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British Obesity and Metabolic Surgery Society Annual Scientific Conference
Obesity Surgery (2019) 29 (Suppl 1):S1S29
S2 OBES SURG (2019) 29 (Suppl 1):S1S29
Abstracts of the 10th BOMSS Annual Scientific Meeting
Oral Presentations
Session 9: Council Prize Session
Friday 25 January 2019
Bariatric surgery for severe type 2 diabetes really a lost cause?
Emma Rose McGlone
, Iain Carey
, Catherine Leonard
, Vladica
, Carel Le Roux
, Rachel Batterham
, Peter Small
Omar Khan
Imperial College, London, United Kingdom;
St George's University, London,
United Kingdom;
Medtronic Ltd, Watford, United Kingdom;
University for
Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria;
University College, Dublin, Ireland;
University College, London, United
NBSR, London, United Kingdom;
Sunderland Royal Hospital,
Sunderland, United Kingdom;
St George's Hospital, London, United Kingdom
Background: Although bariatric surgery is now well established as an
effective treatment for type 2 diabetes (T2D), there appears to be a nihil-
istic attitude towards the management of patients with severe, poorly
controlled T2D amongst some clinicians and commissioners. We have
examined the impact of bariatric surgery on diabetes resolution in patients
with severe (i.e. insulin-dependent) T2D (IDT2DM) using data from a
national database and utilised a health economic model to evaluate the
effectiveness of surgery compared to optimal medical management.
Method: The UK National Bariatric Registry (NBSR) was interrogated to
identify patients with ID2DM who underwent primary bariatric surgery be-
tween January 2009 and May 2017. The demographic, peri-operative, and
post-operative outcomes were collected and analysed. Based on NBSR data,
a model-based economic evaluation was developed to estimate incremental
cost-effectiveness of bariatric surgery versus optimal medical management
(as determined by an expert consensus panel). The model was developed as a
patient level state-transition simulation, and all cost and outcomes were eval-
uated using NHS tariff costings and with a time horizon of five years.
Results: 1878 patients were identified: 142 underwent adjustable gastric
bands (AGB), 400 sleeve gastrectomy (SG) and 1336 Roux-en-Y gastric
bypass (RYGB). Mean pre-operative BMI was 47.1.
One year following surgery, outcomes were as follows:
Compared to optimal medical treatment, surgery was associated with
a total direct medical cost savings of £2,110 per patient over 5-years,
comprising lower treatment costs (incremental difference of £2171
per patient), reduced diabetes-related complications costs (£132 per
patient) but higher treatment-associated adverse events costs (-£192 per
Conclusion: SG and RYGB (but not AGB) are associated with a high
incidence of post-operative diabetes resolution and cessation of insulin
therapy. Performing bariatric surgery in patients with IDT2DM leads to
total direct medical cost savings of £2,110 per patient over a 5-year time
Enhanced Recovery After Bariatric Surgery(ERABS): Analysis Of
Outcomes from a Tertiary Referral Centre
Md Tanveer Adil, Irene Fitt, Rosie McGrandles, Thomas Chapman, Jane
Rix, Aruna Munasinghe, Farhan Rashid, Vigyan Jain, Periyathambi
Jambulingam, Douglas Whitelaw, Omer Al-taan
Luton and Dunstable University Hospital, Luton, Bedfordshire, United Kingdom
Background: Obesity is a growing problem affecting one in four adults in the
United Kingdom. Bariatric surgery is the most effective treatment for morbid
obesity, however, it incurs the highest upfront cost and an estimated average
hospital bed cost of £400 per day. There is a need to develop a gold standard of
care to reduce the length of stay(LOS) after bariatric surgery, reduce the risk of
complications, improve patient outcome and increase access to bariatric surgery.
Method: Published literature was used to create a local ERABS protocol.
A multidisciplinary team was created which included pharmacy, pain man-
agement, nursing roles, dieticians, anaesthetists and surgeons. All patients
undergoing gastric bypass(LRYGB) and sleeve gastrectomy(LSG) between
1/4/17 and 31/3/18 were included. All those patients followed the ERABS
program (encompassing full patient journey from education and managing
expectations). The aim of the study was to assess if ERABS can reduce the
LOS and examine reasons for delays in discharge. LOS was the primary
endpoint measure and readmission rates was the secondary endpoint.
Results: 71%(188/267) patients with LRYGB and 64%(120/187) with
LSG were discharged within 24 hours of surgery with a median LOS of 1
day(IQR=1-2). This was an improvement from median LOS of 2
days(IQR=2-3) in 2015. Factors identified for this improvement were
standardisation of surgical technique, elimination of unnecessary use of
drains, catheters and HDU beds, reduced use of opioids, switch to
buprenorphine patches, standardised antiemetic guidelines and criteria-
led discharge. Readmission rate reduced from 1% in 2015 to 0.8% in
2018(P=0.7). Patient turnover increased from 198 in 2015 to 458 in 2018.
Conclusion: Implementation of an ERABS program using an evidence-
based approach improves patient care without an increase in postoperative
complications as evidenced by our reduction in readmission rate. This facil-
itates an increase in patient turnover and reduces the pressure on hospital
beds enabling increased patient access to bariatric surgery at reduced costs.
Quality of life after bariatric surgery in the modern era: preliminary
results from the By-Band-Sleeve study
Richard Welbourn
, James Byrne
, Graziella
, Eleanor Gidman
On behalf of the By-Band-Sleeve study investigators, United Kingdom;
Musgrove Park Hospital, Taunton, United Kingdom;
General Hospital, Southampton, United Kingdom;
University of
Bristol, Bristol, United Kingdom
Mean BMI (SD) 39.4 (6.5) 36.6 (7.6) 32 (8.9)
T2D resolution (%) 9 (6.3) 120 (30) 501 (37.5)
OBES SURG (2019) 29 (Suppl 1):S1S29 S3
Background: Severe and complex obesity is associated with develop-
ment of serious co-morbidities and increased mortality. It is also associ-
ated with psychological distress and social stigma, both of which impact
on quality of life (QoL). Few studies have comprehensive QoL assess-
ment and follow up. This study examines generic and symptom-specific
aspects of QoL in patients undergoing bariatric surgery up to 3 years.
Method: By-Band-Sleeve is a multicentre RCT comparing gastric by-
pass, gastric banding and sleeve gastrectomy. The target sample size is
1341 participants. The primary outcomes are weight and QoL at 3 years.
Generic and symptom-specific QoL is collected at 6 months, 1-year, 2-
years and 3-years after randomisation, using the EQ-5D-5L (co-primary
outcome), SF-12 health survey, IWQOL-Lite (Impact of Weight on
Quality of Life), GIQLI (Gastrointestinal Quality of Life Index), and
HADS (Hospital Anxiety and Depression Scale). Means and standard
deviations (SD) are presented for the whole group. Except for HADS,
higher scores depict better QoL.
Results: At October 2018, 1118 patients were recruited, and 200 had
reached 3-years. Response rates for the EQ-5D-5L were >99% at baseline
and 84% at 3-years.
EQ-5D-5L utility scores improved from a mean of 0.61 (SD 0.28) at
baseline to 0.70 (0.31) at 3 years. SF-12 physical health followed a similar
trend, but there was little change in the mental health component. The
IWQOL overall score improved from 41.8 (21.2) at baseline to 73.8
(24.4) at 3-years and the GIQLI rose from 86.1 (16.8) at baseline to
98.5 (16.2) at 3-years. Anxiety and depression was also reduced at 3-
Conclusion: Across all measures quality of life has improved over the 3-
years the participants have been in the trial.
Patient Perspectives: An Evaluative Account of the Dietetic
Education Programme in a Surgical Weight Management Tier 3
David Hopson, Neil Scothern, Helen Bellamy, Susan Bird, Kelly
Harland-McBeth, Lindsay Wooton, Tracy Webb
City Hospital Sunderland Foundation Trust, Sunderland, United
Background: The integration of Tier 3 services to assess, educate and
support pre-surgical bariatric patients has led many to question its effica-
cy. In theory, the provision of dietary and lifestyle education in prepara-
tion for Bariatric surgery ought to positively influence long term out-
comes for patients, for whom weight loss and weight loss maintenance
are essential goals. Evaluating the patients' experience of the dietetic
education programme is important to establish the perceived benefit of
the service to patients. Assessing practice is vital to progressively improve
services and to determine if there is sufficient support for patients in the
Tier 3 pathway.
Method: Pre-surgical patients completed an evaluation questionnaire on
the conclusion of four dietary and lifestyle education groups. Patients
rated specific aspects of four groups which were captured via a Likert
Scale, using a scale of 0 (poor) to 10 (excellent). The perceived level of
motivation and lifestyle changes influenced by the dietetic programme
(none to many) were also recorded. Questionnaires included no identifi-
able information for consenting participants. Emphasis was specifically
placed on questions relating to educational content, information re-
sources, learning environment, programme delivery and the level of die-
tetic support in the Tier 3 pathway.
Results: Of 635 questionnaires collated (July 2017 to November 2018),
554 viable responses were included in the evaluation. 539 (97%) patients
rated the educational content from 8-10 and 549 (99%) recorded handout
information resources as helpful. 503 (91%) indicated increased motiva-
tion to change and 550 (99%) reported positive lifestyle changes. 418
(75%) considered group members supported their learning. 537 (97%)
rated the education delivery by the dietetic team from 8-10. 297 (54%)
requested additional dietetic support before/after groups. 164 (30%) pa-
tients requested more than four groups and 390 (70%) stated four groups
adequately supported their learning experience.
Conclusion: The outcome of the evaluation evidenced how pre-surgical
bariatric patients found the dietetic education programme beneficial.
There is a perceived positive influence on behavioural changes from
attendingdietary and lifestyle education groups. Patients indicated a pref-
erence for increased dietetic support at interim stages in the Tier 3 path-
way. Increasing the number of educational groups may further support
patients. In future research projects, it may be beneficial to determine the
level of dietary knowledge learned from dietetic education. Longitudinal
research should be considered to compare post-operative outcomes for
patients whom underwent Tier 3 and those prior to its implementation.
Long term outcomes after bariatric surgery (5 and 10 years data)
analysed using Bariatric Analysis and Reporting Outcome System
Md Tanveer Adil
,Sonal Halai
, Charlotte Taylor
Catherine Chapple
, Eleonora Gkigkelou
, Aruna Munasinghe
, Periyathambi Jambulingam
, Douglas Whitelaw
Omer Al-taan
Luton and Dunstable University Hospital, Luton, Bedfordshire, United
University College London, London, United Kingdom
Background: Bariatric surgery has gained worldwide acceptance as the
most effective therapy for morbid obesity and obesity related comorbid-
ities. Existing data shows excellent weight loss within 3 years of a bar-
iatric procedure with variable degrees of weight regain on the long term.
Quality of life(QoL) is known to improve after a bariatric procedure in
short term but data on its long term effects are inadequate. The aim of the
study is to evaluate the effect on weight loss and QoL5 years and 10 years
after bariatric surgery.
Method: All patients who underwent bariatric surgery in 2008 and
2013 were included for the 10-year and 5-year analysis respec-
tively. Patients with incomplete data, who could not be contacted
or refused to participate were excluded. Homogeneity in baseline
characteristics was assessed using Levenes test and Chi
test for
comparability. Primary outcome measure was long-term Quality of
Life(LT-QoL) graded according to Moorehead-Ardelt Quality-of-
life Questionnaire II. Secondary outcome measure was %Excess
Weight Loss(EWL). The groups were compared using a regression
model or general linear model depending on the distribution of
variables in the dataset.
Results: The 5-year(63 patients) and 10-year(63 patients) groups
were homogeneously matched with respect to baseline character-
istics, type of surgery and comorbidities. LT-QoL was similar
between the 2 groups[F(1,124)=0.773;P=0.381]. Age(P=0.001),
EWL(P=0.002), minor complications(P=0.007), residual
arthritis(P=0.029) and hyperlipidemia(P=0.022) showed positive
correlation with LT-QoL. Mean(SD) of EWL did not differ be-
tween the 5-year[48.3(27.3)] and 10-year[46.1(33.2)] follow-up
groups[F(1,124)=0.172;P=0.679]. Patients who had gastric bypass
showed higher EWL compared to sleeve gastrectomy(P=0.009).
Major complications, re-intervention, diabetes, hypertension and
OSA showed no correlation with EWL or LT-QoL.
