The 13th Annual Scientific Meeting of AUGIS, September 3-4, 2009

nottingham_2009The 13th Annual Scientific Meeting of AUGIS, held in Nottingham, was a great success. The East Midlands Conference Centre proved to be an excellent venue and delegates from around the world gathered to share their knowledge, learn about advances in treatment and take advantage of networking opportunities.

The meeting was preceded by a well-attended teaching day for trainees and young consultants and this also went extremely well.

The Scientific Programme gave delegates the chance to hear an array of fascinating talks on a host of topics, many delivered by speakers with international reputations.

The second day’s parallel, specialist sessions on OG/BOMSS and HPB, proved very useful for delegates keen to increase their knowledge of specialist areas. These sessions also saw the launch of new OG/Bariatric and HPB databases.

Nurse affiliates were also much in evidence at the Meeting and the vital role they play in multi-disciplinary teams was highlighted by several speakers and during their own parallel session on the first afternoon.

The Meeting was well supported by partners in Industry with a lively trade exhibition taking place next to the Conference Hall.

The Annual Dinner was held in Nottingham Castle following a drinks reception on the Terrace. This proved to be a wonderful evening with delicious food and excellent company in an elegant setting.

Training Day:

An Upper GI training day for 36 delegates preceded the annual meeting.

Training Day Report
Natasha Henley, AUGIS Trainee Representative
Natasha Henley
AUGIS Trainee Representative

We tried something slightly different this year for the pre-conference training day in Nottingham. We opted for small group practical workshops and interactive tutorials to allow more trainee involvement.

The training day was held at the Trent Simulation & Clinical Skills Centre on the Queens Medical Centre Campus, close to the East Midlands Conference Centre. The workshops allowed trainees to practice with laparoscopic simulators, energised liver dissection, ultrasound and thoracic trauma techniques.

The highlight of the morning was undoubtedly the session with in the ‘Sim-Man’, a simulator set up to resemble the resuscitation area of A&E. We were thrown in at the deep end with a critically ill patient and an anxious parent. Four of us from each group had to manage the situation under the watchful eye of the tutors and the other delegates. I suspect it was quite entertaining for the audience but quite scary for those taking part.

The afternoon session was a combination of viva practice for those taking the FRCS (Gen Surgery) exam and a “meet the experts” Q&A session. Members of the AUGIS Council and invited speakers from the main conference generously gave their time and put us through our paces. Discussions focused around interesting cases which covered the exam syllabus and included some interesting management dilemmas. For those of us taking the exam, this session proved invaluable and happily, several of the topics we covered came up in the exam the following week.

The last word of the day came from two colorectal surgeons who run the ‘Going for Gold’ exam revision course in Derby. Both have won the Gold Medal in the Exit Exam and they gave us some hints on how to prepare and, most importantly, to keep calm under pressure. They finished with a mock viva for two of us which was filmed and conducted in front of the rest of the delegates. It was actually more terrifying than the real thing!

We are grateful for the generous support of Covidien and Ethicon, who sponsored the day as well as Valley Lab and Olympus for providing the CUSA and the laparoscopic equipment respectively. The day ran very smoothly thanks to the input from the staff of the TSCSC and, finally, thank you to Ian Beckingham for coming up with the idea and organising the day.

 

Day 1 – Plenary Session:
What are the boundaries between ‘general surgery’ and ‘specialist upper GI surgery?

Chaired by Mr Merv Rees and Prof Derek Alderson

 

Prof James Garden | The management of gall stones

Prof Garden set the scene by highlighting how laparascopic cholecysectomies have gone from zero to 80% of the total in the ten years since the operation was introduced. Its introduction corresponded with a reduction in the 90-day mortality rate.

More challenging patients still require open cholecystectomy. Risk factors include extreme old age, obesity, previous surgery and severe disease. In terms of length of hospital stay, there is considerable variation from 1.2 – 6 days, partly accounted for by the age of the patient, with the shortest stays typically being among those in their twenties and thirties. Surgical experience can also be a factor in deciding which type of operation is best and the length of hospital stay. However, Prof Garden highlighted variations in one study showing post-operative stays across Scottish regions which he believes warrants further investigation.

Prof Garden gave further information on bile duct injury surveys and current audits with preliminary results which show variations across the service in the UK, possibly related to the experience of surgeons and the number of cholecysectomies they have carried out.

He concluded by saying: “I can’t say if a specialist or generalist surgeon is the best person to undertake a cholecysectomy but I am absolutely sure that an ‘occasionalist’ wouldn’t be the best person.”

