The 4th BOMSS Scientific Meeting, held in Glasgow, was a great success. It was opened by out-going President Professor Alberic Fiennes who reviewed the society’s achievements in the past three years – a well-established disease model, a better functioning society a growing number of members, many of them AHPs, a written constitution, and quality improvement including the NBSR, BOMSS Service Standards, and work on the NCEPOD report.
Prof Fiennes said: “There is more to do – and the direction of travel is the responsibility of the members.” He finished by congratulating Mr Richard Welbourn, who took over as President of BOMSS at the end of the meeting.
Speakers of of national and international renown and a mix of highly informative talks by specialists from across the UK then followed over the two-day meeting.
The Meeting had been preceded by a successful teaching day for trainees, with ‘meet the experts’, lectures from specialists and consultants, roundtable discussions, simulator sessions and input from AHPS.
Our partners in industry supported the Meeting generously and a busy trade exhibition there were ample opportunities for networking. The social programme included a wonderful Annual Dinner with a Burns Night theme.
Training and Education
Bariatric Surgical Training: A USA perspective
Dr Mal Fobi, USA
Dr Fobi started his talk by pointing out that bariatric surgery was first performed in 1954 and added: “Let’s see how far we have come.” Dr Fobi outlined the development of bariatric surgery in the USA and said that it took until 2004 to become an accepted mainstream procedure.
He believes that the introduction of laparoscopic bariatric surgery led to its wider acceptance and popularity, but it also gave surgeons a new leaning curve as they “re-invented the wheel.”
Formal training programmes have been essential to the development of bariatric surgery and, with the advent of the Lap-Band, bariatric surgery became the second most popular minimally-invasive operation in the USA.
The Minimally Invasive Fellowship Council led to fellowships being extended to a year, with a set curriculum and requirements.
Last year, the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Programme – a collaboration between the ASMBS and the ACS – was launched to collect data. Dr Fobi praised this development as helping to establish what might be the best surgery.
Dr Fobi also gave delegates his personal story as a bypass patient who says he has lost his appetite. “I eat because I know I must eat. Surgery changes gut hormones.”
He finished his informative talk by saying: “After 40 years of bariatric surgery, we still don’t know what the hell we’re doing!”
Bariatric Surgical Training: A UK perspective
Professor Alan Osborne, Taunton
Professor Osborne, who works in the South-West, talked the meeting through training from a British trainee. Prof Osborne sits on the BOMSS council as the trainee representative and pointed out that acting as a gateway to education and training is a key BOMSS target.
He said that the best place to learn is in the operating theatre. He also reflected on the advantages offered via Procedure-Based Assessments.
He added: “The simple fact is that there are currently twice as many bariatric trainees as there are jobs. Half of you will have to do something else in the end.”
Another area of concern for Prof Osborne lies in revisional surgery. “All surgeons needs to be competent to undertake what will become an increasingly large volume of work in the future.”
Bariatric Surgical Training: What can we learn from our colorectal colleagues and the LapCo model of training and assessment
Professor George Hanna, London
Professor Hanna described the lessons learned from the National Training Programme in Laparoscopic Colorectal Surgery.
He said that the value of laparoscopic colorectal surgery for cancer was proven by randomised controlled trials and recommended by NICE – but just 8% of colorectal resections were done laparoscopically before 2007.
The laparoscopic colorectal surgery programme allocates case-by-case funding, assigns trainees to training centres and monitors the progression of their training. There are 13 centres of excellence across the UK. In the training, an initial course is followed by one-on-one training and then solo training.
In terms of lessons learned, Prof Hanna commented: “Leadership, commitment and clinical co-ordination are absolutely essential.” The selection of training centres should be based on merits, commitment and workload. An academic component worked well and an interactive website are all important.
Competency assessment is an integral part of the training programme and identifies surgeons who would benefit from additional training. In terms of cost/benefit analysis, Prof Hanna said they found that surgeons who took the training course had a similar level of proficiency at 30 cases as others who had not taken the course achieved after 150 cases. He believed that the benefit of the course was at least £18 million, measured in reduced post-surgery complications.
Metabolic Surgery – an overview of the need for metabolic surgery
Professor Michael Lean, Glasgow
Professor Lean outlined a number of targets for solving the obesity epidemic, for example, encouraging healthier body shapes and creating a better quality of life for people.
He pointed out that in Scotland, BMI is not increasing fast but mean waist circumferences are – suggesting that people are gaining fat but losing muscle mass. He added: “The NHS needs to ‘wake up and smell the coffee’, over the risk of obesity to public health.”
Prof Lean said that about 30 per cent of people have genes which make them predisposed to metabolic syndrome – and so are at a higher risk of obesity from the outset.
He said that young men were a good target for intervention as this is a group in which fast weight gain is occurring and added that a 15% weight loss usually normalises glucose levels and extends life expectancy for overweight T2DM patients by 3-4 months per kilogram of weight lost.
He said: “Bariatric surgery can achieve the 15 per cent weight loss that is required to give patients a good chance of diabetes remission – but can we achieve it without surgery?”
Prof Lean then described a Scottish trial of a treatment of low-calorie food and dietary advice along with prescribed Orlistat, which led to a 15% weight loss in 33 per cent of patients after 12 months and at a cost £811 per patient.
