The 14th Annual Scientific Meeting of AUGIS,
September 9-10, 2010
AUGIS Scientific Meetings continue to go from strength to strength. The very successful 14th Meeting, held in the heart of Oxford, saw presentations from several speakers of international renown, an array of talks from highly-regarded specialists and fascinating insights from specialists.
The Friday parallel sessions numbered four, with robust sub-groups in oesophago-gastric, hepato-pancreato-biliary, bariatric and the increasingly active Affiliates group.
The Meeting was preceded by a well-attended teaching day for trainees and young consultants and this also went extremely well.
Partners in industry supported the Meeting which included a busy trade exhibition which took place in a central marquee.
The Annual Dinner was held in the Great Hall of Christ Church College following a drinks reception. This was a truly wonderful evening with delicious food and good company in a magnificent setting and ended with music from a brass quintet.
The AUGIS Training Day has now become an integral part of the annual AUGIS Conference, and on Wednesday, September 8 2010 the third AUGIS Training Day was held at the John Radcliffe Hospital, Oxford.
We had an unprecedented array of experts to teach them, including all six Past Presidents of AUGIS, the current AUGIS Council Members, some of our International Speakers and seven local Oxford Consultant Surgeons.
In the morning the trainees split into two groups – oesophagogastric/bariatric and hepatopancreaticobiliary – for concurrent sessions on operative surgery. The OG session was run by the local Oxford OG Surgeons, Nick Maynard, Bob Marshall and Bruno Sgromo while the HPB session was run by the local Oxford HPB Surgeons, Zahir Soonawalla, Peter Friend, Michael Silva and Jens Brockmann. Don Low and Ugo Boggi joined the OG group and HPB group respectively. The sessions were based around DVDs of operations, and were lively and interactive. As expected, the contribution from Don Low was particularly good!
In the afternoon the AUGIS Past Presidents and Council Members joined the Training Day for a session of group tutorials entitled “What do I do now?” This provided a unique opportunity for the trainees to be vivaed by a spectacular selection of experts. Many found it very reassuring to see the experts frequently arguing amongst themselves about the best way of managing some difficult problems!
There then followed two interactive lectures from the outgoing (Simon Paterson-Brown) and incoming (Graeme Poston) Presidents of AUGIS with advice on pursuing careers in OG and HPB surgery respectively. The day finished with a symposium on the Management of Liver Metastases, sponsored by Merck Serono.
There was a fantastic turnout from both trainees and trainers, and the AUGIS Training Day is now a permanent fixture on the day before the Annual Meeting.
Day 1 – Symposium – Complex Upper GI surgery and complications
Chaired by Mr Simon Paterson-Brown and Mr Merv Rees
Prof Rene Adam, Paris
Revisional Liver Surgery
Summary of the talk
Prof Adam started his talk by saying: “In spite of our efforts to undertake as much curative surgery as possible, many patients will re-present for repeat hepatectomy. There is an increasing demand for repeat surgery in this field.” Prof Adams said he believed that the reasons for this increased demand were three-fold:
- The spread of disease at the time of the first operation
- Natural progression and metastasis
- inadequate resection margins at the time of the first operation
He then pointed to advances in skills and techniques and said that despite the risks, he believes that surgery is often the best option even for patients with a poor prognosis, for example, a high number of tumours. However, Prof Adam also referred to the many technical problems connected with second and subsequent resections, such as changes in the vascular structure of the liver.
Of those patients who come forward for resection and are deemed suitable, the operation is generally successful with a low mortality rate of 1.9% and a complications rate which runs at around 25%. Five-year survival is 40%.
Prof Adam then outlined a Japanese study on patients with a poor prognosis which concluded that curative resections are safe and a good option.
He then went on to discuss patients who came forward for a third hepatectomy – saying that he believed a third hepatectomy for colorectal metastasis was a safe option in many cases – and added: “In the near future we are likely to be talking to more patients about a fourth hepatectomy.”
In the light of this, Prof Adam recommended that surgeons consider the possibility of future resections at the time of the first operation. He concluded by saying:
- A first liver resection should be complete but economic preserving as much future remnant liver as is technically feasible.
- Repeat hepatectomies offer a survival benefit which is comparable to a first operation and should be considered as part of a multi-modality approach
- Further resections may be the best way to achieve long term remission for some patients.
Dr Don Low, head of Thoracic Surgery and Thoracic Oncology,
Virginia Mason Medical Centre, Seattle
Categorising complications of Upper GI surgery and their cost
Summary of the talk
Dr Low pointed out that “complications are the single greatest factor which influences cost but is rarely investigated.” He reported that such studies as existed showed that complications across institutions range from 23 -72% and that age is one of the factors which affect the rate of complications with problems increasing across the age range from 40-80 (although there are also a high rate of complications in the under-40 age group).