Mr Mike Rhodes | Anti-reflux surgery

Mr Rhodes discussed laparascopic fundoplication in light of the “specialist or generalist” debate. He looked at three areas, firstly pre-operative assessment and referring to the results of a trial of 340 patients showing symptoms. He also referred to relevant case studies. Mr Rhodes called for specialist investigation pre-operatively in order to identify any risk areas – rather than having to deal with problems post-operatively.

He then moved on to look at operations and said that he believed specialist fundoplication surgeons have been shown to have fewer complications than generalist surgeons.

Post-operatively, he pointed that that as well as the success stories, there is a high rate of recurrence of problems from this type of surgery, plus some side effects which people might find unpleasant.

He concluded by saying: “When you operate for functional problems, you have to accept that you will occasionally get long stories full of complexities.”

Ms Sally Norton | Laparascopic gastric bands

Ms Norton started by saying that the costs of obesity to society has been set at £6 billion a year and added: “People have to accept that beer and curry are not the way forward for a healthy life.”

She added: “We are facing an epidemic. There is a huge demand from people for operations to control their weight. Gastric banding is increasingly seen as the only way to help weight reduction in the morbidly obese.”

Ms Norton that success is due to work of multi-disciplinary teams and surgical expertise. Good long-term follow-up is needed for many patients, for example, people who have gone abroad for operations and lack post-operative follow-up care.

Norton pointed out that obese patients don’t just present for weight-loss surgery but rather they can be found across the health services – requiring knee operations, hip replacements, C-sections and other routine procedures. She added: “We can’t avoid offering them a proper standard of care with the appropriate equipment to meet their needs, be that larger beds, wider chairs or other facilities.”

Referring to the fact that “there are other outcomes other than weight loss.” Ms Norton gave the example of an obese man who was unemployed and clinically depressed but, following surgery, is now employed, no longer on medication and is happier.

Looking to the future she called for national leadership, the forging of international links, a supply of good training materials and rigorous auditing.

Responding to the debate about whether upper GI surgery is a generalist or specialist service she came down in favour of specialists and even spoke of super-specialists to concentrate on key procedures and deal with the specialist management of high risk patients.

Mr Simon Paterson-Brown | The advantages of emergency GI surgical sub-specialisation

Mr Paterson-Brown started his talk by saying: “We have spent a lot of time over the past 10-20 years on training to ensure that most surgeons ‘fit’ into a specialist category.” But he added that this can have the result that some people feel uncomfortable working on emergencies that are outside of their specialist area.

He also pointed out that a recent survey showed that around two-thirds of patients with acute cholcystitis didn’t have an operation on admission but rather were transferred to a specialist unit – so it may be that on-call surgeons needn’t worry too much about being asked to undertake this type of tricky operation on an emergency basis.

Mr Paterson-Brown gave examples of his work in the Lothian region, for example, on patients with peptic ulcers or colorectal cancer which supported the view that specialisation could lead to fewer post-operative problems and complications. He also highlighted some practical issues, for example, surgeons on split sites who have to travel to the patient to undertake surgery. But he concluded that this would have to be seen as part and parcel of the job in the future as hospital sites became more complex and surgical roles more specialised.

He was also concerned about the possibility of ‘consultant de-skilling’ if someone specialises in one small area for many years but he weighed this against the benefits of great achievements in specialist areas.

Mr John Black, President, Royal College of Surgeons, England | The view from the top

The President of the RCS (England) started his talk by saying that in his experience, when asked, most chief executives of Hospital Trusts said they would prefer to see specialists working in high risk areas and generalists working elsewhere.

He added: “From my point of view, I think that most delegates at this Meeting are general surgeons with an interest in upper GI surgery.”

He also commented that it was sometimes hard to prove that specialist surgeons are a better choice given the complexity of the patient database and other factors which may influence outcomes.

Mr Black also highlighted what he saw as potential downsides to being a specialist – boredom, over-confidence and the possibility of developing a ‘silo’ mentality which makes someone unwilling to take on board advice and learning from other professionals.

In terms of the optimum caseload for a surgeon, Mr Black said it was clear that very low numbers of cases are wrong but that there seems to be a number above which surgical results don’t improve. He also pointed out: “It’s not about the surgeon, it’s about the team.”

Mr Black concluded the debate by coming down in favour of upper GI surgeons being seen as generalists and said he believed that they should be happy to be on call and willing to tackle a range of ops, routine or emergency.

