Abstracts of the 5th Annual Scientific Meeting of the British Obesity & Metabolic Surgery Society, 23-24 January 2014, Leamington Spa, UK.

BOMSS abstracts 2014

The 5th Annual Scientific Meeting of the British Obesity & Metabolic Surgery Society (BOMSS) took place on 23–24 January 2014 in Leamington Spa. A02

CONTENTS Abstracts

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Page Number

Council Prize Session – Kenilworth (Friday 24 January 2014 12:00–13:00)

A01–A06

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Free Paper Session – Kenilworth (Thursday 23 January 13:30–15:00)

B01–B10

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Free Paper Session – Kenilworth (Friday 24 January 08:30–09:50)

C01–C10

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Posters of Distinction

Luton & Dunstable University Hospital NHS FT, Luton, UK Background: Laparoscopic abdominal wall hernia repair (LAWHR) in obese

PoD1–PoD6

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P07–P50

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Posters

Abstracts

Council Prize Session - Kenilworth (Friday 24 January 2014 12:00–13:00) A01 The impact of Bariatric Surgery on Urinary Incontinence in Women Hayder Shabana, Colm J O’Boyle Department of Bariatric Surgery, Bon Secours Hospital, Cork, Ireland Background: Morbid Obesity is known to be a contributing factor to the

development of stress urinary incontinence in women. We evaluated the urinary symptoms of morbidly obese patients pre and post bariatric surgery. Methods: Between January 2011 and January 2013, 47 morbidly obese women with incontinence underwent bariatric surgery. All 47 completed detailed urinary function questionnaires both pre- and post-operatively. Results: The median BMI was 48(39–61) kg/m2 . Thirty-two (68%) patients underwent gastric bypass, fourteen (30%) underwent sleeve gastrectomy and one underwent a banding procedure. Thirty-three patients (70%) reported urinary leaking on more than one occasion per day. Thirty-five (74%) required daily incontinence pads. Eighteen (38%) reported changing pads more than once per day. Nineteen (40%) reported moderate to severe leakage. Thirty-four (72%) reported leaking on sneezing or coughing. Eighteen (38%) reported significant interference with their daily life (> 6/10, visual analogue). At a median 6(1–12) months following bariatric surgery the median weight loss was 62(20 to 162) lbs. Eighteen patients (38%) reported complete resolution of their symptoms (p < 0.001, χ2 ). Thirty-five (74%) did not require pads (p < 0.001, χ2 ). Only 5(11%) changed their pads more than once per day (p < 0.01, χ2 ). Forty-three (91%) reported mild or no leakage (p < 0.001, χ2 ). The interference with life score dropped from a median preoperative level of 5 to 1. Thirty-four (72%) women reported a marked improvement in their symptoms (> 6/10, visual analogue). Conclusion: Bariatric surgical intervention results in a clinically significant improvement in urinary stress incontinence in the early months following surgery in the majority of symptomatic morbidly obese females.

 2014 The Authors BJS  2014 BJS Society Ltd

Laparoscopic Roux-en-Y Gastric Bypass and Concomitant Laparoscopic Abdominal Wall Hernia Repair with Prosthetic Mesh is Safe and Feasible Carlo Nagliati, Marco Barreca, Durgesh Raje, Douglas Whitelaw, Periyathambi Jambulingam, Vigyan Jain

patients is a recognised approach. There is lack of consensus regarding timing and method of repair for such hernias in patients who will undergo bariatric surgery. Moreover, the use of prosthetic mesh is controversal in cleancontamined cases such as laparoscopic Roux-en-Y gastric bypass (LRYGB), where the gastrointestinal tract is opened to perform multiple gastrointestinal anastomoses. On the other hand, there is a risk of small bowel obstruction in patients undergoing LRYGB with untreated ventral hernias. Aim: To present our experience on LRYGB and concomitant LAWHR, using a prosthetic mesh. We aim to demonstrate that it is a safe and feasible option. Methods: We retrospectively queried our prospectively collected database. One hundred thirty-four morbidly obese patients with a abdominal wall hernia were identified. Eighty-four (62.7%) patients underwent LRYGB and concomitant LAWHR with prosthetic mesh from Jan. 2007 to Oct. 2013, and represent the subject of the present study. All patients underwent regular follow-up. We recorded BMI, age, size of the hernia, length of hospital stay, mesh-related complications and time of recurrence of the hernias. Results: Fifty-six patients were female. Mean age was 49.7 years. Mean preoperative BMI was 51.5 kg/m2 . Mean size of the hernia was 22.9 cm2 . Three (3.6%) patients developed non-mesh related complications postoperatively (2 leaks, and 1 bleeding). Laparotomy and mesh removal was required in one leak and on the bleeding patient. The other patient, who developed an early leak, was treated with laparoscopic wash-out and drainage without mesh removal. Mean length of hospital stay was 3.9 days. There were no cases of mesh infection or early recurrence. Four out of 82 (4.9%) patients developed late recurrence of the hernia and required a reoperation. Mean time of recurrence after surgery was 13.2 months (range: 8–18 months). Conclusion: LRYGB and concomitant LAWHR using a prosthetic mesh is safe and feasible. There were no cases of infection, or other mesh related complications, and an acceptable late recurrence rate. To our knowledge, this is the largest series of LRYGB and concomitant LAWHR with mesh reported in literature.

A03 Laparoscopic Removal Of Retained Gastric Band – Caplin’s Procedure Hazem Al-Momani, Rami Radwan, Jonathan Barry, Scott Caplin Welsh Institute of Metabolic and Obesity Sugery, Swansea, UK Background: Complication rates following laparoscopic adjustable gastric

banding are approaching 50%. Erosion is one of a number of recognised complications. Methods of removing eroded bands include endoscopic retrieval or formal laparoscopy and removal of the band at the proximal stomach should endoscopic removal prove unsuccessful. A major disadvantage of laparoscopic removal directly on to the band is encountering dense fibrotic tissue and inadvertent injury to the stomach. We describe a novel technique of laparoscopic distal gastrotomy and removal, therefore avoiding fibrotic tissue. This technique has proved its worth for many years in our unit hence, Caplin’s Procedure.

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Methods: We use three ports (1 × 5 mm, 2 × 10/12 mm). The distal stomach

Background: Notwithstanding its controversial aspects, Mini Gastric Bypass

is fixed to the anterior abdominal wall by two stay sutures of 2–0 prolene. A longitudinal distal gastrotomy is performed using a Harmonic Ace. The laparoscope is introduced into the open stomach and the eroded band grasped. The gastric band tubing is divided after incising the skin over the subcutaneous port. The gastric band is then retrieved via the gastrotomy and removed via the left 10 mm port. The gastrotomy is closed in a hand sewn continuous fashion. Conclusion: This technique provides an alternative to more recognised methods of eroded band removal and should be considered as the next step after failed endoscopic retrieval.

is an attractive bariatric procedure which is being performed by an increasing number of surgeons globally. To the best of our knowledge, there is no previous report of this procedure from any unit within the National Health Service. This study reports our early experience with this procedure. Methods: We analysed our prospective database to determine early results with this procedure in terms of complications, readmissions, weight loss, and comorbidity resolution. Results: A total of 40 Mini Gastric Bypasses have been performed in our unit between October 2012 and October 2013. All operations were performed using a standardised laparoscopic approach with formation of a long lesser curve based gastric pouch and a gastro-enterostomy at 2.0 meters from Duodeno-Jejunal flexure. Twenty nine (72.5%) of these patients were females. The mean age was 41 years. The average weight and BMI of patients was 127 kg and 44.3 kg/m2 respectively. Ten (25%) patients suffered with type II diabetes mellitus and 15 patients (37.5%) suffered with hypertension preoperatively. Two (5%) patients had a prior gastric balloon insertion. All patients were discharged on second postoperative day following appropriate dietetic advice. There was no early complication or mortality in this series. There were however two (5%) late (> 30 days) readmissions. The first patient was readmitted with vomiting at 3 months and diagnosed to have a marginal ulcer on endoscopy. Patient was treated with Lansoprazole and Sucralfate and ulcer has been seen to have healed on a subsequent endoscopic examination. Second patient was readmitted 5 weeks after surgery with unexplained vomiting that lasted a short period. It was presumed to be due to a viral infection. Upper GI Endoscopy and contrast studies were normal. We found an excess weight loss of 67.4% at 6 months (n = 14) and 89.7% at 12 (n = 4) months in these patients. All diabetics and hypertensive patients report a reduction in their medication. Conclusion: This study reports early safety of Mini Gastric Bypass in a large bariatric unit within the National Health Service with acceptable complication rates and weight loss. Longer term data are awaited.

A04 Emergency admissions in patients that have undergone bariatric surgery-are we prepared for the inevitable? Tanvir Hossain, Clare McNaught, Serban Giorgiou, Karl Mainprize, Karen Maude, Marcel Gatt, Robert Macadam Scarborough Hospital, Scarborough, UK Background: As the demand for bariatric surgery increases year on year in

response to the United Kingdom’s obesity epidemic, the presentation of patients who have undergone previous weight loss surgery to the emergency general surgery service of the district general hospital that does not have an in-house bariatric surgical service is an increasingly common phenomenon. Whilst by no means all abdominal emergencies in this patient group are a consequence of their weight loss surgery procedure, they can represent a challenging patient group for the nonspecialist to manage. Methods: The surgical handover documentation dataset, established in December 2009 and including a brief patient history incorporating past surgical procedures, was searched for common weight loss surgery terms to identify patients who had undergone previous bariatric surgery admitted under the care of the general surgical consultant on-call during the period to August 2013. Discharge data was then used to establish the patient’s in hospital management. Results: Between December 2009 and August 2013 there were 54 identified admissions in 38 patients (aged 21–67, mean 44 years, 78% female), who had undergone a previous bariatric procedure either in the UK or mainland Europe. 35 admissions (64%) occurred within the last 20 months of the study period (p = 0.0026 chi square). Inpatient episodes were managed by consultant surgeons with the following subspecialty interests: colorectal surgery (44), vascular surgery (7), breast surgery (2), upper gastrointestinal surgery (1). The previous bariatric procedure was a RYGBP (57%), L AGB (24%), LSG (9%), LSG to RYGBP (8%), intragastric balloon (2%). The majority of inpatient episodes were managed non-operatively (discharge diagnoses included post-operative pain, constipation, wound infection, abdominal wall cellulitis and cholecystitis) however a significant number of patients required surgical intervention during their admission (adhesive obstruction, incisional hernia, port site hernia, abdominal wall sinus, foreign body in abdominal wall, laparotomy for peritonitis) and two patients required transfer to other hospitals for management of post-operative intra-abdominal sepsis and gastric ischaemia. Conclusion: It is increasingly likely that the general surgical on-call service in nonspecialist centres will encounter patients who have previously undergone a weight loss surgery procedure. These patients will commonly be managed by consultant surgeons with little or no exposure to bariatric surgical procedures. It is important for the bariatric surgery community to address the provision of emergency care to this patient group in order to provide optimal services for patients and appropriate support for nonspecialist colleagues.

A05 Early Experience with Mini Gastric Bypass in a Large NHS Unit Maureen Boyle, Neil Jennings, Kamal Mahawar, Shlok Balupuri, Peter K Small Bariatric Unit, Sunderland Royal Hospital, Sunderland, UK


A06 Closure of mesenteric defects after Roux-en-Y Gastric Bypass: Is there enough evidence to decide? Venkatesh Kanakala, Dipankar Chatopadhyay, Rupa Sarkar, Neil Jennings, Kamal Mahawar, Schlok Balupuri, Peter Small Sunderland Royal Hospital, Sunderland, UK Background: Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) is increas-

ingly a common procedure of choice in bariatric surgery. Internal hernia (IH) after LRYGB is a serious complication leading to rise in patient’s morbidity and mortality. However the controversy continues whether to close or not to close the mesenteric defects (MD) to prevent IH. The aim of this study is to compare the benefit of closing and not closing the mesenteric defects to prevent IH. Methods: A thorough literature search was performed in Pubmed, Medline and Google Scholar for relevant articles till November 2013. Search was carried out using key words like ‘‘laparoscopy’’, ‘‘gastric bypass’’, ‘‘mesenteric defects’’ and ‘‘internal hernia’’. All the studies on LRYGB (prospective, retrospective and randomised controlled study) in English literature, to compare the incidence of internal herniae with or without mesenteric defect closure were included. Results: More than 100 articles were found in the search, of which only 16 articles (Level III and IV evidence) were considered to be suitable for the analysis. Most of the studies were retrospective studies which have shown benefit of closing MD, but failed to show statistical significance. Out of 16 studies, only one study was conducted prospectively (non-randomised) showed benefit of closing MD; however this study too did not achieve statistical significance. Till today there are no randomised controlled studies to prove either technique is beneficial. Conclusion: Although majority of studies have shown the benefit of closing mesenteric defects to prevent internal hernia, the dilemma continues as there is no high quality studies to prove the same. A multicentre randomised controlled study with a standardised technique in closure of MD should be performed.

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BOMSS abstracts 2014 3

Free Paper Sessions Free Paper Session - Kenilworth (Thursday 23 January 2014 13:30–15:00)

B01 Mini-Gastric Bypass – Short-term weight-loss, long-term risk of oesphago-gastric malignancy? John Bennett, Richard H Hardwick, Peter Safranek, Vijayendran Sujendran, Andrew Hindmarsh Cambridge Oesophago-gastric centre, Cambridge, UK Background: Roux-en Y Gastric Bypass (RYGB) surgery is effective at

reducing weight and improves obesity related co-morbidities, which in turn may improve life expectancy. However, it is a technically challenging procedure with associated morbidity and mortality. This has led to the development and popularisation of the ‘Mini-Gastric Bypass’ (MGB) involving the formation of a loop gastro-jejunostomy (LGJ) similar to the Biliroth II procedure. MGB achieves weight loss comparable to RYGB but with fewer early complications. The reconstruction fashioned in MGB generates continuous reflux of bile into the gastric pouch. Bile reflux is implicated in both gastric and oesophageal carcinogenesis and we are concerned this patient group maybe at increased risk of oesophago-gastric cancer (OGC). We review the evidence. Methods: Pubmed & EMBASE were searched using the terms ‘‘mini-gastric bypass’’, ‘‘gastric remnant cancer’’, ‘‘oesophageal cancer’’, ‘‘bile reflux and gastric/ oesophageal cancer’’. Results: Case series record over 5,000 MGB cases up-to 2013 (age range 14–72 yrs). Significantly higher concentrations of bile salts are recorded in the gastric remnant of patients undergoing LGJ for gastric bypass as opposed to RY. Symptomatic bile reflux in MGB necessitates revision to RY reconstruction – longterm results relating to the effect of constant, sub-clinical reflux are not available. There is substantial evidence from in vitro and ex vivo models indicating a pro-mutagenic effect of bile salts in the upper GI tract. Combined acid and bile reflux increases this effect and is associated with oncogene expression modulation. In fact, animal models of Barrett’s oesophagus and oesophageal adenocarcinoma utilise surgically generated entero-oesophageal reflux to enduce carcinogenesis. In humans, population based studies show a significant increase in the relative risk of developing OGC in patients 20 years after Billroth II reconstruction for benign ulcer disease (RR 3.7). Conclusion: The benefits of reduced peri-operative complications in MGB may be outweighed by the long term risk of developing OGC. Given the likely risk of malignancy, MGB should not be offered to young patients seeking weight loss surgery.

B02 Foregut and hindgut hypotheses for remission of diabetes – a systematic review of clinical studies in humans Zaher Toumi, Ravindra Date Lancashire Teaching Hospital and University of Manchester, Preston, UK Background: While bariatric surgery achieves remission of type 2 diabetes

mellitus in a significant proportion of morbidly obese patients, the mechanisms of the remission are not fully understood. Animal research proposes two major hypotheses (foregut and hindgut hypotheses) as possible mechanisms of remission. The aims of this review are: 1) to review the procedures that are based on these theories and are designed to treat type 2 diabetes mellitus (T2DM) and


2) to evaluate clinical relevance of foregut or hindgut hypotheses in remission of diabetes in humans. Methods: We performed a systematic review of Embase, Medline and Pubmed to identify the hypotheses-based procedures that were performed in humans from January 1995 to November 2013. We then extracted the relevant data in relation to number of subjects, follow up, weight loss, definition of remission of diabetes and remission rates. Results: We found three procedures that are based on the foregut and hindgut theories: ileal interposition, duodenojejunal bypass and duodenojejunal bypass liners. After excluding animal studies, abstracts, non-English articles and duplicate publications, 25 studies reported the effects of these procedures on treatment of T2DM on 687 subjects. Only ten used an acceptable definition of remission of DM. Most articles have short follow up (= < 12 months). Remission rates were 20-40% for duodenojejunal bypass, 73-93% for duodenaljejunal bypass with sleeve gastrectomy, 70-75% duodenal sleeve liner and 47–95.7% for ileal interposition with sleeve gastrectomy. Conclusion: Most studies based on the foregut and hindgut theories reported short follow up and did not use consensus definitions of remission of diabetes. Addition of sleeve gastrectomy improves the results of duodenojejunal bypass. Ileal interposition has never been used without sleeve. It is likely that stomach plays primary role in glycaemic control and role of duodenum, jejunum or ileum may be facilitating.

B03 Structural Changes in Intestinal Enteroendocrine L Cells after Isolated Ileal Interposition in Lean Rats Joao-Luiz Azevedo1 , Gilmara Aguiar-Yamacuchi1 , Wellington Cardia1 , Lucas Leal1 , Gustavo Miguel2 1 Federal University of Sao Paulo, Sao Paulo, SP, Brazil, 2 Federal University

of Espirito Santo, Vitoria, ES, Brazil Background: No therapeutic approach has significantly impacted the

progression of diabetes. As early improvement of glycemic control is observed after metabolic surgeries, there is currently a search for surgical procedures that can promote euglycemia also in non-obese patients. Glycemic control can be achieved by increasing the blood concentration of GLP-1, a hormone produced by L cells that are more densely concentrated in the terminal ileum. The isolated ileal interposition (III) to a more anterior region (proximal jejunum) can promote a greater stimulation of the L cells by poorly digested food, increasing the production of GLP-1 and reflecting on glycemic control. Nevertheless, is uncertain if the III retains the same L cell number per area of mucosa, thus perpetuating the increased production of GLP1 or, instead of it, the segment interposed will acquires a scarce density of L cells typical of the neighbor jejunum. The aim of this research is to investigate long-term histological modifications of L cells pattern in intestinal mucosa of rats submitted to III. Methods: Twenty-five male Wistar rats were distributed into Interposition Group (IG), which underwent III and Sham Group (SG), subjected to sham operation. All animals were followed until the 60th postoperative day when they were euthanized. Segments of jejunum and ileum were collected and scrutinized by immunohistochemistry. L cells density as calculated by the relation between the number of L cells identified and the total area of tissue examined at high magnification fields. Results: There was no difference between groups regarding intestinal L cells density in any of the intestinal segments analyzed. Jejunum: IG = 1,19 × SG = 1,34 (p-value = 0,014); ileum: IG = 3,33 × SG=3,35 (p-value = 0,050). Ileal interposed segments: IG = 3,26 × SG = 3,01 (p-value = 0,0311). Conclusion: After III, L cell number per area remains the same. Several studies showed adaptation of the transposed segment of ileum in order to mimic the structure of the neighbor jejunum. Nevertheless, this study demonstrated that after ileal interposition, the number of L cells per area were maintained as before III and the interposed ileum do not adopted the sparse L cells pattern that is typical of the jejunum. So, there is no cause for concern with the loss of efficacy of intervention with the passage of time.