He said that an ideal system for classifying complications would be:
- Simple to apply
He discussed a severity grading system used to categorise complications called the Accordian Severity Grading System which he says can be used to compare outcomes between similar operations across different institutions.
He said: “The cost of providing healthcare in the USA was $2 trillion in 2005 and this figure has increased by 2.5% each year since. This is not a sustainable situation and the Government is increasingly looking at ways to reduce costs. I have to say that if people die quickly of their complications they become less expensive but surgeons don’t see this as a good outcome.”
As an example Dr Low pointed out that anastomotic leaks increase the cost of an individual’s healthcare by two and a half times.
He has set up a study group to help move the issue forward, called the International Study Group of Complications Associated with Oesophageal Resections.
In the discussion which followed Dr Low’s excellent presentation, part of the debate concerned differences between the US and the UK and organisations within the two countries which analysed healthcare and promoted best practice across institutions. Dr Low conceded that the UK is ahead of the US in establishing nationwide procedures through organisations such as NICE but did point out the very active consumer group, Leapfrog, in the US which is dedicated to analysing outcomes in the health system.
Dr Harry Frydenberg, Melbourne
President, Epworth Centre for Bariatric Surgery
Managing complications of weight loss surgery
Summary of the talk
Dr Frydenberg started his talk by giving a brief personal history of his route to surgery. He said he started doing bariatric surgery in Australia in 1974 when it was considered a slightly odd choice for a surgeon and a niche interest. At that time complications following bariatric surgery were more common than today and included malnutrition, vomiting and stromal stenosis. Dr Frydenberg said that most complications could be resolved, for example, by restapling, oversewing leaks or giving supplementary diets. He added that in the early days many operations had to be redone but that techniques have obviously been improving over the years.
The late 1990s saw the introduction of the adjustable gastric band which was first offered through open surgery and then laparascopically. Complications of this procedure included slippage, pouch dilation and perforation. Dr Frydenberg said that the ideal position for a gastric band was to lie from 2 to 8 o’clock across the stomach.
He pointed out: “Primary gastric surgery is straightforward but once you get into revisional surgery it’s a different ballgame. These operations can be tricky and complex. There is also the question of what to do if you have to remove a gastric band – do you replace it or go for another procedure or none?”
The presentation included three interesting video clips of Bariatric surgery techniques.
Day 1 – Session 2, Lecture
Chaired by Mr Nick Maynard
Prof Paul Johnson, Director of islet Transplant Programme, University of Oxford
Pancreatic Islet Transplantation – from Bench to Bedside
Summary of the talk
Prof Johnson gave a fascinating insight into islet transplantion and said he would be focusing on allo-transplantation for insulin-dependent diabetics.
He pointed out that most patients are diagnosed as insulin-dependent before the age of 20, so treatments must be appropriate for young people and ideally associated with the fewest possible complications. He said that the benefits of islet transplantation are that it is minimally invasive, applicable to children and has the potential to restore normoglycaemia. He added: “Islet transplantation is applicable to children, whereas pancreas transplants are not due to morbidity issues.”
Prof Johnson then outlined the islet transplant process, describing how the islets are removed from the pancreas, purified and separated. He made reference to strict EU guidelines which have been in place for the past 20 years. He then described the transplants themselves and discussed post-transplant procedures.
In terms of results he said that between 1990 and 2000, 493 procedures were carried out in 40 institutions and of these patients, just 11% achieved insulin independence. Prof Johnson commented: “At that time this was looking like a therapy which would prove hard to move from bench to bedside.”
However, he said that the situation changed post-2000 following key research and trials in Edmonton which led the way to much greater success – one factor being that large numbers of islets were used in the operations.
Currently 85% of islet transplant patients are insulin-independent at one year but Prof Johnson said that current challenges included:
- Variability of human islet isolation
- A shortage of donor organs
- Immunity challenges
Finally, looking to the future, Prof Johnson outlined work around stem cells, studies to encapsulate the islets to offer them better protection during transplant and manipulation of T-cells to boost results.
He concluded by saying that islet transplantation works well with selected patients, there are ongoing challenges around donors (because there is an increase in donors with marginal organs, for example, organs with layers of fat around them) and that development of immune tolerance protocols are needed before the treatments can be made available to children.
Day 1 – Symposium – New Technologies in Upper GI Surgery
Chaired by Mr Iain Tait and Mr Roger Ackroyd
Dr Harry Frydenberg, Melbourne
New Interventional Modalities in Metabolic Surgery
Dr Frydenberg discussed the merits of the Duodenal JeJunal Bypass Sleeve (Endobarrier Liner) which is still in the research phase in the Netherlands, the USA and Chile.
