Report from the OG lead

Professor Ashraf Rasheed
AUGIS OG Lead

Welcome to all clinicians diagnosing and treating elective and emergency oesophageal and gastric diseases. The OG report is designed to be a resume of what happened or happening across the country and in the rest of the OG World that might be of interest to you and a reminder of some events of relevance to your practice. I hope you find it useful.


Meetings

The 3rd Welsh AUGIS Chapter, March 2018

Further to last summer’s newsletter, The 3rd Welsh AUGIS Chapter was held in Cardiff in spring. The programme as always had a multi-disciplinary philosophy, with sessions organised and hosted by WAGE and AUGIS. We had the misfortune to choose St David’s Day, when the “Beast from the East” met Storm Emma, and blizzards gripped South Wales. Fortunately, our guest speakers were already in Cardiff when the storm arrived.

The Boston Scientific State of the Art lecture on bile duct stones by Prof Attila Nakeeb from Indianapolis was extraordinary

Prof Luigi Bonavina from Milan delivered a lecture on achalasia and another one on managing complications following anti-reflux interventions. The case-based session was interactive facilitated by Prof Ashraf Rasheed and Dr Miles Allison drawing on Prof Nakeeb and Prof Bonavina vast experience in relation to management of end stage achalasia and failed hiatal hernia surgery. The session was loaded with tricks of the trade and pearls of wisdom.


16th Annual International Oesophago-Gastric Symposium, March 2018

This was organised by Abrie Botha and held in Central Hall, London on 9th March 2018. An excellent international faculty led the over 100 delegates in discussions on a range of topics. The morning session was devoted to the potential benefits of anatomical resection of OG cancers. Abrie Botha talked about total adventitial resection of the cardia (TARC) for OG junction cancers, Richard Hardwick discussed extended total gastrectomy for proximal gastric cancers, George Hanna explained what an optimal lymphadenectomy entails and Jianping Gong explained complete the concept of meso-gastric excision (CME) for distal gastric cancer. Jane Blazeby presented the evidence for advantages of minimal access OG cancer surgery and Richard van Hillegersberg shared his experience with robotic OG resection. The morning ended with a lively discussion about the relative merits of 3D laparoscopic versus robotic assisted laparoscopic surgery for anatomical dissection.

The afternoon session was devoted to recent advances in benign OG surgery particularly flexible endoscopic surgery. Ralph Aye presented the Seattle results of hybrid anti-reflux surgery consisting of cardiapexy plus fundoplication. Don Menzies shared his experience with laparoscopic exploration of the common bile duct for stones after which Abrie Botha presented his results with POEM for achalasia. James Kelly discussed flexible endoscopic options for bariatric surgery and shared his technique for endoscopic sleeve gastroplasty. Lee Swanstrom reviewed the current experience with flexible endoscopic OG surgery including pharyngeal pouch, oesophageal leiomyoma, pyloroplasty, resection of high-grade dysplasia and T1 cancer, and presented future technological advances that will expand the range of operations by flexible endoscope. The afternoon session ended with trainee surgeons presenting a selection of interesting cases from Guy’s & St Thomas’ Hospital.


Trent Region Education Day, May 2018                                                                                                              This was held on Friday the 18th May in Nottingham and included the following important topics: Difficult Day on Call – Case Discussions, Safety in Cholecystectomy, Benign Biliary Strictures, Management of Acute Pancreatitis, Complications of Bariatric Surgery, Career Options in Upper GI Surgery, ERCP vs Laparoscopic CBD exploration – Debate, Surgery for Giant Hiatus Hernia and Getting it Right First Time – Implications for UGI Surgery.


European Gastric Cancer Congress, 7-8 June 2018, Leiden University Medical Center, Leiden, the Netherlands.                                                                                                                    

This multidisciplinary programme covered all the aspects of the management of gastric cancer including diagnostic modalities, minimal invasive surgery, multimodality treatment, pathology, targeted & immune therapy and quality of care. Furthermore, the latest results of some large trials and the EURECCA project was presented.


South West UGI Educational Day, 4 July 2018                                                                                                     Andy Strickland and Richard Krysztopik will host an Educational Day to highlight key topics in UGI surgery, on Wednesday, 4 July 2018 at the Holiday Inn in Bristol including the following topics: endoluminal treatment of oesophageal disease, complications of bariatric surgery for the non-bariatric surgeon, management of common bile ducts stones, severe acute pancreatitis and its complications.


16th International Society for Diseases of the Esophagus World Congress, September 2018                           The 16th ISDE World Congress will be held in Vienna on the 16th -19th of September 2018. The ISDE is the premier multi-disciplinary international organisation focused on esophageal diseases and its biennial congress aims to gather together all specialties involved in the clinical management and research of patients in the world of oesophagology.