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patterns emerge or worsen and these relate to poorer weight loss and quality of life outcomes.

B04 Mesenteric defects after Laparoscopic Gastric bypass procedure: to close or not to? Venkatesh Kanakala, Rupa Sarkar, Andrew Hollingworth, Dipankar Chatopadhyay, Neil Jennings, Kamal Mahawar, Schlok Balupuri, Peter Small Sunderland Royal Hospital, Sunderland, UK Background: Laparoscopic Roux-En Y Bypass (LRYGB) is considered to be

most common bariatric procedure performed in UK. However it is still not clear and the debate continues whether to close or not to close the mesenteric defects. Most of the non-randomised controlled studies suggest closing the mesenteric defects to prevent internal hernia as these mesenteric spaces are considered to be potential cause for bowel obstruction leading to increase in morbidity and mortality. We hereby present our experience of Internal Hernia before we started closing the mesenteric defects routinely. Methods: We have performed about 1325 LRYGB procedures in our dedicated bariatric unit. Majority of the patients had retro gastric and ante colic anastamosis as a standard procedure with linear stapling. All the enterotomies were closed in two layers. We routinely follow patients at 6 weeks, 3 months, 6 months and annually thereafter. Results: Out of 1325 LRYGB procedures, 1088 (82%) were female patients [Mean, 46yrs (range, 19-71yrs)] and rest were male [Mean 48.3 yrs (range, 20–74 yrs)]. Mean body weight of total cohort is 140.7 Kg (81–304), Mean excess body weight 67.5 Kg (22.5-151.8) and mean Body mass Index of 45.9 (33.6-94.5). Total of 8/1325 (0.60%) patients developed Internal Hernia postoperative in whom the mesenteric defects were not closed. All of these patients had subsequent surgery to reduce the hernia and close the mesenteric defect. Three patients required laparotomy and one of them required small bowel resection anastamosis. There was one mortality related to Internal Hernia. Conclusion: In our experience we have observed about 0.60% incidence of internal hernia due to mesenteric defects. Recently, we have changed our practice to close all the mesenteric defects to avoid further events. We propose to follow a standardised technique to close these defects laparoscopically, as inadequate closure may lead to increase in the incidence of Internal Hernia.

B05 Eating profiles post bariatric surgery Jolyon Poole1 , Denise Ratcliffe2 , Rukshana Ali2 1 Chelsea and Westminster Hospital Foundation Trust, London, UK, 2 Central

and North West London NHS Foundation Trust, London, UK Background: Bariatric surgery generally results in improved physical and

psychological functioning. However, some psychological problems can emerge or become re-activated following bariatric surgery. Binge eating patterns of behaviour have been shown to relate to poorer weight loss. However, relatively little is known about other types of problematic eating following surgery e.g. emotional eating (EE), night eating (NE), grazing. This study investigates the prevalence of these types of eating problems amongst individuals who had bariatric surgery in relation to time elapsed since surgery ( < 2 years ago versus > 2 years). In addition, we report how these eating patterns relate to quality of life and excess weight loss. Methods: 165 people completed the Eating Habits Questionnaire and EQ-5D quality of life measure at routine post-op bariatric clinic appointments Results: 52% of patients attending post-surgery review experienced problematic eating e.g. binge eating, emotional eating, night eating. The rates of problematic eating increase after two years e.g. 29% report EE < 2 years compared with 48% who report EE at 2 years +. Individuals with problematic eating have lower quality of life scores and have poorer weight loss outcomes. Conclusion: Relatively little is known about non-binge eating types of problematic eating patterns after bariatric surgery and this preliminary data highlights a number of other difficulties. Many bariatric services discharge patients up to 2 years post-surgery, when many of the problematic eating


B06 Identifying post bariatric surgery complications: A comparative study assessing the clinical effectiveness of oesophagogastroduodenoscopy (OGD) and water-soluble contrast swallow Prashant Patel, Amit Rajput, Anna Elshaw, Frances Young, Sarah Dalrymple, Salman Mirza, Amir Khan Walsall Manor Hospital, Walsall, UK Background: Symptoms of dysphagia and dyspepsia are common following

a bariatric operation. Current practice reveals a variation between a watersoluble contrast swallow and oesophagogastroduodenoscopy (OGD) as a first line investigation to assess for complications. Our aim was to identify and compare the clinical effectiveness of both. Methods: A retrospective study was conducted on 146 patients between 2008–2012; at a level 4 bariatric surgery hospital. Patients who had ≥ 1 OGD to investigate a post-operative complication were included for analysis. Patient demographics, OGD, water-soluble contrast and additional interventions reports were collated from electronic records, pathology and radiology results. Results: 146 patients presented with a post-operative complication following a bariatric operation: (n = 111, 76%) open gastric bypass, (n = 1, 0.5%) laparoscopic gastric bypass, (n = 13, 9%) gastric bands, and (n = 21,14%) laparoscopic sleeve gastrectomy. The main (n = 108, 74%) postoperative complaint was dysphagia (+/−) vomiting. In addition, patients also presented with dyspepsia, port site infection and abdominal pain. A total of (n = 92, 63%) OGD(s) found a significant pathology, the most important of which were (n = 57, 39%) strictures (all following an open gastric bypass), (n = 14, 10%) gastritis and (n = 9, 6%) gastric ulcers. A total of (n = 82, 56%) patients had a water-soluble contrast swallow prior to the OGD, of which only (n = 13, 16%) found a significant pathology, the most significant including: (n = 3, 3.6%) narrowing, (n = 1, 1%) stricture. A large proportion of reported ‘normal’ watersoluble contrast swallow (n = 45, 65%) had a significant pathology on an OGD. In total, there were (n = 54, 66%) pathologies reported following an OGD that was not reported on a water-soluble contrast swallow, the most significant including: (n = 28, 52%) strictures, (n = 10, 19%) gastritis, (n = 6, 11%) gastric ulcers and (n = 2, 4%) hiatus hernia. Conclusion: An OGD is more reliable in identifying post-operative complications following a bariatric operation compared to a water-soluble contrast swallow. A vast number of pathologies, 66%, were missed on a watersoluble contrast that was identified on an OGD, in particular strictures. We recommend that an OGD should be the first line investigation to investigate for post bariatric surgery dysphagia, vomiting or dyspepsia.

B07 Is Late (> 30 day) Mortality after Bariatric Surgery an Under-Recognised Problem? Kamal Mahawar, William RJ Carr, Maureen Boyle, Neil Jennings, Shlok Balupuri, Peter K Small Bariatric Unit, Sunderland Royal Hospital, Sunderland, UK Background: Early (< 30 day) mortality is widely used as an indicator of

surgical safety after bariatric surgery. Focus on 30-day mortality has helped bariatric surgeons reduce their early mortality significantly. However, surgical procedures are often also associated with late (> 30 day) mortality. Late mortality can be an ignored and under-recognised clinical problem. The purpose of this study was to study all bariatric surgery related deaths in our unit to understand comparative clinical relevance of early and late mortality. Methods: We analysed our prospectively maintained bariatric database to identify all deaths, which could be potentially related to performance of a bariatric surgical procedure in our bariatric unit.

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Results: A total of 2400 surgical procedures (1325 laparoscopic roux en y

gastric bypasses, 676 laparoscopic adjustable gastric bands, 365 laparoscopic sleeve gastrectomies, and 34 laparoscopic mini gastric bypasses) have been performed in our unit between January 2000 and September 2013. There was no early mortality in this cohort. However, we are aware of 6 late deaths till date, potentially related to bariatric surgery. Two of them were possibly due to liver failure (in patients who underwent roux en y gastric bypass), one was due to malnutrition (roux en y gastric bypass patient. Patient was deemed not to be coping well psychologically with surgery and declined reversal of bypass), one due to internal hernia (following an earlier roux en y gastric bypass in our series), one due to a possible overdose (following sleeve gastrectomy, had known psychological issues and was seen and cleared by psychologist preoperatively) and one due to massive upper gastrointestinal bleeding in a patients who had a stent in situ (following sleeve gastrectomy complications). We believe careful patient and procedure selection, closure of internal defects with roux en y gastric bypasses, and early management of complications could have prevented some of our late deaths. Conclusion: As surgeons achieve excellent results, early (< 30 day) mortality is no longer a significant clinical problem for patients undergoing bariatric surgery. Surgeons should be aware of their late (> 30 day) mortality and take steps to minimise them.

B08 The effect of Roux-en-Y gastric bypass on diabetic kidney disease in the Zucker diabetic fatty rat model Jessie A Elliott1,3 , Karl J Neff1 , Debra Higgins1 , Caroline Corteville2 , Thomas Lutz2 , Catherine Godson1 , Marco Bueter2 , Carel W le Roux1 1 Conway Institute of Biomolecular and Biomedical Research, University College Dublin, Dublin, Ireland, 2 Dept of Visceral and Transplant Surgery Research, Zurich Centre for Integrative Human Physiology, Zurich, Switzerland, 3 Department

of Surgery, Trinity Centre for Health Sciences, St. James’s Hospital, Dublin, Ireland Background: Roux-en-Y gastric bypass (RYGB) produces sustained weight

loss and significantly improves glycaemic control in patients with diabetes. However whether RYGB can ameliorate or prevent diabetic end organ complications has yet to be definitively established. The aim of this study was to determine the effect of RYGB on diabetic kidney disease (DKD) in a rodent model. Methods: 18 week old Zucker diabetic fatty (ZDF) fa/fa rats (n = 21) were randomly assigned to RYGB (n = 15) or sham surgery (n = 6); Zucker fa/+ rats (n = 5) acted as non-operated healthy controls. Body weight and blood glucose were measured twice and four times weekly, respectively. Urinary protein was measured at 12 weeks and kidneys harvested 13 weeks postoperatively. Periodic Acid Schiff stained sections were subjectively assessed for glomerulosclerosis, and both glomerular size and prevalence were measured. Immunohistochemistry for collagen subtypes (I, III, IV) and macrophage marker ED-1 (CD68) was performed. Immunostained sections were quantitatively analysed using Imagescope and findings were correlated with qPCR and western blot analysis. Results: RYGB and sham surgery were associated with 27% and 17% perioperative mortality rates, respectively. RYGB was associated with significant weight loss (mean final weight 380 versus 480g, P = 0.02) and improved glycaemic control (glucose AUC, P < 0.001), but no significant difference in proteinuria was detected (mean urinary protein 2.58 versus 3.12g/dL, P = 0.65). RYGB resulted in significantly less glomerulosclerosis (17% versus 30%, P = 0.01), more glomeruli per unit area (P = 0.02), reduced glomerular hypertrophy (P = 0.001) and a trend towards reduced macrophage infiltration (P = 0.057) compared with the sham-operated group. However there was no difference in total cortical collagen I, III or IV between sham-operated and either control or RYGB groups. Conclusion: This study confirms that RYGB can improve histopathological changes associated with DKD in the ZDF model. However the model did not develop significant cortical fibrosis at 31 weeks. Therefore further investigation is required to determine the timing of progression to renal fibrosis in the ZDF


rat, to characterise the functional improvements associated with pathological disease regression and to determine mechanisms that may contribute to improvement in DKD after RYGB.

B09 Development and evaluation of a Bariatric Specialist Nurse role within Multidisciplinary Team (MDT) Jenny Abraham, Louise Halder, Sue Bridgwater, Maria Williams, Vinod Menon University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK Aim: To identify key components for the bariatric specialist nurse role whilst

evaluating the organisational need and establishing the optimum point for nurse intervention during the patient journey to improve the quality of patient care and postoperative outcomes. Method: 20 articles were reviewed to identify key components for specialist nurse role. Original service was evaluated for baseline comparison using gap analysis of patient journeys (June-December 2012), stakeholder evaluation (patient and MDT) self-administered questionnaires, and a snapshot audit of radiological gastric band adjustment waiting times. Preliminary evaluation of 3-month pilot of specialist nurse role. Result: No published literature on specialist bariatric nurse roles in UK, literature from other specialities identified 4 key components for specialist nurse role: supportive care, direct patient care, continuity in care and training requirements. Service evaluation gap analysis- revealed no specialist nurse involvement in bariatric patient care and inconsistent follow-up. Radiological gastric band adjustment patient waiting times from referral to adjustment: 50% waited > 6 weeks for first and subsequent adjustments. MDT electronic questionnaire: 14/23 (60% response rate); 84% considered role useful/very useful, 64% preferred a combination of nurse-led and shared (with other health professionals) clinic. Patient postal questionnaire: 16/40 (40% response rate); 69% preferred nurse or shared clinics, 80% preferred clinics to be located in weight management centre, 81% disliked group appointments. < 40% want long-term nurse follow-up or 7 days post-op follow-up. With the exception of 1 week post-operative follow-up, the MDT and patient questionnaire demonstrated the specialist nurse importance pre and postoperatively (up to 8 weeks) but not long-term. Preliminary pilot evaluation of RN-AHP gastric band adjustment clinic revealed 95% gastric adjustment success rate with excellent patient satisfaction, appointment waiting times reduced by 5 weeks and improved radiological appointment times. Nurse-led pre-op clinics revealed 50% attendance, 100% received a ward visit and telephone follow-up within 1 week. Postal evaluation of patient pathway revealed 97% satisfaction. Conclusion: Development of a bariatric specialist nurse role is supported by the literature from other specialities revealing 4 main components: supportive care, direct patient care, continuity in care and training requirements. The specialist bariatric nurse role was supported by clinical governance. Gap analysis revealed inconsistent follow-up with no specialist bariatric nursing involvement. The specialist nurse role was therefore incorporated pre and postoperatively till 8 weeks. Nurse-led and shared (RN-AHP) clinics improved follow-up, reduced waiting times whilst enhancing the delivery of quality patient care and gave 100% patient satisfaction.

B10 Gastric bypass leads to sustained short and midterm improvement in cardiovascular risk in morbidly obese patients Ajay Gupta1 , Stewart Pattman2 , Mohsin Choudhury1 , Sean Woodcock1 , Keith Seymour1 1 North Tyneside General Hospital, Tyne and Wear, UK, 2 James Cook University

Hospital, Tyne and Wear, UK

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Aim: Weight loss with intensive lifestyle modification improves cardiovascular

risk. However, substantial long-term successes from lifestyle modifications and drug therapy have been disappointing. The aim of the study was to assess the improvement in bariatric patients following gastric bypass and to assess if this improvement was sustained. Methods: We analysed cardiovascular risk in 100 bariatric patients undergoing gastric bypass using a validated scoring system (QRISK II) to study their 10-year cardiovascular risk. Only patients who had at least 2-year followup were included. Retrospective analysis was performed on a prospectively collected database. Paired t-test was used to assess if there was statistically significant difference in the QRISK. Results: In our study, with 100 patients (M:F = 1:6), mean age 45.6 years (24–64 years), we found a statistically significant fall in the QRISK II score from baseline (6.328 ± 6.75) at one year (3.62 ± 3.45, p < 0.0005), which persisted at 2 years as well(3.79 ± 3.58) (P < 0.002). This was more pronounced in patients with resolution/ remission of comorbidities like diabetes and hypertension. Patients who had long standing diabetes and whose diabetes persisted despite gastric bypass had less significant improvement in QRISK II score. Weight loss was significantly related to reduction in QRISK II. Conclusion: Patients undergoing gastric bypass have significant sustained reduction in their 10-year cardiovascular risk. This is most pronounced in patients who had resolution of metabolic syndrome. We propose early referral to bariatric surgery to improve long-term cardiovascular morbidity.

Free Paper Session - Kenilworth (Friday 24 January 2014 08:30–09:50)

C01 Significant Reduction in Ten Year Cardiovascular Risk Following Bariatric Surgery Rami Radwan, Hazem Al-Momani, Scott Caplin, Jonathan Barry Welsh Institute of Metabolic and Obesity Surgery, Swansea, UK

C02 Temporal changes in glucose homeostasis and incretin hormone response at 1 and 6 months following laparoscopic sleeve gastrectomy Akhila Mallipedhi1 , Sarah Prior1 , Gareth Dunseath1 , Richard Bracken1 , Kathie Wareham2 , Jane Griffiths2 , Nia Ayre3 , Jonathan Barry3 , Scott Caplin3 , Imran Alam3 , James Morgan3 , Sam Rice4 , John Baxter3 , Steve Luzio3 , Stephen Bain1 , Jeffrey Stephens1 1 Diabetes Research Group, Institute of Life Sciences,Swansea University, Swansea, UK, 2 Clinical Research Unit, Morriston Hospital, ABM University Health Board, Swansea, UK, 3 Welsh Institute of Metabolic and Obesity Surgery, Morriston Hospital ABM University Health Board, Swansea, UK, 4 Department of Diabetes & Endocrinology,

Hywel Dda Health Board, Llanelli, UK Background: To examine the detailed metabolic effects of laparoscopic

sleeve gastrectomy (LSG) on the temporal changes in insulin and glucose homeostasis, incretin hormones and hepatic insulin clearance in patients with type 2 diabetes mellitus. The effects were also examined in participants undergoing Bilio-pancreatic Diversion (BPD) and Laparoscopic Roux-en-Y gastric bypass (RYGB). Methods: A non-randomised clinical trial with 20 participants undergoing LSG (BMI 51.9 kg/m2 , HbA1c 51 mmol/mol) and 18 participants BPD or RYGB group (BMI 58.4 kg/m2 , HbA1c 61 mmol/mol). Serial measurements of glucose, insulin, C-peptide, glucagon like peptide-1 (GLP-1) and glucosedependent insulinotropic hormone (GIP) performed during oral glucose tolerance testing pre-operatively and at 1 and 6 months post-operatively. The areas under the curve were examined at 30, 60 and 120 minutes (AUC0-30 , AUC0-60 and AUC0-120 ). Results: Within the LSG group we observed significant improvements at 1 and 6 months postoperatively in glucose control (HbA1c : −0.7%, −0.9%), insulin sensitivity (fasting insulin: −4.8 mU/L, −8.5 mU/L; fasting C-peptide: −0.6 pmol/L, −1.1 pmol/L; HOMA-IR: −0.144, −0.174; HOMA %S: +28.7, +92.4), hepatic insulin clearance (+0.07, +0.13) and postprandial GLP-1 response (AUC0-30 pmol h L−1 : +300, +331, AUC0-60 : +300, +294, AUC0-120 : +316, +295). These results were comparable to the BPD or RYGB group. Conclusion: LSG is associated with early improvements in glucose homeostasis and remission of diabetes. Marked improvements in insulin sensitivity, hepatic insulin clearance and postprandial GLP-1 responsiveness were observed with LSG.