 

Day 1 – Session 2

BJS Invited Lecture
Professor Steven Strasberg, professor of HPB Surgery, Washington University St Louis
| The advantages of emergency GI surgical sub-specialisation

Prof Strasberg gave a fascinating talk on injuries caused during surgery due to surgeons wrongly identifying complex body parts – and he also made several recommendations to help people avoid such pitfalls.

He started by saying that he believed the most common injury during surgery occurs when surgeons cut the common bile duct instead of the cystic duct. He said there were several reasons why this error might occur, for example, if there is acute or chronic inflammation in the area which causes changes the shape and position of the anatomy. To avoid making an error in these circumstances Prof Strasberg recommended that surgeons first lift the gall bladder off the liver bed to one-third of its length to give them the all-round view they require.

Prof Strasberg said that his recommendations in avoiding ‘error-traps’ had been partly informed by the State of Maine’s advice for hunters aimed at ensuring that they didn’t mistakenly shoot a person instead of a moose! The hunters are urged to ensure that they have a ‘critical view’ before they fire – for example, there is little chance of confusion between the head of a moose – complete with antlers – and the head of a person, whereas the legs of a moose and a man could be mistaken for each other.

Prof Strasberg said that there are two different views about why errors happen – one that there are failures in methodology (the error trap) the other that there is inherent human falliability.

The second error trap is to avoid undertaking surgery if inflammation distorts the surgical view to the extent that a mistake becomes a possibility. ‘Don’t do the difficult cases,’ said Prof Strasberg. ‘Send the patient to a specialist. There is merit in teaching surgeons how NOT to do the difficult cholecystectomy. The message is that you shouldn’t always go into the areas of great danger where injuries occur.’

Error trap three occurs when a surgeon fails to identify a duct that doesn’t conform to the usual anatomical patterns.

Finally, error trap 4 means remembering that ‘The Critical View’ isn’t perfect and a surgeon may have to undertake more dissection to fully understand the anatomy.

In summary, Prof Strasberg said that prevention of injury was better than a cure and surgeons shouldn’t be wary of halting a procedure in which they have lost full confidence. He urged surgeons to teach their students how to avoid injuries by:
1. Teaching them to avoid error traps
2. Using the critical view
3. Making liberal use of cholangiographs
4. Inculcating a culture of ‘safety first’.

Professor Ronnie Poon, Professor of HPB Surgery, University of Hong Kong | Advances in the management of liver cancer

Professor Poon gave a detailed and fascinating account of recent advances in the treatment of liver cancers, drawing on his experience and surveys and trials conducted in Hong Kong and further afield.

He described the current curative treatment options – resection, transplant or ablation – plus palliative options. He said that surveys showed that surgery can be the best option even for people with large tumours and that improved techniques and growing expertise should see this trend continue. For example, he cited a fall in the need for blood transfusions from 90% to 10% in the years 1989-2003.

He also pointed out that surgeons can help patients by avoiding dissemination of tumour cells during surgery using good techniques – although post-operative recurrence rates remain high at 80%.

Recent developments mentioned by Prof Poon include new laparascopic tools and treatments which result in shorter hospital stays, less blood loss and less pain.

Transplants were also considered a good option as they deal both with a cancer and with underlying cirrohosis and using live donors is one way to source enough donor organ parts (although it is important to remember risks to the donor).

Prof Poon spoke about advances in ablation treatments which offer curative therapies and mentioned several ongoing trials.

He concluded by saying that peri-operative outcomes and long-term survival have improved in recent years but there is still some way to go. He added that molecular targeted therapies may prove effective.

 

Day 1 – Session 3 – Introduction of new techniques

Chaired by Mr Richard Hardwick and Mr Ian Beckingham

This was a lively series of debates and discussions concerning new procedures and approaches to treatments and trials.

 

Professor Bruce Campbell | Guidance from NICE

Professor Campbell opened the session by giving an overview of the work of NICE and outlining how a procedure would go through the testing process before being recommended as a treatment.

He started by saying: ‘In a perfect world, a surgeon would offer information on a new procedure, colleagues would become interested in its potential, it would be brought to the attention of NICE and it would then be appraised.’

He said that once NICE has taken on a topic, treatment or procedure a set of key steps are followed:
– Experts look at published studies
– Specialist advisors give their views
– Patient commentators are engaged
– Committee members are shown detailed information and are asked for their views
– Public consultation takes place.