Conclusion: EWL achieved in the first 5 years of bariatric surgery
seems maintained on the 10 years follow up. There is no signif-
icant difference in LT-QoL after 5 years and 10 years of bariatric
surgery. The choice of surgery predicts EWL in long term but this
does not impact on LT-QoL experienced by the patient. EWL
achieved by patients shows positive correlation with better LT-
QoL. Minor complications that are difficult to treat impacts neg-
atively on LT-QoL but major complications needing re-
intervention shows no correlation with LT-QoL.
S4 OBES SURG (2019) 29 (Suppl 1):S1S29
Session 5: Free Paper Session Surgical & IHP
Thursday 24 January 2019
Visceral adipose tissue loss is maintained despite weight regain 5
years after adolescent Roux-en-Y gastric bypass
Andrew J. Beamish
, Olivia H. Dengel
, Elise F. Northrop
, Eva
, Aaron Kelly
, Torsten
, Justin Ryder
Sahlgrenska University Hospital, Gothenburg, Sweden;
Royal College
of Surgeons of England, London, United Kingdom;
Welsh Institute of
Metabolic and Obesity Surgery, Swansea, United Kingdom;
of Minnesota, Minnesota, USA
Background: Visceral adiposity is associated with a wide range of met-
abolic complications including type 2 diabetes and dyslipidaemia.
Laparoscopic Roux-en-Y gastric bypass (LRYGB) leads to marked re-
duction in adiposity, yet little is known about its effect on specific adi-
posity depots in the short and medium term. No previous study has re-
ported measures of visceral adipose tissue (VAT) and their relation to
cardiometabolic health after bariatric surgery in the adolescent.
Method: Fifty-nine adolescents (18 males; mean age 16.3years; mean
BMI 43.3kg/m
) undergoing LRYGB for severe obesity underwent
prospective dual x-ray absorptiometry (DXA) body composition anal-
ysis preoperatively and at baseline, 1- and 5-year follow up. A validat-
ed algorithm was manually applied to original DXA scans to calculate
the DXA VAT content. The association of adiposity depots with
markers of cardiometabolic health risk (ALT, HbA1c, fasting plasma
insulin, LDL, HDL, triglycerides, hsCRP, systolic and diastolic BP)
was assessed using Spearmans correlation coefficient and regression
Results: Mean BMI decreased from 43.3 to 30.0kg/m
at 1year, rising to
at 5years. Mean VAT decreased across 1year (1.9-0.6kg), re-
maining stable to 5years (0.7kg, p=0.103). Meanwhile, regain was ob-
served in BMI (mean difference 1.6kg/m
p=0.013), total (4.5kg,
p=0.004), gynoid (1.1kg, p<0.001), android (0.5kg, p=0.013) and subcu-
taneous fat mass (4.6kg, p=0.007) between 1 and 5 years. Baseline VAT
correlated with markers of hepatic (ALT, p= 0.02), glycaemic (fpInsulin,
p=0.042), and cardiovascular (systolic BP, p=0.003) risk. Absolute VAT
change correlated with fpInsulin (p=0.027) and triglyceride (p=0.034)
change. Following adjustment for age, sex, and baseline value, only total
fat mass change was associated with any cardiometabolic health marker
change (LDL p=0.042).
Conclusion: VAT decreased markedly in thefirst year following LRYGB
in adolescents and was a novel and useful additional marker of current
and potential postoperative cardiometabolic health. Unlike other adipos-
ity depots and measures, the reduction in VAT was well maintained to 5
years despite net weight regain.
Patientsexperiences and needs for longer term follow up care after
bariatric surgery: a rapid review and qualitative synthesis
Helen Parretti
, Carly Hughes
, Laura Jones
University of Birmingham, Birmingham, West Midlands, United
Fakenham Weight Managaement Services, Fakenham,
Norfolk, United Kingdom;
University of East Anglia, Norwich,
Norfolk, United Kingdom
Background: Current guidance in the USA, Europe and UK recommend
long term routine metabolic and nutritional monitoring for all patients
who have had bariatric surgery as well as an annual clinical review.
Initial post-operative care is at the surgical unit, but longer term care
may transfer to medical specialist units and/or primary care. However,
attendance can be low and failure to attend is associated with poorer
clinical outcomes. Understanding patientsexperiences and needs is cen-
tral to the delivery of effective care.
Method: This rapid review has synthesised the current qualitative litera-
ture on patient experiences of healthcare professional (HCP) led follow-
up from 12 months after bariatric surgery. Data extraction, critical ap-
praisal, and qualitative synthesis were in line with established systematic
review and qualitative synthesis methods. The thematic synthesis ap-
proach proposed by Thomas and Harden was used.
Results: Synthesis of data from 20 studies highlighted the range of prob-
lems experienced after bariatric surgery and patientsdesire for knowl-
edgeable HCP support. A recurring theme was the need for more and
extended follow-up care, particularly an increased psychological compo-
nent and specific support to address weight regain. Enablers to attending
follow-up care were patient self-efficacy as well as HCP factors such as a
non-judgmental attitude, knowledge and continuity of care. Barriers in-
cluded unrealistic patient expectations and perceived lack of HCP exper-
tise. Some preferences were expressed including patient initiated access
to HCPs and more information pre-operatively about potential post-
surgery issues.
Conclusion: This review has highlighted the complexity and continuing
medical, nutritional and psychological needs of patients post-bariatric
surgery. We have identified barriers and enablers to attendance as well
as preferences regarding components of longer term follow-up care after
bariatric surgery. The findings of this review suggest that from the patient
perspective there is a need for continued support from knowledgeable
HCPs beyond two years post-surgery for a variety of issues that patients
can find themselves contending with in the longer term. Given the range
of potential issues it is likely that an array of services and types of support
are needed.
Regional variation in unmet need for bariatric surgery in England
Andrew Currie
, Richard Newton
, Lorraine Albon
, Will
, Guy Slater
, Chris Pring
Department of Bariatric & Metabolic Surgery, St Richard's Hospital,
Chichester, United Kingdom;
Department of Upper Gastrointestinal
Surgery, Watford General Hospital, Watford, United Kingdom
Background: Bariatric surgery has level 1 evidence for the resolution of
comorbidities associated with obesity. The UK National Institute for
Health and Clinical Excellence criteria for eligibility are those with body
mass index (BMI) 3540kg/m
with at least one comorbidity potentially
improved bylosing weight or a BMI >40kg/m
, with a recent extension to
include patients with BMI 30-35kg/m
with diabetes. This study aimed to
evaluate the eligible population and the unmet need for bariatric surgery
within English regions.
Method: Data from adult respondents (>18 years) to the 2010 Health
Survey for England(HSE) (n=6584) and ONS population estimates were
used to estimate the bariatric surgery eligible population by English re-
gion. NHS Digital data was examined to calculate the volume of bariatric
surgery procedures by region (2017). Additionally, regression analysis
was used to examine for factors associated with bariatric surgery eligibil-
ity. Unmet need was calculated using the potentially eligible population
against the operative procedure volume by region.
Results: 7.2% of the English population is potentially eligible for the
recent extended NICE criteria for bariatric surgery after accounting for
survey weights. 5.4% were eligible according to the established guidance,
with an additional 1.8% eligibility in patients with diabetes and BMI30-
. Eligibility varied by region from 5.0-12.1%. From the HSE
analysis, the bariatric surgery eligible population was more likely to be
female, older, havefewer educational qualifications and have higher dep-
rivation. The overall percentage of potentially eligible English population
OBES SURG (2019) 29 (Suppl 1):S1S29 S5
receiving bariatric surgery is 0.25%, with regional variation of 0.08% to
Conclusion: Despite over 7% of the English population (3.13 million)
being potentially eligible for bariatric and metabolic surgery, only a very
small percentage of this eligible population receive metabolic surgery.
There is a pressing need to explore potential disparities in access nation-
The impact of weight reduction surgery on liver enzymes in biopsy
confirmed cases of non-alcoholic fatty liver disease
Jessica Bennett, Abdalla Mustafa, Kamal Mahawar, Neil Jennings,
Norbert Schroeder, William Carr, Peter Small, Shlok Balupuri
City Hospitals Sunderland NHS Foundation Trust, Sunderland, United
Background: Non-alcoholic fatty liver disease (NAFLD) is a spectrum
ranging from benign steatosis to steatohepatitis (NASH), the latter of which
can progress to fibrosis, cirrhosis and subsequent predisposition to hepato-
cellular carcinoma. NAFLD is estimated to affect more than 67% of over-
weight patients (BMI > 25) and 94% of obese patients (BMI > 30).
Metabolic syndrome and obesity are major risk factors for NAFLD and
therefore weight reduction surgery has proven to be a key tool in the treat-
ment of NAFLD. So far, there is no evidence to guide which bariatric pro-
cedure provides NAFLD patients with the greatest benefit and least harm.
Method: Bariatric patients in whom there was an intraoperative visual
suspicion of NAFLD had prospective 16 gauge Trucut liver biopsy taken
from the left lobe of the liver. The cohort consisted of 22 patients, with
histologically confirmed NAFLD, who underwent either laparoscopic
Roux-en-Y gastric bypass (RYGB), one anastomosis gastric bypass
(OAGB) or laparoscopic sleeve gastrectomy (LSG) between December
2012 and April 2017. These comprised 10 cases of Steatosis, 5 of
Steatohepatosis, 5 of Fibrosis and 2 of Cirrhosis. The patients pre-
operative Alanine Aminotransferase (ALT) levels were then compared
with their ALT results at post-operative follow up (mean 12.4 months).
Results: The mean pre-operative BMI was 45.7 compared to 34.4 post-
operatively, a mean reduction of 24%. The overall mean pre-operative
ALT was 54.7 versus 21.7 post-operatively, a 43% reduction. Patients
with steatosis had a mean reduction of 47% in their ALT whereas those
with steatoheapatosis had a mean reduction in ALT of 50%. This com-
pared to a 28% reduction in ALT for fibrosis patients and a 45% reduction
in patients with cirrhosis. RYGB patients had a greater reduction in ALT
(50%) than OAGB patients (42%) who in turn had a greater reduction in
ALT than those undergoing LSG (25%).
Conclusion: The percentage reduction in BMI positively correlates with
the percentage reduction in ALT, suggesting that weight loss surgery is
beneficial to those with NAFLD. Malabsorptive weight loss procedures lead
to a greater improvement in liver enzymes in biopsy proven NAFLD than
restrictive procedures. In all NAFLD patients, irrespective of progression of
disease, post weight loss surgery ALT improvement suggests improvement
in liver status in keeping with the overall metabolic improvement.
Influence of pre-operative HbA1c on bariatric patient outcomes a
single institutions experience
Nicholas Wei, Nehemiah Samuel, Neil Jennings, Norbert Schroeder,
Shlokarth Balupuri, Peter Small, Kamal Mahawar, William Carr
City Hospitals Sunderland Foundation Trust, Sunderland, Tyne & Wear,
United Kingdom
Background: AAGBI recommend a HbA1c of < 8.5% prior to elective
surgery. However, metabolic surgery is offered to diabetics for better
control &/or cure of diabetes and achieving this, without surgery, can
be troublesome. This study aims to correlate the effect of pre-operative
HbA1c on the rate of peri-operative complications and to establish wheth-
er elective bariatric surgery should be delayed in poorly controlled
Method: This study is a retrospective analysis of prospectively collected
data. Consecutive patients who underwent primary bariatric procedures
gastric sleeve, loop bypass and Roux-en-Y bypass between January,2014
to April,2018 were included. Patients were categorised into Group-1:
Non-diabetics with a HbA1c Primary outcome was peri-operative com-
plication rates and secondary outcomes included post-operative length of
stay, re-admission within 30 days of surgery, HbA1c control at 6 months
& 12 months post-operatively.
Group-1(n=978), 81.8% female, median age 44 (IQR34-52), median
BMI 42.0 (IQR38.7-46.7); Group-2(n=350), 66.3% female, median age
51 (IQR45-59), median BMI 41.8 (IQR37.5-46.5); Group-3(n=90), 60%
female, median age 52 (IQR45-56) and median BMI 41.4 (IQR36.9-
No difference in early complication rates was observed:Group-1 1.0%
(n=10), Group-2 1.7% (n=6), Group-3 1.1% (n=1)(p=0.592).
Median LOS was 2 days across groups. No difference in 30-day re-ad-
mission rates was found:Group-1 2.8% (n=27), Group-2 2.9% (n=10),
Group-3 3.3% (n=3)(p=0.983). At 6 months and 1-year, there was
sustained and equal reduction in HbA1c in all groups irrespective of
pre-operative HbA1c(p< 0.05).