Background: The prevalence of obesity and metabolic syndrome is rising

in the UK. Bariatric surgery is the only evidence-based method of long-term weight control in obese individuals. The reduction in individual cardiovascular risk following bariatric surgery has not yet been quantified.QRISK2 is a UK designed, validated and widely used algorithm to predict cardiovascular risk over a ten year period. In this study we calculated the QRISK2 scores for patients’ pre- and post-bariatric surgery at our institute in an effort to objectively assess cardiovascular risk reduction following bariatric surgery. Methods: We reviewed all patients who had undergone bariatric surgery over a ten year period (June 2003 – June 2013) at our institute using the Welsh Institute of Metabolic & Obesity Surgery (WIMOS) database. All demographic and cardiovascular risk data was obtained and QRISK2 score was calculated pre- and post-operatively for all patients. Post-operative score was calculated at the point of longest available follow up duration. Results: A total of 250 patients were included in our cohort; 184 female, median age 36 years (range 24–59 years). Median follow-up post-operatively for all patients was 24 months (mean 34 months, range 1–109 months). The majority of patients (n = 100; 70 female) underwent a sleeve gastrectomy, 67 (26.8%; 45 female) patients had biliary-pancreatic diversion (BPD), 50 (20%; 39 female) patients had a roux-en-y gastric bypass (RYG), and 33 (13.2%; 30 female) were fitted with Gastric Bands. Overall median pre-operative 10-year QRISK2 score was 5.6% (mean 9.4%, range 0.3%-45%). Median postoperative 10-year QRISK2 score in these patients was lower at 4.4% (mean 7.2%, range 0.2%-36.1%); p < 0.001. Conclusion: This study is the first to use a validated scoring system to assess ten year cardiovascular risk reduction in bariatric patients. We have demonstrated a significant reduction in cardiovascular risk following bariatric surgery.


C03 Salvage Laparoscopic Adjustable Gastric Banding After Failed Roux-en Y Gastric Bypass John Loy, Heekoung Youn, Bradley Schwack, Marina Kurian, George Fielding, Christine Ren-Fielding NYU Langone Medical Center, New York, USA Background: After Roux-en-Y gastric bypass (RYGB) up to 15% patients

fail to achieve 50% excess weight loss (%EWL) at 2 years. Various endoscopic therapies have been reported, most with limited success. Salvage laparoscopic adjustable gastric banding (LAGB) over the primary gastric bypass is well described, although there are few studies sufficiently powered to assess its efficacy. The largest published series of salvage band over bypass to date is 43 patients from our own institution. We aim to update these data with a further 3 years follow-up and report our experience with an additional 82 patients. Methods: Retrospective review of our prospectively maintained database was undertaken. Data collected and analysed included weight, height, body mass index (BMI), gender, race, age, operative time, band type, hiatal hernia repair, length of stay and post-operative complications. Results: A total of 125 patients (102 female, 23 male) underwent salvage LAGB for weight loss failure after primary RYGB, the majority 102 (83%) having undergone initial surgery elsewhere. An average of 12.7 years (range 15–1324 months) had elapsed from primary RYGB. Mean age at revision was 47.0 years (+/−10.7). Mean BMI before RYGB was 51.2 kg/m2 (+/−8.78),

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before salvage LAGB 43.0 kg/m2 (+/−6.57) and fell to 35.9 kg/m2 (+/−6.75) at 1 year, 33.8 kg/m2 (+/−7.19) at 2 years and 33.9 kg/m2 (+/−6.37) at 3 years. There was improvement in excess BMI loss from 30.4% (+/−19.6) on referral to 50.1% (+/−38.7) on average 28 (+/−21) months from revision band over bypass. Nineteen (15.2%) patients required re-operation for complications related to the LAGB including 6 (4.8%) band erosions, 10 (8%) port/tubing revisions for leakage or migration, 2 (1.6%) band slips and 1 (0.8%) port infection. The significant factor in predicting band erosion was length of interval from initial bypass surgery (301 months versus 152 months p < 0.05). There was no mortality. Conclusions: Patients with weight loss failure after LRYGB have limited options. Surgical options such as lengthening the bypass or performing a duodenal switch have been associated with complications such as malnutrition. Salvage LAGB provides good further weight loss, although the higher rate of reoperation for band-related complication merits appropriate patient counselling and close follow-up.

C04 Band slippage following laparoscopic adjustable gastric band (LAGB) insertion: A single centre experience James Skipworth1 , Angela Fanshawe1 , Dimitri Raptis2 , Maryam Alfa-Wali1 , James Hollingshead1 , Gianluca Bonanomi1 , Jeremy Thompson1 , Evangelos Efthimiou1 , James Smellie1

prospective study was to analyse the activity of this service with particular emphasis on patient who had undergone previous private bariatric surgery. Methods: Between November 2011 and November 2013, all patients presenting to A&E with an emergency relating to their previous bariatric surgery were referred to a dedicated emergency bariatric surgical service. All patients admitted from clinic and those who were diagnosed with non-bariatric surgical problems were excluded. The remaining patients who presented with a bariatric surgical emergency were recorded and their outcomes analysed. Results: Over the two year period, 71 patients with bariatric surgical emergency were referred to our service, of whom 19 had previous surgery in the private sector (16 in the UK, 3 abroad). Of these patients, 11 had a previous gastric band, 2 had an intra-gastric balloon, 5 had a bypass and 1 had a VBG. Of these 19 patients only 2 were transferred to a private institution. 11 required surgery on the index admission (2 patients required 2 operations) specifically gastric band removal (4), repair of internal hernia (2), diagnostic laparoscopy (2) upper GI endoscopy (1), balloon removal (2) and resection of the alimentary limb (2). Conclusions: There is a significant volume of private patients who present as emergencies with complications related to bariatric surgery requiring NHS intervention. These findings have potentially important financial implications for both the private sector and the NHS.

C06

1 Department of Bariatric Surgery, Chelsea and Westminster Hospital, London, UK, 2 Department of Visceral and Transplantation Surgery, University Hospital Zurich,

Evaluation of the first four years of a Tier 3 (Community Dietetic) Clinic

Zurich, Switzerland

1 University Hospitals of Leicester NHS Trust, Leicester, UK, 2 Leicester Partnership

Background: Slippage of LAGBs from their original position to lower in the

Trust, Leicester, UK

fundus of the stomach can result in obstruction, erosion and ischaemia. We aimed to identify the incidence of slippage and the factors that may influence its development. Methods: All LAGBs inserted at one centre (via a pars flaccida technique) between November 1999 and December 2012 were analysed utilising a prospectively-maintained database, computerised records and case-notes review. Results: 719 LAGBs were inserted and 33 slips treated; however, only 22 slips had their LAGB inserted at our centre (local slip-rate 3.1%). Multivariate analysis demonstrated a significant association between LAGB slip and younger median age at LAGB insertion (41 yrs slip vs. 45 yrs non-slip; p = 0.027), higher median total excess weight loss (64% slip vs. 36% non-slip; p = 0.000) and higher median XS weight loss per month (2.41% slip vs. 1.00% non-slip; p = 0.000). There was no significant effect by sex, BMI at insertion or band type. Patients requiring emergency intervention were more likely to require LAGB removal (rather than repositioning/replacement: 75% emergency vs. 41% semi-elective; p > 0.05) but this did not reach statistical significance, likely due to small cohort numbers. Conclusions: Low slip-rates are consistently achievable in dedicated, bariatric centres with standardised LAGB programmes. Band slips are associated with greater excess weight loss and younger age. Larger studies may be necessary to further elucidate the risk factors contributing to, and mechanisms of, band slippage.

C05 Emergency care for private bariatric patients – are we robbing the poor to bail out the rich? Omar Khan, Rajesh Kumar Jain, Nimalan Sanmugalingam, Marcus Reddy, Andrew Wan St Georges Healthcare NHS Trust, London, UK Background: A significant proportion of bariatric procedures are performed

in the private sector either locally or in international centres. The provision of aftercare for these patients, particularly in the emergency setting can be variable. Our NHS institution provides a 24 hour emergency bariatric surgical on- call service provided by specialist bariatric surgeons. The purpose of this


Gary Young2 , Jane Calow1 , Sukhbir Ubhi1 , David Bowrey1

Background: The new Clinical Commissioning guidelines for bariatric

surgery include access to a tier 3 (community based) specialist clinic. The impact of this on the number of patients being referred for bariatric surgery and the ‘‘quantity’’ of surgery being commissioned is unclear. The aim of the current evaluation was to report our experience with a tier 3 clinic. Methods: A tier 3 clinic was introduced in 2009. Local referral guidelines in place at the time comprised a BMI> = 50 without medical comorbidity or BMI > = 45 with comorbidity. The outcome is reported for patients attending during a four year period (2009–2013). Results: To date, 453 patients have been referred to the tier 3 clinic. One hundred and thirteen are still in follow up or investigation in the tier 3 or 4 clinic. Three hundred and forty patients have completed the tier 3 or 4 pathway. Of these, 117 patients (117/340, 34%) did not attend or complete their tier 3 assessment. Ninety-nine patients (99/340, 29%) have either undergone (n = 88) or are scheduled (n = 11) for bariatric surgery. Sixty-three patients (63/340, 19%) were considered unsuitable for surgery after MDT discussion while 61 patients (61/340, 18%) decided not to proceed with surgery. Of the 63 patients considered ineligible for bariatric surgery, the rationale comprised medical comorbidity in 49/63 (77%), psychiatric comorbidity in 8/63 (13%) and unwillingness to adjust an unsupported or chaotic lifestyle in 6/63 (10%). Conclusion: In this population, only a third of patients referred to a tier 3 clinic progressed onto bariatric surgery. Although the referral criteria in place were 10 BMI points above NICE criteria, our evaluation suggests that implementation of a tier 3 clinic allows a large number of patients to be assessed but the proportion that proceed to surgery is small. The tier 3 clinic identifies and filters those patients who would otherwise be seen in a tier 4 clinic.

C07 A Systematic Review of Studies Reporting Internal Hernia After Laparoscopic Roux-en-Y Gastric Bypass (LRYGB): Is it Negligent to Not Close the Peritoneal Spaces? Abeezar Sarela1 , Michael McMahon2 1 St James’s University Hospital, Leeds, UK, 2 Nuffield Hospital, Leeds, UK

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Background: A substantial minority of bariatric surgeons does not close the

Conclusion: Pre-operative very low calorie diet (VLCD) decreases liver

peritoneal spaces during LRYGB. We reviewed published studies to determine whether closure of mesenteric spaces during LRYGB is associated with > 50% reduction in the incidence of re-operation for internal hernia (IH). Methods: The review protocol is registered in PROSPERO, York (CRD42013006289) and adheres to PRISMA guidance. PubMed was searched for ‘‘gastric bypass’’ AND ‘‘internal hernia’’. No randomised trial was identified; hence, study eligibility was extended to time-series that compared the incidence of IH before and after implementation of space-closure. IH was defined as detection of prolapsed bowel at laparoscopy or laparotomy. Study quality, bias and outcome were analysed. Results: The search identified 298 reports. There were 8 eligible studies (publication dates, 2003–2013); further, 9 studies reported IH after spaceclosure, 10 studies after non-closure and 12 studies were on other technical issues. Of the eligible studies, 5 had prospective data collection, 2 had a formal protocol, 4 pre-specified IH as an outcome, 2 reported the number of patients available for follow-up and 1 attempted to contact all patients. All studies did a ‘‘completers-only’’ analysis. Only 1 study explicitly reported length of follow-up separately for non-closure patients (mean 100 months) vs. closure (40 months). In total, spaces were not closed in 5880 patients vs. closure in 4878 patients. The alimentary limb was ante-colic in 8798 patients, retro-colic in 895 and unclear in 1065; other technical differences were extent of mesenteric division, specification of spaces (mesenteric, Petersen’s and mesocolic) and method of closure. The length of follow-up was derived from accrual and publication dates in 7 studies and was notably longer for non-closure patients vs. closure. Because of substantial inter-study variations, the data were not suitable for meta-analysis. The reported incidence of IH ranged from 2.9%-6.8% (1 outlier: 15.5%) for non-closure vs. 0–2.0% with closure. Conclusion: Available data are not sufficiently robust to state that non-closure of peritoneal spaces increases the incidence of IH by > 50% at comparable intervals. It is clinically prudent to close all spaces; but it is not clear that failure to close is legally negligent.

volume. This however does not seem to alter peri-operative outcomes. Therefore the routine use of a VLCD prior to bariatric surgery is questionable.

C08 Randomised controlled trial comparing the effect of pre-operative liver shrinking diet on peri-operative outcomes in morbidly obese patients undergoing gastric bypass: Is it time to change our practice? Saurav Chakravartty, Beth Murgatroyd, Ounali Jaffer, Pau Sidhu, Gill Vivian, Ameet Patel King’s College Hospital, London, UK Background: Pre-operative liver shrinking diets are routinely adopted to

make bariatric surgery less technically challenging. While there is good evidence to suggest that such diets decrease liver volume, there is little evidence that peri-operative outcomes are improved. Methods: A randomised controlled trial (clinical trial no: NCT01950052) was undertaken in morbidly obese patients undergoing laparoscopic roux-en-y gastric bypass. The two arms of the study included a control group on normal diet and a diet group on a very low calorie diet (800kcal) for a period of 4 weeks. The effect of diet on liver volume and fibrosis was analysed with an ultrasound and Acoustic Radiation Force Impulse (ARFI). Body composition was analysed pre and post dietary intervention with a dual-energy X-ray absorptiometry scan. Outcome measures included operating time, blood loss, length of stay and complications. Results: In both the diet group (n = 10) and control (n = 10) group, patient characteristics were similar in terms of age (median 43.5 vs 38.5 years, p = 0.25), gender (female: male; 10:0 vs 9:1, p = 1) weight (median 125 vs 136 kg, p = 0.43) and body mass index (median 53.4 vs 52.75 kg/m2 ; p = 0.9) and co morbidities. Pre intervention both groups had similar liver volume, body fat composition, lean mass and resting energy expenditure (REE) (1905 vs 2055 kcal, p = 0.18). After 4 weeks, the diet group had a significant decrease in mean body weight (6.5 ± 2 vs 0.3 ± 1.6 kg; p < 0.001), liver volume (23% vs 2%, p = 0.03) and REE (73 ± 23 vs −5.4 ± 20 kcal, p < 0.001) but there was no difference in body fat or abdominal fat percentage. There was no difference in median operating times (129 vs 139 mins, p = 0.16), blood loss (25 vs 22.5 ml, p = 0.5), length of stay (3 vs 3 days, p = 0.12) or complications.


C09 Resolution of Non-Alcoholic Fatty Liver Disease And Metabolic Syndrome In Adolescents Undergoing Laparoscopic Adjustable Gastric Banding (LAGB) John Loy, Heekoung Youn, Bradley Schwack, Marina Kurian, Christine Ren-Fielding, George Fielding NYU Langone Medical Center, New York, USA Background: The associations between obesity, non-alcoholic fatty liver

disease (NAFLD) and metabolic syndrome (MS) are well recognised. NAFLD is the most common cause of chronic liver disease in adolescents and it is likely that NAFLD cirrhosis will become the most frequent indication for liver transplantation in the developed world. We sought to assess the effect of bariatric surgery on adolescents with evidence of NAFLD at presentation. Methods: Adolescents undergoing Laparoscopic Adjustable Gastric Banding (LAGB) with abnormal liver ultrasound or deranged liver function tests at presentation were scored for NAFLD severity using a validated NAFLD scoring system. They were also assessed against the International Diabetes Federation (IDF) MS criteria. NAFLD fibrosis scores were calculated preoperatively and at 1 and 2 years post-operatively. MS criteria were assessed at the same time intervals. Other data recorded included weight, body mass index (BMI), complications, percentage excess weight loss (%EWL), metabolic and lipid panels and body fat composition using body composition scanning. Results: 56 adolescents, 39 female and 17 male, mean age 16.1 years (14–17.8yr.s) with evidence of fatty liver disease on presentation underwent LAGB for treatment of morbid obesity. Mean pre-operative weight was 138 kg (+/−27.6) and BMI was 48.8 kg/m2 (+/−7.0).There was no mortality and one patient was re-admitted with acute appendicitis within 30 days. Follow up rates were 54/56 (96%) at 1 year and 49/51 (96%) at 2 years. NAFLD fibrosis scores improved significantly by 0.68 (+/−1.03, p < 0.0001) at 1 year and by 0.38 (+/−0.99, p = 0.0096) at 2 years post-operatively on paired t-testing. Fifteen of 18 (83.3%) patients who met IDF metabolic syndrome criteria had complete resolution within 2 years of surgery. Mean %EWL was 48.96% (+/−22.1) at 2 years. There were 3 (5.4%) band slips and 2 (3.57%) port problems requiring re-operation giving a re-operation rate of 8.9% for band related complications at 2 years. Conclusions: LAGB is a safe and effective treatment for obese adolescents with evidence of metabolic syndrome and fatty liver. The improvement in NAFLD scores which occurred following LAGB demonstrates its value as a metabolic operation in the adolescent population.

C10 Risk reducing strategy in super obese patients: the potential role for the Endobarrier Diwakar Sarma1 , Saurav Chakravartty1 , Beth Murgatroyd1 , Alexander Miras2 , Bu Hayee1 , Ameet Patel1 1 King’s College Hospital, London, UK, 2 Imperial College London, London, UK

Background: The Endobarrier (Endoscopic duodenojejunal bypass liner) is

an endoscopically employed device that can lead to significant weight loss and improvement of glycaemic control when compared to diets or sham procedures. However its exact role in bariatric and metabolic surgery is yet to be fully evaluated. The aim of this study is to evaluate the Endobarrier in a high risk group of super obese patients. Methods: After approval from the Hospital review committee, high risk super obese patients (BMI > 50 kg/m2 ) were carefully selected for an Endobarrier insertion between January and October, 2013. Patient outcomes which included length of stay, complications, weight loss, and impact on glycaemic control were prospectively observed.

