Digestive disorders: issues debated

An estimated 4,000 delegates are expected to attend the Digestive Disorders Federation (DDF) conference and exhibition, which takes place 17-20 June 2012, at the Arena Convention Centre (ACC), Liverpool, UK. It will be the first combined meeting of the Association of Upper Gastrointestinal Surgeons (AUGIS), British Association for Parenteral and Enteral Nutrition (BAPEN), British Association for the Study of the Liver (BASL) and British Society of Gastroenterology (BSG). The conference programme will reflect the combined interests of these groups, featuring presentations on a wide range of topics including: key issues in bariatric surgery; optimising surgical outcomes for inflammatory bowel disease; quality and outcomes in upper GI cancer surgery; news, views and updates from the world of nutritional care; how the NHS will meet the challenge of viral hepatitis; pushing the boundaries of endoscopic therapy; and a review of the quality and safety of colonoscopy.

AUGIS

The aims of the Association of Upper Gastrointestinal Surgeons (AUGIS) of Great Britain and Ireland are to improve care delivery and outcomes for patients undergoing surgery for conditions of the oesophagus, stomach, duodenum, pancreas, liver and biliary tract. Founded 15 years ago, the society now includes three distinct groups of surgeons in the fields of: oesophageal cancer surgery; bariatric surgery (part of the subgroup, the British Obesity and Metabolic Surgery Society [BOMSS]); and liver and bile duct surgery (under the direction of the Great Britain and Ireland Hepato-Pancreato-Biliary Association – another sub-set of AUGIS). It has over 600 members, including 500 consultants, as well as trainees in upper-GI surgery, clinical nurse specialists and dietitians. AUGIS works closely with the DH, NICE and the GMC in delivering, regulating and designing specialist upper- GI surgery services, with the aim of raising quality standards. It also delivers a robust system of clinical audit – central to improving clinical outcome for patients with upper-gastrointestinal disease. Surgeons operating within the three key fields of oesophageal cancer surgery, bariatric surgery and liver and bile duct surgery are required to submit data to the national register that AUGIS administers. In partnership with the GMC, the association also has a key role in designing training programmes for surgeons – setting the curriculum, the number of cases that surgeons need to perform, the standards of competency to be achieved at each stage of training, and – with the Joint Committee of Higher Surgical Training – has an important role in signing off surgeons to become consultants that are capable of working as independent practitioners. The association is also involved with the development of a number of international guidelines – dealing with areas such as primary liver cancer, pancreatitis and secondary, metastatic liver cancer. Most recently, AUGIS has been working closely with the DH on the development of the Government’s Health and Social Care Bill to ensure that high quality services in the field of upper-GI surgery are maintained under the new commissioning framework. “Gallstone disease, which is extremely common, will be commissioned by GPs, but the highly specialised surgery undertaken by AUGIS members – such as Upper GI cancer surgery for the gullet, stomach, pancreas and liver, along with complex bariatric surgery, will be commissioned separately,” explained Graeme Poston, president of AUGIS. “I will be chairing the committee responsible for commissioning of hepato-pancreatobiliary surgery. This is relatively expensive, technically challenging and higher risk, which is why specialist input is required.” Graeme Poston said that hepatopancreato- biliary and oesophago-gastric surgery will be performed in specialist centres to ensure surgeons have the levels of competency and experience required to ensure the best outcomes. “We would be opposed to any suggestion that these specialist centres, which have been established over the last 10 years, should be disbanded to allow every local hospital to have its own upper- GI cancer surgeon – this was a potential concern under GP commissioning, and would have presented a serious safety issue,” he commented, adding: “The volume of cases that these surgeons perform is crucial to achieving the best outcomes. AUGIS has been proactive in championing the centralisation of specialist services to achieve the best outcomes. If a patient is admitted to an oesopho-gastric cancer centre, there will always be an oesophogastric cancer surgeon available to deal with out of hours’ emergencies. “Under the old system, there may have been only one oesopho-gastric cancer surgeon available to perform the surgery at a district hospital, but in the event of a problem arising, they may not be available to intervene. This is why results were so poor in the past. We have been proactive in ensuring that, under the new Bill, the specialist services are fully funded and delivered properly.” Another key focus area for AUGIS is improving standards in cholecystectomy (surgical removal of the gall bladder). “Twenty years ago, there was a move towards performing cholecystectomy laparoscopically. However, while there are very good laparoscopic surgeons, there are also variable levels of skill and ability across the UK – as with any profession. This operation has been linked to a catastrophic complication, in which the surgeon cuts the bile duct leading from the liver, which the courts consider negligent,” commented Graeme Poston. He pointed out that, if performed via minimally invasive surgery, the risk of damaging the bile duct is higher than if it is performed by the open surgery route. “All general surgeons are licensed to perform this type of gall bladder surgery – despite the fact their area of expertise may be vascular, breast or colorectal surgery. However, patients are often not aware of this, when they are referred to a hospital for a cholecystectomy. They naturally assume they are going to see an expert in gall bladder surgery, who regularly performs the procedure, yet this may not be the case. “We know that the incidences of these bile duct injuries are higher in the hands of non-specialist surgeons, as they are simply not performing the volumes to develop the experience required to ensure consistent, high standards of safety. We are working very closely with the legal community and will be running a meeting later this year, raising awareness of this issue.” Graeme Poston added: “We will be urging patients to ask the surgeon: how many of these do you perform a year, who does more than you and what are their results? What is your real specialty, are you actually a specialist upper-GI surgeon, what is your safety record and why, if this is not your specialty, are you planning to operate on me? We want patients to understand that the risk is very real – one in 200 gall bladder operations end in disaster.” AUGIS will also be conducting a national audit this year to evaluate the number of injuries that occur. By the end of the year, it aims to present the evidence as part of a publicity campaign – urging patients to ensure their GP refers them to a surgeon that regularly performs this surgery. “We also need to get the message across to GPs who will be commissioning gall bladder surgery,” Graeme Poston asserted. The conference programme will reflect AUGIS’s focus on the issue of quality and there will be some high profile international speakers attending – including Professor Cornelius van der Velde, professor of surgery at the Leiden University Medical Center, Leiden, The Netherlands, who became the new president of ECCO (the European Cancer Organisation), earlier this year. He is also chairman of the European cancer audit process, known as EURECCA, which aims to improve the quality of cancer care through surgical audit. Professor van der Velde will be speaking about quality and outcomes in clinical trials. Also speaking is Professor Robert Padbury, director of the division of surgical and specialty services at Flinders Medical Centre, Adelaide, Australia, who will be discussing quality and outcomes in upper-GI surgery. Professor Peter Naredi, professor of surgery at Umea University in Sweden and the president of the European Society for Surgical Oncology (ESSO), will also be giving a presentation on quality and outcomes in clinical trials relating to cancer surgery. Professor Jane Blazeby, professor of surgery at the University of Bristol, and a consultant upper GI surgeon, will talk about quality and outcomes from the patient’s perspective – having conducted important research on the issue of quality of life and cancer surgery. “There will also be some interesting data presented on radiotherapy and oesophageal cancer surgery, by Professor Jan van Lanschott, professor of surgery at the Erasmus University of Rotterdam,” Graeme Poston revealed. “The results of the Dutch trial show that if you combine radiation therapy with surgery, for oesophageal cancer, the cure rate increases by at least a third – if not 50%.”