He described the sleeve which mimics a gastric bypass, sits in the small bowels and works by not allowing food to touch the sides so it can’t be absorbed. Referring to randomised trials – in which the comparator group was diet-based – he said that out of 41 operations, there were four fails and minimal side-effects. After 12 weeks, results showed 19% excess weight loss over the comparator group. Results had been particularly beneficial to the eight patients in the trial who were diabetic.
Dr Fydenberg went on to talk about second generation devices which slow the rate at which food passes along the tube. A recent cohort study has shown excess weight loss of 39.6% for these devices although there have also been complications. Several patients had to have the restricting ‘hole’ in the gastric sleeve widened.
He concluded by saying that gastric sleeves are safe and effective, offer long term stability, show good results for people with Type 2 Diabetes – but he said that they are not a replacement for other surgical options just yet.
Prof Uggo Boggi, Pisa
Robotic Pancreatic Surgery
Prof Boggi spoke about the benefits of robotic surgery which he practises in Italy. These include the ability to be incredibly precise during operations as the robot allows for tremor control and scaling-up of movements.
The downsides of robotic surgery include the high cost and lack of direct contact between surgeon and patient. Prof Boggi said that robotic procedures may be best if limited to one abdominal quadrant.
He went on to describe clinical trials using robots ad then showed a series of fascinating video clips of robotic surgery in progress, saying: “The visual clarity using the robot is incredible – for some reason I see better using the eye-piece than I do in real life.”
Following the video presentation he ran through the results of robotic trials and concluded: “This could work. It’s reasonable safe and you can reproduce exactly what you would do in open surgery.”
Mr Sri Kadirkamanathan
Mr Kadirkamanathan gave the symptoms of gastroparesis as chronic nausea, vomiting and bloating and said the problem would be manifest in 20-40% of patients with diabetes. Problems with blood glucose may be the first indication of its presence.
In terms of solutions he pointed out that diet – frequent small meals, liquid meals and low fat, low fibre meals – and drugs were options. Turning to surgery he said that results with gastronomy tubes were good but there are side-effects.
He went on to say that the latest thinking pointed towards gastric pacing using electrical stimulation. A film clip was used to illustrate a robot-assisted gastric pacing procedure and trial studies were discussed which gave a mixed picture.
Mr Kadirkamanathan concluded by saying that gastric pacing appears to produce significant improvements to nausea and vomiting over a prolonged period of study.
Mr Barry Paraskevas
Single Port Laparascopic Surgery
“No scars” is the promise of single port surgery said Mr Paraskevas as he outlined the surgical options of open surgery, minimally invasive and natural orifice transluminal surgery. He said of the technique which uses the belly button as the entry point for surgery: “We are striving for trauma-free surgery.”
Mr Paraskevas referred to a survey of 1,006 people which showed that 37% were comfortable with the use of new surgical techniques and that single port laparascopic surgery was the first choice of many. He said that single port surgery is often particularly welcomed by children and their parents.
He then described how to use the single port via the belly button and gave an example of operation in which a patient had their gall bladder removed through a single port. Single ports can be a good option for obese patients, he added, as they use the thinnest part of the abdominal wall.
Mr Paraskevas show a film clip of a patient – a woman in her 30s – have a single port procedure and explained how the surgeon can use sutures which pass through the body wall to act as the ‘left hand’ of the surgeon and mimics the action of open surgical techniques.
Of his 241 cases so far, the mean operation time is 43 minutes and most patients were discharged as day case or overnight cases.
In terms of challenges, Mr Paraskevas called for more clinical trials and industry support and said that staff engagement was also crucial for success.
Day 1 – Lecture
Chaired by Mr Richard Charnley
Pre-operative biliary drainage and pancreatic surgery
Dr Olivier Busch, Amsterdam
Day 2 – Oesophagogastric
Chaired by Prof Derek Alderson and Mr Bill Allum
Day 2 – Hepatopancreatobiliary
Chaired by Prof John Primrose and Mr Giles Toogood
Prof Peter Friend, Oxford
Prof Friend said that currently many patients with diabetes die on the transplant lists and that transplants are necessary to improve quality of life and limit the symptoms of diabetes. He pointed that, following renal failure, life expectancy for people with diabetes is around five years.
However, he also highlighted the long-term risks of surgery, for example cancer.
Patients suitable for transplant include:
- People with chronic renal failure
- Those who have had a previous successful kidney transplant
- People who have hypoglycaemic unawareness
- People with brittle diabetes
Prof Friend related the history of the procedure with the first transplant successfully taking place in 1966. He discussed key developments and the management of exocrine drainage.