Prof Campbell pointed out that a typical NICE committee is made up of about 25 members including GPs, nurses, statisticians, lay members, experts and representatives from various bodies such as the NPSA and the ABHI.

He said: ‘We have to take account of many factors – for example, we may be faced with mixed results from various studies and we have to keep up with fast-moving technologies for example.’

Prof Campbell encouraged input from AUGIS. For example, he said members could:
– Notify NICE of new procedures
– Offer specialist advice
– Put forward patient commentators
– Take part in data collection
– Seek membership of NICE
– Join Nice committees
– Undertake research

Mr Paul Barham, Bristol Royal Infirmary | Minimally invasive oesophago-gastric surgery

Mr Barham offered advice on using new procedures with a four stage plan. The first and second stages are to learn the new operation and to make sure it complies with local regulations after which you can start to perform the operation and, finally, teach the operation.

He said that he thought the advantages of minimally invasive surgery is that it is the best option for survival although many surgeons still favour open surgery.

Mr Barham pointed out that there is still a high cost when it comes to oesophageal cancers – mortality rates at 12 months are around the 30% mark. But he still advocated pursuing improvements which could offer patients a better quality of life for whatever time they have left.

He then explained how he went through the process of learning and introducing a new procedure for oesophagectomy to his Trust including seeing the operation performed in several other centres and then moving from open surgery to part laparascopic and full laparascopic as he learnt the techniques. Surgeons now learn the operation by performing it in different stages before conducting a full laparascopic operation.

Mr Barham said: “We are tracking our progress and an increasing number of surgeons are using the procedure and skills are being spread across the team.”

Mr Neil Pearce | Minimally invasive liver resection

Japanese surgical results on gastric cancer seen as gold standard, however, their good results have never been matched in the West. Better Japanese outcomes might be at least partially due to the fact that gastric cancer in Japan are localised more distally (antrum versus proximal stomach), are less of diffuse type, less obese patients, more radical surgery.

Total gastrectomy mortality is similar between Tokyo and Leeds studies, however, D2 gastrectomy in the West has never achieved significant survival benefit over D1 lymphadenectomy. Stage 2 cancers are the only ones that may benefit from a D2 lymphatic dissection.

The original Dutch study (Lancet 1995) randomising D1 and D2 resections showed no survival benefit at 11 years post-surgery. MRC study shows a higher mortality for D2 but no difference in five years survival (33% D1 vs 35% D2). However, a criticism was that most Western surgeons were on their learning curve and the higher mortality was registered in the pancreatico-splenectomy group (12%T3 and 40% T4 have lymph node mets at the splenic hilum). Cochrane review of D2 shows overall no benefit for D2 lymphadenectomy. D2 is recommended only for stage 2/3 in high-volume centres. JCOG 9501: D2 vs D3 (para aortic node dissection): no survival benefit.

Summary:

1. No benefit from superextended surgery (D2 can be performed in high-volume centres)
2. No need for prophylactic pancreatico-splenectomy
3. No para-aortic node dissection
4. New field of interest: quality of life and adjuvant/neoadjuvant chemotherapy

Laparoscopic gastrectomies results

Difficult to compare East and West: In the east more laparoscopic assisted procedures and early disease, whilst in the west various procedures and less numbers. There is a benefit for quality of life for laparoscopic assisted distal gastrectomy.

Consider suitability for Siewert type III; young patients and advanced disease, multiple organ resections.

 

Day 1 – Session 4 – Invited lecture (co-sponsored by Bayer and Biocompatibles)

Dr Phil Schauer, Professor of Surgery, Cleveland Clinic Lerner College of Medicine | The status of bariatric surgery

There were 250,000 new primary bariatric procedures this year in the USA. There is a 15% failure rate of gastric bypass; 25% failure for gastric banding; 5% for BPD/DS. There were 23,000 revision procedures in 2004 in USA.

Dr Schauer said that the cause of inadequate weight loss is multi-factorial and includes lifestyle, poor compliance and orthopaedic problems.