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Results: The Endobarrier was inserted in 11 super obese patients (9 males,

2 females) with a median age of 53 years (range 32–68 years), a median weight of 185 kg (range 120–237 kg), a BMI of 61 kg/m2 (range 51–70.4 kg/m2 ). The median obesity surgery mortality risk score (normal score 1–5) of 4 (mortality risk = 2.4%). Overall, device insertion took 39 mins (range 16–85 mins) and was successful in all patients with no removals required till date. Length of stay was 1 day (range 1–5 days).One patient suffered a minor upper gastrointestinal bleed which resolved with conservative measures. The median excess weight loss at 6 weeks, 3 and 6 months was 10.5% (range 3.7-23.6%), 16.3% (range 10.527%) and 17.3% (range 15.5-30.8%) respectively. Post-operatively, diabetic medication were either decreased (n = 4/7) or no longer required (n = 2/7) in the diabetic patients and at 3 months the HBa1c levels improved significantly from a mean value of 7.7% to 6.6% (p = 0.02). Conclusion: In the super obese group the Endobarrier achieves significant weight loss and good glycaemic control. In this high risk group for peri-operative complications and mortality the Endobarrier may be a useful stepping stone to definitive weight loss surgery.

Posters of Distinction PoD1

gastric bypass surgery (RYGB), we hypothesized that there may be a similar, and as yet unrecognized causative relationship between RYGB and pancreatitis or pancreatic cancer. This study aimed to systematically review the literature to investigate whether there is any causal relationship between RYGB and pancreatitis or pancreatic cancer. Methods: We performed a systematic review of reports of pancreatitis or pancreatic cancer following RYGB using Pubmed, EMBASE and the Cochrane database. We also reviewed and compared serum levels of GLP-1 following RYGB and exogenous administration of GLP-1. Results: We identified 359 studies, of which 68 were excluded immediately. 281 studies were excluded after more detailed evaluation. 10 studies were included. In these studies there were only two case reports of pancreatitis as an early complication after RYGB, and 8 cases as a late complication. There were three studies reporting four cases of pancreatic cancer after RYGB, but none of which focused on the cause of the pancreatic cancer. 112 articles were reviewed for GLP-1 levels after RYGB. After evaluation, 10 were included in our analysis. GLP-1 levels post RYGB were found to be lower than those associated with exogenous administration of GLP-1 analogues. Conclusion: Unlike exogenous GLP-1 analogue administration, RYGB does not appear to result in an increased incidence of pancreatitis or pancreatic cancer. This would concur with the findings of lower serum levels of GLP-1 after RYGB compared to those resulting from exogenous administration.

Bariatric Surgery and Its Impact on Sleep Xie Huizhuang1 , Hayder Shabana3 , Liam Doherty2 , Colm J. O’Boyle3

PoD3

1 School of Medicine, University College Cork, Cork, Ireland, 2 Department of Respiratory Medicine, Bon Secours Hospital, Cork, Ireland, 3 Surgery, Bon Secours

Hospital, Cork, Ireland

Laparoscopic Bariatric Surgery in Super-Obese Patients (Body Mass Index > 50 kg/m2 ): A Systematic Review and Meta-Analysis

Background: There is a strong association between morbid obesity and

Ashok Menon, Basil Ammori

obstructive sleep apnoea syndrome (OSAS). Anecdotally, daytime sleepiness is also noted in the morbidly obese without OSAS. We aimed to explore the effect of bariatric surgical intervention in morbidly obese patients with and without OSAS. Methods: Between June 2009 and July 2012, Apnoea- Hypopnoea Index (AHI) and Functional Outcomes of Sleep Questionnaires Scores (FOSQ) were prospectively evaluated before and six months after surgical intervention in patients undergoing bariatric surgery. Results: A total of 167 subjects were studied, 75.4% were females. The median age was 46 (14–75)years and median BMI 49 (36–69) kg/m2 . Ninety two (55%) patients were diagnosed with Obstructive Sleep Apnoea (OSA) preoperatively. Fifty (54%) required positive airway pressure (PAP) therapy. The mean reduction in BMI at six months post-operative was 12 ± 4.5 kg/m2 . Eightyeight percent reported improved sleep quality reflected by improved scores in all domains of the FOSQ (General Productivity, Social Outcomes, Activity Levels, Vigilance and Intimacy) (p < 0.001, paired t-test). The improvement in FOSQ scores remained significant (p < 0.05) in those with and without OSAS. Ninety one percent of patients were able to discontinue PAP. Only 2 patients had persisting severe OSAS despite dramatic weight loss. Conclusion: Weight loss following bariatric surgery has a positive impact on sleep in the majority of patients. In those with OSAS there is a dramatic benefit with only a small minority still requiring nocturnal positive airway support.

PoD2 Do the increased levels of GLP-1 following Roux-en-Y gastric bypass surgery cause pancreatic cancer and pancreatitis?: A Systematic Review

Department Of Obesity And Metabolic Surgery, Salford Royal Hospital, Salford, UK Background: Laparoscopic bariatric surgery for super-obese patients (Body

Mass Index [BMI] > 50 kg/m2 ) poses significant technical and physiological challenges. However there is a paucity of high quality evidence relating to postoperative outcomes in this population. Methods: A systematic review and meta-analysis was performed to compare postoperative weight loss and remission of type-2 diabetes mellitus (T2DM) following the most commonly performed laparoscopic bariatric interventions (Roux-en-Y Gastric Bypass [LRYGB], Sleeve Gastrectomy [LSG], Adjustable Gastric Banding [LAGB], and Biliopancreatic Diversion/Duodenal Switch [BPD/DS]) in the super-obese. The MEDLINE, EMBASE, and Cochrane library databases were searched for relevant articles that were subjected to two-level screening. A random effects model was used for the meta-analysis. Results: After preliminary screening of 234 citations, 15 studies comprising 1065 patients were included in the meta-analysis. BPD/DS resulted in the highest levels of postoperative weight loss and T2DM remission compared to the other procedures, but these effects were not found to be significant. Patients experienced significantly lower weight loss following LAGB at 1 year following surgery, but this effect was not seen after 2 years. Conclusion: All of the bariatric procedures investigated appear to result in good rates of diabetic remission, and both short and medium-term weight loss in super-obese patients. However, the low number of studies that met the inclusion criteria for this meta-analysis makes it difficult to reliably discern any significant differences in efficacy between these procedures at the present time.

PoD4

Stacy Wardle, Ian Finlay Royal Cornwall Hospital, Cornwall, UK

275 Single Incision Laparoscopic Gastric Bands: What Have We Learnt?

Background: Concern has been raised in the literature that use of GLP-1

Saurav Chakravartty1 , Beth Murgatroyd2 , Ameet Patel1

analogues in the treatment of Type 2 diabetes causes acute pancreatitis and pancreatic cancer. As GLP-1 levels are also elevated following Roux-en-Y


1 King’s College Hospital, London, UK, 2 Princess Grace Hospital, London, UK

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Introduction: Single incision surgery in the morbidly obese patient has not

been widely adopted, but remains a popular choice amongst patients. It does present its own surgical challenges with hepatomegaly and increased abdominal adiposity. Here we present our experience of 275 single incision laparoscopic gastric bands. Methods: Between June 2009 and August 2013 275 obese patients underwent single incision laparoscopic adjustable gastric banding through a single transverse incision using a multichannel single port and via a pars flaccida technique. Prospective data collection was undertaken including operating time, additional ports and additional procedures undertaken. Results: In this series, median operative time was 60 (range 34–170) minutes. An additional port was placed in 14 patients (5%), with one conversion to 5-port technique (0.4%). Of these patients (n = 15) the majority were male (p < 0.05). Reasons for additional port placement included repair of hiatus hernia and difficult anatomy. Additional port placement occurred more often within the first 100 cases (8/15, 53%). BMI was not a predictive factor of additional port placement. There were no mortality and minimal morbidity with 2 wound infections resulting in band removal. Conclusion: Single incision laparoscopic adjustable gastric banding can be performed safely with minimal morbidity and mortality in the morbidly obese patient and our technique has a high rate of success. Following 275 single incision band insertions, additional port placements were more commonly required in male patients, and earlier in the learning curve.

PoD5 Laparoscopic Mini Gastric Bypass (LMGB) and resolution of metabolic syndrome: Does it really help? Venkatesh Kanakala, Maureen Boyle, Arun Sekhar, Rupa Sarkar, Dipankar Chatopadhyay, Neil Jennings, Kamal Mahawar, Schlok Balupuri, Peter Small

PoD6 Outcomes of Laparoscopic Sleeve Gastrectomy versus Roux-en-Y Gastric Bypass at 2 years: A case-matched study Ashok Menon, Mohammed Al-Rashedy, Pho Thawdar, Khurshid Akhtar, Polobody Siba Senapati, Basil Ammori Department Of Obesity And Metabolic Surgery, Salford Royal Hospital, Salford, UK Background: Although published evidence comparing laparoscopic sleeve

gastrectomy (LSG) to Roux-en-Y gastric bypass (LRYGB) has shown comparable medium-term weight loss, it lacked control for potentially confounding factors. We provide an update of an ongoing case-matched comparison of outcomes of LSG and LRYGB. Methods: This is a retrospective, case-matched analysis of patients who underwent either LSG (n = 26) or LRYGB (n = 26) in a single institution between October 2008 and March 2012. The groups were matched for age, gender, diabetic status and preoperative body mass index (BMI). Outcome measures were postoperative morbidity and mortality, percentage excess weight loss (%EWL), and resolution of type-2 diabetes (T2D) defined as glycosylated haemoglobin < 42 mmol/mol. Results: The groups were comparable for age (46 vs. 46 years), sex (female 73% each), preoperative BMI (50 vs. 52 kg/m2 ), and prevalence of T2D (27% each). There were no leaks, conversions or mortality. There were no significant differences between LSG and LRYGB in %EWL at 6 months (50% vs. 50%), 12 months (62% vs. 65%), and 24 months (65% vs. 70%). In super-obese patients, comparable %EWL was achieved at 12 months (64% vs. 61%) and 24 months (76% vs. 69%). Whilst rates of postoperative remission of T2D were higher after LRYGB, these changes were not significant (43% vs. 86%, p = 0.09). Conclusion: Both LSG and LRYGB result in comparable weight loss at 2 years with low postoperative morbidity. Further data is required to see whether the differences in postoperative diabetic remission are significant.

Sunderland Royal Hospital, Sunderland, UK

Posters

Background: Laparoscopic Mini Gastric Bypass (LMGB) is considered to

be equally effective procedure of choice compared to Laparoscopic Rouxen-Y Gastric Bypass (LRYGB)1. The short term results of both procedures are comparable with regards to loss of excess body weight and resolution of metabolic syndrome. We present our short term follow-up data on effect of LMGB on metabolic syndrome. Methods: This is a prospective study form October 2012 till November 2013. All the patients had blood tests taken preoperatively to assess metabolic syndrome. Post operatively, assessed at 3months, 6months and annually thereafter. International diabetes federation guidelines were followed to define metabolic syndrome. Results: Total of 41 patients underwent LMGB during the study period. Eleven patients were male [mean, 49.7yrs (range, 40-69yrs] compared to 30 are female [Mean, 37yrs (range, 24-60yrs)]. Body Mass Index was higher for Male [Mean, 51.4, range (36.2-71.1)] compared to female [Mean, 41.8, range (35–47.5)]. Of these 41 patients who underwent LMGB, 12/41 (29%) were diagnosed to have metabolic syndrome preoperatively. Out of these 12 patients, 7/12 (58%) had complete resolution of metabolic syndrome at 6months follow-up period and the rest are still under follow-up. As a part of metabolic syndrome, 9/12 (75%) had established diagnosis of diabetes and we have noticed complete resolution in 4/9 (45%) patients and the rest are due for follow-up tests. Excess weight loss was 67.4% at 6 months (n = 14) and 89.7% at 12months (n = 4) respectively. Conclusion: We have noticed encouraging short term follow-up results of metabolic syndrome and resolution after Laparoscopic Mini Gastric Bypass operation. Long term follow-up data with large sample size is still awaited to establish the same. Ref: WJ Lee etal, Laparoscopic Roux-en-Y versus Mini-Gastric Bypass for the treatment of Morbid Obesity: A prospective Randomised Controlled Trial. Annals of Surgery,Volume 242(1),20-28.


P07 Is there an association between social rank of deprivation and percentage weight loss following roux-en-Y gastric bypass? Sarah Elizabeth Welsh, Cirran Pike, Shlok Balupuri Sunderland Royal Hospital, Sunderland, UK Background: It has been shown that obesity is a disease of the lower social

classes. Of the top ten obese cities in the UK, five are in the North East of England. Methods: This audit evaluates bariatric patient’s social rank of deprivation in relation to their weight loss following roux-en-Y gastric bypass. It was a retrospective analysis of 309 post-operative bypass patients. Percentage weight loss 1 and 2 years following surgery were correlated with social rank of deprivation, which was determined according to the patients’ postcodes using the Office of National Statistics scale 0 to 32,482. Results: The correlation co-efficient for social rank of deprivation and percentage weight loss 1 and 2 years after roux-en-Y gastric bypass were −0.1015 and −0.1059, respectively. The mean percentage weight loss 1 and 2 years post-operatively from initial weight was 32.4% and 32.8% respectively. The average weight loss between years 1 and 2 post-operatively was 0.4%. Conclusion: The study found that higher social rank does not correlate with increased weight loss post roux-en-Y gastric bypass in this data set. Further assessment is recommended in studies with increased distribution of social rank within the cohort.

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P08 Are there clinical and demographic differences between morbidly obese patients with and without severe obstructive sleep apnoea? Laura Hancox1 , Elizabeth Bonsels1 , Claire Capper1 , Maria Palloyova2 , Dev Banerjee3 , Shahrad Taheri4 1 School of Clinical and Experimental Medicine, University of Birmingham, Birmingham, UK, 2 Birmingham and Black Country National Institute for Health

Research Collaborations for Leadership in Applied Health Research and Care, University of Birmingham, Birmingham, UK, 3 School of Life and Health Sciences, Aston University, Birmingham, UK, 4 Diabetes Centre and Specialist Weight Management services, Heart of England NHS Foundation Trust, Birmingham, UK Background: Obstructive sleep apnoea (OSA) is highly prevalent in obese

adults and independently linked to metabolic disturbances. Our study aimed to determine demographic and clinical differences in morbidly obese patients with severe OSA and those without OSA. Methods: Data was obtained from the Heart of England trust database for 56 morbidly obese (BMI≥40 kg/m2 ) adults with polysomnographically-established severe OSA (apnoea hypopnea index-AHI≥30 events/hour; n = 30) or no OSA (AHI < 5 events/hour; n = 26). Age, sex, ethnicity, BMI, prevalence of type 2 diabetes (T2DM), HbA1c (DCCT-aligned), and bariatric surgery intervention were compared between the two subgroups at baseline and at 12–18 month follow-up. Results: Compared to non-OSA adults, OSA patients were older (P = 0.005) and more obese (P = 0.025), with trends towards a higher prevalence of T2DM (P = 0.054) and male sex (P = 0.073). The presence of T2DM was associated with older age (P = 0.008), male sex (P = 0.041), and lower minimum oxygen saturation (P = 0.033) in the entire cohort. Follow-up HbA1c values were improved [6.7(6–7.8) vs. 6.6(5.9-7.2)%; P = 0.028] in T2DM patients with treated OSA. There was no significant difference but greater variability in follow-up decrease in HbA1c in OSA T2DM patients on ventilatory treatment who underwent bariatric surgery than in controls without surgical intervention [−0.9 ± 1.15 vs. −1.1 ± 0.27%; P = 0.038]. Conclusion: Obesity, age, and male sex are important risk factors for OSA, even in a morbidly obese population. Complex management of OSA and obesity is associated with improved T2DM control. The greater variability in follow-up HbA1c in T2DM patients undergoing weight-loss surgery highlights the need for improved guidelines for T2DM management after bariatric surgery.

P09 Day-case Laparoscopic Gastric Band Insertion is a safe normal Practice Ashok Gunawardene, Shree-eesh Waydia, Jeremy Gilbert, Michael Clarke, Allwyn Cota, Ian Finlay

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of post-policy change patients (p = 0.33). All complications in either group were Clavien-Dindo Grade IIIb or below. Conclusion: Adopting a policy of aiming to perform all gastric band operations as day-cases resulted in a significant increase in day-case rates without any significantly increased risk of early readmission or complication rate. Day-case gastric band surgery is safe.

P10 How effective is the Multi-Disciplinary Team approach in bariatric surgery? Naomi Bullen, Jeremy Gilbert, Michael Clarke, Alwan Cota, Ian Finlay Royal Cornwall Hospitals Bariatric and Metabolic Surgery Unit, Truro, Cornwall, UK Background: Multi-Disciplinary Team (MDT) decision making meetings

are widely recommended in the management of bariatric surgery patients. However, there is limited evidence for the effectiveness of the MDT approach in bariatric surgery. This study aimed to assess the impact of the MDT approach upon decisions regarding bariatric patients. Methods: Retrospective analysis of bariatric surgery MDT treatment decisions made over a 14 month period (July 2012-October 2013) was performed by examination of hospital case notes. Initial (pre MDT meeting) opinions of the surgeon, anaesthetist and dietitian were compared, with conflicting opinions and the ultimate MDT decision being noted. MDT decisions were also compared to patients’ subsequent management. Results: Decisions regarding 132 patients were analysed. Surgeons recommended further investigations for 13 (9.8%), with 119 (90.2%) being deemed ready for operation. In 83/119 (69.7%) cases the MDT agreed and patients were listed for surgery. There was MDT disagreement regarding 36/119 (30.3%) patients, with conflicting opinions expressed by anaesthetists in 20/36 (55.6%) of cases, and dietitians in 16/36 (44.4%) of cases. 6/36 (16.7%) of patients were referred for sleep studies (2 requiring pre-operative Continuous Positive Airway Pressure (CPAP)), 6/36 (16.7 %) for myocardial perfusion scans, 2 (5.6%) for echocardiograms, 2 (5.6%) for lung function tests with 4 (11.1%) referrals for other speciality opinions. Further dietetic input was recommended for 16/36 patients (44.4%). Of these 36 patients 18 (50.0%) were ultimately listed for surgery, 13 (36.1%) are still undergoing investigation and 5 (13.9%) withdrew. Conclusion: The MDT approach resulted in a change in decision for 30.3% of patients and can therefore be judged to have a significant impact upon bariatric patient care. This information suggests that MDT management is effective in bariatric surgery.

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Royal Cornwall Hospitals Bariatric & Metabolic Surgery Unit, Truro, Cornwall, UK

National Bariatric Surgical Registry – what do patients want?