Conclusion: Our study shows that patients undergoing metabolic surgery
for poorly controlled diabetes can achieve comparable peri-operative out-
comes as patients with optimal diabetic control, & delaying metabolic
surgery in an attempt to optimize diabetic control may not be necessary.
From our results, we hypothesise that post-operative diabetic control may
be a better predictor of patient outcomes than pre-operative diabetic con-
A pilot rescue clinic within NHS for private bariatric surgery patients
requiring urgent interventions to reduce A&E attendance
Gillian Drummond, Brian Joyce
NHS Lothian, Edinburgh, United Kingdom
Background: The regional NHS service started in 2008. Until 2018 we
only offered bariatric weight loss surgery follow up to patients who had
surgery within the NHS. There was no provision to care for patients who
had elected to undertake bariatric surgery within the private sector, al-
though these patients could access emergency treatment via Accident &
Emergency (A&E) department.
Method: We introduced a fortnightly clinic ran bythe Specialist Dietitian
& Nurse Practitioner with the aim to reduce these patients attending the
A&E Department & to deliver specialist care for complications of private
bariatric surgery. All patients underwent bariatric nutritional screening &
further investigations targeted to their symptoms.
Results: The 27 patients who attended during the six month pilot were
retrospectively reviewed with regards to the outcomes of any investiga-
tions undertaken.
Patients seen by surgical procedure and site of surgery.
Balloon LAGB LSG Gastric bypass Revisions
1 8 6 12 3 (inclusive)
Scotland England Non-UK
13 8 6
S6 OBES SURG (2019) 29 (Suppl 1):S1S29
By investigations/outcomes
Conclusion: This pilot clinic identified a number of patients with undi-
agnosed nutritional deficiencies & complications of bariatric surgery.
These patients benefited from specialist assessment & treatment.
Evaluation of the learning curve for primary laparoscopic Roux-en-
Y gastric bypass and sleeve gastrectomy
Haris Markakis
, Christopher Pring
, William
Lewisham and Greenwich NHS Trust, London, United Kingdom;
Imperial College Healthcare NHS Trust, London, United Kingdom;
Western Sussex Hospital NHS Foundation Trust, Chichester, United
Background: Laparoscopic Roux-en-Y gastric bypass (RYGB) and lap-
aroscopic sleeve gastrectomy (LSG) can be technically demanding for
trainees. The Royal College of Surgeon (RCS) have established senior
fellowships in bariatrics aimed to allow trainees to become independent
bariatric surgeons. This study aims to analyse the learning curve for both
RYGB and LSG procedures.
Method: A retrospective analysis was performed on 189 consecutive
patients undergoing RYGB and LSG by a single RCS fellowship trainee
(for two fellowships) over a 20-month period. The learning curve was
evaluated by reviewing operative videos and using parameters including
total operative time and time for each component of the operation.
Results: 132 RYGB and 57 LSG were performed during the study peri-
od. Operative time was significantly lower after the first 16cases for LSG.
For the RYGB the learning phase for the jejunojejunostomy and the
gastric pouch was achieved after 22 and 43 cases, respectively, while
for the gastrojejunostomy, the learning phase was 94 cases. Total opera-
tive time for RYGB continued reducing significantly throughout the
study period. There were no anastomotic or staple-line leaks. The mean
hospital stay was 1.6 days. Early complications included 3 cases of small
bowel obstruction while 1 further patient was operated for internal hernia.
Conclusion: Duration of surgery improved with experience for both pro-
cedures. RYGB has a longer learning curve. Fellowships should take this
into account to ensure there are sufficient number of operative opportunities
for trainees to achieve the learning curve required for both RYGB and LSG.
What influences vitamin and mineral supplementation after 12
months following bariatric surgery?
Nerissa Walker, Judy Swift, Rhianna Morris
University of Nottingham, Nottingham, United Kingdom
Background: Nutritional supplementation (NS) is recommended life-
long to patients following bariatric surgery to minimise nutritional
deficiencies and the associated negative health consequences. However,
despite thousands of bariatric procedures being undertaken annually in
the UK, little is known about the influences that affect NS adherence in
people who are >12 months following bariatric surgery. The aim of
the study was to explore the barriers and motivations to taking NS
and the influence of others on NS > 12 months following bariatric
Method: A prospective online survey with ethical approval was piloted
and then posted for 6 weeks via a well established UK based online
bariatric patient support forum. The inclusion criteria was adults >16
years living in the UK, who were >12 months following sleeve gastrec-
tomy, laparoscopic adjustable gastric banding or gastric bypass (GB)
surgery undertaken in the UK. The anonymous survey included closed
and open questions regarding NS types, sources and advice, the role of
HCP's, NS adherence including motivations and barriers to taking NS.
The qualitative data was coded into themes and the quantitative data
analysed using Microsoft Excel.
Results: There were 47 responses. The majority of participants were
female (83.0%), white British (95.7%), >45 years of age (68.1%), who
had a GB (63.8%) and were NHS funded (76.6%) Most respondents were
taking NS at the time of the survey (87.2%). Almost every participant
(97.9%) indicated a HCP had advised NS and 72.3% were still frequently
following the NS advice from their bariatric centre. Nurses (34.0%),
dietitians (21.3%), other BS patients (17.0%) provided the most NS ad-
vice. Health/wellbeing, HCP advice and low blood levels were the most
prominent motivations while forgetting, cost and side effects were the top
Conclusion: There are numerous influences that affect NS >12 months
following bariatric surgery. Many barriers to NS adherence exist, while
prominentmotivations includehealth/wellbeing andbeing advised NS by
a HCP. HCPs and other BS patients also positively and negatively influ-
ence NS, particularly >12 months post-surgery as the frequency of
follow-up care reduces. HCP-patient relationships should be strengthened
to maintain follow-up care in which individual barriers and motivations to
NS can be identified and nutritional deficiencies prevented. Collaboration
between bariatric MDTs and primary care HCPs may be key to positively
influencing NS adherence and improving long-term health outcomes of
Session 8: Parallel Free Paper Session IHP
Friday 25 January 2019
Development of an evidence based, interactive database to quantita-
tively assess the impact of medication on the nutrient status of pa-
tients pre-and post-bariatric surgery
Michael Wakeman
University of Sunderland, Sunderland, United Kingdom
Background: Significant numbers of patients, prior and subsequent
to bariatric surgery are deficient in micronutrients with guidelines in place
to manage this situation. Many patients also require medication/s, often
from different classes to control co-morbidities. Although bariatric inter-
vention may reduce use completely or allow dose reduction-new
medications, typically, proton pump inhibitors may subsequently be
introduced. A significant literature exists describing the impact of
medication/s on micronutrient status. Currently no tools allow this data
to be used to quantitatively determine the single or cumulative impact
medications might have on nutritional status to help further personalise
dietary and supplement recommendations.
Method: A database of non-parenteral, licensed medications-prescription
and over-the-counter-was created, by generic and brand name. A search
was conducted of electronic databases of peer reviewed literature
published through to September 2018. A search strategy was performed
Barium Swallow 10
Endoscopy 4
CT Scan 2
Nutritional screen showing deficiencies 10
Band decompression 3
Onward Referral to Weight Management Service 3
Band removal 2
Dietetic/behavioural advice 6
Anastomotic Ulcer Treatment 1
OBES SURG (2019) 29 (Suppl 1):S1S29 S7
using keywords and the Medical Subject Headings (MeSH) of classes of
drugs as defined in the British National formulary and 26 recognised
micronutrients as well as descriptors of the microbiome. Other references
or review articles identified within the primary research were also exam-
ined. Studies were screened against inclusion criteria, followed by a re-
view of the abstract and then the full paper.
Results: 1050 references were identified with 4073 incidences of a med-
ication interacting with 25 micronutrients, essential fatty acids and the
microbiome. These were assessed as either major, moderate or minor
based upon the conclusion/s of the author/s of the publication. Within
the database, an algorithm was developed that enabled the impact of each
medication on micronutrient status to be interrogated quantitatively and
cumulative scores from multiple medications aggregated. The tool en-
abled a rapid assessment of the impact of medication/s on micronutrient
status to be made, with a hyperlink to the relevant abstract, enabling
validation of any conclusions.
Conclusion: This tool enables rapid assessment of the impact
medication/s might have upon micronutrient status through an easy to
understand report of summary findings. Potential minor and moderate
negative impacts resulting from inputs can be advised to be corrected
firstly by diet, and any major potential deficiencies by additional supple-
mentation wherever necessary. The impact of multiple medications is
rapidly evident. This development provides practitioners the opportunity
to access a tool that complements their clinical skills and contributes to
optimise the nutritional status of patients by delivering evidence-based
Integrating Undergraduates in a Pre-Surgical Bariatric Patient
Education Programme can challenge beliefs, change attitudes and
is highly valued by students
Lorraine Albon
, Elaine Mathews
, Lisa Sheldrick
, Mandy Gault
Christopher Pring
Western Sussex Foundation NHS Trust, Chichester, West Sussex, United
University of Chichester, Chichester, West Sussex, United
Background: Many universities offer degree courses in Sports and
Exercise Science. Such students anticipate a career which may involve
delivery of health-related education to the public in a variety of settings,
yet it is recognised that obese people face stigma and bias, even from
health care professionals.
The unit in question is a high volume centre. We integrated Sports and
Exercise Science undergraduates into our pre surgical preparation pro-
gramme. Closely supervised, they delivered Increasing Physical Activity
Seminars to pre surgical patients. We aimed to find out how the students
viewed the placement
Method: All students integrated into the service and who deliver an
Increasing Physical Activity seminar were asked to comment on their
experiences and the challenges they faced. They were also asked about
the usefulness of the placement to their future careers. Responses were
studied using thematic analysis methodology.
Results: Prior to placement students stated they had limited knowledge/
understanding of causes/consequences of obesity. Themes included in-
creased awareness of psychological factors including prior abuse/trauma,
and a positive change in attitude towards obese people. Challenges in-
cluded the lack of prior patient education surrounding activity/healthy
eating, the lack of available patient financial resource and the extent of
medical co-morbidity impacting on patients ability to engage. Students
valued the experience, gained an appreciation of the multidisciplinary
team, and expressed a high degree of satisfaction in allowing them to
apply use skills learnt in theory to a real life setting.
Conclusion: The supervised integration of undergraduates into a pre-
surgical preparation programme has the potential to challenge previously
held student beliefs surrounding obesity, can encourage awareness, and
offers a real life setting in which students can deliver activity related
education which they value highly.
The use of gastrostomy tube feeding to treat reactive hypoglycaemia
post Roux-en-Y Gastric Bypass
Fiona Macleod, Neil Jennings, Karen Johnson, Nimantha De-Alwis
Sunderland Royal Hospital, Sunderland, United Kingdom
Background: Reactive hypoglycaemia following Roux-en-Y Gastric
Bypass can cause significant symptoms and have major lifestyle implica-
tions. First line dietetic and medical interventions are often sufficient in
treating the symptoms. We describe the case of a 37 year old male whose
symptoms failed to improve with medical intervention. Quality of life
was significantly affected in this individual with multiple daily episodes
of debilitating hypoglycaemia. Ultimately, Percutaneous endoscopic
gastrostomy (PEG) tube insertion was agreed to treat the hypoglycaemia.
Method: Routine biochemical investigations suggested a clear case of
Reactive hypoglycaemia after exclusion of insulinoma and other possible
causes. A 72 hour fast was negative. Two years after the initial surgery, a
laparoscopic assisted PEG tube was inserted to control blood sugar. A
continuous nutritionally complete feed was established during the pa-
tients working hours at a rate of 7g of carbohydrate per hour. A night
feed was required at a very low rate to prevent nocturnal hypoglycaemia.
A break from feeding was managed through the day with a strict high
protein diet and avoidance of carbohydrates.
Results: No further significant hypoglycaemia was reported by the pa-
tient. He used a FreeStyle Libre sensor to monitor blood sugars. Once
established feeding regimens were in place, Libre and glucometer analy-
sis by the diabetes team confirmed stable glycaemia with no low blood
sugar recordings. Rare episodes of hypoglycaemia were recorded when
food containing carbohydrates were consumed. The patient was able to
go back to work and restart leisure activities which were restricted prior to
PEG feeding. After 2 years the patient reports high level of satisfaction
with PEG feeding.
Conclusion: The majority of post Gastric Bypass patients presenting with
reactive hypoglycaemia are managed with simple dietetic intervention.