In the UK transplants rose steadily from around 60 a year in the early days to 200 a year by 2006. There has been a slight fall in the last few years as the quality of organs has declined often due to having excess fat on them as the population as whole increases in size. In 2009, for example, there were 491 donor organs but many weren’t converted into transplants.
Prof Friend said that there are few studies which measure quality of life after a transplant but that most people would intuitively feel that patients who have become insulin-free would be happier.
At Prof Friend’s unit in Oxford there were 358 transplants between 2004 – 2010 with a 95% survival rate and a 23% complication rate.
He concluded his talk by saying that surgeons should consider operating at an earlier stage to reduce some of the complications associated with late transplants. He also called for an expansion in donor and recipient criteria.
Robotic Liver Surgery
Prof Uggo Boggi
Prof Boggi described the da Vinci robot which he uses in surgery and highlighted its benefits such as hand tremor filtration. He did say that it was unusual for a surgeon to have no contact with a patient during an operation, adding: “We have to develop new skills and liaise effectively with those colleagues who are at the operating table.
He described a study which ran from April 2008-2010 and covered 32 patients, 13 women and nine men with an age range of 39-87. Examples of the operations included hepatic vein repair, right hepatic lobectomy and left hepatic lobectomy. He showed a video of a left hepatic lobectomy and went on to discuss possible complications, saying, for example, if you need to convert to open surgery it is tricky to disconnect and move the robot away from the patient.
He said it was important to undertake a risk / benefit analysis for each patient and that for some operations the message is “don’t try this at home!”
Prof Boggi referred to study results which showed a post-op mortality of zero per cent and post-op morbidity of 54%. The mean operating time was 354 minutes.
In conclusion, he said: “There is a long way to go but this type of surgery has shown that it can work and it has some clear advantages over other methods.
“Some operations are long and complex and very tiring for the surgery but it’s worth noting that the robot doesn’t get tired. It is costly, however, and should be used frequently to help make it cost-effective.”
Pancreatic Trials and Hepatobiliary Trials
Ms Paula Ghaneh, Reader in Surgery, Liverpool, Professor John Primrose
Ms Ghaneh, presented a comprehensive overview of pancreatic trials and introduced the audience to the forthcoming PET panc study designed to assess the usefulness of PET scanning in patients with a possible diagnosis of pancreatic cancer. Professor Primrose gave an overview of ongoing Hepatobiliary trials, including New EPOC and BILCAP.
Recruitment to New EPOC had been affected by the introduction of Kras testing, but Professor Primrose indicated that BILCAP is recruiting well and is/will be the largest trial of adjuvant therapy in biliary tract cancer. Both Ms Ghaneh and Professor Primrose encouraged all present to enter patients into ongoing hepatobiliary and pancreatic clinical trials.
The need for agreed and standardised procedure codes for all aspects of HPB surgery
Mr Bill Allum
Mr Allum presented to the audience in his capacity of Chair of the Upper GI clinical reference group from NCIN. Mr Allum emphasised the need for agreed and standardised procedure codes for all aspects of HPB surgery and the codes must adequately reflect the surgery. The concept is to facilitate meaningful interpretation of HES data and procedures performed without complex procedures either being mis-coded or broken down to the component parts.
At present there are numerous codes for what is essentially the same operation and the upper GI clinical reference group has been working towards simplifying the codes and encouraging the use of just a few codes, so that these codes can then be mapped, to give a true reflection of activity. This work will marry in with the minimum data set work and the outcomes work ongoing.
There was general agreement that the use of a limited number of codes would be a significant advance.
An overview of the AUGIS HPB cancer resection database
Mr Iain Cameron
Mr Cameron presented an overview of the AUGIS HPB cancer resection database. The database had been developed by Professor David Berry, Mr Iain Cameron, Professor John Buckels and Ms Fenella Welsh and launched in Nottingham in September 2009. To date, more than 750 cancer resections had been entered. Mr Cameron pointed out that some units had yet to enter data and indeed within units, only some surgeons had entered data. He encouraged everyone to enter their data.
One of the major concerns raised had been duplication of data, ie the collection of local data and the input of data to the National Database. It was explained that CSV files could be provided to units which would allow automated data transfer and this is the next project for the HPB audit committee and it was hoped that CSV files could be rolled out to all units over the coming few months.
The second half of the session consisted of free papers presented by a variety of Trainees from the various HPB units. A number of topics were discussed including bile duct injury at cholecystectomy. There was much discussion about the nature of bile duct injuries and the possibility of a bile duct injury register was discussed. There was agreement that such a register would be useful and that AUGIS should have a major role in any such register.