The reasons behind revision of gastric bypass include:
– Inadequate weight loss
– Anatomic problems (large pouch, marginal ulcers, persistent reflux)
– Malnutrition

He said that it is difficult to establish what represents success for a bariatric procedure: % Estimated Weight Loss <50% or <25%; BMI< 30 or <35; reduction or resolution of co-morbidities. He said that there is a need to set realistic expectations; understand patient anatomy, request patient to demonstrate compliance, assess intelligence. Surgical tips from Dr Schauer included: Look for familiar landmarks; green staplers, reinforce anastomosis with sutures; beware of excessive traction of the liver; liberal use of NG tube; 15 mls gastric pouch; 50 cm BP limb - 150 cm roux limb. Elements that may affect weight loss: - Pouch size - Intact staple line - Diameter of gastrojejunostomy - Extent of bypass (roux limb/BP limb) Revisional strategies - Reduce pouch size - Narrow the gastrojejunostomy - Excise a gastro-gastric fistula - Lengthen of roux limb

 

Day 2 – Thursday, September 3 – Parallel Affiliate Session

Dawn Elliot, Affiliate representative on the AUGIS Council, opened the lively session and chaired.

Claire Sedgewick, NS at Royal Victoria Infirmary, Newcastle, reported back on the Raising Public Awareness of Oesophageal and Gastric Cancer Week which included events in the North and highlighted the fact that early detection is often the key to saving lives.

Several posters were presented to the session covering topics as diverse as how endoscopy improves efficiency and outcomes, the challenges of diagnosis and a case report into a small bowel obstruction caused by a carcinoid tumour.

Tom Palser also gave an update on the National OG Cancer Audit and presented some early results.

Jane Tallet, who is based in Norwich, was introduced to the meeting as the successor to Dawn Elliot.

 

Day 3 – Friday, September 4,
Session 1 Parallel Session OG / BOMSS

Mr Nick Maynard | Gastric cancer – laparoscopic versus open gastrectomy

Japanese surgical results on gastric cancer seen as gold standard, however, their good results have never been matched in the West. Better Japanese outcomes might be at least partially due to the fact that gastric cancer in Japan are localised more distally (antrum versus proximal stomach), are less of diffuse type, less obese patients, more radical surgery.

Total gastrectomy mortality is similar between Tokyo and Leeds studies, however, D2 gastrectomy in the West has never achieved significant survival benefit over D1 lymphadenectomy. Stage 2 cancers are the only ones that may benefit from a D2 lymphatic dissection.

The original Dutch study (Lancet 1995) randomising D1 and D2 resections showed no survival benefit at 11 years post-surgery. MRC study shows a higher mortality for D2 but no difference in five years survival (33% D1 vs 35% D2). However, a criticism was that most Western surgeons were on their learning curve and the higher mortality was registered in the pancreatico-splenectomy group (12%T3 and 40% T4 have lymph node mets at the splenic hilum). Cochrane review of D2 shows overall no benefit for D2 lymphadenectomy. D2 is recommended only for stage 2/3 in high-volume centres. JCOG 9501: D2 vs D3 (para aortic node dissection): no survival benefit.

Summary:

1. No benefit from superextended surgery (D2 can be performed in high-volume centres)
2. No need for prophylactic pancreatico-splenectomy
3. No para-aortic node dissection
4. New field of interest: quality of life and adjuvant/neoadjuvant chemotherapy

Laparoscopic gastrectomies results

Difficult to compare East and West: In the east more laparoscopic assisted procedures and early disease, whilst in the west various procedures and less numbers. There is a benefit for quality of life for laparoscopic assisted distal gastrectomy.

Consider suitability for Siewert type III; young patients and advanced disease, multiple organ resections.

Dr Phil Schauer, Professor of Surgery, Cleveland Clinic Lerner College of Medicine | Bariatric Surgery: Salvaging the failed gastric bypass – what next?

There were 250,000 new primary bariatric procedures this year in the USA. There is a 15% failure rate of gastric bypass; 25% failure for gastric banding; 5% for BPD/DS. There were 23,000 revision procedures in 2004 in USA.

Dr Schauer said that the cause of inadequate weight loss is multi-factorial and includes lifestyle, poor compliance and orthopaedic problems.