Background: Gastric banding is well established worldwide and is well-

Rajesh Kumar Jain, Omar Khan, Cathy Edge, Nimalan Sanmugalingam, Marcus Reddy

described as a day-case procedure. However, recent UK data from the National Bariatric Surgery Registry reveals that only 28 % were performed as day-cases. Our unit adopted a policy of aiming to perform all gastric band operations as day-cases in March 2011. This study aimed to assess the safety of that policy. Methods: We reviewed prospectively collected data of all gastric bands performed between July 2009 and October 2013 by two Consultant bariatric surgeons. Early re-admission (within six weeks of operation) rates and complication rates were compared between patients having an operation before and after the change in policy. Statistical analysis was performed using Chi Squared tests. Results: 93 patients were included in the study. There were 42 (45.1%) in the pre-policy change group and 51 (54.8%) in the post-policy change group. 3 (7.1%) patients in the pre-policy change group were discharged on the day of surgery compared to 33 (64.7%) of the post- policy change group, this was statistically significant (p = 0.001). The numbers of patients returning with early readmissions were 4 (9.5%) and 5 (9.8%) (p = 0.96) respectively. Complication occurred in 7 (16.7%) of pre- policy change patients and 5 (9.8%)


St Georges Healthcare NHS Trust, London, UK Background: The National Bariatric Surgical Registry (NBSR) is designed to

provide a comprehensive analysis of the short and medium term complications of patients undergoing bariatric surgery in the United Kingdom. In an attempt to improve the quality of the data and increase transparency it has been proposed that every patient is given a unique identifier in order to allow tracking of outcomes with the aim of publishing anonymised data on individual surgeons. We analysed patient attitudes towards this new policy. Methods: A questionnaire was given to all patients who have had previous bariatric surgery or awaiting surgery attending bariatric support group. Structured questions were designed to assess attitudes towards publication of data on outcomes, surgeon specific data and tracking of patient data across different bariatric centres. Results: A total of 48 patients (M: 13; F35) completed the questionnaire. Of these 34 have had previous bariatric surgery and 14 were awaiting/ thinking

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about having bariatric surgery. 32 pts (67%) were happy with publication of unit specific data outcomes and 4 disagreed and 11pts were unsure. 34 pts (71%) were happy with the publication of surgeon specific data for public view, 6 disagreed and 7 pts unsure. In terms of data of patients being tracked to different bariatric units, 33 pts (69%) were willing and 8 pts unsure. 38 pts (80%) were also satisfied with their data being stored centrally for the purposes of research and quality control of surgery. Conclusion: This study suggests that there is a significant patient support for the publication of surgeon and unit specific data as well as tracking of patient data across different bariatric centres. Significant numbers of these patients also were willing for this data to be used for research and quality control of surgery.

P12 Bariatric Psychology in the NHS: a survey of resources and input across the patient pathway Denise Ratcliffe1,2,3 , Rukshana Ali1,2 , Jolyon Poole1,2

Methods: There were three key components to the study. 1) A literature

review to ascertain the evidence-base for dietary advice and vitamin & mineral supplementation for pregnancy post gastric bypass surgery. 2) A literature review to obtain information on the risk of toxicity and under supplementation of vitamins & minerals in pregnancy. 3) Data on the over the counter vitamin & mineral supplements for pregnancy was collected and analysed. Results: The literature review revealed that there is little consensus of opinion on which vitamins and minerals should be supplemented after gastric bypass; there is risk to pregnancy outcomes on a range of vitamins and minerals for both toxic and low levels of nutrients. There is great variation in the levels of vitamins and minerals between the brands of supplements targeted for pregnancy. Conclusion: Both under and over supplementation of vitamins and minerals present a risk in pregnancy. This poses a problem in gastric bypass patients who require supplementation due to malabsorption of nutrients. There is agreement that women are more at risk if they become pregnant within two years of surgery. However, they are also at risk the longer the time since they have had surgery. Based on the findings, guidelines for dietary advice (which will be included in the poster), vitamin & mineral supplementation, and a food frequency checklist for women during pregnancy after gastric bypass surgery were devised.

1 Chelsea & Westminster NHS Foundation Trust, London, UK, 2 Central & North West London NHS Foundation Trust, London, UK, 3 Phoenix Health, Chester, UK

Background: Although providers of bariatric surgery within the NHS are

required to provide psychological input, operational definitions regarding the purpose and scope of this are lacking. This has led to significant variation in the provision of psychological input across bariatric services, with some providing an assessment-only service and others providing a more comprehensive package of intervention throughout the patient pathway.The aims of this paper are to document the current psychology provision and service models of NHS bariatric surgery services in the UK. Methods: Psychologists belonging to a bariatric psychology online forum hosted by the British Psychological Society completed a survey. This focused on the provision of psychological input throughout the bariatric pathway as well as the ratio between psychology resources and number of bariatric procedures per year. We obtained information from 22 NHS services which provided 3691 procedures per year. Results: There is significant variation in the ratio between psychology resources and number of bariatric procedures undertaken per service. Whilst all services provide pre-surgery psychology assessments, less than one-third routinely assess all potential bariatric surgery candidates. Over 90% of services have capacity to provide pre-surgery individual interventions and 41% offer presurgery groups. None of the services routinely offer post-surgery assessments but 68% have capacity to offer post-surgery interventions following re-referral. None offered post-operative structured psychological group interventions. Conclusion: There are significant disparities and inconsistencies in the provision of psychology resources in relation to surgery volume in the NHS. Most of these resources are directed at pre-surgery assessment and this raises issues regarding the function of these assessments. Rather than focusing on assessing psychological (un)suitability for surgery, an evidence-based approach involves psychologists offering pre-operative interventions to improve readiness for surgery and post-operative interventions to address recurring/emerging difficulties which impact on outcomes.

P14 An evaluation of staple line bleeding during gastric resection with varying duration of stapler compression Duncan Light, Albert Ngu, Michael Courtney, Millind Rao, Bussa Gopinath North Tees Hospital, Stockton on Tees, UK Background: Duration of stapler compression during laparoscopic gastric

pouch formation is highly variable between surgeons. There is a discrepancy between industry recommendations for staple compression and expert opinion. This study aimed to evaluate bleeding from the staple line with varied duration of compression before firing of a stapling device. Methods: 20 cases were included prospectively. Cases were non-randomised between two surgeons performing laparoscopic gastric bypass with a triple row stapling device. Staple line bleeds from the gastric pouch were examined. One surgeon applied the stapler for 40 seconds before firing while the other surgeon applied the stapler for 60 seconds. The end points were number of endoscopic clips applied for haemostasis and number of cycles of irrigation and inspection for bleeding. Results: The mean age was 44 years (range 21 to 61). All procedures were a laparoscopic Roux-en-Y gastric bypass. Mean duration was 145 minutes. There were 10 cases in each group. In the 40 second group the mean number of endoclips was 8 (0 to 15) with 4 cycles of haemostasis (2 to 6). In the 60 second group the mean number of endoclips was 6 (0 to 10) with 4 cycles of haemostasis (2 to 5). There were no postoperative staple line bleeds or other early complications in this study. Conclusion: There is a marginal advantage in haemostasis with staple compression for 60 seconds over 40 seconds. A larger randomised study would be useful to evaluate this further.

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Dietary advice for pregnancy after gastric bypass surgery

Is 23 hour discharge post Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) Surgery Safe?

Anita Attala, Claire Garside, Amy Jamieson, Keith Seymour, Sean Woodcock, Ann Geddes

Shree-eesh Waydia, Ashok Gunawardene, Jeremy Gilbert, Michael Clarke, Allwyn Cota, Ian Finlay

Northumbria Healthcare NHS Foundation Trust, Tyne and Wear, UK Background: As more women become pregnant after gastric bypass surgery,

clear dietary guidelines, including safe advice regarding vitamin & mineral supplementation are required. As yet, however, there has been little research on these matters, despite the growing demand from women in this situation. This work responds to a timely problem and provides a set of guidelines, which are urgently needed within this field of practice.


Royal Cornwall Hospital, Truro, UK Background: LRYGB is well established, yet it is unclear when patients

should be discharged post operation. After noting that many of our patients met discharge criteria sooner than anticipated, we implemented a policy of aiming for 23 hour inpatient stay post LRYGB in January 2012. The aim of this study was to assess the safety of this policy.

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Methods: We reviewed data of all patients undergoing LRYGB at our

Unit from 09/2010 to 10/2013. We compared the length of inpatient stay, complication rate, and re-admission rate of patients treated before and after the introduction of the 23-hour length of stay policy. Results: Of 161 LRYGB procedures, 38 patients (29 female) underwent LRYGB from 09/2010 to 12/2011 (pre-policy) and 123 (107 female) underwent operation after this date (post-policy). Both groups were similar in terms of mean age (46.1 v.s. 46.2, p = 0.932), mean BMI (46.8 v.s. 46.6, p = 0.868) and median number of pre-operative co-morbidities (3 vs 3, p = 0.9). There were significant reductions in median inpatient stay (2 v.s. 1 days, p < 0.0001), re-admission rate (21.1% to 6.5%, p = 0.009) and complication rate (18.4% v.s. 3.2%, p = 0.001) after the policy change. There were 7 complications pre-policy change: pulmonary embolus (n = 1), chest infection (n = 1) and constipation and anal fissure (n = 1), umbilical hernia requiring operation (n = 2), adhesional obstruction (n = 1) and persistent food intolerance (n = 1). Post-policy change there were 4 complications: adhesional obstruction (n = 2), staple line bleed (n = 1) and persistent dysphagia (n = 1). There were no deaths. Conclusion: Patients undergoing LRYGB can be safely discharged on the first post-operative day. This reduction in length of inpatient stay may offer significant cost savings.

P16 Internal herniation following laparoscopic roux-en-Y gastric bypass Louis Savage, Caroline Yao, Rajarajan Ramamoorthy, Sarah Pollock, Sasindran Ramar, Pratik Sufi Department of Bariatric Surgery, Whittington Hospital, London, UK Background: Internal herniae following laparoscopic roux-en-Y gastric

bypass surgery is an increasingly recognised phenomenon. There is debate in the bariatric surgical community as to the merit of routine closure of mesenteric defects (Petersen and jejunojejunostomy) at the time of the index procedure. The practice in our unit until recently has been to leave these mesenteric defects open. The aim of this study was to review our internal hernia rates following laparoscopic roux-en-Y gastric bypass and to explore factors that may help identify patients at higher risk of developing a symptomatic internal hernia. Methods: This was a retrospective review of the local bariatric service database with focused review of patient notes, imaging and electronic records. Patients that underwent imaging and/or further surgery following a bypass procedure were analysed. Results: There were 335 laparoscopic roux-en-Y gastric bypasses performed at our unit between 28/03/2007-11/09/2013, by 6 surgeons. 80 patients were identified as having a possible diagnosis of internal hernia based on electronic records and imaging findings. Only 7 definitive internal herniae (confirmed at operation) were found on more detailed analysis (2.1% incidence of symptomatic internal hernia). All of the patients were female, age range 23–54 (mean 38.7), BMI range at time of herniation 21.7-39 (mean 30.1), with range of BMI loss between 7 and 18 (mean 13.7). 2 patients presented electively and 5 as emergencies. Interval between surgery and presentation was between 0.5 and 36 months post-operatively (mean 24 months). Only 1 patient had a CT confirmed diagnosis of internal hernia pre-operatively. Conclusion: The decision to not routinely close mesenteric defects is not associated with a higher than expected symptomatic internal hernia rate. Our sample size is not great enough to draw conclusions about risk factors for internal herniation, although would suggest that female sex and significant weight loss may be contributory, and that presentation can occur at any stage in the post-operative period. CT has variable sensitivity for detecting internal herniae, and laparoscopy should be considered in all patients with suggestive symptoms. Randomised trials are needed to definitive clarification.


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P17 Oemntectomy, alone or in conjunction with conventional bariatric procedures for control of diabetes is of doubtful clinical benefit – a review of clinical studies Akshay Date1 , Zaher Toumi2 , Ravindra Date2 1 Imperial College, London, UK, 2 Lancashire Teaching Hospital NHS Foundation

Trust and University of Manchester, Preston, UK Background: Metabolic surgery achieves remission of type 2 diabetes mellitus

in a significant proportion of morbidly obese patients. Animal research suggests that visceral fat, rather than subcutaneous fat reduces insulin sensitivity. Subsequently, it was proposed that the addition of omentectomy to conventional bariatric procedures would improve remission of T2DM. This study aims to evaluate the significance of omentectomy, either on its own or in conjunction with other metabolic operations in clinical practice. Methods: We performed a review of Pubmed, EMBASE and MEDLINE from January 1995 to October 2013 to identify procedures performed in humans that included omentectomy for control of diabetes and then to review their outcomes. Results: Ten original studies were identified. Only one study looked at omentectomy alone. 6 studies have compared addition of Omentectomy to Roux en Y gastric bypass (RYGB) to RYGB alone, one study compared addition of omentectomy to gastric banding with banding alone. Two studies have used novel operations that included ometectomy as part of operation. Only 2 studies have used HbA1c for reportingT2DM and for end point of the study. Remission rate of T2DM was 0 with omentectomy alone and was 59-100% in other studies, however there was no signifcant difference in remission after addition of omentectomy to conventional surgery. Conclusion: Omentectomy alone or in conjunction with other conventional procedures have failed to show any benefit in glycaemic control. The clinical benefit of omentectomy, unlike its theoretical benefit, is doubtful.

P18 Systematic review of the effects of intentional weight loss on the risk of colorectal cancer Sorena Afshar1 , John C. Mathers2 , Seamus Kelly1 , Sean Woodcock1 , Keith Seymour1 1 North Tyneside General Hospital, Newcastle-upon-Tyne, UK, 2 Newcastle University,

Newcastle-upon-Tyne, UK Background: Increased adiposity is an established risk factor for colorectal

cancer (CRC) but the effects of intentional weight loss (IWL) on CRC risk is uncertain. To address this gap, we performed a systematic review to assess the evidence for the effect of IWL in overweight and obese individuals on subsequent CRC risk. We focused on the effect of bariatric surgery given the increasing prevalence of this approach in the management of obesity. Methods: The protocol for this systematic review was registered on PROSPERO (PROSPERO 2013:CRD42013004719) where the detailed methodology can be accessed. Results: After screening 3,691 articles, we found only 4 studies (all bariatric surgery) that reported effects on CRC per se. Meta-analysis, using a random effects model, revealed that bariatric surgery was associated with a significantly (P = 0.004) lower CRC incidence (RR 0.73, 95% CI: 0.58 to 0.90). Conclusion: There are very few studies of the effects IWL on CRC risk and all studies found which addressed this issue directly employed bariatric surgery. We observed that bariatric surgery was associated with lower CRC risk. The design of these studies makes it impossible to determine whether the reduced CRC risk resulted from IWL per se or was due to other effects of the surgery.

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P19 Laparoscopic roux-en-y gastric bypass is a safe and effective option for treating morbid obesity in older patients Waleed Al-Khyatt, Javed Ahmed Royal Derby Hospital, Derby, UK Background: A recent report by the Public Health England Obesity

Knowledge and Intelligence team showed that bariatric surgery is undertaken most frequently in people below the age of 55 years. The reason behind this attitude is probably that increasing age is associated with additional risk. In this study, we investigated the safety and efficacy of using laparoscopic roux-en-y gastric bypass (LRYGB) for treatment of morbid obesity in patients older than 55 years (> 55) compared to patients younger than 55 years (≤ 55) from a UK tertiary centre. Methods: Retrospective analysis of a prospectively maintained database of 304 consecutive patients underwent LRYGB between September 2009 and March 2013. Demographic data and preoperative comorbidities, operative outcomes, percentage excess weight loss (EWL) and diabetic remission at one-year follow-up were compared between patients > 55 versus patients ≤ 55. Results: All 304 patients (220 female) underwent LRYGB. There were 224 patients (74%) ≤ 55 versus 80 patients (26%) > 55. There was no gender based difference between both groups (p = 0.7). Mean body mass index (BMI) at presentation were 54 and 52 kg/m2 for ≤ 55 and > 55 respectively (p = 0.4). Comorbidities like diabetes, hypertension, ischemic heart diseases, sleep apnoea, and arthritis were significantly higher in older patients in comparison to younger patients (p < 0.001). There was no postoperative mortality in either group. There was no difference in early postoperative complications like bleeding, anastomosis leak, thromboembolism and chest infection (p = NS). Likewise, late complications like anastomotic stricture, dumping syndrome and symptomatic internal hernias were also comparable between two groups (p = NS). At postoperative follow-up interval of 11–15 months, there was comparable median EWL% of 72% for ≤ 55 versus 67% for > 55 (p = 0.8), and diabetes remission rate (complete remission or reduced used of anti-diabetic medications) of 75% for ≤ 55 versus 82% for > 55 (P = 0.46). Conclusion: Although older patients with morbid obesity have higher rate of preoperative comorbidities, our results demonstrate that LRYGB for older patients with morbid obesity has comparable very low complications rates, and high efficacy in achieving excellent EWL, and diabetes control.

P20 Decision making in adolescent bariatric surgery: Perspectives from clinicians and adolescents Jacqueline Doyle1 , Susie Colville1 , Patrick Brown2 , Marco Adamo1 , Deborah Christie1 1 University College London Hospital, London, UK, 2 University of Amsterdam,

treatment option unlike others, iii) the view that adolescence is a complex developmental period, iv) the perception that bariatric in adolescents is controversial to the public. In study two four key themes emerged i) wanting a different future, ii) the dilemmas, iii) ways to manage the dilemmas, iv) surgery as the last resort but not an easy option. Conclusions It is argued here that shedding light on this process of decision making in clinicians and their adolescent patients has implications for policy and practice and for the counselling of patients considering these sorts of treatments.

P21 Does type of bariatric surgery affect development of renal stones? Andrew Deytrikh, Dominic Blunt, Ahmed Ahmed, Ranan Dasgupta Imperial College London, London, UK Background: The management of renal stone disease in the bariatric

population presents unique challenges (eg with limitations in treatment options such as lithotripsy), as does the changes in metabolic profiles in this population following surgery. We review our experience of bariatric surgery in a national referral centre, with CT imaging before and after, to assess the development of renal tract stones. Methods: We retrospectively studied the database of a single surgeon for all bariatric procedures (sleeve gastrectomy, gastric bypass and gastric band) during a 4 year period, comparing the incidence of renal tract stones (based on CT imaging) according to type of surgery. Results: Of a total of 111 patients who had undergone CT imaging preoperatively, 68 underwent gastric bypass, 15 laparoscopic gastric banding, and 28 sleeve gastrectomy, with a mean age of 46.9 years (range 19–70 years). Of the gastric bypass group, 10 had renal stones diagnosed on CT (5 of which developed after surgery), 1 patient who underwent banding had a new stone following surgery, and 6 patients undergoing sleeve gastrectomy had stones (of which 4 developed after surgery). Only 2 patients required intervention, both for ureteric stones. The range of stone size was 4-8 mm. No patients underwent percutaneous surgery or extracorporeal lithotripsy, with most passing stones spontaneously. Conclusion: The incidence of new stone disease (9%) in the post-bariatric surgery population does not differ significantly from the population at large. One may speculate whether the incidence was higher for the sleeve gastrectomy group (14%) than the bypass (7.3%) or the banding (6.7%) groups due to a metabolic disturbance than just the potentially higher urinary concentration (calcium, oxalate, etc) due to smaller reservoir volume. Obese patients present specific challenges for endourological procedures (eg limitations of extracorporeal lithotripsy, difficulties for percutaneous access), and therefore it is relevant to counsel these patients correctly with information about the incidence of stone disease in this population and also in those who are undergoing bariatric surgery, and whether this surgery is likely to impact on the incidence of stones.

