Training Day Report, Bristol 2012

The inaugural BOMSS training day was held on 18 January in Bristol the day before the Scientific Meeting. Miss Sally Norton (BOMSS Council) who kindly organised the Training Day, welcomed the delegates to the Royal Marriott Hotel and reviewed the programme.

Operative session

Professor Wendy Brown described her experience of gastric banding in Australia. She said: “I saw my first banding operation in 1993 and thought ‘who would be crazy enough to do this sort of surgery!’ There was a minimum of a five-day stay in hospital, for example. Now we can do bands as day cases.” Their experience now involves routine day case surgery with 5 mm cameras and often uses a calibration balloon (or even band manometry performed with special catheters). Large fat pads are removed and the risk of erosion with sutured bands versus the risk of slippage without suturing was debated.

For trainees it is clear the future of obesity surgery is going to involve delivering revisional surgery: Prof Brown added: “We have to be sure that we are offering care that predicts future needs.” Revisional gastric banding, the NERD procedure, was detailed with good outcomes: 50% EWL after band to band revision at 15 years. This might allow further revision in future to sleeve and then bypass procedures. A stepwise approach to surgical options may be increasingly important in the future and there may even be a role for a third band revision.

Prof Brown said: “With UGI surgery you often have around a five-year relationship with patients. Bariatric surgery offers us the chance to have a much longer relationship with them.

  1. It is also necessary in Australia for all surgeons to be familiar with urgent band removal, raising questions over our own emergency service. “In Australia, we are keen to teach surgeons how to put in and remove gastric bands. We have a lot of remote communities and surgeons have to be able to tackle a range of operations. There are many people walking around with gastric bands and some of them will turn up in the emergency department.” This is also an increasing issue in the UK population.

Mr David Hewin, College Bariatric tutor, went on to discuss the sleeve gastrectomy including complications and failures, saying: “Bariatric surgery increases satiety and reduces hunger – if it didn’t do this, all operations would fail.” Take-home messages included remembering to avoid the “hourglass stomach” when forming the sleeve. The bougie size commonly used is reducing (32-36) and it remains crucial to avoid a stricture at the incisura and angle away from the GOJ when stapling the proximal end. Reflux post-surgery can be an issue and it remains important to perform a crural repair in hiatus hernia.

Mr Jim Hewes, a North Bristol Consultant, explained how to achieve quality gastric bypass surgery. He said: “The key message for gastric bypass is that there are several ways of doing it. The data suggests that consistency of technique is more important than any individual procedure.” As a consultant it is important to develop your own method and then be consistent using the same technique. This standardisation of surgery may improve outcomes.

Professor Antonio Torres kept the presenters on their toes and delivered video presentations on interesting complications with tips and tricks to survive as a consultant. This included internal hernia surgery: remember if you have an internal hernia it is commonly the BP limb (there will be no contrast in it on CT). Start at the caecum and work through the small bowel backwards to delineate your anatomy. Another video demonstrated endoscopic gastric band cutters after a band erosion. Remember to re-laparoscope complications first as most post-operative problems can be managed with laparoscopic surgery.

MDT

After coffee we had the first break-out session with the mock MDT. Miss Mary O’Kane described the Leeds approach, “MDT is about trying to find the best way forward for the patient. The patient is at the heart of this process. Surgery is the start of a long pathway for the patient – we make a commitment to life-long care.” The small groups included role playing as members of the MDT. As a dietitian herself Miss O’Kane commented: “Surgeons are stricter than I am about diet which has come as a surprise to me.”

  1. Mr Simon Higgs, Consultant UGI surgeon at Cheltenham and Gloucester, facilitated the session which received excellent feedback including the top marks on the feedback forms for the radiology round table. This was led by Dr Karen Mason, Consultant Radiologist at Cheltenham and Gloucester. Here Bariatric radiology case studies were reviewed prompting some interesting debates.

Simulation

In the afternoon trainees divided up to use the latest simulators and a dry laboratory where each trainee was able to place and remove a gastric band and perform a sleeve gastrectomy.

The Trainees’ Session

The trainees’ career session finished the day with the Professors talking about opportunities for training and fellowships in Europe and the Southern Hemisphere. It is obvious if you want the Australian Fellowship you need to attend the wine tasting session at the Obesity Surgery Society of Australian and New Zealand (OSSANZ) in April in Darwin so if you want a fellowship in the southern hemisphere, consider going! This year’s Meeting is themed “For Our Children’s Children,” and will be held in Auckland in October so if you want a fellowship, consider going!

  1. Closer to home the European Accreditation Council for Bariatric Surgery (www.EAC-BS.com) offers one year training grants most recently at “The Centro Laparoscopico Dr. Ballesta”. The recipients report to IFSO and after working in an IFSO-EC endorsed Centre of Excellence in Barcelona Spain.

The benefits of a training day for the trainee members of BOMSS were clear and we are very grateful to the entire faculty who gave up their valuable time to help teach. E – IFSO trainees will be meeting in Barcelona for a round table on training where we hope to start forming a Bariatric trainees’ community: please get involved if you are coming.

We look forward to seeing you all next year in Glasgow.

Alan Osborne
Trainee Representative on Council