Third Oesophageal Neoplasia Masterclass (ONM), September 2018                                                     Will be held on 18th of September at UCLH Education Centre. This is a one-day masterclass exploring novel and innovative advances in the early diagnosis and endoscopic treatment of patients with oesophageal neoplasia. This year’s workshop will focus on the latest updates on real time endoscopic imaging for diagnosis and staging of oesophageal neoplasia. There are also lectures and live demonstrations on the latest resection and ablative techniques for oesophageal neoplasia.


21st AUGIS Annual Scientific Meeting, 19 – 21 September 2018                                                                                                                              The meeting will be held in Edinburgh on the 19th to 21st of September. The OG sessions are loaded with the stars of the speciality. Professor Takeshi Sano is this year’s BJS Lecturer and will be talking about how RCT’s have changed the treatment of gastric cancer. Takeshi has lectured and given live surgical demonstrations in more than 35 countries as a ‘publicist’ of Japanese-style D2 gastrectomy and as a steering committee member of the Japan Clinical Oncology Group, he also played central roles in clinical trials on gastric cancer surgery. His lecture will be on the Friday morning and “a must attend” session.


OG Guidelines Updates

  • Oesophago-gastric cancer: assessment and management in adults. NICE guideline [CG83], published January 2018 
  • Suspected cancer: recognition and referral. NICE guideline [CG12], published 2015 and updated 2017
  • AUGIS Provision of Services Document, updated 2016 
  • Asia-Pacific working group consensus on non-variceal upper gastrointestinal bleeding: an update 2018. Sung JJY, et al. Gut 2018; 0:1–12. doi: 10.1136/gutjnl-2018-316276

Initiatives

NHS Wales plan to introduce a Single Cancer Pathway (SCP)

The latest National Oesophago-Gastric Cancer Annual Audit report shows that 50% of patients are waiting over 60 days from referral to radiotherapy and chemotherapy and over 90 days for surgery. About 7 years ago the Upper Gastro Intestinal (UGI) clinical community in Wales noticed that despite what seemed a long and complicated diagnostic and cancer staging pathway for patients with oesophago-gastric cancers, the system was reporting near 100% compliance with the Not Urgent Suspected Cancer (nUSC) Cancer Waiting Time (CWT) target.

The overall majority of cancer patients (55-65%) are diagnosed via the n-USC route, as patients typically present to emergency departments or their diagnosis is picked up following a test that was not requested via the USC route.

More worryingly is the high proportion of patients presenting with UGI malignancy (up to 70 to 80% in some Health Boards) present via this nUSC pathway. For these patients even when the tumour is seen at endoscopy and the patient had waits for CT scan, CT-PET scans, endoscopic ultrasounds and MDT decisions, the CWT clock only starts when the patient accepts the treatment plan, usually just before start of treatment.

At the then Welsh Health Minster’s request the clinical community was asked via the National Specialist Advisory Group (NSAG) to consider what the best measure of cancer waiting times would be. Their response was that waiting times were important (delays adversely affect patient outcomes and experience), and that 62 days should be the longest time any patient should wait for treatment. Patient focus groups said they wanted information on how long they would be expected to wait and they wanted assurance that they would not come to harm through waiting.

Due to these concerns Welsh Government (WG) then indicated they would consider what a single CWT target for all would look like. This single suspected cancer pathway (SCP) would record and report all patients from the point of suspicion (PoS) of cancer be that through primary care suspected cancer referral or other routes to diagnosis (e.g. radiology, endoscopy, A&E, secondary care inpatients/outpatients).

It was clear therefore that the system is:

  • Not reporting the actual patient experience
  • Not reporting the pressures in the diagnostic system.
  • Not driving improved performance through improving the causes of delays

Single Suspected Cancer Pathway (SCP): A single suspected cancer pathway would measure CWT from the point of suspicion of cancer.

  • For current USC referrals there is little change except the clock starts at the date the GP referred the patient rather than receipt of referral by secondary care.
  • For current nUSC routes to diagnosis the time the clock would start is from clinical point of suspicion, when a clinician refers and/or requests a test thinking cancer, with as a minimum the point being the same as NG12 NICE Guidance on Suspected Cancer.

CWT pathways and performance, and diagnostic workforce/infrastructure issues are similar in England and Wales as evidenced by respective Government statistical reports, National Clinical Audits and the International Cancer Benchmarking Partnership (ICBP). Whilst Wales is the first home nation to pilot the SCP, England is considering adopting the Faster Diagnosis Standard (FDS). The learning derived from this change to the SCP and from the FDS will support efforts across the UK to improve cancer outcomes.


BSG UGIB (Upper GI Bleeding) EQIP (Endoscopic Quality Improvement Project

Dr John Morris is leading a quality improvement project for UGI bleeding on behalf of the BSG with involvement of AUGIS. This is a response to the recent NCEPOD report in 2015 and aiming to develop a bundle that helps to improve outcomes with regards to mortality, risk of re-bleeding, length of hospital stay and quality of life