Amsterdam, The Netherlands Background: Bariatric surgery for young people is potentially fraught with

many medical and ethical dilemmas (Caniano 2009). A recent systematic review concluded that bariatric surgery leads to significant short-term weight loss in obese children and adolescents. However, the authors also argue the need for long-term, prospectively designed studies to firmly establish the harms and benefits of bariatric surgery in children and adolescents. (Black et al 2013). In the UK, NICE guidelines suggest that bariatric surgery should only be offered to people under the age of 18 in ‘‘exceptional circumstances’’, however, in the absence of long term outcome data to guide patient selection decision making may be a complex task. Methods: Two qualitative studies were undertaken in which clinicians in bariatric surgery teams and adolescents who have had bariatric surgery were interviewed. Results: The interviews were analysed using Interpretative Phenomenological Analysis Smith et al (1999). The results of study one revealed a pervasive ‘‘uncertainty’’ amongst the clinicians, with sources of uncertainty relating to i) the lack of research in this area, ii) the perception of bariatric surgery as a


P22 Effect Of Prior Bariatric Fellowship On Peri-operative Outcomes In The First Three Years As Independent Consultant Bariatric Surgeon Irfan Halim, Morven Allen, Sanjay Agrawal Homerton University Hospital, London, UK Background: Bariatric

surgery (laparoscopic Roux-en-Y gastric bypass(LRYGB), sleeve gastrectomy(LSG), and gastric banding(LAGB) has been proven to be the only effective, long-term treatment for morbid obesity. These are technically challenging operations associated with low, but significant risk of complications and mortality. The aim of this study was to evaluate the peri-operative outcomes for bariatric surgeries in the first three years as independent Consultant Surgeon following completion of bariatric fellowship training.

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Methods: Prospectively collected database of all patients undergoing

primary bariatric procedures between March 2010 and February 2013 was analysed. Data on patient demographics, conversion to open, length of stay(LOS), and peri-operative(14-day) complications including mortality were analysed. Results: Over the 36-month period, 237patients (188female, 49male) underwent primary bariatric procedures(190LRYGB, 35LSG, 12LAGB). The mean age was 45(20–67)years and BMI was 48.7(36.3-64.8) kg/m2 . The ASA classes were I-6(2.5%), II-132(55.7%), and III-99(41.8%). The majority(61.6%) were in OS-MRS Group B(Group A:43.6%, C:6.7%) classification system. The average LOS was 2.5days(range 1–14). There were no conversions to open surgery and no in-hospital mortalities. There were 6(2.5%) immediate post-operative complications as shown below: Complications (No. of patients) Post-operative bleed (3) Chest infection (3)

Re-operations 3 (Re-laparoscopy) 2 (Negative re-laparoscopy)

One patient(0.4%) was re-admitted with small bowel obstruction following internal hernia requiring laparoscopy and repair. Conclusion: Bariatric fellowship ensured high-quality surgical outcomes for laparoscopic bariatric surgery from the very beginning as independent Consultant Surgeon. Fellowships should be an essential part of bariatric training throughout the world.

P23 C-Reactive Protein On Post-Operative Day One Can Detect Major Complications Of Laparoscopic Gastric Bypass Surgery

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P24 Prospective Study: The Role Of Endoscopy In Patients Who Have Undergone Laparoscopic Sleeve Gastrectomy Yiwen Loh, Rajesh Jain, Nimalan Sanmugalingam, Georgios Vasilikostas, Andrew Wan St George’s Healthcare NHS Trust, London, UK Background: Laparoscopic sleeve gastrectomy is an effective treatment for

morbid obesity, however a proportion of patients re-present with gastrointestinal symptoms requiring upper GI endoscopy (OGD) as a diagnostic and therapeutic tool. Methods: Using a prospectively collated database, we identified those bariatric patients who underwent endoscopy post sleeve gastrectomy between April 2010 and October 2013. We analysed the indications and findings of post-operative sleeve gastrectomy patients. Results: Seventeen post-sleeve gastrectomy bariatric patients were referred for OGD to investigate gastrointestinal symptoms. Indications were dyspepsia in 5, dysphagia in 4, abdominal pain in 3, nausea and vomiting in 3, cessation of weight loss in 1 and melaena in 1 patient. Nine of the 17 patients had normal findings, 4 were diagnosed with gastritis, 3 were discovered to have a kink in their sleeve and 1 patient had a healed ulcer in the staple line. Gastrograffin swallow revealed non-specific findings in patients with kinking on OGD including slow bowel transit. Following OGD, 6 out of 17 patients had a change in their management, including 2 who had repeat surgery (sleeve gastrectomy conversion to gastric bypass). Conclusion: OGD post bariatric surgery in those patients with non-specific upper GI symptoms is a useful diagnostic assessment and changes the management of a significant proportion of patients. It is most beneficial in identifying those patients with kinking after having undergone sleeve gastrectomy.

Thomas Pike, Alan White, J Peter A Lodge

P25

Leeds Teaching Hospitals NHS Trust, Leeds, UK Background: Following laparoscopic Roux-en-Y gastric bypass surgery,

many surgeons routinely undertake radiological studies to try and promptly delineate those patients who have developed early complications. However, these methods have limited diagnostic value and add further cost. This study aims to evaluate the effectiveness of serum C-Reactive Protein (CRP) on day 1 post-operatively as a determinator of early major complications following laparoscopic gastric bypass. Methods: All patients who underwent laparoscopic gastric bypass surgery, conducted by a single surgeon, were included in the study (May 2010 - Oct 2013). Data on CRP and post-operative complications, as well as potential confounding factors, were analysed from a prospectively maintained database. Complications were classified according to the Clavien-Dindo system. Descriptive statistical analysis was conducted using Mann–Whitney U and Pearson’s chi-squared tests, as appropriate. The diagnostic value of CRP as a prognosticator of postoperative complications was evaluated using the area under the curve of the receiver operating characteristic curve. Results: 112 patients who underwent a laparoscopic gastric bypass were included in the sample (35 male : 77 female, median age 44 [range 18–73]). Major complications were observed in 3 patients (2.7%), all graded as Clavien-Dindo Grade IIIb. One patient developed a gastric leak, one a small bowel perforation and one had a negative laparoscopy. There were no post-operative deaths. There was no significant difference between those patients who developed complications and those that did not in terms of sex, age, pre-operative BMI, previous surgeries or medical co-morbidities. Serum CRP day 1 post-operatively directly correlated with major complications (p = 0.001). A CRP > 100 day 1 post-operatively can predict major complications with 100% sensitivity and 95% specificity with a diagnostic accuracy of 0.98 (95% confidence interval: 0.944 - 1, p = 0.001). Conclusion: Serum CRP accurately predicted post-operative complications on day 1 following laparoscopic gastric bypass. This can be used to support the early discharge of the majority of patients undergoing laparoscopic gastric bypass, or conversely, the expeditious identification of patients who may require further investigation.


Gastro-oesophageal reflux disease and bariatric surgery Cynthia-Michelle Borg1 , Jean Deguara2 1 University Hospital Lewisham, London, UK, 2 Kingston Hospital NHS Foundation

Trust, Kingston, UK Background: Morbidly obese patients have a higher incidence of hiatal

hernias and gastro-oesophageal reflux disease (GORD) when compared to the general population. Most bariatric operations involve surgery near the hiatus of the diaphragm and this dissection may interfere with the function of the lower oesophageal sphincter (LOS) and the anti-reflux mechanisms. Methods: A systemic review of the literature was performed to investigate changes in the incidence of GORD symptoms and abnormal oesophageal physiology after bariatric surgery. Results: Sleeve gastrectomy (SG): SG may interfere with the anti-reflux

mechanism by weakening the phreno-oeshophageal ligament and changing the cardio-oesophageal angle. 8 studies in the literature showed increased prevalence of GORD after SG while 5 studies showed decreased prevalence. The extent of hiatal dissection to exclude a hiatal hernia was unclear in most of these studies. Gastric Banding (GB): 15 studies were found in the literature about changes in GORD after GB. Studies showed heterogeneity in terms of length of followup, investigations used to assess change in oesophageal symptoms/function as well as technique and band employed. The incidence of oesophageal dilatation post-banding varied between 7.5 - 56% of patients. The incidence of reflux symptoms also varied greatly with some studies showing improvement, others no change and some worsening of GORD. Four studies evaluated oesophageal manometry in patients pre-and post GB. 2 of these studies showed no change in oesophageal motility while the other 2 showed weaker peristalsis and contractions in the lower oesophagus after GB. Pressure at the lower oesophageal sphincter was either unchanged or increased post-banding.

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Roux-en Y gastric bypass (RYGB): According to the literature, RYGB is

the best operation in patients who had pre-operative GORD symptoms and is associated with the smallest risk of post-operative reflux symptoms. Conclusion: The literature is still somewhat controversial regarding the effects of gastric banding and sleeve gastrectomy on gastro-oesophageal reflux and oesophageal motility. The incidence may vary with length of follow-up and surgical management of incidental hiatal hernias. RYGB has been shown to be an excellent treatment option for patients with pre-op symptomatic GORD.

P26 Fast Track Laparoscopic Roux-en-Y Gastric Bypass Surgery - < 48 Hour Postoperative Stay Is Safe In The Majority And Should Be Routine Practice! Irfan Halim, Morven Allen, Sanjay Agrawal Homerton University Hospital, London, UK Background: Laparoscopic Roux-en-Y gastric bypass (LRYGB) is considered

the gold-standard bariatric procedure and is being increasingly performed throughout the world. A recent systematic review showed that discharge within 23 hours is unsafe, except in selective patients. The usual inpatient length of stay is 2-3days. The aim of this study was to assess the feasibility and safety of discharge within 48hrs following LRYGB. Methods: A prospectively collected database of consecutive LRYGBs performed by a single consultant surgeon between March 2010 and February 2013 was analysed. Patient demographics, operative time, conversion to open, complications, and length of stay were reviewed. Results: Over the 36-month period, 181 patients(135 females, 46 males) underwent primary LRYGB. The mean age was 45(20–67)years and body mass index was 48.9(36.3–64.8) kg/m2 . The obesity surgery mortality risk score, classes A:B:C were 72:96:13, respectively. There were no conversions to open surgery and no deaths. 4(2.2%)patients developed post-operative complications prior to discharge, as shown below:

10 years ago, to assess the weight loss potential, complication risk and longevity of this procedure. Methods: Retrospective analysis of a prospectively maintained database was performed. Patients were included if they had a LRYGB within the initial first 3 years of this bariatric procedure, in this bariatric unit. Dates of procedures ranged from January 2003 to December 2006. 18 patients were identified, of these 66% were female, with an age range of 33–69 years. When analysing readmission and reoperation, they have been categorised into early and late. Early within the first 30 days and late over 30 days. Weight loss has been based upon the last documented weight subtracted from weight on the day of surgery, with 2 patients having no weight recorded post-procedure. Results: 11% of patients had early readmission and 38.8% of patients had late readmission. In total there were 20 post-LRYGB admissions, however, 2 patients had several admission. Reasons for admission ranged from oesophageal obstruction to nausea and vomiting, the most common presenting complaint being pain. Within this cohort no patients had an early reoperation but one patient went on to have a ‘late’ re-do Gastric bypass. A zero early and late mortality rate has been demonstrated in this cohort, with no intra-operative complications or laparoscopic to open conversions. These patients demonstrated an average weight loss of 45.51 kg and no patients had a documented weight gain. Patient attendance at follow up decreased throughout the years post procedure with a 6 month follow-up showing 83.3% attendance, to a 66.6% at 3 years, 33.3% at 5 years and 16% at 7 years. The last follow up appointment for these patients was on average 2131 days post procedure, with a range of 740 – 4320 days. Conclusion: These results demonstrate a safe, effective procedure with only minimal late complications. This also highlights the poor compliance in follow up, this is not isolated to LRYGB and therefore a good safety record and a low complication rate is essential in all bariatric procedures. Although there are many developments in bariatric surgery, the wealth of new research and evidence supporting the cost effectiveness and safety surrounding LRYGB will keep this procedure in the forefront of bariatric surgery for years to come.

P28 Complications(No. of patients)

Re-operation < 30 d

Post-operative bleed(2) Chest infection(2)

2(Re-laparoscopy) 1(Negative re-laparoscopy)

LOS(days) The effects of laparoscopic sleeve gastrectomy on postoperative erythrocyte and haematinic indices at 1 year

5,5 3,6

Ashok Menon1 , Polobody Siba Senapati1 , Khurshid Akhtar1 , J New2 , Aa Syed2 , Basil Ammori1

146(81%) patients were medically fit for discharge in < 48 h, though 4 patients stayed an extra night for social reasons. The average length of stay (LOS) for the remaining 35 patients was 4.1(range3-10) days. The reasons for prolonged stay were for nausea and vomiting(7), pain(4), hypoxia(2), pyrexia(1), tachycardia(3), hypotension(1), raised CRP > 100 (6), ECG changes(3), drop in haemoglobin(3), glycaemia control(3), re-warfarinisation(2). Conclusion: Patients undergoing LRYGB can be safely discharged within 48hrs of surgery in the majority (81%) of cases. Fast track LRYGB should become routine practice in the world.

P27 Laparoscopic Roux en y Gastric bypass – a ten year review Jennifer Wilson, Kamal Mahawar, Maureen Boyle City Of Sunderland Hospitals, Sunderland, UK Background: Bariatric surgery has developed in popularity, becoming an

increasingly accessible and appropriate management option for obesity. New procedures are continually emerging, with some surgeons leaning towards safer, more cost effective procedures at the expensive of greater weight loss results. Where does the Laparoscopic Roux en y gastric bypass (LRYGB) fit within this spectrum? I aim to examine the first 3 years of LRYGB procedure within a large bariatric centre, where their first LRYGB was performed over


1 Department Of Obesity And Metabolic Surgery, Salford Royal Hospital, Salford, UK, 2 Department Of Obesity Medicine, Salford Royal Hospital, Salford, UK.

Background: Laparoscopic sleeve gastrectomy (LSG) is thought to alter iron

and B12 absorption, which may affect erythrocyte synthesis resulting in anaemia. This study investigates changes in erythrocyte and haematinic indices following LSG, and the effect of iron and vitamin B12 supplementation. Methods: A single-centre, retrospective analysis was conducted on patients who underwent LSG (n = 42) between July 2009 and October 2011. Outcomes were anaemia (Hb < 12 in females and < 13 in males), haemoglobin (Hb, g/dl), mean corpuscular volume (MCV, femtolitres/cell), mean corpuscular haemoglobin (MCH, picograms/cell), ferritin (ng/ml), B12 (picograms/ml), and folate (ng/ml) levels at 12 months. Results: 25 patients (60%) received both iron and B12 supplementation postoperatively, whilst 6 (14%) received iron only, with none (0%) receiving B12 only. Hb (13.9 vs. 13.7), ferritin (102 vs. 136), MCV (90 vs. 93), and folate (6.2 vs. 9.8) did not significantly change at 12 months. There were significant increases in MCH (30 vs. 31, p = 0.02), B12 (387 vs. 659, p = 0.01), and iron (10.1 vs. 14.4, p = 0.02) at 12 months. Non-receipt of iron did not lead to microcytic anaemia (0% vs. 0%) or result in significant changes in ferritin (120 vs. 123), and iron (15.2 vs. 8.6) at 12 months. Non-receipt of B12 was not associated with megaloblastic anaemia (0% vs. 11%), B12 deficiency (0% vs. 0%), significant changes in B12 (493 vs. 393) at 12 months. Conclusion: These preliminary data throw doubt as to the need for routine iron and B12 supplementation after LSG. A larger study population with longer follow up is required.

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P31

Bariatric surgery and hypothalamic obesity – a prospective study

Reflux in Laparoscopic Sleeve gastrectomy

Omar Khan, Rajesh Kumar Jain, Emma McGlone, Marcus Reddy, Gul Bano

Jennifer Wilson, Kamal Mahawar, Maureen Boyle

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City Of Sunderland Hospitals, Sunderland, UK

St Georges Healthcare NHS Trust, London, UK Background: There is considerable controversy as to the role of bariatric

surgery in patients with hypothalamic obesity, with some advocating no surgical intervention or the performance of calorific malabsorptive procedures. In our institution we have performed conventional restrictive bariatric procedures on hypothalamic obesity patients deemed appropriate for bariatric surgery by the MDT. The purpose of this prospective study was to assess the efficacy of this approach. Methods: Between 2010–2012 a total of 6 patients with hypothalamic morbid obesity deemed suitable for bariatric surgery were assessed at MDT and underwent bariatric surgery. Their clinical status was prospectively recorded pre- and post- operatively and analysed. Results: There were 5 females and 1 male with a mean age of 42 years. 4 patients has pituitary adenoma, 1 had a craniopharyngioma and 1 had tubercular meningitis The mean BMI pre-procedure prior to surgery was 47 (range- 40–55). 3 patients underwent laparoscopic sleeve gastrectomy and 3 underwent a gastric bypass. There were no peri-operative complications. One year following surgery, all patients were reviewed and the mean BMI of the cohort had fallen to 35 (range 29–47). Conclusion: Conventional bariatric surgery may be an effective treatment for suitably selected patients with hypothalamic obesity.