Day 2 – Batriatric
Chaired by Mr David Kerrigan and Mr Shaw Somers
Quality counts: hospital volume, surgeon volume and outcome
Dr Harry Frydenberg, Melbourne
Dr Frydenberg opened the symposium with the thorny topic of surgical volume. Arguments regarding experience and hospital volumes have apparently been superseded by latest evidence showing that current experience, within the last year, is the most relevant volume determinant of outcome.
Where there’s smoke, there’s fire: monitoring for early detection of complications and re-intervention
Mr Alberic Fiennes
Mr Fiennes took forward the theme of complications, illustrating his talk with examples of complications and, in particular, emphasising the importance of a pro-active environment and early re-intervention.
Weighed in the balance: defensibility and risk management
Dr Richenda Tisdale
The prevention of litigation took centre stage as Dr Tisdale from the MDU gave an overview of complaints and legal action. Getting all the C’s correct appears to be the best strategy – communication, consent, confidentiality, clinical records, complaint handling, and clinical skills. The talk was well received with a very active discussion following on.
All or Nothing: Minimum facilities, staff and procedures for bariatric provider sites
Professor John Baxter
Prof Baxter provided another sage overview of requirements for bariatric units, based on his experience of assessing units for provision of bariatric surgery. Issues including patient support, MDT structure, infrastructure and staffing, training and database support were all raised.
Put not your trust in numbers: are patient numbers the mark of quality?
Ms Sally Norton
Ms Norton wound up the session with a tongue-in-cheek reaction to those sticklers who promulgate surgeon volume as the only legitimate determinant of outcomes. She proposed several caricatures of bariatric surgeons including the responsible and careful “starting out” surgeon, the overcommitted and busy, but thinly spread, Porsche-driving specialist, the lower volume teacher and revisional specialist and the “have a go” chancer. Most of the audience were able to recognise the personalities represented and a straw poll confirmed that surgeon volume could be a misleading determinant of quality.
Day 2 – Batriatric audit
Chaired by Mr Duff Bruce and Mr Mike Rhodes
Is the Grass Greener: Bariatric Audit – around the world
Mr Richard Welbourne
Mr Welbourne explained that he had used a combination of published literature, the internet and personal contacts to gather information for his audit of Bariatric data from around the world – and he promised to take the audience on a whistlestop global tour.
His findings revealed:
USA: the US Bariatric Centres of Excellence Data are a goldmine of information with 57,918 patients. Another useful source is the Hospital Complication Rates with Bariatric Surgery in Michigan with 15, 275 patients. Gastric banding is the predominant operation. Studies show that low volume hospital and low volume surgeons equal twice the complication risk.
Canada: Mr Wellbourne said that the audit, Bariatric Surgery Waiting Times in Canada, was published as a plea to the health authorities to invest in bariatrics. It showed that Canada – which has the same levels of obesity as the US – sees just 5% of the comparative volume of bariatric surgery.
Europe: Mr Wellbourne referred to an Austrian database and a Belgian study and then spoke about French data which showed an estimated 22,000 patients in that country which is 10 times the number in Belgium. In terms of surgical preference, gastric bands are popular in France.
Italy has the best set of published data in Europe. The commonest operation is the gastric band and the quality of the data means that surgeons can use it to identify risk factors, for example, how the presence of diabetes in a patient may affect outcomes.
A Swedish report, published in August 2010, so “hot off the press” shows that bariatric patients in this country number around 5,000 every year, 95% having a gastric bypass.
In Russian there is no bariatric registry and only two centres of surgery, the main one being in Moscow.
Australia / New Zealand: Mr Wellbourne reported that bariatric registers were being developed in these countries and the same applies to India and Asia generally.
In conclusion, Mr Wellbourne said that he would like to see a collaborative comparison of data from around the world and that putting data into the public domain would help reassure people that bariatric surgery was safe and would help mitigate against “Daily Mail scare stories.”
Does size matter” What’s the minimum data set for audit
Mr Roger Ackroyd
Mr Ackroyd started his talk by asking why it was necessary to capture data on bariatric surgery. He said that it was necessary for many reasons, including the fact that bariatric surgery was a rapidly growing branch of surgery. In 2000, there were just over 200 operations, in 2007, there were more than 2,000 and the figure for 2010 is likely to show a huge rise.
The advantages of a minimum dataset would be that it would be quick / easy, user-friendly and allow for good comparisions. He recommended collecting minimal data, arguing that while detailed data would give detailed results it would be time-consuming and over-complex to collect and sift through.
He said: “I think there is a happy medium. There has to be enough data to allow for a meaningful analysis, which are easy to access and user-friendly. Does size matter? Yes!”