Some patients may require medical management with Acarbose and other
oral agents. When most non-surgical interventions have failed, it is pos-
sible to manage some cases of reactive hypoglycaemia with a PEG tube
feeding regime. This patient was highly motivated and compliant with
Does Dumping Syndrome influence weight loss and body composi-
tion changes following Gastric Bypass Surgery?
Fathimath Naseer
, Adele McElroy
, Carel Le Roux
Ruth Price
, Barbara Livingstone
Ulster University, Coleraine, United Kingdom;
University College
Dublin, Dublin, Ireland
Background: Gastric Bypass Surgery (GBP) continues to be remarkably
efficient in achieving sustainable weight loss in individuals with severe obe-
sity. Apart from the primary weight loss mechanisms of energy restriction
and malabsorption, there are additional physiological mechanisms that ac-
count for a positive shift in postsurgical eating behaviour. One of these
postulated mechanisms includes Dumping Syndrome (DS), a term used to
describe postprandial gastrointestinal and vasomotor symptoms following
gastric surgery that may deter patients from consuming energy-dense foods
and promote weight reduction. The aim of this study was to assess the
influence of DS on postsurgical weight loss and body composition changes.
S8 OBES SURG (2019) 29 (Suppl 1):S1S29
Method: 16 GBP patients (11 females; baseline BMI 45.0 ± 8.2 kg/m
47·4 ± 10.4 y) and 16 time-matched and weight-stable controls (10 fe-
males; baseline BMI 28·5 ± 8.2 kg/m
; 40.1 ± 15·0 y) were evaluated at
baseline and at three months post-surgery. The diagnosis of DS was based
on the Sigstads scoring system. Lean body mass (LBM) and fat mass
(FM) were measured using dual energy X-ray absorptiometry (Lunar
iDXA, GE Healthcare). The results were analysed with descriptive and
parametric statistics using SPSS, Version 24.0. Armonk, NY: IBM Corp.
Results: At follow-up, none of the participants (n=32) obtained a score
that is suggestive of DS. However, 14 patients (87.5%) and four controls
(25%) reported postprandial discomforts. 11 patients avoided consuming
fatty foods (81.8%), chocolates (81.8%) and sugar-rich products (100%)
to mainly prevent nausea and vomiting. Only two controls avoided fatty
foods (50%), potatoes (50%) and spicy foods (50%) to chiefly avoid
abdominal bloating. Similar to controls, there was no difference in weight
(-20.5 vs. -17.5kg; P=0.662), FM (-15.9 vs. -14.8 kg; P=0.831) and LBM
(-4.5kg vs. -2.5kg; P=0.423) loss between patients who experienced post-
prandial discomforts vs. those without discomfort respectively.
Conclusion: Contrary to existing literature, DS is not observed in this
group of GBP patients at three months post-surgery. Nevertheless, post-
prandial discomfort, particularly nausea and vomiting were commonly
reported post-surgery and it led to a reported decrease in consumption
of high-fat and sugar-rich food products. However, the presence of these
postprandial symptoms had no impact on post-surgical weight and body
composition changes. Further research that employs direct measurement
of ingestive behaviour with a bigger sample size over an extended time
frame is warranted to confirm the significance of these findings.
Results of a preliminary analysis of eating psychopathology and
food-related parenting practices among mothers attending a tier 3/4
specialist weight management service
Chloe Patel
, Eleni Karasouli
, Emma Shuttlewood
, Caroline Meyer
University of Warwick, Coventry, United Kingdom;
Hospital Coventry and Warwickshire NHS Trust, Coventry, United
Background: Given the evidence indicating a transmission of weight and
eating behaviours from parent to child, the aim of the study was to capture
the current eating psychopathology and food parenting practices (FPPs)
of motherswho were attending a specialist weight management service
(WMS) in the West Midlands, UK.
Method: All mothers completed demographic questions followed by the
Eating Disorder Exam Questionnaire (EDE-Q), the Dutch Eating
Behaviour Questionnaire (DEBQ), the Weight Efficacy Lifestyle
Questionnaire (WEL-Q), and the Comprehensive Feeding Practices
Questionnaire (CFPQ). Data were collected from three matched groups:
twenty-five mothers with obesity attending a specialist weight manage-
ment service (BMI 35), twenty-five mothers with healthy-weight (BMI
18.5 - 24.9), and twenty-five community-based mothers with overweight/
obesity (BMI 25 34.9).
Results: Kruskal-Wallis Tests comparing mothers with healthy-weight to
mothers attending the WMS indicated: Significantly higher levels of re-
strained (p<.000) and emotional eating (p=.002), significantly higher
concern about shape (p<.000) and weight (p<.000), significantly less
modelling of healthy-eating (p=.02), significantly less confidence
resistingfoods when dealing with negative emotions (p=.001), when food
is available (p=.004), when experiencing physical discomfort (p=.05),
and when undertaking positive activities (p=.02). There were a range a
of positive, significant correlations between eating behaviours and FPPs
including child control, emotion regulation, teaching about nutrition and
Conclusion: Although preliminary results suggest that there is no differ-
ence between mothers with overweight/obesity in a community setting
and mothers with obesity in a clinical setting, there does appear to be a
relationship between the eating behaviours of mothers attending the
weight management service and subsequent use of food parenting prac-
tices. The findings are based on a preliminary analysis on a small sample
of data therefore more research is required to further understand the pre-
sented findings.
The impact of an intensive pre-operative patient information course
on weight loss outcome after Bariatric Surgery
Christine Ward, Mhairri Duxbury, Gillian Drummond, Brian Joyce,
Nicole Allison, Peter Lamb, Bruce Tulloh, Andrew De Beaux
NHS Lothian, Edinburgh, United Kingdom
Background: Our service, set up 2007, initially provided individual ed-
ucation to prepare patients for surgery. The latter was considered time
consuming and unsustainable in terms of resources as referrals increased.
In 2010 we introduced a 12-week intensive Pre-operative Information
Course (IPIC). This was designed to educate patients and their carers
about the surgical pathway, surgical risks and complications, healthy
eating, behavioural change and psychological issues. It discusses realistic
post surgical expectations and stresses the patients central role in achiev-
ing good outcomes from surgery. Engagement with this process and a 5%
weight loss are required prior to full assessment for surgery.
Method: Baseline preoperative data regarding demographics, starting BMI
and sex distribution were recorded prospectively. % Excess Weight Loss
(%EWL) was documented post operatively, when patients were followed
up in outpatient clinic, at the following time points: 6 months, 1, 2, 3 and 4
years. Retrospective analysis was undertaken to compare the 4 year % EWL
outcome data of those patients operated upon between 2007 and 2010, control
group and those attending the IPIC in 2011-2013. Mann-Whitney statistical
analysis was undertaken to determine whether %EWL outcomes were sig-
nificantly different (P< 0.05) between these two groups of patients.
Conclusion: Analysis showed a statistically significant difference be-
tween %EWL outcomes for all time points for the IPIC patients. There
remains a statistically significant difference when bands are excluded.
Control IPIC P-value P-value
N = 71 136
21 bands, 23
gastric sleeves,
55 bypasses
Male to
female ratio
1 :1.48 1: 3.1
Age 49 [±8.7] 49[±9.6]
range 35.7
51.8kg/m2 0.00028 0.00008
39.2% 60.1% 0.00001 0.00001
% EWL 1 year 46.6% 67.9%, 0.00001 0.00001
% EWL 2 year 46.7% 67.7%. 0.00001 0.00001
% EWL 3 year 48.0% 60.6%, 0.00038 0.00086
% EWL 4 year 46.1% 59.2% 0.00338 0.02382
OBES SURG (2019) 29 (Suppl 1):S1S29 S9
The IPIC course continues to be popular with patients and continues to be
associated with improved weight loss outcomes up to 4 years post surgery.
BA critical part of obesity management^: A questionnaire looking at
the multidisciplinary team view of the role and input of psychology
across a bariatric surgery service; suggestions for service delivery
development discussed
Maria Vidal, Chantelle McKenzie, Natasha Hill
Chelsea and Westminster NHS Foundation Trust, London, United Kingdom
Background: NICE (2014) guidelines outline how bariatric surgery
should be undertaken only by a multidisciplinary team (MDT) that can
provide psychological support both pre- and post-operatively. The
disparity in the provision of psychological care and resources across
UK bariatric services, as well as the intent / role of psychological assess-
ment, however, has been highlighted (Ratcliffe et al, 2014). In addition,
there is limited information with regards to how a bariatric MDT utilises
and perceives psychological input. As part of service development initia-
tives, further information regarding the role of psychology within a major
London provider of bariatric surgery was sought.
Method: A 15 item questionnaire was designed. Items focused on the
bariatric MDTs perspective on referral procedures to psychology; feedback
mechanisms; team understanding of psychology input across the surgery
pathway; satisfaction and value, and suggestions for future development.
Respondents were asked to provide self-ratings on items via a likert scale
relating to satisfaction and quality. Qualitative sections inviting additional
comments on role and development, were also included. Questionnaires
were administered by the psychology team to all members of the MDT
(N = 17). The core MDT is represented by specialist nursing, dietitians,
the surgical team, endocrinology, anaesthetics and plastic surgery.
Results: Questionnaire administration was rolled out at the beginning of
November with completion planned for December 2018. With a 47%
response rate to date, preliminary data indicates 100% of respondents high-
ly or extremely satisfied with the psychology service provided. Clinical skill
(mental health knowledge and expertise in bariatric care) together with
accessibility, were aspects of psychology highly valued. Emergent themes
linking psychology assessment to risk identification; understanding behav-
iour and managing failure after surgery, have been identified. Service de-
velopment suggestions trend towards joint clinics, skills training and
targeting psychology resource towards post-operative support.
Conclusion: The importance of and value placed on psychological provi-
sion within a bariatric MDT is clear. The perceived intention of the
psychology assessment as managing patient risk, readiness and selection
for surgery is being uncovered. Responses to date, however, indicate a
move towards further collaborative care within the bariatric MDT and a
request for shared decision-making processes. This, together with the drive
towards the development of psychology support within post-operative bar-
iatric care, could enable a changing framework for service delivery; a move
consistent with ongoing discussions in the literature (Jumbe and Meyrick,
Session 8: Parallel Free Paper Session Surgical
Friday 25 January 2019
Accuracy of data reporting on PHIN (Private Healthcare
Information Network) and NBSR (National Bariatric Surgery
Register) compared with surgeons database
Ahmed Ghanem
, Oscar Martin
, Ahmed Ahmed
St. Mary's Hospital, London, United Kingdom;
Cromwell Hospital,
London, United Kingdom
Background: Bariatric surgeons have to self-report in the NBSR as part
of NHS bariatric surgery commissioning and good medical practice.
Since 2017, hospitals in the independent sector have been sending data
to PHIN as part of empowering patients to make better-informed choices
of care provider. The aim of this study is analysing the accuracy of infor-
mation in these two databases
Method: We analysed surgeon specific data during a randomly selected 3
month period, between 1st March till 31st May 2018 and compared the
data sets for the same group of patients who were done by the same
surgeon. The chosen variables were the 5 basic recorded fields from
PHIN which ate are age, gender, date admission, discharge date and type
of operation.
Results: Of 25patients analysed, 17 patients (68%) were not recorded on
NBSR. In theremaining 8 there was an error in 1 patient (4%) in the dates
of admission and discharge. With regard to PHIN, there was a discrepan-
cy in 2 patients (8%) in the type of operation recorded. One of these
patients was having sleeve gastrectomy and recorded as (no procedure
coding) and the second one was having mini-gastric bypass and recorded
as sleeve gastrectomy.
Conclusion: Our analysis suggests that surgeons must monitor data that
is being submitted about their practice in a stringent manner. Surprisingly,
PHIN was more accurate than NBSR in reflecting surgeons true practice.
Obstructive sleep apnoea screening pre-operatively with the
Epworth questionnaire: Is it worth it...?
Peter Vasas, Ajay Gupta, Corinne Owers, Oluyemi Komolafe, Sashi
Yeluri, Abdulzahra Hussain, Srinivasan Balachandr
Doncaster Royal Infirmary, Doncaster, United Kingdom
Background: Risk-reducing screening tools have been developed to
identify and optimise patient co-morbidities pre-operatively. One such
co-morbidity is obstructive sleep apnoea (OSA). However, it remains less
qualified and quantified than other conditions associated with obesity.
The Epworth screening tool can identify those at high risk of OSA, but
has a low specificity and a low negative predictive value. Consequently,
screening may over-estimate those requiring OSA treatment pre-opera-
tively, leading to greater costs including unnecessary ICU admissions.