P30 Outcomes of Bariatric Surgery for Obstructive Sleep Apnoea in a District General Hospital Andrew Chung, Muhammad Aslam, Abdulmajid Ali University Hospital Ayr, Ayr, UK

Background: Laparoscopic Sleeve gastrectomy (LSG) is gaining in pop-

ularity as a weight loss procedure but patients may have problems with gastro-oesophogeal reflux post operatively. The aim was to determine the frequency and aetiology of reflux post LSG and the need for further investigation and intervention. Methods: Data was collected retrospectively within a large NHS based hospital of all patients who underwent a LSG between June 2007 and August 2012. All patients who subsequently underwent an oesophagogastroduodenoscopy (OGD) post LSG were identified and the indication and findings of procedure analysed. Reflux in the study was defined by endoscopic diagnosis, based upon the Los Angeles grading system, whereby reflux was defined by any finding of mucosal breaks, which can further by graded A –D. Results: Over the time period a total 223 patients had LSG procedures. Since surgery 25 (11% of patients) have required an endoscopy. The average time from surgery to endoscopy was 233 days (range of 49 – 538 days). The indication for endoscopy was symptoms suggestive of reflux (10, 40% of patients), vomiting (6, 24%), dysphagia (5, 20%) and weight gain, weight loss, abdominal pain and anaemia (1 each, 4%). Endoscopy demonstrated pathology in 48% of patients with a hiatus hernia in 4 patients, oesophagitis in 4, gastritis and ulcer in 2, gastric polyp in 1 and a sleeve narrowing in 1. Of these 83% showed endoscopic evidence of reflux according to the Los Angeles grading system, thought to be associated with, or causing the presenting compliant. Despite maximum medical treatment of reflux symptoms 2 patients necessitated conversion to a gastric bypass. Conclusion: Many patients post-LSG develop reflux symptoms. Endoscopy has a high positive rate of identifying reflux and should be advocated in all sleeve gastrectomy patients with reflux symptoms. This can be performed pre-operatively to identify patient with conditions such as; hiatus hernias or oeosphagits who may benefit from alternative procedures. This also demonstrated the need and prevalence of conversion surgery due to reflux and the extent of ongoing medical management for reflux with this bariatric cohort.

Background: Obstructive sleep apnoea is a commonly associated co-

morbidity of obesity. In our bariatric service, obstructive sleep apnoea is a primary selection criteria used in the consideration of bariatric surgery. We performed an audit to review the condition of patients with sleep apnoea up to 5 years following surgery. Methods: From a locally maintained database of patients referred to our bariatric centre, all patients with obstructive sleep apnoea confirmed with polysomnography who underwent a bariatric procedure were selected for the study. A 5-year period between May 2008 and May 2013 was chosen to allow a minimum 6-month follow-up period. A telephone consultation with each patient was conducted to confirm pre-operative status of sleep apnoea and to establish their individual post-operative outcomes. Results: A total of 41 subjects with obstructive sleep apnoea underwent bariatric surgery in the study period. Four patients not contactable by telephone were excluded from the study. The median (range) age was 48 (35–66) years and the mean pre-operative body mass index was 52.9 (33.3-61.8) kg/m2 . Eighteen patients were male; 19 patients were female. Out of 37 patients, 34 (91.9%) had expressed a better quality of life after bariatric surgery. Eighteen patients (48.6%) no longer required nocturnal continuous positive airways pressure (CPAP) therapy; 16 patients (43.2%) with sleep apnoea but not requiring CPAP therapy reported improvement or complete resolution of symptoms. Of 34 patients, 21 had laparoscopic sleeve gastrectomy, 12 had laparoscopic Rouxen-Y gastric bypass and 1 laparoscopic adjustable gastric band. Three patients (8.1%), who all underwent laparoscopic sleeve gastrectomy, reported no change in CPAP therapy following surgery. Conclusion: Our data demonstrates that bariatric surgery can successfully reduce patients’ weight and achieve resolution of sleep apnoea in over 91% of cases. This is good justification that a district general hospital can offer bariatric surgery as a viable treatment option in obstructive sleep apnoea.


P32 Impaired vascular function of isolated subcutaneous resistance arteries in severely obese patients Adil Abushufa1 , Philip Evans2 , Paul Leeder3 , Javed Ahmed3 , Chris McIntyre2 , Saoirse O’Sullivan1 1 University of Nottingham School of Medicine, Derby, UK, 2 Department of Renal Medicine, Royal Derby Hospital, Derby, UK, 3 Department of Bariatric Surgery, Royal

Derby Hospital, Derby, UK Background: Microvascular and macrovascular dysfunctions are the principle

factors contributing to the increased risk of morbidity and mortality associated with obesity. We aimed to directly investigate the vascular reactivity in subcutaneous arteries isolated from severely obese patients. Methods: Abdominal subcutaneous fat biopsies were obtained from obese patients (n = 12), non-obese healthy controls (n = 26) and six months post bariatric surgery (n = 4). Arteries (< 600 µM or > 600 µM internal diameter) were mounted on a wire myograph and concentration-response curves were carried out to noradrenalin (NA), endothelin-1 (ET-1), U46619 (U4), angiotensin II (AngII), vasopressin, bradykinin (BK), acetylcholine (Ach) and sodium nitroprusside (SNP). Results: The maximal contractile response to all agents was significantly enhanced in subcutaneous arteries from obese patients compared to non-obese controls (P < 0.05-0.001). For ET-1 and NA, this was more pronounced in the larger arteries (> 600 µM, P < 0.0001). The maximal relaxant response to the endothelium-dependent relaxants BK and Ach were significantly blunted

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in obese patients (P < 0.05). By contrast, the maximal relaxant response to the endothelium-independent relaxant SNP was not affected by obesity, in fact the potency of SNP was enhanced in arteries > 600 µM (P < 0.05). Post-surgery, pilot data showed a trend for reduction in the contractile responses to U4 and enhancement of BK (n = 3). Conclusion: This data supports the theory that obesity is associated with microcirculatory dysfunction. In some cases, this is worse in larger arteries. Preliminary data suggests bariatric surgery can improve vascular function.

P34 Short-term outcomes of laparoscopic sleeve gastrectomy - a learning curve experience Caroline Taylor, Umar Shariff, Peng Choong Lau, Jenny Abraham, Louise Halder, For Lam, Vinod Menon Department of Upper Gastrointestinal & Bariatric Surgery University Hospitals Coventry & Warwickshire NHS Trust, West Midlands, UK

Results: 7 studies were found in the literature that compared liver volume

before and after acute diet-induced weight loss in patients undergoing bariatric surgery. The duration and the type of the diet varied. Most used a low or very low calorie diet (VLCD). In these studies, the pre-op diets were associated with significant reduction in liver volume and liver fat content. There was only one study with a control group - this did not report any significant difference in operating time or hospital stay between the 2 groups. One controlled, single-blind study compared VLCD (n = 137) with a control group (n = 136) but no liver imaging was used. Although surgeons found the operation subjectively easier in the VLCD group, there was no statistical difference in operating time or in the amount of intra-op bleeding. There was a reported increase in complications in the control group at 30 days in this study. Conclusion: Although pre-operative diets are widely used, there is limited evidence that they improve patient outcome but they may make surgery easier for the surgeon especially early on in the learning curve. There may however be concerns regarding cost, patient compliance and the catabolic effects of a prolonged diet before major surgery.

P36

Introduction: Laparoscopic sleeve gastrectomy (LSG) as a choice for bariatric

surgery is becoming increasingly popular. The initial weight loss and short-term outcomes for the more established practice of gastric banding and gastric bypass are widely reported, similar results from LSG are emerging. We report our learning curve experience and short term outcomes following LSG. Method: A retrospective analysis of a prospectively collected database was carried out at a regional bariatric centre with a well-established multidisciplinary bariatric approach. All patients undergoing a LSG between 2011–2013 were included. Pre-operative weight, BMI and percentage excess weight were recorded and this was compared for the same outcomes during their first 6 months post-surgery. Length of inpatient stay and rate of complication rate were also recorded. Results: 64 LSG were performed during this period. 15 (23%) male: 49 (77%) female. Median pre-operative weight was 147.1 kg (range 115–210 kg); BMI was 54.2 kg/m2 ; mean excess weight was 68.1 % (range 55-87%). The median weight 6 months post-bariatric surgery was 119.2 kg and the mean percentage excess weight loss was 42% (range 16-73%). 4/64 patients had a post-operative leak, 3 resolved with conservative management and 1 patient required percutaneous drainage, these were all within the first 25 procedures. The median inpatient stay following LSG was 2.5 days (range 1–8) with 70.5% patients discharged within 2 days of surgery. There was no mortality. Conclusion: Short-term outcomes following LSG are good in the hands of experienced laparoscopic surgeons, even within their learning curve for this procedure, with low morbidity and short post-operative inpatient stay. The successful weight loss achieved in the short-term post-operatively suggests LSG is a safe and feasible option and suitable alternative to LAGB for the surgical management of morbid obesity.

P35 Pre-operative diets and their effects on liver volume and early post-operative outcomes after bariatric surgery

National Bariatric Surgical Registry – what are we missing? Omar Omar, Rajesh Kumar Jain, Emma McGlone, Amanda Bond, Marcus Reddy St Georges Healthcare NHS Trust, London, UK Background: The first published report of the National Bariatric Surgical

Registry (NBSR) was designed to provide a comprehensive analysis of the short and medium term complications of patients undergoing bariatric surgery in the United Kingdom between 2008 and 2010. However the voluntary nature of data submission has led some to question whether this register truly represents the complication rates associated with bariatric surgery. We analysed the medicolegal practice of a single surgeon in an attempt to assess the validity of this register as a measure of morbidity following bariatric surgery. Methods: Between November 2011 and June 2013 a total of 59 cases were referred to a single bariatric consultant for a medico-legal opinion. Of these, a total of 20 cases involved patients who underwent primary bariatric surgery in the UK between March 2008 and March 2010. These cases were identified and the operating surgeon and complications of these cases recorded and cross-referenced against the published data for the NBSR report and compared. Results: 12 of the 20 cases involved surgeons registered on the NBSR. Of these 12 cases, there were 7 early complications (namely leak in 5 cases and abdominal sepsis in 2 cases) and 5 late complications (obstruction (2), ulceration, stricturing and sepsis). None of the late complications were recorded in the NBSR. In addition 8 cases involved complications from surgeons not registered with the NBSR. These complications included 3 early complications (2 major haemorrhages requiring laparotomy and post-operative nerve damage) and 5 late complications (slipped gastric band (2); band fracturing (2) and small bowel obstruction) none of which were listed in the NBSR. Conclusion: This study suggests that there is a significant volume of early and late complications following bariatric surgery which do not feature on the NBSR. This raises questions as to the reliability of the register in reflecting true complication rates following bariatric surgery in the United Kingdom.

Cynthia-Michelle Borg1 , Alice Gazet1 , Jean Deguara2 1 University Hospital Lewisham, London, UK, 2 Kingston Hospital NHS Foundation

P37

Trust, Kingston, UK Background: Morbid obesity is associated with hepatomegaly and non-

alcoholic steatohepatits (NASH) and has become one of the most common causes of cirrhosis. Most bariatric operations involve dissection around the hiatus and large fatty livers make retraction and visualization of this area difficult. Large heavy livers also tend to be friable and bleed easily. Pre-operative liver reduction diets are widely used before bariatric surgery but their clinical benefits are not clear. Methods: A systematic review of the literature was performed to investigate the effects of pre-operative diets on the liver size/volume as well as their effects on the early outcome after bariatric surgery.


Mid-term results with Band on Bypass (BOB) Procedure. A Safe and Effective Treatment for Weight Regain after RYGB Karthik Maruthachalam, Charlotte Harper, Luca Leuratti, Shafiq Javed, DD Kerrigan Phoenix Health, Liverpool, UK Background: Treatment of weight regain after RYGB using re-stapling has

disappointing results and a high complication rate. The BOB procedure (placing an adjustable gastric band around the mid-portion of the pouch) could offer a safer alternative -but does it work?

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P38

Body weight (kg after RYGB and BOB Revision 190

Does the use of a Pre-operative Dietetic-Led Specialist Lifestyle Management Programme Improve Outcome Post Gastric Band Surgery?

170

Adrian Brown1 , Jacob Matthews2 , Gemma Roberts2 , Jo Callaby2 , Miriam Cox2 , Ding Yang2 , George Watson2 , Raj Nijjar3 , Martin Richardson3 , Paul Super3 , Shahrad Taheri4

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130

1 Specialist Weight Management Services, Heart of England Foundation Trust, Birmingham, UK, 2 3rd Year Medical Students, University of Birmingham, Department of Medicine, Birmingham, UK, 3 Upper GI and Minimally Invasive

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Background: Predictors of weight loss following bariatric surgery have

Surgery Unit, Heart of England NHS Foundation Trust, Birmingham, UK, 4 Kings College London, Department of Medicine, London, UK attracted much attention as although the majority of patients successfully lose weight, some do not. Specialist Lifestyle Management (SLiM) is a dieteticallyled structured group education and self management programme run on a monthly basis for 6-months. This study investigated whether attending the SLiM programme prior to bariatric surgery was associated with greater postoperative body weight loss. Methods: A retrospective cohort study of 182 patients (mean age 45.2 ± 9.7 years, females [72%], mean BMI 53.1 ± 8.8 kg/m2 ) who underwent gastric band surgery between 2006–2012 was conducted. We examined whether the SLiM programmes improved post-operative weight loss outcomes compared to a control group who did not participate in SLiM (intervention = 41; control = 141). There was no significant difference between groups in sex, ethnicity and age. Results: SLiM produced a significantly greater weight loss at pre-op and 3months following surgery compared with control (14.9 kg vs. 5.9 kg, p = 0.0001; 24.4 kg vs. 16.5 kg, p = 0.0001 respectively). At 6 and 12-months, this became non-significant. Further analyses adjusted for age, sex, ethnicity and diabetes showed that SLiM was a predictor of weight loss and percentage excess weight loss at pre-op and 3 months (β = 0.4, p = 0.0001; β = 0.3, p = 0.0001 respectively), although again this became non-significant at 6 and 12 months. Age was an independent predictor of weight loss at 6 and 12 month percentage excess weight loss with younger patients losing more weight (β = −0.2, p = 0.02; β = −0.4, p = 0.03, respectively). Conclusion: SLiM prior to surgery helps patient to lose significantly greater body weight at pre-op and 3-months. The effect of SLiM post-surgery appears to be limited to the initial 3 months post-surgery. The major change between pre- and post-surgery was the greater frequency of pre-surgery contact, which has been shown to be influential on weight loss outcome. Thus further studies are required to assess the impact of similar patient contact following surgery.

90

70

50

Start weight

Nadir weight

Weight at BOB

Latest weight

% EWL after RYGB and BOB Revision

100 90 80 70 60 50 40 30 20

P39 10 Routine Vitamin A and E levels following bypass – Is it really necessary?

0

Start EWL

Nadir EWL

EWL at BOB

Cathy Edge, Rajesh Kumar Jain, Cathy Barrett, Omar Khan, Andrew Wan

Final EWL

St Georges Healthcare NHS Trust, London, UK Methods: Prospective data collection (weight, %EWL, complications) in

Background: It is widely accepted that after a Roux en Y Gastric Bypass,

patients with at least 9 months follow-up after BOB treatment following failed primary RYGB. Results: Eight patients with a mean follow-up of 20 months (range 7–39) were studied. Mean weight gain after RYGB was 20 kg (range 11–39). The only post-op complication was a case of SB obstruction (lassoed by the band tubing). There have been no band erosions or slippage to date. Conclusion: The BOB procedure appears safe and resulted in improved %EWL in 88% (7/8) patients treated. It should be considered as an option in those with a failed RYGB.

patients undergo regular blood tests including levels of fat soluble vitamins. This study looks at the necessity and efficacy of testing these vitamin levels as some literature posits that patients have a low frequency of deficiencies in Vitamin A and Vitamin E after a Gastric Bypass compared to more malabsorptive procedure such as a Distal Roux en Y Gastric Bypass and Duodenal Switch. There is also the cost implication of checking these levels which is an important factor. Methods: In our Institution, we routinely check Vitamin A and Vitamin E levels at 1 year post surgery. A total of 100 patients from the prospective database, who had undergone Roux en Y Gastric Bypass, had their blood test analysed for their Vitamin A and Vitamin E levels. All patients were on the recommended daily vitamin and mineral supplementation. Results: Of the 100 patients (M:33; F:67), Mean age was 43 yrs (range 23–69) and had a mean pre-operative BMI of 49 (range 36–68). 1 patient from this group had marginally low Vit A level of 0.94 umol/L (normal range


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0.99–3.35 umol/L) and none of these patients had Vit E deficiency at 1 year following the surgery. In our study, none of these patients were on added supplementation or required extra supplementation. Conclusion: This is a limited study however, as no baseline levels before surgery had been done. The non-weight loss surgery population often have vitamin deficiencies too but the results show that there is probably not a need for regular testing of Vitamin A and Vitamin E levels unless there are clinical indications to do so post Roux en Y Gastric Bypass surgery. There is also a monetary cost in doing these tests which as the results show is an unnecessary burden to the NHS.

Results: 112 patients who underwent a laparoscopic gastric bypass were

included in the sample (35 male : 77 female, median age 44 [range 18–73], median BMI 49.4 [range 36.5 - 75.0]). Complications were observed in 5 patients (4.5%), Clavien-Dindo Grades I - IIIb. 98 patients (87.5%) were discharged one day following surgery. The average inpatient stay was 1 day (range 1–6). Of the 14 patients with a greater than one day in-patient stay, 7 remained in hospital for social reasons and were deemed to be fit for discharge on day 1. Consequently, 105 patients (94%) were fit for discharge on day 1. No patient discharged on day 1 was subsequently readmitted. Conclusion: The majority of patients can safely be discharged one day following laparoscopic gastric bypass. Pre- and post-operative patient education helps to achieve this without affecting patient outcomes.

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The Modification of Eating Behaviour Prior to Bariatric Surgery Jacqueline Doyle, Rachel Batterham, Siri Steinmo

The need for a revisional or additional bariatric procedure after sleeve gastrectomy after 5 years follow up – systematic review

University Collge London Hospitals NHS Trust, London, UK Background: Maladaptive eating patterns (e.g. binge eating, ‘grazing’,

disinhibited and emotional eating) are common in patients presenting for bariatric surgery. The question of how pre-operative eating behaviour might impact on surgical outcomes is debated, with some researchers suggesting that disordered eating (DE) is a poor prognostic indicator of weight loss (WL) (Canetti et al., 2009) whilst others argue that it is post-operative, not preoperative eating behaviours that are significant (Wadden et al., 2011). Whilst the pre-operative DE/WL relationship is equivocal, the negative impact of pre-operative DE on psychosocial functioning, as well as post-operative eating is clearer (Busetto et al., 2005; Colles et al., 2007) suggesting there may be a role for pre-operative psychological intervention. Methods: Bariatric surgery patients were invited to attend a series Cognitive Behavioural Therapy workshops with the aim of modifying unhelpful eating patterns prior to bariatric surgery. A continuous improvement model was deployed and data from two phases of the programme are presented. Results: Patients were given a range of questionnaires pre and post workshops to measure depression, eating restraint, incidence of binge eating, regular eating, and eating in the absence of hunger. Changes to these key variables are presented from Phases 1 (n = 50) and 2 (n = 31) as well as a comparison of excess weight loss at one year in a selection of patients who had completed Phase 1 versus a non-treatment control group. Conclusions: The complexity of evaluating pre-operative psychological change and the significance of short term change and longer term outcome are discussed. This presentation aims to add to the debate about the role of psychology in this fast developing area.