Referring to available databases he listed:
- Local databases
- The original BOSS database (which has now been shelved)
- The UK National Bariatric Surgery Register.
Mr Ackroyd said that this third database is increasingly used. Information required includes the date of the operation, patient demographics, funding categories, baseline co-morbidities, an operation record and post-op course / discharge.
Day 2 – Symposium – Perioperative management in Upper GI surgery
Chaired by Mr Simon Paterson-Brown and Professor Graeme Poston
Dr Mike Grocott
Optimisation and problems of pre-operative chemotherapy
Dr Grocott opened his lecture by outlining the issues around perioperative fluid management for oesophageal patients and pointed out that there is a general consensus that “some fluid is necessary.” But he added that it was difficult to assess accurately how much fluid is present or needed. He also pointed out that outdated studies are seen as increasingly less relevant in helping surgeons reach a decision about fluid.
Dr Grocott highlighted the reassuring fact that studies show that interventions made inter-operatively are most effective compared with pre- and post- operatively and that goal-directed fluid therapy improves outcomes. He also pointed out that the fitness level of a patient before an operation could be used to predict five-year survival chances and added: “Being fit is good for you.” He added a cautionary warning a proper evaluation of fitness should be undertaken with patients rather than relying on their own subjective views. Dr Grocott said: “Someone from a family of marathon runners will tell you they are very unfit because they ‘only’ walk five miles a day while someone from a family of TV addicts will say they are fit because they stroll to the corner shop twice a week.”
He gave an example of a study which showed that submaximal cardiopulmonary exercise testing predicts complications both in surgery and post-operatively. He said: “CPX is helpful but is only part of the answer. You should also take a full history of the patient. However, I think that it has become increasingly apparent that CPX can help predict outcomes. The question is what can we do to change outcomes?”
In answer to this question Dr Grocott said that his team was exploring the possibility that the benefits of chemotherapy could be outweighed by the loss of fitness associated with such regimes.
Dr Don Low
“Enhanced recovery and improving outcomes of surgical resection after oesophagectomies are more important than ever,” said Dr Low. He added that one reason for this was that some members of the medical profession were starting to favour methods other than surgery for oesophagectomies, for example, radiation chemotherapy.
Looking at ways to improve recovery he said that goal-setting was important, for example, more than 85% of patients achieved mobilisation on day one after an operation.
Dr Low highlighted the importance of teamwork and the critical role of the nurses and allied health professionals, arguing that they should always feel empowered to promote, design and influence patient pathways. He told the AUGIS audience: “If there is anyone is this room who thinks that they can achieve all the goals on their own they are sorely mistaken.”
Dr Low suggested that one way to enhance recovery rates would be look at the one-year complication tables and then try to work back and discover what factors of contributing factors may have led to the complications.
He also emphasised delirium as a complication and said that it is an under-studied area of research.
Dr Low suggested two key ways to enhance recovery:
- Pay attention to dietary and nutritional needs. “Make the diet rigid and patients are more likely to follow it.”
- Engage the patient and the patient’s family in discussions and planning
Dr Low concluded his talk by saying that while the surgeon is only part of the process, surgical leadership is a key requirement to institute and initiate change and he warned that “if surgeons don’t continue to show improved outcomes we will become marginalised in the treatment of oesophageal cancer.”
Prof Mike Bellamy, Leeds
Anaesthesia for the severly obese
Prof Bellamy said that the challenges for surgical teams included getting the correct technical equipment and the infrastructure.
Prof Bellamy said that – no pun intended – the big questions facing anaesthetists when facing obese patients are “Is she / he fit for surgery” and “What about the airway”?
He said that the answer to the first question is that his team often deal with patients who are by no means fit in traditional terms. He said that the perception is that one of the risks is cardiovascular but as surgery is often for weight loss then a successful operation is partly aimed at reducing cardiovascular risk – so it was a risk / benefit question.
He warned his audience that sleep apnoena is a good market for other problems and referred to a study which showed that of 293,478 estimated cases, most were male and 64% were aged 40-69 years.
He pointed out that obesity doubles the risk of heart failure independent of co-morbidities.
He said that the obesity surgery mortality risk score has been increasingly validated over the past few years and that key risk factors included a BMI of over 50, being male and being over 45 years old. He added: “The vast majority of our patients look pretty ropey but, in fact, they can be classed as reasonably low risk.”
Discussing pre-operative evaluations, Prof Bellamy advised colleagues that patients with an ‘android’ shape – thin arms and legs and a very large stomach – should be seem as more risky than ‘pear-shapes.’ Surgery can be trickier because the stomach is so large and these patients may need to be intubated which can prove “tricky.”