The reasons behind revision of gastric bypass include:
– Inadequate weight loss
– Anatomic problems (large pouch, marginal ulcers, persistent reflux)
– Malnutrition

He said that it is difficult to establish what represents success for a bariatric procedure: % Estimated Weight Loss <50% or <25%; BMI< 30 or <35; reduction or resolution of co-morbidities. He said that there is a need to set realistic expectations; understand patient anatomy, request patient to demonstrate compliance, assess intelligence. Surgical tips from Dr Schauer included: Look for familiar landmarks; green staplers, reinforce anastomosis with sutures; beware of excessive traction of the liver; liberal use of NG tube; 15 mls gastric pouch; 50 cm BP limb - 150 cm roux limb. Elements that may affect weight loss: - Pouch size - Intact staple line - Diameter of gastrojejunostomy - Extent of bypass (roux limb/BP limb) Revisional strategies - Reduce pouch size - Narrow the gastrojejunostomy - Excise a gastro-gastric fistula - Lengthen of roux limb

 

Day 3 – Friday, September 4,
Session 1 Parallel Session HPB

Professor Max Malago | Surgery for hilar cholangiocarcinoma

Prof Malago started by saying that hilar cholangiocarcinoma has a short history, having been first described within the past 50 years and added that establishing successful surgical treatments have been a struggle. He said around 20% of patients are amenable for treatment.

He said that it is also a reasonably rare condition with only 1,500 new cases a year, 65% in the elderly – which means that palliative treatment is important. In most centres, mortality for liver resection is 5% but in the case of this condition it is 15-20 %.

Mr Malago said that one of his aims was to improve access to surgery and he used a footballing analogy, saying that the surgeon must be focused on results while also playing defensively.

He said surgeons were looking for new horizons and that teams in Japan, for example, were making good progress. He added that several papers are worth reviewing to work out the best treatment options and survival rates are slowing improving. He said he believed that transplantations should also be considered.

Mr Malago concluded that surgery is the best treatment option and that attention must be paid to correct diagnosis. A versatile surgical policy would be a good idea and surgeons should be open to the idea of transplants. A multi-disciplinary approach will also pay dividends.


Launch of the HPB database

David Berry, consultant HPB surgeon, announced the launch of two new and important databases – the HPB Cancer Resection database and the International Ablation database. These two databases have been designed to be as user-friendly as possible for surgeons and will help fulfill professional requirements due to come into force in the next couple of years. Results from the audits will not be analysed for three years. 

Delegates were encouraged to access the databases through the AUGIS website. AUGIS Council member Graeme Poston said: “Providing this sort of information is going to be an essential component of assessment in the future and a legal requirement in England from 2012.”

Dr Phil Schauer, Professor of Surgery, Cleveland Clinic Lerner College of Medicine | The operating room of the future

Dr Schauer spoke about how he had the chance to design two operating suites in the past and showed slides of his suites and highlighted changes over the past decade, for example, the move from equipment which had to be wheeled in to the room for use to the installation of overhead tracks. Recent innovations – such as the ‘intelligent operating room’ which allows for two-way communication and voice-activated controls – were praised.

However, Dr Schauer pointed that that not all innovations “stick,” giving the example of the robotic camera which was introduced in the 90s but didn’t work out. He said the future would continue to show exciting new developments and ones which don’t perform well.

Future projects and products in the operating room are likely to include head-mounted displays and the use of wireless equipment. Moving to the ward, Dr Schauer spoke of the possibility of computers which can be used at the bedside to deliver tutorials to students or to give the patient post-operative advice. The computer could also be used for two-way communication between consultant and patient – cutting the risk of contamination around a hospital and saving on doctor time.

Looking even further ahead, Dr Schauer spoke of “Doctor Robot” – which can be wheeled from patient to patient – with the doctor’s head viewed on a TV-style screen.

In terms of the evolution of surgery, Dr Schauer briefly described the evolution of surgery through open, laparascopic and endoscopic methods – and then said that he believed the next driver for innovation would come through endoscopic bariatic surgery.

He said this was because he believed it was becoming seen as the only way to successfully tackle obesity. In terms of the bariatic devices, there are restrictive techniques such as gastric bands, implanted devices and space fillers and malabsorbatives which stop food being absorbed.

Dr Schauer said there would be high volume caseloads for each of these areas of surgery in the coming years, leading to increases in expertise and driving innovations in the operating theatre.

Professor Hugh Barr | Rapid endoscopic identification and destruction of degenerating Barrett’s mucosal neoplasia

Prof Barr spoke about the prevalence of Barratt’s Oesophagus, screening techniques and the challenges faced by physicians in deciding at which point to intervene. “Early detection induces dread, later detection means death.”

He said: “The fact is that it’s hard to beat this disease once you have got it – survival rates are typically 18 months to 3 years – so the skill is to spot the dangerous signs early enough when intervention will be beneficial whilst bearing in mind quality of life issues.”

Prof Barr pointed out that screening would show warning signs in about 60% of the over-60s but that experts were trying to identify which were the “bad cells” which would go through the pores and cause cancer.