He concluded his informative talk by describing a low-tech method of stopping people buying fizzy drinks – placing ‘out of order signs on vending machines!
Metabolic Surgery – what is new in the management of T2DM?
Professor Roy Taylor, Newcastle
Professor Taylor described his work looking at how liver fat and diabetes could be related and discussed various studies and data on plasma glucose levels. He also discussed the results of studies into Incretin.
He initiated the Counterpoint study – a very low calorie diet over eight weeks, measuring beta cell function, liver and muscle insulin sensitivity, liver and pancreas fat. He said: “It worked. Patients lost an average of 15.3kg over eight weeks and fasting plasma glucose levels dropped extremely rapidly.”
Prof Taylor used the TV presenters ‘The Hairy Bikers’ as a case study describing how he put them on a low calorie diet with an exercise plan for 12 weeks. The diet represented a 50 per cent reduction in their usual food intake with alcohol banned. He said they each achieved a weight loss of 2.5 stone.
Dieting rather than weight loss is a superior way of resolving diabetes than surgery for those who can do it, he said, but few can. “The Hairy Bikers were motivated, had clear goals and were in competition with each other. This is a good medical model but continuing motivation is tricky.”
Metabolic Surgery – an overview of the outcomes of metabolic surgery
Dr Torsten Olbers, Sweden
Doctor Olbers discussed the use of bariatric surgery to treat metabolic syndrome and posed the question: “What do surgeons want to achieve in their patients? Losing body weight? I would say no. They want to improve patients’ quality of life, reduce morbidities and prevent premature death.”
Dr Olbers pointed out that the Swedish Obese Subjects study showed how surgery can achieve long-term weight loss and reduce mortality but he also cautioned against the idea that surgery alone “cures” patients without regard to the role of medicine. “It’s not medicine or surgery – it’s medicine AND surgery.”
He concluded his talk by highlighting the links between bariatric surgery, long-term weight control, improvement in cardiovascular risk factors, improvements in T2DM control and a 30 per cent drop in overall mortality.
Primary care of Primary Importance
Professor David Haslam, UK
Professor Haslam, chair of the National Obesity Forum, started off his talk by describing his work a GP in North London and a bariatric physician at Luton and Dunstable NHS Trust.
He pointed out that the first port of call for most obese patients is a GP’s surgery, adding: “GPs have to engage the patient and are crucial to a successful outcome – and it can be tricky.”
trated the role of a GP with case study in which a man brought his son in for a minor medical complaint but was himself clearly morbidly obese. Prof Haslam described how he won the man’s trust and persuaded him to start attending surgery for help. He said his tip to GPs is to say “Am I looking after your general health,” as a non-threatening way of starting to engage with reluctant patients.
Prof Haslam expressed concern at the poor level of information available on websites which patients often refer to rather than visiting a GP. And he discussed commissioning issues. He urged fellow GPs to pick up on sleep aponea and T2DM which offer access to surgery. He added: “We need to pick up on binge eating.”
He finished his informative and entertaining talk by highlight the crucial importance of communication is ensuring patients are able to access treatments that best suit their needs.
20/20 Vision: A Multidisciplinary Approach
NBSR, bariatric tariffs and revisional surgery
Mr Richard Welbourne summed up the session on the British National Bariatric Surgery Registry – asking if it be made compulsory for British bariatric surgeons to submit their outcomes?
At a show of hands, around 80% of attendees at the session agreed that it should be compulsory. However, concerns were raised over ownership of data and cost.
Moving on, Mr Welbourne raised the issue of the cost to the NHS of revisional surgery? His group also discussed if NHS tariffs for bariatric surgery are appropriate.
Follow-up: By whom? How and for how long?
Professor Duff Bruce reported back on an engaging and interesting debate which he happily admitted went off-topic. He said the group discussed the MDT nature of bariatrics and the vital roles taken by AHPS. He suggested that BOMSS looks to further integrate AHPS into the organisation and explore new avenues of communication such as online forums and possibly a dedicated website.
What is the most appropriate effective use of AHP skills within the MDT?
Ms Mary O’Kane discussed the role of dietitians and how best to use their skills within the MDT saying: “It seems that for some patients being ‘sent to see the dietitian’ is viewed as a punishment. We have to challenge this notion.” She said a functioning MDT would mean that patients saw the right person on the right day throughout their treatment and would always receive individualised advice.
What is it that we have not understood about people’s eating behaviour that makes it so very difficult to achieve lasting weight loss, even after surgery?
Psychologist Doctor Matilda Moffett reported back on this session which had included a group exercise to identify psychological and social reasons for obesity. She said: “People don’t become overweight by accident. People have issues.” Emerging themes included entrenched patterns of over-eating, the normalisation of weight gain, cultural pressures and low self-esteem.
But Dr Moffett also reminded people that undoing the factors which cause obesity do not undo obesity itself.
The group concluded its discussions by agreeing that clinicians needed to support the development of improvements in emotional intelligence, self-esteem and inter-personal relationships among obese patients.
End of the Meeting
Mr Richard Welbourne closed the meeting by thanking the speakers and the organisers. He paid tribute to Prof Fiennes and added: “It’s a great privilege to be your new President.”
Best training day audio/visual presentation: Nicholas Carter.
The Training Day: James Young.
Best poster presentation: William Carr.
Best oral presentation: James Brown