This study examines the incidence of OSA in bariatric surgery patients,
use of the Epworth and polysomnography, and compares complications
in those with or without OSA.
Method: Prospective data for 425 consecutive patients undergoing bar-
iatric surgery in one unit was collected. All patients were screened with
the Epworth screening questionnaire (range 0-24 with a score of 10 being
suggestive of possible OSA). Patients who scored over 11 were referred
for polysomnography. Those requiring treatment had 3 months pre-oper-
atively. All patients underwent a standardised pre-operative pathway and
followed an enhanced recovery pathway. Data was collected for baseline
characteristics, ITU stays, post-operative complications (as per Clavien-
Dindo scale) and re-admissions to hospital. Statistical analyses were per-
formed using the Chi squared, Fischer-exact and one-way ANOVA sta-
tistical tests where appropriate.
Results: Mean age was 45.2 years; mean pre-operative weight 139.5kg
and BMI 49.7kg/m2. Fifty-nine patients had a pre-referral diagnosis of
OSA (14%). Of the 366 patients without a pre-operative diagnosis of
OSA, those with a score >11 underwent polysomnography (PSG); 48
patients. Twenty-nine patients were subsequently diagnosed with OSA;
a prevalence of 20% compared to up to 77% in published literature.
Patients with OSA were older and more likely to be male. There was no
significant difference in BMI. Unplanned ICU admissions and complica-
tions were comparable between OSA groups. Hospital stay overall was
longer for OSA patients (p=0.017).
Conclusion: Although OSA is a well recognised co-morbidity in bariatric
patients, it may be less prevalent than previous literature studies have
suggested. The Epworth sleepiness scale may over estimate the number
S10 OBES SURG (2019) 29 (Suppl 1):S1S29
of patients with OSA, leading to an unnecessary number of patients un-
dergoing polysomnography. In this study, the number of patients
experiencing post bariatric surgery complications did not differ signifi-
cantly between those with and without OSA. Therefore, as a result, ICU
admission following bariatric surgery in our unit is no longer routine, but
assessed onan individual basis. This, and more tailored PSG, may lead to
significant cost savings.
Endoscopic Sleeve Gastroplasty: a modified technique with greater
curvature compression sutures
Michael Glaysher, Alma Moekotte, Jamie Kelly
University Hospital Southampton NHS Foundation Trust, Southampton,
Hampshire, United Kingdom
Background: Endoscopic Sleeve Gastroplasty (ESG) is rapidly being
established as a safe and effective means of achieving substantial weight
loss via the transoral route. New ESG suture patterns are emerging and
herein we report the outcomes of patients undergoing ESG with a unique
combination of longitudinal compression sutures and U-sutures.
Method: This is a retrospective review of prospectively collected data of
all patients undergoing ESG in a single UK centre. BetweenJanuary 2016
and December 2017, 32 patients (23 females) underwent ESG in our
centre; n=9 consecutivecases were completed utilising a standardsuture
pattern (no compression) and the subsequent n=23 consecutive cases
were completed using a longitudinal compressionsuture pattern.
Results: In the no compression and compression groups the median
baseline weights were 113.6kg (82.0-156.4) and 107kg (74.0136.0)
and BMIs were 35.9kg/m
(30.943.8) and 36.5kg/m
(29.842.9) re-
spectively. After 6 months, body weight had decreased by 21.1kg
(12.234.0) in the compression group (n=7) versus 10.8kg (7.025.8) in
the no compression group (n=5) (p=0.042). Correspondingly, BMI de-
creased by 7.8kg/m
(4.911.2) and 4.1kg/m
(2.67.2)(p=0.019). In ad-
dition, %TBWL was superior in the compression group at 19.5% (12.9
30.4%) compared to 13.2% (6.217.1%) in the non-compression group
(p=0.042). No significant adverse events were reported in this series.
Conclusion: ESG is now established as a safe and efficacious minimally-
invasive treatment modality in the armamentarium against obesity and
obesity-related diseases. The technique of ESG is evolving and outcomes
from EBTs continue to improve. We provide preliminary evidence of
superior weight loss achieved through a modified gastroplasty suture
pattern but further prospective data is required to validate these findings.
Total small bowel length varies considerably among patients with
obesity and diabetes: Is there a role for individualisation of limb
lengths in Roux-en-Y gastric bypass?
Anna Kamocka
, Belén Pérez-Pevida
, Alexander D. Miras
, Lidia Castagneto-Gissey
, James Casella
, Francesco Villa
Spyros Panagiotopoulos
, Arasteh Reyhani
, Barbara Petronio
, Krishna Moorthy
, Sanjay Purkayastha
, Ahmed R.
, Steve Bloom
, Francesco Rubino
Imperial College London, London, United Kingdom;
Imperial College
Healthcare, London, United Kingdom;
King's College London, London,
United Kingdom
Background: Using fixed, predetermined lengths of alimentary (AL) and
biliopancreatic (BPL) limbs in Roux-en-Y gastric bypass (RYGB) is
common practice. However, significantinter-individual variability in total
small bowel length (TSBL) might exist, potentially influencing the out-
comes of the procedure. In this study we aimed to investigate the degree
of variance in TSBL among patients with obesity and type 2 diabetes
(T2D) undergoing laparoscopic RYGB as part of the LONG LIMB trial
at two bariatric surgical centres.
Method: By using a mark on laparoscopic graspers as a reference, the
entire small bowel was measured from the ligament of Treitz to ileocaecal
valve. Pearson correlation coefficient and χ
test were used to explore
correlations between TSBL, baseline demographics (age, gender, ethnic-
ity, height, weight, BMI, HbA1c) and postoperative outcomes (weight
loss and T2DM remission at 12 months postoperatively).
Results: TSBL was measured in 46 patients (67% female, age 48±9
years, 67% Caucasian, baseline weight 118±24 kg, BMI 42±7 kg/m
HbA1c 74±17mmol/mol). TSBL ranged between 320 and 910 cm (mean
610±106 cm), whereas common channel measured 170-660 cm (405
±107 cm). TSBL correlated weakly with baseline BMI, with longer
TSBL found in patients with higher BMI (r=0.3, p=0.05). No association
between TSBL and other pre- or postoperative measures was found.
Conclusion: There is a wide range of total small bowel length in patients
with severe obesity and T2D. Larger clinical studies are warranted to
understand if such intestinal variability may explain variance in clinical
outcomes and require individualised limb lengths when performing
RYGB su rg er y.
Recent-Onset Type 2 Diabetes Is Defined As <10 Years Duration
Olivia Szepietowski
, Gheed Mahir
, Jennifer Murphy
Erdal Ozdemir
, Kevin Murphy
, Terence Dovey
, Carel Le Roux
Tricia Tan
, Ahmed Ahmed
, Harvinder Chahal
, Sanjay Purkayastha
Alex Blakemore
Imperial College London, London, United Kingdom;
Medical Centre, Amsterdam, Netherlands;
Brunel University London,
London, United Kingdom;
University College Dublin, Dublin, Ireland
Background: The National Institute for Health and Care Excellence
(NICE) 2014 guidance for treatment of type 2 diabetes (T2DM) recom-
mends patients with recent-onset T2DM be considered for bariatric sur-
gery, including in people with a body mass index of 30-34.9kg/m
poor glucose control. The term recent-onsetwas defined by the NICE
Guideline Development Group as a diagnosis made within a 10-year time
frame, but there is no evidence to support such a threshold. This aim of
this study was to determine whether a duration of
Method: 174 patients undergoing bariatric surgery (Roux-en-Y gastric
bypass RYGB n=140, vertical sleeve gastrectomy VSG n=34) were re-
cruited to the study as part of a larger clinical trial. To determine the most
appropriate threshold for the diagnosis of recent onsetT2DM the percent-
age of patients who achieved T2DM remission within 1 year of surgery
were plotted according to different duration thresholds increasing in one
year increments. T2DM remission was defined according to the
American Diabetes Association definition of complete or partial remis-
sion; HbA1c 48 mmol/mol in the absence of pharmacological therapy
for T2DM.
Results: 34.5% (n=60) of participants achieved complete T2DM remis-
sion within 1 year of bariatric surgery, and remission prevalence was
equal between the procedures (34.3% RYGB n=48, 35.3% VSG n=12).
The mean T2DM duration for the whole group was 7.6 ±6.5 years (re-
mission group 3.2 ±2.9 years, non-remission group 9.5 ±6.6 years).
T2DM duration at the time of surgery ranged from 0 (diagnosed within
1 year of surgery) and 30 years, and 29.9% (n=52) of participants had a
T2DM duration of more than 10 years. As shown in figure 1, none of the
participants with a T2DM duration >10 years achieved remission.
Conclusion: Our data support the concept that subjects with greater than
10 years duration of diabetes are unlikely to achieve remission, for both
RYGB and VSG equally, although almost all patients experienced im-
provement in glycaemic control. However, it remains to be determined
whether those with longer duration of diabetes benefit more as regards
morbidity and mortality.
OBES SURG (2019) 29 (Suppl 1):S1S29 S11
Implementation of a bariatric fast track protocol (enhanced recovery
after bariatric surgery) significantly reduces intensive care bed
utilisation and may reduce length of stay
Andrei Ilczyszyn, Siri Gowda, Anna Kessler, Lydia Ioannidi, Amy Kirk,
Kayon Carr-Rose, Naim Fakih-Gomez, Mohammed ElKalaawy, Majid
Hashemi, Andrew Jenkinson, Andrea Pucci, Rachel Batterham, Marco
UCLH Bariatric Centre for Weight Management and Metabolic Surgery,
London, United Kingdom
Background: Bariatric surgery is generally regarded as a safe and effec-
tive treatment for obesity and associated comorbidities. Although length
of stay is generally short and the complication rate low Enhanced
Recovery After Bariatric Surgery (ERABS) has been proposed to im-
prove this further. We modified our current post-operative protocol to
fully encompass ERABS principles. Key elements included a multidisci-
plinary team approach, patient education, enhanced anaesthetic protocols
and rapid return to normal activity. We aimed to reduce hospital stay and
ITU bed usage without compromising patient outcomes.
Method: The modified protocol had three elements:
1. Preoperative: Patient education sessions, bariatric-specific pre-admis-
sion and anaesthetic review. Standard liver shrinkage diet. Admission on
day of surgery, no prolonged fasting.
2. Intraoperative: Standardised anaesthesia avoiding opioids. Immediate
mobilisation, resumption of oral intake post-operatively. All administra-
tion for discharge completed.
3. Postoperative: Early multidisciplinary review; rapid discharge with full
Between January 2018 and June 2018 our original protocol (FT-1) was used.
Between June 2018 and November 2018 our modified protocol (FT-2) was
trialled. Patient demographics, length of stay, ITU stay and complications
were retrospectively collated from electronic health records in each group.
Results: 146 patients were included, 63 on original protocol (FT-1) and 83
on modified protocol (FT-2) with no significant difference between groups.
Implementation of the Modified Bariatric Fast-Track Protocol (FT-2) result-
ed in a significant decrease in ITU bed usage from 30.2% to 10.1%. There
was a non-significant reduction in length of stay from 2.2d to 1.6d.
Conclusion: Implementation of our Modified Bariatric Fast-Track Protocol
using ERABS principles resulted in a significant decrease in ITU bed usage.
There was also a reduction in length of stay which did not reach significance.
This did not affect our very low complication rate. Using ERABS protocols
may have significant positive benefits for patient outcomes and resource
utilisation. There may be wider implications for improving uptake of bariatric
surgery and further effort will be directed to elucidate this in our unit.
Weight loss surgery for obstructive sleep apnoea: are women really
the fairer sex?
Emma Rose McGlone
,Vas h a K a u r
, Iain Carey
, Rachel Batterham
, Peter Small
Imperial College, London, United Kingdom;
St George's University,
London, United Kingdom;
St George's Hospital, London, United
University College, London, United Kingdom;
London, United Kingdom;
Sunderland Royal Hospital, Sunderland,
United Kingdom
Background: Weight loss surgery (WLS) causes resolution of obstruc-
tive sleep apnoea (OSA) in many cases. There are, however, no validated
methods to predict which patients will experience OSA resolution follow-
ing WLS. A previous large scale study from the USA reported that male
patients and those with other obesity-related comorbidities are less likely
to experience OSA resolution following WLS. Verifying this information
is important to assist fair and appropriate allocation of limited WLS re-
sources. We therefore used the UK National Bariatric Surgery Registry
S12 OBES SURG (2019) 29 (Suppl 1):S1S29
(NBSR) to conduct the largest study to date and analyse the applicability
of these findings to the UK.