Practically speaking, Prof Bellamy said that surgeons should make sure that there are enough pairs of hands in the room, for example, if the patient needs turning. It is also important to have an appropriate large-size operation table.
He said that in his experience anesthetists preferred to put obese patients to sleep in the theatre rather than in an anaestheticroom. He said that keeping the patient warm was important and went on to discuss issues such as vascular access, intubation and the position of the airway during the operation. He said that the traditional “sniffing the morning air” position wasn’t always appropriate for obese patients and that aiming to raise the head and neck away from the chest – using pillows – worked better.
The appropriate place for post-operative management, said Prof Bellamy, depends on co-morbidity factors and expertise.
He concluded his highly informative talk by reassuring colleagues that they can operate successfully on obese patients provided they follow good guidelines.
Day 1 – Upper GI Disease
Chaired by Miss Jane Tallett and Mrs Anne-Margarethe Phillips
Ms Claire Morris and Ms Noeline Young
National Cancer Survivorship Initiative – Assessment and Implementation
Ms Young opened the talk by saying that the National Cancer Survivorship Initiative (NCSI) had been set up to study and help the many patients who are living with cancer – which numbers one in 10 people – and those who have had cancer but are currently free of disease
She added that patients need to be assessed because evidence shows that their needs, for example, for psychological help or follow-up appointments. aren’t always addressed. In addition, she pointed to the fact that the number of cancer survivors is increasing which has led to concerns that the long term effects of disease must be studied and the need for secondary prevention messages met.
The NCSI has suggested new models of care to health commissioners based on the results of its studies. Success factors found in studies include:
- Good clinical support
- A focus on quality
- A multi-disciplinary approach
- Good baseline date
- Sharing good practice
- An enthusiasm for change
Currently the team is working on an economic evaluation and Ms Young pointed out that “the improvement story so far” can be found on the NCI website. She added that patient feedback including statements such as “I’m less worried about my cancer coming back,” highlighted the value of the work.
The team is looking to outreach exercise programmes and educational events to further help patients.
Ms Morris started her section of the session by sating: “Noeline has told you all the good news stories but I have to tell you about all the work that still needs to be done.”
She then outlined the Holistic Needs Assessment (HNA) which she said is aimed at achieving an informed patient with a supportive care plan, which, she asserted, would lead to better self management.
Ms Morris finished by citing an ongoing study in Southampton which has already thrown up some interesting results. For example, problems in implementing a HNA included:
- Many miles of hospital corridors
- Elements of HNA taken but not recorded
- Too much duplication\inconsistent quality of information recorded
Mr Alex Wilson, team lead, physiotherapy and critical care, Radcliffe Hospitals, Oxford
Preoperative physiotherapy for patients undergoing oesophagectomy
Mr Wilson spoke about some of the problems faced by patients who have post-operative complications following oesophageal surgery which his team handled. He said: ‘We started to think about whether physio could have an input pre-operatively.”
His team recommend the use of an Inspiratory Muscle Training device (IMT) which patients are taught how to handle and then encouraged to use for two weeks prior to their operation. Mr Wilson said studies showed that use of IMT reduced post-operative stay. He added: “Patients appreciate that using the IMT device could help their recovery time and this, in turn, helps them become more engaged and helps them feel positive because they are able to contribute to their own care.”
Looking at cost, Mr Wilson pointed out that the IMT device cost £20, one hour’s instruction in its use by a physio cost £20 – but a post-operative ward day costs £500 and an ICT bed £1,500 a day.
In conclusion he said: “We are working on the idea of prehabilitation, rather than rehabilitation. We are placing physio firmly in the pre-op stage and in the surgical clinics.
The BJS Prize
A novel ex-vivo organotypic model of the oesophagus reveals stromal determinants of epithelial cell behaviour.
Tim Underwood, Mathieu Derouet, Michael White, Phillip Coates, Gareth Thomas, Jeremy Blaydes.
United Kingdom, Cancer Sciences Division, University of Southampton, Southampton, United Kingdom, University of Dundee, Dundee
Background: Adenocarcinoma of the oesophagus is the most rapidly increasing cancer in the UK. The molecular mechanisms underlying oesophageal carcinogenesis are still to be elucidated, but recent evidence suggests that stromal-epithelial interactions are fundamental to this process. We have generated a novel oesophageal organotypic model and compare the incorporation of primary tissue with commonly used cell lines. Furthermore, we have used our model to interrogate the stromal determinants of epithelial cell behaviour.
Methods: A reconstituted oesophageal mucosa containing primary cells taken from oesophageal resections was prepared in organotypic culture. Using RT-PCR and immunohistochemistry we have compared our ex-vivo model with the most commonly used normal squamous oesophageal cell line, HET-1A. We have examined the role of stromal cell signalling by comparing the morphology of epithelial cells cultured over normal (NOF), Barrett’s (BAF) and cancer associated fibroblasts (CAF).
