roger Ackroyd, Sheffield
Click here to read a summary of the talk
Mr Ackroyd started the session with a discussion of controversies around gastric bypass including the circular versus linear stapled anastomosis debate. He also spoke about post-operative problems including staple line bleeds and port site hernia. Pointing out that his Sheffield clinic had dealt with 1,400 patients between May 2004 and May 2012, he said that the weight of numbers was also presenting its own problems. He said: “Our clinics have become so full that we have agreed to discharge patients after two years into the care of their GPs. They need to have annual blood tests and be on a multi-vitamin regime but we cannot administer this from our clinic.” Mr Ackroyd concluded that despite many controversies, gastric bypass is a good option for many patients including “nibblers, sweet-eaters and diabetics.”

Energy expenditure after gastric bypass: just gut hypertrophy?
Dr Marco Bueter, Zurich
Click here to read a summary of the talk
Dr Bueter discussed models which showed energy expenditure with or without gastric bypass. He also spoke about randomised clinical trials and concluded: “Bypass patients show higher energy expenditure compared with other techniques.”

Fat malabsorption after gastric bypass: a flash in the pan?
Mr Alberic Fiennes, London
Click here to read a summary of the talk
Mr Fiennes started his talk by saying: “In the past we have described gastric bypass patients as having a combination of restriction and malabsorption – but I want to challenge this.” Mr Fiennes discussed bypass surgery and research which he said went back to the 1970s and involved surgeons interpreting results and trying to make sense of science. He pointed out that studies show that at 10 years there was no significant difference in BMI between patients left with long or short intestines after operations. He added that complexities make comparing studies difficult, for example, because of differences in intestine lengths and also that evidence for faecal fat is patchy. He also pointed out that patient behaviour can affect study results. Mr Fiennes concluded his talk by suggesting that gastric bypass can be most safely described as having a weight-loss phase and a weight maintenance phase and added: “We should exercise caution describing gastric bypass until there are systematic well-controlled studies.”

Food choices after gastric bypass
Ms Mary O’Kane, Leeds
Click here to read a summary of the talk
Ms O’Kane started her talk by outlining the role of dieticians as: “Helping to prepare patients for their operation and encouraging them to eat healthily after surgery.” She said that her experience showed people could lose a lot of weight post-surgery but that this took a great deal of effort and required a determined change in diet and attitudes. Some of the stumbling blocks post-surgery came from the unrealistic expectations of patients over how much weight loss they could achieve without effort.
Ms O’Kane also described problems faced by patients such a drop in the uptake of vitamins, a poor intake of protein and an increase in snacking. She said: “We all under-report what we eat and the super-obese under-report it by as much as 40% – so we have to be cautious about collecting information from patients.”
However, she also spoke about the positive results achieved by many patients and anecdotal evidence of healthy lifestyles. One patient wrote to her: “It used to be all about the food, now it’s all about the company.”

Banded bypass: Keep you seatbelt fastened!
Dr Marco Bueter, Zurich
Click here to read a summary of the talk
Dr Bueter started his talk by pointing out: “It is important to see that surgery is currently the best treatment for obesity for some patients.” He went on to describe how banded bypasses worked and discussed how to measure success. He said: “It might be best to judge success in individual patients in different ways, for example getting rid of diabetes or seeing a patient playing with their children means more to me than someone losing 50kgs of weight  rather than 40kgs.”
Dr Bueter also discussed differences between studies across the world pointing out, for example, that one study in Australia included follow-up work while one in France had no follow-up. He said this could make it difficult to judge success rates accurately across countries.