Method: From the NBSR, we extracted data from all patients with con-
tinuous positive airway pressure (CPAP)-dependent OSA that underwent
primary WLS between January 2009 and May 2017, with evidence of at
least one follow-up visit between 12 and 24 months post-procedure.
Demographic, peri-operative and follow up data were recorded and are
presented as mean with standard deviation or number with percentage.
Data were fit to a modified Poisson model with the outcome OSA reso-
lution, offset for follow up time, allowing the calculation of adjusted
relative risks with 95% confidence intervals (RR, CI) for OSA resolution
(defined by cessation of CPAP).
Results: 4016 patients were eligible for inclusion: 337 gastric band (GB);
1196 sleeve gastrectomy (SG); and 2483 Roux-en-Y gastric bypass
(RYGB). Overall, 2378 (59.2%) experienced resolution of OSA at aver-
age follow up of 471 days (100). Rates of resolution were significantly
higher for patients undergoing SG or RYGB when compared to GB (RR
1.47, CI 1.26 to 1.8, and 1.51, CI 1.23-1.77 respectively). Older age, and
higher pre-operative BMI were negative predictors of OSA resolution;
whereas greater weight loss was associated with better rates of OSA
resolution. There was no significant effect of smoking, gender or
Conclusion: In this, the largest assessment of OSA outcomes following
WLS to date, SG and RYGB were associated with a better rate of reso-
lution when compared to GB. Greater weight loss was also associated
with better rates of OSA resolution. However, neither gender nor presence
of other comorbidities predicted OSA resolution. These data suggest that
in patients with OSA, pre-operative characteristics should not restrict
access to WLS.
UK Single Centre Early Experience of the Elipse Biodegradable
Intragastric Balloon
Jennifer Darrien, Sandra Johnson, Charlotte Harper, Aisling Duffy, David
Phoenix Health, Chester, Cheshire, United Kingdom
Background: The Elipse intra-gastric balloon was launchedin the UK in
2018. It is an ambulatory outpatient procedure with a novel delivery
system that does away with the need for endoscopic insertion. After 4
months the inflation valve biodegrades, and the deflated balloon passes
spontaneously PR. Elipse is one part of a weight loss programme provid-
ing dietetic support using smartphone technology and wireless scales.
Method: Prospective data collection and analysis. Patients were screened
to ensure BMI >27 and exclude contraindications, particularly their risk
of intra-abdominal adhesions that might impede spontaneous passage of
the deflated balloon. A standardised drug regime (including pre-op PPI
and Aprepitant) to minimise balloon intolerance was used. The balloon is
swallowed with water (sometimes aided by a stiffening stylet) without
sedation. Fluoroscopy confirms intra-gastric position both before and
after inflation. Dietetic support continues for six months.
Results: Between February and October 2018, 87 Elipse insertions were
performed (74% female; median age 42yrs). Median pre-insertion weight
and BMI were 99kg and 35.5kgm
. All patients successfully swallowed
the balloon, although a third (28/87) required assistance with a stylet. Of
the 35 who have passed the balloon to date, median weigh loss at 4
months was 7kg, (range 1 - 18kg); median BMI reduction 3.6, (range
0.4 - 6). The overall complication rate was 4.6%, (4/87), with 1% early
balloon removal; 1% severe vomiting (successful conservative manage-
ment) and 2/87 patients reporting early mild haematemesis, (one stylet
insertion, both conservatively managed).
Conclusion: Although one third of patients require stylet insertion to
assist with swallowing the balloon, Elipse remains an attractive, safe,
well-tolerated option for patients seeking a minimally invasive procedure
to assist with weight loss, Complication rates in this early UK experience
are low and appear to be less frequent than those reported after conven-
tional intragastric balloon treatment. Bowel obstruction is a potential
concern (incidence 1/700 reported globally) but was not seen in this
series. The weight loss reported at 4 months is modest, although this
may have been influenced by the relatively small number of patients
completing the programme to date.
DVD Presentations
Thursday 24 Friday 25 January
Challenges during Revisional Bariatric Surgery
Sami Mansour, Ahmed Ahmed
Imperial College Healthcare NHS Trust, London, United Kingdom
Background: A 48 year old female presented for Revisional
bariatric Surgery. She previously underwent vertical banded gastroplasty
in 1999. Multiple abdominal wall hernia and abdominal hysterectomy.
Method: Revisional roux-en-y gastric bypass was performed laparoscopically.
Results: Dense adhesions were encountered between the stomach and
the liver. The procedure was completed safely and patient discharged
Conclusion: Revisional bariatric surgery should be performed in high
volume centres with previous expertise in such operations.
Weight regain post Roux-en-Y gastric bypass: presentation of differ-
ent revisional options
Haris Markakis
, Jessica Mok
, Ahmed Ahmed
Lewisham and Greenwich NHS Trust, London, United Kingdom;
Imperial College Healthcare NHS Trust, London, United Kingdom
Background: Weight regain after Roux-en-Y gastric bypass (RYGB) is
relatively uncommon when compared to sleeve gastrectomy. Revisional
surgery after RYGB is, however, more technically demanding and there is
no consensus regarding the optimal operative strategy.
Method: We aim to present different revisional options for weight regain
post RYGB and demonstrate a logical approach to revisional surgery, by
presenting a standardized approach in 3 different patients.
Results: A stepwise approach is demonstrated in the video. This includes
adhesiolysis, small bowel length measurement, revision of gastric pouch
and/or gastrojejunostomy and biliopancreatic limb lengthening with mes-
enteric defect closure.
Conclusion: Revision of RYGB for weight regain can be technically
demaning. There is no consensus on the exact surgical technique for
revision of the gastrojejunostomy or the optimum bowel length.
Following a standardized technique, which incorporates different treatment
options, is necessary to minimize operative risks for this challenging group
of patients.
Definitive Laparoscopic Roux-en-Y Oesophagojejunostomy - A Safe
and Effective Management Option for Refractory Sleeve Leak
Andrei Ilczyszyn, Jessica Mok, Roxana Zakeri, Naim Fakih-Gomez,
Mohammed Elkalaawy, Andrew Jenkinson, Marco Adamo
UCLH Bariatric Centre for Weight Management and Metabolic Surgery,
London, United Kingdom
Background: Leak following laparoscopic sleeve gastrectomy although
rare is associated with significant morbidity. Conservative and
OBES SURG (2019) 29 (Suppl 1):S1S29 S13
endoscopic treatment options have unclear efficacy and require extended
hospital stay. We demonstrate definitive treatment of a sleeve leak with
laparoscopic resection and reconstruction with Roux-en-Y
Method: A 38 year old male underwent a laparoscopic sleeve gastrecto-
my at another institution and was discharged on day 1 post-operatively.
He was readmitted with abdominal pain and sepsis. A proximal sleeve
leak was diagnosed on contrast CT. He was transferred to our bariatric
tertiary referral centre where he underwent a laparoscopic washout and
drain placement. He was commenced on TPN and had two attempts at
endoscopic management with fistula clipping and placement of an
Endostitch. Despite this he had a continued leak and he underwent a
laparoscopic resection of the leak and reconstruction with a Roux-en-Y
Results: A standard 5-port technique was used with liver retractor.
Extensive adhesions were divided and a full circumferential dissection of
the oesophagus and proximal sleeve was performed. The distal oesophagus
was transected above the leak site in healthy tissue using a linear stapler.
The proximal sleeve and leak site was resected with a linear stapler. Roux-
en-Y reconstruction was performed with a trans-oral OrVil circular stapled
gastrojejunostomy and a linear stapled jejunojejunostomy. Air leak test was
negative and a drain was placed. The patient had an uncomplicated recov-
ery and was discharged on day 6 tolerating liquid diet.
Conclusion: In our case conservative measures and multiple endoscopic
interventions failed to resolve the ongoing leak. This resulted in a
prolonged hospital stay on parenteral nutrition. Definitive laparoscopic
resection of the leak and Roux-en-Y oesophagojejunostomy resulted in a
positive outcome and rapid recovery for the patient. We therefore con-
clude that laparoscopic Roux-en-Y oesophagojejunostomy is a safe and
effective procedure forpersistent leak post sleeve gastrectomy. This offers
a further option if conservative or endoscopic measures have failed. If
used as a primary treatment option for sleeve leak it may reduce hospital
stay and need for unnecessary or ineffective procedures.
Laparoscopic conversion of gastric band to Single anastomosis gas-
tric bypass with hiatus repair
Ahmed Marzouk
St George's University Hospital, London, United Kingdom. Faculty of
Medicine, Cairo University, Cairo, Egypt
Background: Gastric band is a recognised restrictive management of
morbid obesity. However, long term complications regarding weight re-
gain, hiatus hernia and oesophageal dilatation may boost for a revision
surgery. In this work we demonstrate a conversion of gastric band to
single anastomosis gastric bypass together with hiatal repair.
Method: 44 years old lady presented with high BMI 46kg/ m
has past history of Laparoscopic Gastric band 8 years ago with initial
BMI 48 Kg/m
dropped to 38 kg/m2 and due to symptoms of regurgita-
tion complete band deflation was done 3 years and in turn, the patient had
regained her weight despite trials of lifestyle and dietary modifications.
Patient was evaluated by contrast and endoscopic studies which docu-
mented oesophageal dilatation despite complete band deflation. A deci-
sion of conversion to gastric bypass was takenafter discussion in MDT. In
this video presentation, operative steps are shown.
Results: Total operative duration was 150 minutes with hospital stay 2
days, on 6 months follow up patient has complete resolution of her re-
gurgitation symptoms with a drop in her BMI to 38 Kg/m
. No reported
postoperative complications
Conclusion: Currently the need for Laparoscopic gastric band removal
and conversion to other bariatric modalities is rising. a detailed assess-
ment and evaluation in addition to the availability of technical skills and
technologies are mandatory. Despite the complexity of the procedure it
can be done safely with improvement of the outcomes.
Laparoscopic transgastric interventions in bariatric surgery: indica-
tions and technique
Haris Markakis
, Jessica Kam Wa Mok
Lewisham and Greenwich NHS Trust, London, United Kingdom;
Imperial College Healthcare NHS Trust, London, United Kingdom
Background: Endoscopy is invaluable in the management of patients
after both endoscopic and surgical interventions for the treatment of obe-
sity. However, despite the significant evolution of endoscopic techniques,
there are clinical scenarios where a laparoscopic, transgastric approach
remains the only effective option.
Method: We reviewed the operation notes of all patients operated in our insti-
tution during a 16 month period to identify cases where a transgastric approach
was used. The patients records and video recording of the procedures were then
reviewed in detail, focusing on the indications, technique and outcomes.
Results: A laparoscopic, transgastric approach was used in 6 patients. The
indication was access to the excluded stomach after Roux-en-y gastric
bypass (diagnostic oesophagoduodenoscopy in 1 and endoscopic retro-
grade cholangiopancreatography in 2 patients) and removal of endoluminal
devices (gastric band, gastric balloon and gastrointestinal liner). Techniques
used were insertion of trocar to provide access for gastroscopy, simple
gastrotomy and transgastric endoscopic surgery using multiple ports. All
procedures were colmpleted successfuly, while 3 patients had postoperative
complications related to their original pathology.
Conclusion: The laparoscopic, transgastric approach is a useful operative
technique in bariatric patients. The indications identified in our study
were access to endoscopy and removal of medical devices. The technique
is easy to perform and, despite its invasiveness, it is safe and effective.
Trans Gastric Removal of migrating gastric band: video presentation
Ahmed Marzouk
St George's University Hospital, London, United Kingdom. Faculty of
medicine, Cairo University, Cairo, Egypt
Background: Laparoscopic Gastric band is one of the recognized surgi-
cal management of morbid obesity, however, it is noticed recently a rise of
incidence of band-related complications including Gastric perforation and
Method: This video presentation of patient presented with epigastric ab-
dominal pain with past history of gastric band surgery 6 years prior to
presentation, urgent endoscopic and radiological evaluation proved perfo-
rated and migrating gastric band. On discussion with the patient regarding
possible endoscopic and surgical management patient was not accepting
band removal by endoscopy and was agree to proceed for surgical removal
Results: Laparoscopic trans gastric band removal was done safely with
no reported post operative complications, operative time 60 minutes and
total hospital stay was 2 days.