Results: We have characterised a histologically representative 3D model of normal oesophagus, oesophageal squamous cell carcinoma and oesophageal adenocarcinoma. We demonstrate that HET-1A cells are an unsuitable model of normal oesophagus, with the loss of expression of key determinants of squamous epithelial integrity (E-cadherin and p63). Furthermore, by comparison with NOF and BAF, we show that CAF’s promote epithelial cell invasion. Molecular expression studies suggest that this may be related to an epithelial-to-mesenchymal transition.
Conclusion: We have developed a robust and representative ex-vivo model of the oesophagus and demonstrate that the integrity of the oesophageal squamous mucosa may be determined by the expression of p63. Strikingly, we have shown that CAF can promote epithelial cell invasion, suggesting that stromal constituents may be fundamental to oesophageal epithelial behaviour.
Post-operative complications do not independently predict long-term survival following hepatic metastasectomy if analyses incorporate systemic inflammatory variables
Christopher P Neal, Christopher Mann, Giuseppe Garcea, Christopher Briggs, Ashley Dennison, David Berry
United Kingdom, Department of Hepatobiliary and Pancreatic Surgery, Leicester
Introduction: Postoperative complications have repeatedly been shown to predict poor long-term prognosis following resection of colorectal liver metastases, via an undetermined mechanism. Recently it was demonstrated that the preoperative systemic inflammatory response, a known predictor of poor survival following metastasectomy, itself independently predicted the development of postoperative infectious complications following primary and secondary colorectal cancer resection. The aim of this study was to determine whether postoperative complications maintain prognostic significance in survival analyses that incorporate systemic inflammatory variables.
Methods: Outcomes of two hundred two consecutive patients undergoing hepatectomy for colorectal liver metastases between January 2000 and April 2006 were analysed. Multivariable analyses were performed to correlate preoperative and perioperative variables with long-term survival following metastasectomy.
Results: Ninety-day mortality and morbidity rates were 2.0% and 25.7% respectively. The preoperative systemic inflammatory response independently predicted the development of infectious complications following hepatectomy, along with performance of trisectionectomy. Infectious complications were associated with shortened overall and disease-free survival following metastasectomy, but lost independent significance when systemic inflammatory variables were included in multivariable analyses.
Conclusions: Whilst infectious complications are associated with poor long-term prognosis following metastasectomy, they lacked independent prognostic value when systemic inflammatory parameters were also considered, suggesting that much of their prognostic value arises from their association with the preoperative systemic inflammatory response.
Best Affiliate Poster
Weight loss expectations of patients awaiting bariatric surgery
Kelli Edmiston, Evangelos Efthimiou, Paris Tekkis, Fionnuala Davison, Caroline Shannon, Gianluca Bonanomi
United Kingdom, Chelsea and Westminster Hospital, London
Background: This study aimed to investigate the weight loss expectations in patients awaiting bariatric surgery.
Methods: Data is collected prospectively on all patients referred for bariatric surgery. We completed a retrospective analysis of patient record cards. Patient’s expectations for weight loss following surgery were compared to expected weight loss for each procedure based on international data. Factors including age, gender, ethnicity, weight and BMI at assessment, previous dieting attempts, previous successful weight loss, sweet eating, binge eating, and surgery type were considered in our analysis.
Results: 731 dietetic assessments completed between October 2002 and October 2009. The majority were female (f 71%, m 29%). Overall, 71% of patients had unrealistic weight loss expectations. Multiple logistic regression analysis revealed no significant difference for age, race, BMI, comfort eating, self reported binge eating, number of previous diet attempts, successful previous weight loss attempts, or chosen surgical procedure. The only factor of significance for unrealistic weight loss expectation was female gender (p = 0.003). Univariate analysis revealed a trend towards significant difference for self-reported binge eaters and for patients awaiting gastric bypass procedures.
Conclusion: Our study supports the literature that the majority of patients overestimate the amount of weight they are likely to lose from surgery. Females are more likely than males to overestimate the weight loss they are likely to obtain from surgery. There is a slight trend for patients awaiting gastric bypass to overestimate the weight loss compared to those awaiting gastric banding. Pre-operative education of patients continues to be an essential area, including a focus on realistic expectations after surgery.
Great Britain and Ireland Hepato-Pancreato-Biliary Association
Immediately after the close of the main AUGIS Scientific Meeting, Mr Giles Toogood, AUGIS HPB Chair convened the founding meeting of the GBIHPBA as a constitutional branch within AUGIS. Details of this meeting and its outcomes are found elsewhere on the website.