Gastric bypass and T2DM: the class leader
Mr Richard Welbourn, Taunton
Click here to read a summary of the talk
Mr Welbourne started his talk by showing a cartoon which suggested that doctors treat diabetes but surgeons cure it, suggesting, he said that “surgeons are heroes.” He went on to discuss the role of endocrinologists in treating diabetes.
Mr Welbourn described and discussed four studies:
1. Adjustable gastric banding and conventional therapy for type II diabetes.
2. Bariatric surgery versus intensive medical therapy in obese patients with diabetes.
3. Bariatric surgery versus conventional medical therapy for type II diabetes.
4. Effect of the definition of type II diabetes remission in the evaluation of bariatric surgery for metabolic surgery.
He concluded his talk by saying: “Surgeons are still heroes but we should express it as ‘they lower HbAC better than anyone’!”

Endobarrier and T2DM: Is it quite the same?
Mr James Bryne, Southampton
Click here to read a summary of the talk
Mr Bryne pointed out that there are two million people with Type II Diabetes in the UK. He then described the Endobarrier and its operation, pointing out that it is intended to stay in place for one year. He said that there was one paper which showed favourable results for patients with diabetes with two-thirds completing the study, a mean insertion time of 42 weeks and 40% excess weight loss over 12 months.
He said it wasn’t easy to compare Endobarriers with gastric bypass results, however, he added: “It is important to note than this device is removed at one year and while some patients may maintain weight loss others will not and diabetes will return.” He cited a case study of one woman with a complex medical history, poorly controlled diabetes and a BMI of 36 which was reduced to 27 after an Endobarrier procedure.

In conclusion, Mr Bryne said: “This is an expensive intervention at present but there are some niche areas where it could have a valuable role, for example, with adolescents. It is safe, reversible and preferable to surgery for some people.”

Session 2 chaired by Mr Alberic Fiennes and Dr Marco Bueter

Gastric emptying and weight loss: fast or slow?
Professor David Kerrigan, Liverpool
Click here to read a summary of the talk
Professor Kerrigan said: ”Patients ask why they feel hungry but never feel full. He explained that “fullness” comes from stomach distension, but that rapid gastric emptying may have a role to play. He also aid that the answer the question: “Is my stomach bigger than other stomachs?” is “No”. “Obese people have the same levels of relaxation of the stomach as lean people. Gastric emptying in obese people is normal overall but a shorter “lag phase” may mean that larger food particles are ejected into the duodenum. Prof Kerrigan then looked at the effects of surgery on gastric emptying and referred to a study which showed that most food passes through a gastric band in less than two minutes and emptying of the stomach is normal. He said: “The band, working other than by restriction, makes some patients feel less hungry.”

 

Weight regain: bahaviour or biology?
Mr Simon Dexter, Leeds
Click here to read a summary of the talk
Mr Dexter started his talk by saying: “Obesity is the pathological consequence of a range of problems.” He said obesity surgery worked in a variety of ways affecting gut hormones, gut hypertrophy, vagal nerve activation, emotional well-being and physical activity. He pointed out that there is variability of effectiveness of different procedures. He then looked at the complex workings of gut hormones and discussed psychosocial issues. He observed that patient behaviours – among them poor diet, alcohol consumption and grazing – can result in weight gain. He looked at therapeutic interventions which could help stem weight regain including dietary improvements, good follow-up care and efforts to help patients avoid a “revert-to-failure” mentality. In summary, he said: “Biology and behaviour are linked. We need to pay attention to both to help curb weight regain after surgery.”

Eating Disorders and gastric bypass: slipping back?
Dr Denise Thomas, Portsmouth
Click here to read a summary of the talk
Dr Thomas looked at binge eating and described it as a life-long disorder for many patients saying: “Patients have problems before surgery and these problems remain after surgery. They are often vulnerable people caught in a cycle of disordered eating and with low self-esteem and negative feelings.” She said that her team asked post-surgery patients to undertake a lot of “ritualistic” behaviours such as chewing slowly and, as these are also associated with diets, there is a risk that it takes patients back to the feelings they had before surgery. She added: “Patients need to be prepared properly before surgery in the hope that we see better outcomes.”