P41 Managing Patient Expectations For Day One Discharge Following Laparoscopic Gastric Bypass Surgery Thomas Pike, Alan White, J Peter A Lodge

Dipankar Chattopadhyay, Rupa Sarkar, Venkatesh Kanakala, Norbert Schroeder, Shlok Balupuri, Kamal Mahawar, Peter Small City Hospitals Sunderland, Sunderland, UK Background: Laparoscopic sleeve gastrectomy was initially the first step

procedure followed by duodenal switch or Roux-en-Y gastric bypass for the superobese. Recently this procedure has gained increasing acceptance as a primary bariatric procedure for morbid obesity without the need for the second additional procedure. However, there is a concern of inadequate weight loss after five years of the procedure. Our aim was to perform systematic review to find out the need for a secondary bariatric procedure when sleeve gastrectomy failed to achieve adequate weight loss after five years of follow up. Methods: We searched pubmed and embase for English literature documenting the mid and long term outcome of sleeve gastrectomy and the need for revisional procedures. Search items included ‘‘sleeve gastrectomy’’, ‘‘5 years results of sleeve gastrectomy’’. The articles were screened for relevance. Results: Eight publications were found which recorded five year follow up data after laparoscopic sleeve gastretcomy including excess weight loss after 5 years and the need for additional bariatric procedures. A total of 325 patients were found in these studies. Five year follow up data was available in 302 (93%) of these patients and excess weight loss of more than 50% was noted. In 37 (11.4%) of these patients a revisional or additional bariatric procedure was required due to inadequate excess weight loss. The majority of additional procedures were either a gastric bypass or duodenal switch and were needed in the first two years. Conclusions: Available literature shows that laparoscopic sleeve gastrectomy achieves more that 50% weight loss in medium term follow up and a revisional or additional procedure is required in about 12% of cases. This suggests the efficacy of laparoscopic sleeve gastrectomy as an alternative bariatric procedure but in some the second stage procedure will still be needed.

Leeds Teaching Hospitals NHS Trust, Leeds, UK Background: Laparoscopic Roux-en-Y gastric bypass has advantages over

traditional open surgery including reduced post-operative pain and faster recovery times. Despite this, many patients still stay in hospital for several days following laparoscopic gastric bypass surgery due to concerns about potential sequelae. This study aims to evaluate the effectiveness of managing patient expectations for routine discharge one day after laparoscopic gastric bypass. Methods: All patients who underwent laparoscopic gastric bypass surgery, conducted by a single surgeon, were included in the study (May 2010 - Oct 2013). All patients were counselled pre-operatively that, barring complications, they would be discharged the following day. Providing physiological parameters, clinical examination and blood tests (serum C-Reactive Protein and Full Blood Count) were satisfactory, all patients were again counselled post-operatively regarding discharge on day one.


P43 Do we really need to close internal hernia spaces? Ahmed Ahmed1 , Thorrmela Vijayaseelan2 1 Imperial College London, London, UK, 2 St George’s Hospital, London, UK

Background: Internal hernia (IH) is a known complication after gastric

bypass. This study describes our experience with using an antecolic antegastric Roux limb without division of mesentery and without closure of IH defects and its effect on the incidence of IH. Method: A retrospective chart review was performed of all patients undergoing a standard antecolic antegastric technique without division of mesentery and without closure of IH spaces (AA-LRYGB) between January 2008 and June

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2010. Furthermore, a comparison was made in IH rates with a historical sample of retrocolic retrogastric LRYGB with mesenteric division and IH defect closure. Results: Two internal hernias occurred in 212 patients followed up for 25 months (13–35 months), an incidence of 0.9%.The site of internal hernia was at Petersen’s defect for one patient and at the jejuno-jejunostomy for the other. The mean time to intervention for an internal hernia repair was 355 days and average % excess body weight loss (%EBWL) in this period was 78%. The historical retrocolic retrogastric group with mesentery division and IH defect closure, had IH in 52 cases (23 transverse mesocolon, 22 jejunojejunostomy, 7 Petersen’s defect) out of 2215 patients, an incidence of 2.4%. Conclusion: The results of this study demonstrate that in our hands using an antecolic antegastric approach without division of small bowel mesentery and closure of IH spaces, the incidence of internal hernia is less than the incidence seen when we routinely closed all internal hernia defects in the retrocolic retrogastric LRYGB. One potential explanation for this rather paradoxical finding is that in the non mesentery division technique, large redundant spaces are created through which loops of small bowel may displace in and out without becoming stuck. In cases where IH defects are routinely closed, with weight loss, gaps in the mesentery may develop thereby trapping small bowel loops.

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P47 It’s helpful to use BIPG (Bariatric Inpatient Preparation Group) education session preoperatively Cleverly Fong, Alun Myers, Tamara Puplampu, Cecilia Jyamfi-Jones, Laura Carstairs, Yashwant Koak Homerton University Hospital Foundation Trust, London, UK Background: Preoperative education session for bariatric patients help to

increase patient’s awareness of changes in lifestyle required after surgery and the immediate inpatient recovery phase. Bariatric Inpatient Preparation Group (BIPG) is the last stage pre-operative education that is delivered by the Bariatric nurses, dietitians and physiotherapist. It’s not known if BIPG is helpful to the patients and a questionnaire survey was performed. Methods: A staff focus group and a patient questionnaire survey was devised to evaluate how effective is the bariatric service at our unit in preparing patients at the point of BIPG. The objectives were to answer these questions: 1. Has the content delivered in BIPG enhanced patient experience? 2. Did BIPG have any impact on the length of stay after surgery? 3. Was BIPG delivered timely for patients and staff? Results: 42 questionnaires consisting of 28 questions were collected from Oct

P46 Long-term Consequences of Gastric Bypass Surgery: A Qualitative Exploration Sheila Bonas1 , Nicola Buccheri1 , Sukhbir Ubhi2 , Rachel Kemp3 1 University of Leicester, Leicester, UK, 2 Leicester Partnership NHS Trust, Leicester, UK, 3 University Hospitals of Leciester NHS Trust, Leicester, UK

Background: A vital part of the adjustment process after having Gastric

Bypass Surgery (GBS) involves patients addressing their eating patterns. This often requires patients to make significant and drastic changes to their diet. The aims of this research were to explore the long-term impact of GBS on patients’ relationship with food and to investigate how they coped with these changes in the years that followed. Methods: The qualitative methodology of Grounded Theory was utilised to collect and analyse the data. The sample consisted of 17 participants (15 females, 2 men) who had undergone GBS three or more years (mean = 55 months, range = 36 to 96 months) prior to the research interview. Results: A core category titled ‘‘The Battle for Control’’ emerged from the data. The degree to which a participant developed self-control after surgery was conceptualised as falling somewhere on a continuum of two polar extremes, ranging from ‘‘developing self-control’’ to ‘‘continuing the battle for control’’. Furthermore, a proposed theoretical model suggested a number of factors that had an impact on the participants’ sense of control after surgery. These included the degree to which food was used to self-soothe, the perception of having a food addiction, the extent to which participants had been able to work through and make sense of their food issues, and also their level of knowledge about GBS. Other factors included the ability to self-monitor, awareness of bodily cues, readdressing lifestyle balance and engaging with support. Issues related to body image, loose skin and shame were also prominent features of the participants’ accounts. Conclusion: A number of clinical recommendations were made. These included patients having more access to corrective surgery to address loose skin, psycho-education pre-surgery to elicit realistic expectations, support in developing awareness of internal cues and skills in self-monitoring (e.g. through mindfulness), as well as, psychological therapy to help them work through food issues and find alternative ways to self-soothe. It was also felt that encouraging patients to enhance self-compassion and move away concepts such as ‘‘dieting’’, would empower them to cope with set-backs. It was felt that psychologists have much to offer in working alongside surgical teams in supporting this patient group.


2013 to Nov 2013. 96.5% patients felt the session prepared them for surgery; 93% felt this session prepared them timely; 96.5% felt they had enough time to learn about the nursing, diet and physiotherapy perspectives in the session; 97.6% felt they were made aware of what to expect before and after surgery from the session, as well as getting questions answered that they wish to ask before surgery. Patients liked the session being informative, well delivered by the specialists and had their questions answered. Comments and suggestions by the patients and staff were acted upon. The average length of stay was improved from 4.6 days to 3.6 days since BIPG was implemented in Feb 2011. Conclusion: BIPG is a unique opportunity to engage patients around 6–8 weeks before their surgery using a multidisciplinary approach. It was informative for the patients, well received and delivered timely for patients and staff. The average length of stay was improved from 4.6 days to 3.6 days since BIPG was implemented in Feb 2011. BIPG was helpful in educating pre-operative bariatric surgery patients.

P48 Validation of the NEWS Score in a pilot group of Bariatric patients. Preliminary study Rosa Santa Cruz, Andrea Blay, Rhian Bull, Panagiotis Georgiou, Evangelos Efthymiou, Gianluca Bonanomi Department of Surgery, Bariatric Unit, Chelsea and Westminster Hospital, UK Background: The Royal College of Physicians (2012) recommended the

implementation of a National Early Warning Score (NEWS) across the NHS. The NEWS score has mainly been evaluated in acute medical assessment units for the first 24 hours of admission only. The aim of this pilot study was to attempt to validate the NEWS score in a population of bariatric patients from admission to discharge, and to identify other physiological important variables that might improve the detection of early postoperative complications in this group of patients. The validation of the score for all surgical sub-specialities in the post-operative period is vital to improve prognostics and have confidence that the NEWS detects deterioration at the early stage of critical illness. Methods: The admission NEWS score (range between 1–2), and baseline blood pressure of all bariatric patients admitted to our Surgical Department between 7th October and 14th November 2013 were recorded. The highest and lowest NEWS score were recorded on discharge from the recovery and throughout the post-operative stay until discharge. Other variables collected were any drop in the systolic blood pressure > 30 mmHg below the baseline. Demographics included comorbidities and BMI. The type of surgical procedure, post-operative oxygen use, length of stay, complications and outcomes were evaluated.

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Results: A total number of 38 patients were admitted to the Bariatric Unit

Conclusion: Breast related problems are common in the bariatric population.

from the start to the end point; of those 25 were eligible for the study, of whom 3 were emergency admissions with a previous history of bariatric surgery. All patients were given oxygen in the post-operative area the NEWS does not differentiate between 2L and 60% oxygen. The Highest NEWS Score recorded during recovery was 11 and the most common NEWS Score at discharge was 0. Out of the 25 patients, 10 experienced a significant drop in blood pressure which was not detected by the NEWS Score. Two patients experienced bleeding and re-operation occurred in one patient. In one patient who was bleeding the NEWS did not detect deterioration. Conclusion: In this study group there was some standardisation of the physiological results. The preliminary results show that the NEWS score could be improved to include a drop in blood pressure below the baseline to enable early recognition of deterioration and appropriate clinical management. Oxygen therapy masks the true value of the NEWS.

The current commercial methods of bra fitting lack the consistency and fall short of addressing recurring difficulties this specific group of patients face. We recommend that professional bra fitting be provided in the bariatric MDT to help reduce the problems these women have. The use of 3-d measurements to assess bra fit and conducting comparative studies of different methods of bra measurement and designs is needed to unveil more robust solutions.

P50 Intragastric balloons – time for early removal? Anna Kamocka, Mathew Dunstan, Natasha Smith, Michelle Tipping, Shashidhar Irukulla, Samer Humadi Ashford and St Peter’s Hospitals NHS Foundation Trust, Chertsey, Surrey, UK

P49

Background: Intragastric balloons (IGB) are a useful temporary tool

Should the breast fit the bra, or the bra fit the breast? An analysis of bra fit in a bariatric group Omar Tillo, Atul Khanna Sandwell & West Birmingham Hospitals NHS Trust, Birmingham, UK Background: Studies have suggested that ill-fitting bras exaggerate symptoms

related to breast volume. The evidence shows that most patients seeking breast reduction surgery wear wrongly fitted bras and the higher their BMI, the larger the discrepancy is between the recommended and worn sizes. In this study the experience of a group of bariatric patients was explored and elements of some problems analyzed. Methods: Bariatric support groups were approached and a survey with breast measurements was conducted. Data collected about age, bra size, bariatric and breast surgery, symptoms, and patients’ experience with bra fitting. Recommended bra sizes were calculated using traditional and Optifit methods, bra manufacturing data were used to calculate the dimensions and proportions of commercially available bras. Results: Twenty four participants answered the survey and 21 were measured. Over 70% of the participants reported one or more symptoms related to breast volume or ill-fitted bra ranging from infra mammary skin rash (50%), shoulder pain (42%) and neck pain (29%). Post bariatric participants were more likely to consider or have had breast surgery than the pre-bariatric (p < 0.04, Chisquare test). Physical symptoms were the most likely reason for surgery in both groups. If offered well supporting bra to solve their symptoms, those considering breast surgery are more likely to change their minds in the pre-bariatric group compared to the post-bariatric one (P < 0.04, Chi-square test). None of the participants were offered professional bra fitting as part of the bariatric multi disciplinary service. 65% of participants had at least one professional bra fitting in the past. Inconsistency in sizes for the same brands and shops were experienced by 71%, and between different brands or shops by 92% of them. When buying bras, comfort was most important than look and fashion with an average score of 9.7 compared to 5.1 out of 10. Participants reported common patterns of problems with bra designs such as too narrow straps and sliding of the lower edge of bra (bra slide). When measured for bra fitting all participants were found to wear wrong fitting bras. 83% of them wore bands that were too tight with an average of 2 sizes smaller than the calculated one (p-value < 0.002, Wilcoxon Signed-Rank Test). They also tended to wear cups that were 2 sizes smaller than their calculated (p-value < 0.003, Wilcoxon Signed-Rank Test).


facilitating weight loss. They are utilised in our Bariatric Unit in a selected super obese population and removed after 6 months, prior to definitive bariatric surgery. The aim of this study was to investigate the peak weight loss and plateau phenomenon with IGBs and to determine whether there is a case for earlier removal and surgical intervention. Methods: This single centre retrospective pilot study examined patients who had IGBs inserted between May 2010 and November 2013. After ensuring that no GI contraindications existed, Orbera IGBs were inserted by two Bariatric Consultant Surgeons using the same endoscopic technique. IGBs were inflated with a volume of 600–700 mls. All patients had their IGBs removed by the time of the study. Demographic data and patients’ weight, BMI and Excess Body Weight (EBW) were recorded on the day of IGB insertion. Patients were then monitored by the Bariatric Dietician and/or by a Bariatric Surgeon in the Outpatients Department with follow-up after 2 and 4 months. Weight, BMI, EBW and Excess Weight Loss (EWL) were calculated at each follow up, and on the day of balloon removal. The Wilcoxon test was used for statistical analysis. Results: Twenty-six patients were recruited into the study. Seven patients, who required early IGB removal due to excessive vomiting, were excluded from the analysis. No major complications were observed. Nineteen patients (12 female, 7 male) aged 22–57 (median 44) with a mean BMI of 60.6 (46.8 - 77.8) and an EBW of 101 kg (66-148 kg) were analysed. The mean length of the IGB treatment was 206 days (178–245) with an EWL of 20.4% (2.6-41.9%). Patients were stratified into three time periods for analysis: P1: insertion to the first follow-up (mean 54 days), P2: first to the second follow-up (mean 69 days) and P3: second follow up to removal (mean 83 days). In P1 the mean EWL was 12.3%, with a further EWL of 4.6% during P2. A subsequent 3.6% EWL was observed during P3. Three patients gained weight during P2 (up to 2.2% of EBW) and 4 patients gained weight during P3 (up to 3.6% of EBW). A statistically significant difference in the EWL between P1 and P2 was demonstrated (p = 0.00097) with no significant difference between P2 and P3. Eighty-nine percent of these patients underwent further definitive surgery in the form of a laparoscopic sleeve gastrectomy or a laparoscopic Roux-en-Y gastric bypass. Conclusion: This small pilot study suggests that maximum weight loss occurs within the first two months following IGB insertion. The majority of patients demonstrated a trend towards weight plateau or increase during the subsequent months. To optimise patient outcomes, we recommend that in cases in which sustained weight loss is not observed, IGB removal should be expedited prior to the recommended 6 months. A larger sample is currently being recruited into the study.

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Abstracts of the 6th Annual Scientific Meeting of the British Obesity & Metabolic Surgery Society (BOMSS), 22-23 January 2015, Newcastle, UK.

British Paediatric Neurology Association Abstracts of the 2014 Annual Meeting, 29-31 January 2014, Winchester, UK.

Abstracts of the XXXII Annual Scientific Meeting of the British Blood Transfusion Society, 24-26 September 2014, North Yorkshire, UK.

Abstracts of the 54th Annual Scientific Meeting of the British Society for Haematology, 28-30 April 2014, Birmingham, UK.

Proceedings of the British Pharmacological Society Meeting. 3rd-5th January 1990. Abstracts.

British society of breast radiology annual scientific meeting 2014.

Abstracts of the 55th Annual Scientific Meeting of the British Society for Haematology, 20-22 April 2015, Edinburgh, UK.

Abstracts of the British Psychosocial Oncology Society, 2014 Annual Conference, 27 - 28 February 2014, Preston, UK.

Abstracts of the British Society of Breast Radiology Annual Scientific Meeting, 10-12 November, 2013, Liverpool, UK.

Abstracts of the British Society of Gastroenterology Annual General Meeting. June 16-19, 2014.

Irish thoracic society annual scientific meeting 2014.

Abstracts from the Society of Academic and Research Surgery (SARS) Annual Meeting, 8-9 January 2014, Cambridge, England.

Abstracts of the AAGBI GAT Annual Scientific Meeting, 11-13 June 2014, Newcastle, UK.

Abstracts of the British Society for Immunology Annual Congress, 1-4 December 2014, Brighton, UK.

31st annual meeting of the British Association of Cancer Research and the 5th annual meeting of the Association of Cancer Physicians. 19-22 March 1990, Sussex, UK. Abstracts.

Germline & somatic mosaicism: the 2014 annual scientific meeting of the Human Genome Variation Society.

2016 Canadian Society of Surgical Oncology Annual Scientific Meeting Abstracts.

2017 Canadian Society of Surgical Oncology Annual Scientific Meeting Abstracts

Abstracts of the SICB 2014 Annual Meeting, January 3−7, 2014, Austin, TX.

British Society of Breast Radiology Annual Scientific Meeting 2015.

Abstracts of the XXXI Annual Scientific Meeting of the British Blood Transfusion Society. October 16-18, 2013. Birmingham, United Kingdom.

Abstracts of the 2014 SGI 61st Annual Scientific Meeting, March 26-29, 2014, Florence Italy.

Abstracts of the 17th Annual SCMR Scientific Sessions, 16-19 January 2014 New Orleans, LA, USA.

Abstracts of the 2014 NATA Annual Meeting & Clinical Symposia, June 26-28, 2014, Indianapolis, Indiana.