Conclusion: Laparoscopic management of complicated perforated mi-
grating Gastric band is a valid and safe surgical management
Reduced-Port Laparoscopic Sleeve Gastrectomy with the GelPoint
Access Platform
Andrei Ilczyszyn, Jessica Mok, Roxana Zakeri, Naim Fakih-Gomez,
Mohammed Elkalaawy, Andrew Jenkinson, Marco Adamo
UCLH Bariatric Centre for Weight Management and Metabolic Surgery,
London, United Kingdom
S14 OBES SURG (2019) 29 (Suppl 1):S1S29
Background: TheGelPointAccessSystem(AppliedMedical)hasbeen
proposed as a safe and efficient laparoscopic access platform to facilitate
reduced or single incision surgery. We therefore aimed to assess the per-
formance of the device during a laparoscopic sleeve gastrectomy. We
demonstrate the technique of reduced port sleeve gastrectomy using the
GelPoint Access System.
Method: A 3-port technique was used with liver retractor. The GelPoint
access system was inserted through a trans umbilical incision. A 5mm
LUQ working port and 10mm liver retractor port was inserted under
vision. The greater curve and angle of His were mobilised with
Thunderbeat (Olympus). The sleeve gastrectomy was undertaken with
multiple firings of the Echelon Flex 60 linear stapler (Ethicon
EndoSurgery) using Seamgard (Gore). Methylene blue leak test and hy-
pertensive haemostatic test were performed and were negative. The spec-
imen was removed through the umbilicus and the defect closed under
vision with 1-nylon sutures.
Results: The patient had an uncomplicated recovery and was discharged
on day 2 tolerating liquid diet. The patient was not readmitted and there
were no complications with 30 days. At short term follow up the patient
remained well.
Conclusion: A sleeve gastrectomy using the GelPoint Access System
appeared to be straightforward and safe. It requires no special instrumen-
tation or equipment and does not appear to add excessive time to the
sleeve gastrectomy. Reduced port sleeve gastrectomy may be desirable
in terms of post operative pain, cosmesis and potential complications
including wound infections.
Sleeve gastrectomy in a patient with Continuous Ambulatory
Peritoneal Dialysis
Ahmed Ghanem
, Andrew Palmer
Ahmed Ahmed
St. Mary's Hospital, London, United Kingdom;
Hammersmith Hospital,
London, United Kingdom
Background: Obesity is considered an independent risk factor for chron-
ic kidney disease and increased rates of peritonitis after peritoneal dialy-
sis. Obesity in end-stage renal disease (ESRD) population has trends
comparable to those in general population. Also, the risk of surgical site
and soft-tissue complications are increased among obese individuals as
compared to overweight or nonobese (i.e., BMI < 30) counterparts, as is
the risk of delayed graft function; and together, all these issues contribute
to increased risk stratification before placement on transplant list.
Continuous ambulatory peritoneal dialysis (CAPD) is one of the effective
renal replacement therapies used in patients with (ESRD).
Method: We describe Laparoscopic Sleeve gastrectomy in a 39 year old
morbidly obese gentleman with BMI of 60 on CAPD suffering from adult
polycystic kidney disease with secondary end-stage renal failure (stage
IV) and hypertension. The plan was marking the exact site of the
Tenckhoff catheter used in peritoneal dialysis using superficial ultraso-
nography by the radiology team and liaising with the nephrology team
who suggested to drain out the dialysate preoperatively and keeping the
patient off dialysis for two weeks after to allow him to prevent seepage of
dialysate from his wounds.
Results: Operation was performed according to the plan and patient was
discharged in the second post-operative day. Early follow up of the patient
showed 5 Kg weight loss in the first week. Clip removal was done 2
weeks postoperatively without wound infection. CAPD was started again
2 weeks after the operation. There was no deterioration in urine output
and eGFR.
Conclusion: This is the second reported case of sleeve gastrectomy in a
morbidlyobese patient with CAPD. We recommend cooperation between
bariatric surgery and the nephrology team to safely perform more cases in
the future.
Severe acute pancreatitis: Is it a contraindication for bariatric sur-
Joseph Vance-Daniel
, Hiba Shanti
, Ameet Patel
King's College Hospital, London, United Kingdom;
Kings College
Hospital, London, United Kingdom
Background: A history of acute pancreatitis with complications such as
pseudocyst formation is often considered a relative contraindication and
as a result a number of patients are denied bariatric surgery.
Method: This is a case presentation of a 22-year-old female patient who
underwent a laparoscopic sleeve gastrectomy after a history of
severe acute onchronic idiopathic pancreatitis with radiological evidence
of a large pancreatic pseudocyst. The patient underwent non-surgical
weight loss interventions but her BMI continued to increase. Following
laparoscopic cholecystectomy there were no further episodes of pancrea-
titis and the pseudocyst decreased in size. In view of a BMI of 56 there
were strong indications for considering bariatric surgery.
Results: The intraoperative findings were adhesions between
the psudocyst and the posterior gastric wall. After careful dissection the
sleeve gastrectomy was safely completed. Drain fluid amylase was not
elevated and the patient was discharged on the third postoperative day.
Conclusion: Acute on chronic pancreatitis with pseudocyst formation
can be a contraindication to bariatric surgery. However, with careful se-
lection of patient, assessment of radiology and procedure choice bariatric
surgery may be feasible in experienced hands.
Poster Presentations
Thursday 24 Friday 25 January
An investigation of Vitamin B12 status and cost implications of sup-
plementation in patients post bariatric surgery are we over-
Olivia Edwards, Pratik Sufi, Chetan Parmar, Ali Alhamdani, Mohammad
Howlader, Naiara Fernandez-Munoz, Cleverly Fong
Whittington Health NHS Trust, London, United Kingdom
Background: Patients who undergo bariatric surgery are at risk of
Vitamin B12 deficiency due to malabsorption and restricted nutrition
intake. 2014 BOMSS guidelines recommend providing quarterly 1mg
hydroxocobalamin intramuscular supplementation in Roux-en-Y
Gastric Bypass (RYGB) and Mini-Gastric Bypass (MGB) patients, but
the evidence behind recommendations for Sleeve Gastrectomy (SG) pa-
tients is less established. 2016 ASMBS recommendations suggest350μg-
500μg/day disintegrated oral cobalamin. However, there is a lack of oral
supplements at appropriate doses for bariatric patients available on pre-
scription in the United Kingdom. We aimed to investigate B12 status in
post-operative patients complying with BOMSS recommendations and
compare the cost of supplementation.
Method: A retrospective cohort of post-operative outpatient attenders
was selected from a three month period. Patientssupplementation habits
were documented and serum B12 was measured (197-771ng/I) at their
most recent follow-up. Patients were at various stages of follow-up ranging
from three months to seven years post-operation, and at different
stages between hydroxocobalamin injections. A cost analysis was conduct-
ed comparing the quarterly cost of hydroxocobalamin injections with avail-
able oral cyanocobalamin supplementation. Costs were based on BNFs
NHS indicative prices and may vary between trusts and community med-
ical centres.
Results: 94(38 RYGB,35 SG, 21 MGB) patients were selected. 82.98%
were compliant to quarterly hydroxocobalamin injections (31 RYGB, 28
OBES SURG (2019) 29 (Suppl 1):S1S29 S15
SG, 19 MGB). Of those compliant with supplementation, 51.61% of
RYGB, 50.00% of SG, and 47.37% of MGB had high serum B12 levels
at their most recent screening. 12.77% had serum B12 levels higher than
measurable (>1999ng/I). None had low serum B12. Oral cyanocobalamin
is available in 50μg, 100μg, and 1000μg tablets on prescription. To meet
ASMBS oral supplement recommendations (without exceeding) would
cost a minimum of £14.16-£17.70 per quarter per person. Quarterly
hydroxocobalamin injections equate to £1.90 per person.
Conclusion: A large portion of patients across all types of bariatric sur-
gery have high serum B12 levels with the current BOMSS supplementa-
tion protocol. The expense of oral B12 greatly exceeds intramuscular
supplementation, and higher doses of cyanocobalamin are not routinely
prescribed by General Practitioners and may not be readily available.
However, a variety of affordable oral B12 supplements appropriate for
bariatric patients are available for purchase over the counter. Future re-
search should review the recommendations around the route and frequen-
cy of B12 supplementation and screening, and debate whether
supplementing without evidence of deficiency is justified.
Utilisation of barbed suture material for anastomosis formation in
bariatric surgery Systematic review and meta-analysis
Tom Wiggins
, Muhammad Shaukat Majid
, Sheraz R Markar
, Sanjay Agrawal
, Yashwant Koak
Homerton University Hospital, London, United Kingdom;
College London, London, United Kingdom
Background: Anastomosis formation constitutes a critical aspect of gas-
tric bypass procedures. Barbed suture materials have been adopted by
some surgeons to assist in this task. This systematic review and meta-
analysis aimed to compare the safety and efficacy of barbed suture mate-
rial for anastomosis formation compared to standard suture materials.
Method: An electronic search of Embase, Medline, Web of Science and
Cochrane databases was performed. Weighted mean differences (WMD)
were calculated for effect size of barbed suture material compared to
standard material on continuous variables and pooled odds ratios (POR)
were calculated for discrete variables.
Results: There were seven studies included. Barbed suture material was
associated with a significant reduction in overall operative time (WMD: -
12.76 (95% CI= -20.53 to -4.99) (p=0.001)) and specifically time for
gastro-jejunal anastomosis (WMD: -4.63 (95% CI = -9.21 to -0.05)
(p=0.047)). There was no difference in time for jejuno-jejunal anastomo-
sis (WMD: -3.05 (95% CI =-9.16 to 3.05) (p=0.3272)). There was no
difference in rates of anastomotic leak (POR: 1.25 (95% CI = 0.90 to
1.73) (p=0.19)), anastomotic bleeding (POR: 0.61 (95%CI=0.19 to 1.99)
(p=0.41)), or anastomotic stricture (POR: 0.72 (95% CI = 0.21 to 2.41)
Conclusion: Use of barbed sutures for anastomosis formation during
gastric bypass appears to be associated with shorter overall operative
times, with a particular reduction in time required for complex tasks such
as gastro-jejunal anastomosis formation. There was no difference in rates
of complications (including anastomotic leak, bleeding or stricture) com-
pared to standard suture materials.
Fast track bariatric surgery as part of service development
Alan Osborne, Dimitri Pournaras, Jim Hewes
North Bristol NHS Trust, Bristol, United Kingdom
Background: A lack of inpatient hospital beds in a hyper acute NHS
Trust also serving as a major trauma unit, led to frequent cancellations of
bariatric surgical procedures. Applying the principles of fast-track surgery
is associated with reduced hospital stay. The aim of this quality improve-
ment project was to improve utilisation of short stay beds (23 hours stay)
for bariatric surgery, allowing for an expansion in the number of proce-
dures performed.
Method: A multi-modal change in practice was implemented, incorpo-
rating a change in the work force and the establishment of a perioperative
pathway. Surgical and anaesthetic techniques were standardised. A trans-
disciplinary team was built with the objective of accelerating turnaround
between operations, subsequently including three bariatric procedures in
every elective list. Sixteen patients were analysed before implementation
of fast track, and 198 subsequently.
Results: With fast track, 144 patients were discharged within 23 hours
and 54 required admission (p<0.0001 compared to conventional path-
way). The median hospital stay was 1 day (range: 0-6) reduced from 2
(range: 1-23) p<0.00001. The unit expanded from two to four surgeons
and the number of procedures performed annually increased from 98 in
2014 to 176 in 2018. The aim of undertaking three bariatric surgical
procedures with one to two additional procedures performed in an
eight-hour list is now frequently met. The waiting time for elective bar-
iatric surgery has been reduced from 11 to 2 months.
Conclusion: Fast track bariatric surgery can improve efficiency and cost
effectiveness. More importantly, this strategy can facilitate expansion and
ultimately improve access to obesity care.
UK Single Centre Early Experience of Band on Bypass Procedure
for Weight Regain after Roux-en-Y Gastric Bypass
Jennifer Darrien, Charlotte Harper, Shafiq Javed, David Kerrigan
Phoenix Health, Chester, Cheshire, United Kingdom
Background: Weight regain after Roux-en-Y Gastric Bypass, (RYGB) is
often associated with dilatation of the gastric pouch, the GJ anastomosis
(or both) leading to reduced restriction, satiety and increased meal size.
Dietary and psychological input can support change, but without correc-
tion of the anatomical problem significant weight loss is unlikely.
Surgical options include refashioning of gastric pouch and GJ anastomo-
sis, or conversion to a more malabsorptive procedure (limb lengthening/
SADIS), although outcomes are unpredictable and risk malabsorptive
sequelae. Band-on-Bypass (BOB) offers a simpler, safer method of re-
instigating satiety and lost restriction. We describe our UK experience of
this procedure.