Duodenal switch: incretins and absorption
Prof Yuri Yashkov, Moscow
Click here to read a summary of the talk
Professor Yashkov opened his talk by saying that his unit in Russia performed 903 operations between 1992-2012 and noted the increasing number of patients with type II diabetes. He described complications which can arise from surgery and compared mechanisms of action on different operations. In conclusion, he said: “In our experience duodenal switch is effective for weight-loss and ongoing maintenance. It is also effective for metabolic control but it demands careful follow-up and patient selection.”

Royal College of Surgeons Hunterian Oration
Gut Hormones in Bariatric Surgery
Prof Alan Osborne, Bristol
Click here to read a summary of the talk
Professor Osborne showed a picture of Daniel Lambert which hangs in the Hunterian Museum in London. He said Mr Lambert weighed 50 stone and lived in the 19th century, adding: “Obesity isn’t a new disease and neither are attempts to cure it. We want to treat obesity because it kills people.”
He described a study to find out what happens to gut hormones after laparoscopic RYGB which measured gut hormone changes post-operatively and changes to appetite and satiety. The results showed a significant decrease in hunger. He said that this showed that “gastric bypass alters gut hormone satiety responses to food.”
He then turned to insulin resistance and looked at a study of 23 patients, split into three control groups, which showed a difference in outcome depending on whether the patients had diabetes. He said: “Bypass surgery provides a fascinating model for the study of metabolic surgery but we need to look beyond weight loss and also study diabetic outcomes.”
Prof Osborne then turned to quality of life studies saying: “Pre-operatively, patients who qualify under NICE for surgery generally have a poor quality of life, while post-operatively after 12 months the quality of life is normal.”
He also said that looking at the economic impact of surgery showed how bariatric operations saved millions of pounds. He referred to a study of 78 people which showed that before operations they had worked 1,023 hours per week whilst after operations this figure rose to 1,611 hours, a 57% increase. Before bariatric surgery, the patients were claiming 32 benefits but after surgery this dropped to eight. There was a 75% reduction in disability benefit claims.
Prof Osborne moved on to talk about the incidence of obesity in society compared with the number of bariatric trainee positions around the country. He estimated that  50 new consultant posts would result in a £75 million economic saving.
In conclusion he said: “Bariatric surgery is metabolic surgery. It is cost-effective, patients return to a normal quality of life and it saves lives.”

AUGIS Plenary Session
Session 1 Chaired by Professor John Primrose and Mr Bill Allum

Ablation of liver metastasis and the CLOCC Study
Prof T Ruers, Amsterdam
Click here to read a summary of the talk
Professor Ruers outlined the CLOCC Study which started in 2000 and shows a two-year survival of 69%. He described the design of the study, its eligibility criteria and its aims. He then took the audience in some detail through the results and concluded by saying: “The primary objective of the randomised Phase II trial has been reached.”

 

Neoadjuvant chemoradiotherapy for oesophageal cancer
For: Prof J Lanschot, Rotterdam
Click here to read a summary of the talk
Professor Lanschot put the case for neoadjuvant chemoradiotherapy, pointing out that in the 1980s five-year survival stood at 18% even in very selective trials. He said that since then, efforts to improve survival rates have included improved pre-op selection, a focus on reducing post-op mortality and the inclusion of chemo and / or radiotherapy to the surgical programme. Overall, five-year survival now stands at around 35%.

Against: Prof D Cunningham, London
Click here to read a summary of the talk
For his part, Professor Cunningham pointed out that the big benefit of surgery plus chemo / radio therapy had been seen in squamous cell cancers but not in adenocarcinomas and he argued that the two types of cancer should be studied separately to elicit clearer trial results

 

Session 2 chaired by Professor Graeme Poston and Mr Roger Hardwick

2012 AUGIS BJS Lecture
Prof R Padbury, Adelaide
Click here to read a summary of the talk
Professor Padbury described some of the problems facing modern healthcare practice – variations in practice, care-related harm and high rates of waste. He went on to describe an American health care quality study in 2003 which showed a high proportion of errors and omissions in care. Turning to his own unit – Flinders in Adelaide – he said: “We have started programmes of clinical standardisation to improve care.” Prof Padbury then described the process of protocol  development in his centre, for example, how to gain consensus on how a condition should be managed. He said: “It’s not about whether we should drive on the left hand side of the road or right, but about all of us agreeing to drive on the same side.”  He stressed the importance of measuring performance, giving the example of colonoscopies at his centre which showed that only 37% of procedures followed all the right steps prior to intervention which improved treatment to the benefit of patients. He also showed a slide outlining a slow and steady decrease in mortality over several years, adding: “This isn’t a quick-fix but it is effective.” Prof Padbury added that at his centre new protocols were reviewed after 12 months and then every three years. In conclusion, he said: “Concentrate on the positive, standardise care and measure your results.”

 

Optimal multidisciplinary treatment of gastric cancer
Prof Cornelis van de Velde, Leiden
Click here to read a summary of the talk
Referring to trials, including a Dutch gastric cancer trial, Prof van de Velde, spoke about work to improve outcomes for gastric cancer patients. He said a new trial aims to increase quality and decrease variation in treatment and outcomes. He added: “Nationwide improvements require nationwide interventions.”

Measuring outcomes in upper GI cancer surgery
Mr Bill Allum, London
Click here to read a summary of the talk
Mr Allum spoke about the evolution of cancer services in the UK over the past ten years. He described how quantitative needs have been addressed, for example, through the National Oesophago-Gastric Cancer Audit and he pointed out that the National Cancer Intelligence Network has produced various data sets. Mr Allum looked at routes to treatment including the two-week referral rules and emergency admissions to hospital. He added: “We have to get GPs to refer patients to us as the quicker we see them the better the outcomes.” Looking ahead he said: “There is a lot of qualitative and quantitative data. The key to success is that we have to have professional engagement to ensure that data is professional and can show improvements properly.”

 

Improving outcomes through translational research
Prof P Naredi, Sweden
Click here to read a summary of the talk
Professor Naredi illustrated his talk by describing translational research in pancreatic and gastric cancers in Sweden over the past 40 years. He asked: “How can we improve outcomes? It seems surgery is good for dealing with localised disease but prevention and early detection is better.” He also spoke about advances in the early detection of pancreatic cancer and called for more clinical trials. He concluded by saying: “Translational research improves outcomes in upper GI cancer through prevention, earlier detection and individualised treatment.”

 

Measuring quality at the individual patient level
Prof Jane Blazeby, Bristol
Click here to read a summary of the talk
Professor Blazeby said: “My goal is to achieve a patient-centred service, rather than hospital- or service-centred. We will achieve this by getting feedback – which is an important way of improving services and is very cost-effective.” She described the process of getting meaningful feedback – decide what to measure and when to measure it. Use a reliable and valid questionnaire and consider collaborating with social scientists. Prof Blazeby highlighted two factors which she said were crucial to success in gathering feedback. The first is to believe patients and the second is to integrate the information they provide.

The Oesophago-gastric symposium included many fascinating talks and presentations.

Laparoscopic cardioplasty
Mr M Booth, Reading
Click here to read a summary of the talk
Mr Booth gave an account of a relatively new procedure, cardioplasty, for the treatment of recurrent achalasia . Surgical cardiomyotomy is associated with immediate symptomatic success rates of between 70 and 90% but when patients are followed up for more than 15 years only 50 – 60% of patients are free of troublesome symptoms. Revisional surgery is often difficult. With the technique of laparoscopic cardioplasty the aim is to create a common channel between the fundus and oesophagus.
Mr Booth described a laparoscopic procedure which involved clearing the left lateral side of the oesophagus and the gastric fundus.  A small gastrotomy is made in the body of the stomach and an endo GI stapler is introduced into the stomach. One blade is passed into the oesophagus and the other blade into the gastric fundus along side the oesophagus. At the same time the patient is endoscoped to ensure that the blades were in the correct position.  The staple gun is then fired creating a common channel between the oesophagus and fundus. Between one and two fires of the staple gun are required.
Mr Booth reported the results of seven cases from several centres in the UK.  All were carried out without significant complication. Post-operative gastro-oesophageal reflux had not been seen to be a problem and those patients with some degree of reflux were well controlled on standard doses of a PPI.  The results of this technique were soon to be published in the British Journal of Surgery.

Management of recurrent symptoms
Dr Van Berge, Amsterdam
Click here to read a summary of the talk
Dr Van Berge from Amsterdam described the management of recurrent symptoms. He gave an overview of the rationale for primary treatment of achalasia and pointed out that the results between dilatation and myotomy were fairly equivalent.
For patients who have recurrent symptoms it is quite common to find that the patient’s symptoms and functional data from manometry and barium studies do not always match. One of the main risks factors for treatment failure is a low lower oesophageal sphincter pressure at the time of diagnosis. Most surgical failures were due to an incomplete myotomy into the stomach.  Surgery after multiple previous dilatations was associated with lower success rates. Surgery after one dilatation was associated with 10 year success rates of 72%, however, following multiple dilatations the 10 year success rate from surgery fell to 40%.
The technique of per oral endoscopic myotomy was described. A group in Hamburg have treated 16 patients in this way without any major complication.  A video was shown of the technique which involved endoscopically incising the oesophageal mucosa and then creating a sub-mucosal tunnel down to the gastro-oesophageal junction.The muscular layer of the oesophagus was then divided and the mucosal breach closed with clips.
For patients with recurrent symptoms the concept of gastro-oesophageal junction distensibility was thought to give better assessment of success or failure than manometry or barium studies.  Distensibility is measured by a technique called endoflip.

Upper GI surgery in children
Mr M Jones, Liverpool
Click here to read a summary of the talk
Mr Jones gave an overview of the range of upper GI pathologies seen in children. This included oesophageal atresia and tracheo-oesophageal fistulas, reflux disease and surgical problems in children with neuro-disability.
Mr Jones pointed out that very few children require long term upper GI surgical follow-up. Children with oesophageal atresia have an oesophagus that will never be normal. It is often short, scarred and relatively insensitive and therefore they are prone to severe oesophagitis with minimal symptoms.  It is not known what the long term risk is in these children for the development of malignancy. A small but significant proportion often go on to have fundoplications to control their reflux. These patients are becoming increasingly encountered in adult surgical practice as survival from atresia now exceeds 95%.
Mr Jones pointed out that only a small proportion of children who reflux go on to reflux surgery. The largest group are those children with neuro-disabilities, the majority who undergo some form of anti-reflux surgery at some point in time, sometimes for anatomical reasons.
He described the problem of disordered response to feeding in children with neuro-disabilities. They tend to get severe upper abdominal spasms on feeding and it was found that in these patients carrying out a fundoplication along with a vagotomy and pyloroplasty results in a relatively flaccid stomach and resolution of their troublesome symptoms.

Minimally invasive surgery for gastric cancer
Mr M Shrotri, Liverpool
Click here to read a summary of the talk
Mr Shrotri described the advantages and limitations of laparoscopic surgery for gastric cancer.  He described the Aintree experience between 2005 and 2012 of 65 patients operated on by a single surgeon. Approximately 40 of these cases were for a gastric adenocarcinoma.  There were equal numbers of total gastrectomies and distal gastrectomies. 
Patients undergoing total gastrectomy had a stapled anastomosis and in his experience the Orville stapler probably facilitated the anastomosis. His mean operating time was six hours. His patients were mainly early stage cancers. Mr Shrotri reported one clinical leak and two mortalities.
Mr Shrotri covered the literature of Eastern trials of laparoscopic surgery.  The numbers were small and mainly from Japan, China and Korea. It appears an adequate D2 dissection is possible.  In his experience, lymph node dissection was not a problem and he had retrieved a median of 47 lymph nodes per patient.
His conclusions were that laparoscopic resection for gastric cancer was safe and recovery times were shorter. Long term survival is awaited. The problem in the UK was training due to low case volume. 

Spontaneous oesophageal rupture
Mr R Page, Liverpool
Click here to read a summary of the talk
Mr Page gave an overview of the management of spontaneous oesophageal rupture (Boerhaave’s syndrome). This condition nearly always results in an intra-thoracic perforation. The diagnosis is often late and the patients are very ill. There is often a lot of intra-pleural soiling and management is complex. It is an uncommon condition. There are less than 300 cases annually in the UK. 
The key to the diagnosis is the history. In his experience, a contrast swallow might overlook a rupture and a CT scan with oral contrast gives the best resolution. 
Ruptures are either contained within the peri-oesophageal area in the mediastinum or are trans-pleural.  Management is to de-function the oesophagus by placing the patient nil by mouth and instituting alternative feeding. Any distal obstruction should be relieved.  The pleura needs de-soiling and the rupture needs repairing if possible. This often involves establishing an external fistula because following repair there is nearly always a residual leak. 
The traditional management concept was that perforations diagnosed within 24 hours should be operated on and if the diagnosis was delayed longer than this conservative management was more appropriate.  Mr Page considered that this was outdated.  There is often a lot of pleural soiling and a thoracotomy was the best way to deal with this.  In addition, you needed to have the lung fully expanded to cover the oesophagus. 
Often the defect needs enlarging to define its extent.  Mucosal closure is essential, often over a T-tube.  Pleural or intercostal muscle patches do have a place in some cases.
Conservative management should be with chest drainage, jejunal feeding, trans-gastric drainage and be prepared to operate if the patient deteriorates.
With regards to oesophageal stents, these often slip and he has not been impressed with their use. In his opinion, there is no difference between early and late presentation as far as outcome is concerned.

Anti-reflux surgery – controversies
Mr P Barham, Bristol
Click here to read a summary of the talk
Mr Barham gave an overview of a number of controversies in anti-reflux surgery. Tailoring the type of fundoplication to the patient’s physiological test was discussed. Approximately 20% of patients will have disordered motility and post-operative dysphagia is common following fundoplication. There is no evidence that patients with impaired oesophageal body motility benefit from a tailored fundoplication. 
The use of prosthetic mesh to reinforce the hiatus is controversial. It has been advocated for patients who have developed failures after para-oesophageal hernia repairs. Following para-oesophageal hernias, radiological recurrences occur in between 20 and 60% of cases but symptomatic failures only account for 10 – 20% of cases. The use of mesh around the hiatus is associated with erosion, oesophageal stenosis and dense fibrosis. Complications are probably more common than reported.
With regard to oesophageal lengthening, it has been noticed that since the advent of  laparoscopic anti-reflux surgery and the number of patients undergoing oesophageal lengthening procedures has gone down significantly.  In the small number of patients who have true oesophageal shortening this is probably due to scarring from reflux. A short oesophagus should be considered if there is more than 5cm of stomach within the chest. It has been estimated that approximately 10% of patients undergoing anti-reflux procedures have a short oesophagus but only 3% need an oesophageal lengthening procedure. From the technical point of view, Mr Barham noted that some surgeons advocate vagotomy in order to lengthen the oesophagus.

Decision-making in locally advanced oesophageal cancer
Professor J Lanschot, Rotterdam
Click here to read a summary of the talk
Professor Lanschot pointed out that locally advanced oesophageal cancer is often resectable but there is a substantial risk of lymphatic dissemination and local regional recurrence.  Professor Lanschot covered diagnostics including EUS, CT, neck ultrasound and PET scanning.  Their experience was that PET scanning resulted in 15% false positives and therefore any suggestion of metastatic disease needed verifying by biopsy.
Definitive chemo/radiotherapy was only of proven benefit in patients with squamous cell carcinomas.  There appeared to be no advantage in patients with adenocarcinoma compared with chemo/radiotherapy and surgery.
The management of locally advanced oesophageal carcinoma was either high dose definitive chemo/radiotherapy or lower dose definitive chemo/radiotherapy and surgery as required.
He thought that the challenge for the future was attempting to detect the residual disease after definitive chemo/radiotherapy to allow a decision for surgery to be made.

AHPs

Congratulations to Irene Dunkley, Consultant nurse for organising a very successful nursing symposium at the DDF conference. The session was well attended by nurses and AHPs (despite taking place on Sunday!). The presentations covered a variety of topics relating to GI disease and provoked lively debate and discussion. It was a unique opportunity to be able to link with a number of other associations and learn from others.

The presentation from Dr Alison Leary was of particular interest to specialist nurses illustrating a tool to measure the ‘value’ of the nurse specialist role. Dr Alison Leary is an independent healthcare consultant and researcher with a background in nursing. She developed the SQL database Pandora which articulates the work of nurse specialists and Cassandra – a free tool to help show nurse specialist activities – is invaluable information for managers! www.alisonleary.co.uk and click on the resources section for the Cassandra tool.

 

BJS Prize Paper
Click here to read
AN EXPERIMENTAL STUDY TO DETERMINE THE PATHOGENESIS OF OXALIPLATIN INDUCED SINUSOIDAL OBSTRUCTION SYNDROME
S. Robinson 1, 2,*, J. Mann 2, D. Manas 1, A. Burt 2, D. Mann 2, S. White 1
1HPB & Transplant Surgery, Freeman Hospital, 2Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom

Introduction: Sinusoidal obstruction syndrome (SOS) following Oxaliplatin based chemotherapy is a cause for major concern when undertaking liver resection for colorectal liver metastases. To date no relevant experimental models of Oxaliplatin induced SOS have been described. The aim of this project was to establish such a model which could be utilised to identify potential therapeutic strategies to prevent the development of SOS.

Methods: C57Bl/6 mice were treated with intra-peritoneal FOLFOX (n=10), or vehicle (n=10), weekly for five weeks and culled one week following final treatment. Representative biopsies of the liver and spleen were fixed in formalin and paraffin embedded for histological analysis.
RNA and protein were extracted from snap frozen biopsies of the liver and subject to biochemical, analysis by qRT-PCR and western blot respectively, for markers of matrix remodelling, vascular dysfunction/endothelial damage, DNA damage and cellular proliferation. Serum was separated from whole blood and markers of liver injury (i.e. ALT, AST and Alk Phos) were also measured. Statistical significance was assessed with Mann-Whitney U Test.

Results: FOLFOX treatment was associated with the development of sinusoidal dilatation and peri-venular hepatocyte atrophy on H&E stained sections of the liver in keeping with SOS. This was associated with an elevated serum ALT and AST (p<0.05). Immunohistochemistry for γH2AX demonstrated the presence of DNA damage in the sinusoidal endothelium.
In the liver of FOLFOX treated animals there was up-regulation of key genes associated with matrix remodelling such as MMP9 (p<0.001), MMP2 (p<0.001), Pro-Collagen I (p<0.001) and TGFβ (p<0.001). There was evidence of endothelial damage and a subsequent pro-thrombotic state with up-regulation of PAI-1(p<0.001), vWF (p<0.01) and Factor X (p<0.001).

Conclusion: We have developed the first reproducible model of chemotherapy induced SOS that reflects the pathogenesis of this disease process in patients. Through analysis of this model we have gained insights into the molecular changes that underpin the development of SOS and are now able to test potential therapeutic strategies to prevent it.