Method: Prospective data collection and analysis. MDT assessment of all
weight re-gain patients after RYGB, including mandatory dietary and
psychological optimisation. Radiological evaluation of gastric pouch
and GJ anastomosis performed with barium, Weetabix and carbex.
Radiological evidence of pouch dilatation and/or dilated GJ anastomosis
required to consider BOB. First band fill 6 weeks post-op. Incremental
band adjustments made at 4 week intervals with continued MDTsupport.
Results: Twenty three BOBs,(2010-2018) performed median 7 years, (2-
17 years) post RYGB, (3 AMI, 5 APL & 15 APS). Pre-RYGB median
weight and BMI: 148kg and 45.7 kgm
, (nadir 82.7kg and 33.1 kgm
Median weight re-gain post-RYGB 21.8kg, (9.4-62.5kg). Pre- BOB me-
dian weight and BMI: 105.8kg and 40kgm
. Median follow-up 21
months, (0-45 months). Median weight loss 9.6kg, (-4.538.9kg).
Median additional %excess weight loss 11.9%, (-7.952.1%). Nine com-
plications; 4 revision band ports, (2 flipped, 1 migrated & 1 relocated), 3
revision band tubing, (intestinal obstruction),1 band replacement, (APL
to APS) to restore restriction and 1endoscopic removal eroded band.
Conclusion: The feasibility of BOB has been confirmed. 9.6kg median
weight loss anticipated to increase as duration of follow-up increases, (9
patients <12month follow-up). Eight out of nine complications prevent-
able by suture fixation band port to substernal fascia, shortening band
tubing to sit within supra-colic compartment, (minimisingrisk small bow-
el obstruction around tubing) and using APS band, (not APL) to ensure
S16 OBES SURG (2019) 29 (Suppl 1):S1S29
adequate restriction. With learning we anticipate BOB to provide a sim-
ple, safe method of re-instigating satiety and lost restrictionin patients
with dilated gastric pouch +/- dilated GJ anastomosis post RYGB.
Long Term Quality of Life in Bariatric Surgery Patients: a prospec-
tive comparative study
Myutan Kulendran, Emma Norton, Hester Carter, Emelie Hutton,
Andrew Wan, Georgios Vasilikostas, Marcus Reddy, Tarek El-Houssari,
Omar Khan
St George's University Hospital, London, United Kingdom
Background: Although Roux-en-Y bypass (RYGB) and sleeve gastrectomy
(SG) are now well established bariatric procedures there is limited long-term
data on patient quality of life (QoL) after these two procedures. The Bariatric
Analysis and Reporting Outcome System (BAROS) is a validated tool for
generating quantitative scores in bariatric patients based on three main domains:
weight loss, QoL and medical conditions. This aim of this prospective study
was to compare pre-operative, short-term (1-year) and long-term (8-year) QoL
in bariatric patients undergoing RYGB and SG using the BAROS tool.
Method: 136 consecutive patients undergoing RYGB (n=92) or SG
(n=44) between May and October 2010 were recruited into this study.
BMI, BAROS questionnaire responses and details of current medical
conditions were recorded pre-operatively and at 1-year and 8-years
post-operatively. Inclusion criteria for final analysis comprised of com-
pleted responses to follow up questionnaires at 1-year and 8-years.
Longitudinal changes in BMI and questionnaire scores for RYGB and
SG procedures were analysed and compared.
Results: 43 patients were included in the final analysis (RYGB, n=32; SG,
n=11). There was no significant difference in BMI or percentage weight loss
at 1 or 8-years post-operatively betweenRYGBandSG.RYGBpatientshad
comparable 1 year but higher 8-year total BAROS scores (p=0.023) as com-
paredtoSG.Specifically,at8yearsthere was an increased improvement in
medical condition scores (p=0.016) compared to SG patients.
Conclusion: RYGB patients appear to have higher self-reported long-term
quality of life scores compared to SG patients despite similar weight loss.
Bariatricsurgery inpatients with HIVon antiretroviral treatment a
case series
Jessica Mok
, Janine Makaronidis
, Andrei Ilczyszyn
, Roxanna Zakeri
Cormac Magee
, Kusuma Chaiyasoot
, Friedrich Jassil
Naim Fakih-Gomez
, Mohammed Elkalaawy
, Majid Hashemi
, Andrew Jenkinson
, Rachel Batterham
Centre for Obesity Research, University College London, London,
United Kingdom;
UCLH Bariatric Centre for Weight Management and
Metabolic Surgery, London, United Kingdom
Background: Obesity is increasingly common amongst people living
with human immunodeficiency virus (HIV). The chronic inflammatory
state seen in HIV infection coupled with the effect of antiretroviral ther-
apy (ART) on adipocytes and fat accumulation further increases the risk
of developing obesity in this patient group. Currently, there are limited
data on outcomes of bariatric surgery in people with HIV and how bar-
iatric surgery impact upon ART and HIV disease progression.
Method: A prospectively-maintained database of patients who
underwent bariatric surgery at a single, tertiary unit over a 10 year period
(2008 - 2018) was reviewed. Patients with HIV were identified and base-
line data and follow-up data were obtained from electronic health records.
Results: Six patients (4-Female, 2-Male, mean BMI 49.0, mean age 51)
were identified. Five patients underwent laparoscopic sleeve gastrectomy
whilst 1 underwent laparoscopic Roux-en-Y gastric bypass. All patients
received ART and had CD4 count>500 with undetectable viral loads.
Type 2 diabetes was present in 2 patients, obstructive sleep apnoea in 2
and non-alcoholic fatty-liver disease in 1. Median weight loss was 19.0%
(range 13-43%, follow-up duration ranging 5months to 8 years). There
were no post-operative complications. One patient experienced weight-
regain. All patients maintained viral suppression with no change in CD4
count. Remission of their weight-related comorbidities was achieved in
all patients.
Conclusion: Bariatric surgery is safe in people with HIV infection. Good
weight loss outcomes and resolution of weight-related comorbidities are
achievable without adverse effects on HIV disease control.
Long-term outcomes following placement of the laparoscopic adjust-
able gastric band effects of optimising follow-up protocols
Biborka Bereczky M.D. Ph.D., Kay Cresswell, Anna Powell, Carol
Green, James Blackwell MRCS, Chris Neophytou MRCS, Paul Leeder
East-Midlands Bariatric & Metabolic Institute (EMBMI), University
Hospitals of Derby & Burton NHS Foundation Trust, Derby, United
Background: The surgical management of morbid obesity remains a
major challenge, with a significant ongoing burden on the NHS. The
optimal surgical procedure remain elusive. The gastric band has been
used successfully since the 1980s. Success in gastric band surgery de-
pends on multiple factors, one of which is a strict follow-up plan. We
assess the effect of changing follow-up protocols on the long term out-
comes of our patients, where the primary modality of treatment of severe
obesity was the laparoscopic adjustable gastric band.
Method: A retrospective study of a prospectively maintained database
was conducted, analysing all patients that had a laparoscopic adjustable
gastric band placed between 2004-2009. Outcomes were assessed at 1, 2,
5 and 10 years post band placement. From 2004-2007 band patients were
followed up on an ad hoc basis (Cohort A). From 2008 onwards, the unit
attempted to implement the Monash University gastric band follow-up
protocols in an NHS setting (Cohort B). The patientsdemographics,
weight and BMI evolution, complications, interval & number of band
adjustments and excess weight loss (%EWL) were analysed.
Results: Both cohorts were closely matched for age and sex, with a mean
pre-operative weight of 134kg and BMI of 48. There was no band-related
mortality. Over the 10 year follow-up period, 206 (27%) required reop-
eration, although only 60 (7.81%) bands were removed. Time to first
band adjustment was 103 [87-141] days (A) versus 77 [60-97] days (B)
(p<0.0001). The median number of adjustments in the first year was 2 (A)
versus 5 (B). The %EWL1yr 21.62 [-4-60] vs. 27.94 [-15-76], %EWL2yr
OBES SURG (2019) 29 (Suppl 1):S1S29 S17
23.73[-15-71] vs. 27.40 [-11-97], %EWL5yr 30.52 [-19-116] vs. 32.32 [-
14-94], %EWL10yr 18.82 [-23-74] vs. 29.19 [-10-105].
Conclusion: Placement of the laparoscopic adjustable gastric band pro-
vides a safe and effective control of morbid obesity. Regular in-hospital
adjustment of gastric bands presents a challenge to the NHS, however
higher frequency of band adjustments and strict follow-up (every 6-8
weeks initially) can result in improved long-term outcomes.
Outcomes of One Anastomosis Gastric Bypass in Morbid Obese
Patients with GastroOesophageal Reflux and/or Hiatus Hernia
Nayer Rizkallah
, James Latimer
, Kamal Mahawar
, William Carr
Neil Jennings
, Norbert Schroeder
Sunderland Royal Hospital, Sunderland, United Kingdom;
University Hospitals, Cairo, Egypt
Background: One Anastomosis Gastric Bypass (OAGB) is now a rec-
ognized bariatric procedure for patients suffering from morbid obesity.
GastroOesophageal Reflux Disease (GORD) and morbid obesity often
coexist. Some surgeons believe that GORD and/or Hiatus Hernia (HH)
are relative contraindications for OAGB. There is limited data on the
effect of OAGB on obese patients with GORD and/or HH. This study
reports our experience of OAGB in these patients.
Method: Data was analyzed retrospectively from a prospective electronic
database of 336 OAGB performed between October 2013 til October 2017.
We collected information on preoperative reflux symptoms, antireflux med-
ications, Oesophogastroduodenoscopy (OGD) findings and postoperative
outcomes. Weight loss was recorded as Excess Weight Loss% (EWL %) &
Total Weight Loss% (TWL %). Complications were divided into Early (less
than 30 days) and Late (more than 30 days).
Results: In our unit, 79 patients with GORD and/or HH had OAGB.
Females accounted for 64.5 % (n=51). Mean age & initial weight were
46.6 years & 136.7kg respectively. Mean EWL% was 74.3%. Mean follow
up was 33.26 months. Preoperative OGD showed esophagitis in 8(10%)
patients and HH in 35(44.3%) patients. Postoperatively, number of patients
with GORD requiring medications dropped from 35(44.3%) to 10(12.6%)
while those with GORD not requiring medications dropped from 21(26.5%)
to 2(2.5%). Eight (10%) patients developedulcers,6(7.5%)patients required
Roux En Y conversion for reflux and 1 patient had HH repair.
Conclusion: This study has clearly highlighted the effect of OAGB on
GORD. The percentage of population suffering from GORD requiring
medical treatment has dropped from 44.3% to 12.6% postoperatively
which is extremely significant (p value <0.0001). To conclude, OAGB
has proven its success in controlling GORD symptoms as well as achiev-
ing around 74% EWL in morbid obese patients.
Successful T2DM Remission post Sleeve Gastrectomy is Dependent
on Higher Baseline Vitamin D Levels
Alanoud Aladel
, Jenny Abraham
, Philip G
, Vinod Menon
University of Warwick, Coventry, PhD student, United Kingdom;
Said University, Riyadh, Lecturer, Saudi Arabia;
School of Medicine,
Western Sydney University, Sydney, Senior Lecturer, Australia;
University Hospitals Coventry and Warwickshire (UHCW) NHS Trust,
Coventry, Bariatric Dietitian, United Kingdom;
Nottingham Trent
University, Nottingham, Head of Biosciences, United Kingdom;
University Hospitals Coventry and Warwickshire (UHCW) NHS Trust,
Coventry, Consultant, United Kingdom
Background: Both obesity and Type II Diabetes Mellitus (T2DM) are
associated with Vitamin D (VITD) deficiency. However, it is unclear
whether VITD levels can predict weight loss or T2DM remission. Thus,
the aim of this study was to investigate baseline VITD levels on weight and
T2DM outcomes 12 months following sleeve gastrectomy (SG).
Method: A cohort of 309 participants (76.4% females) with T2DM (age:
49.8±9.6yr, BMI: 51.1±7kg/m2; n=146) and without T2DM (age: 46±10yr,
BMI: 52.6±6.6Kg/m2; n=163) undergoing SG from a single bariatric centre
in the UK. Anthropometric (including excess weight loss (EWL) and bio-
chemistry blood data were collected until 18 months post-SG. Participants
receiving VITD supplementation at baseline were excluded from the study.
Results: Baseline VITD inversely correlated with baseline BMI
(P<0.001). Those with VITD deficiency had significantly lower BMI
over all time points. Age, pre-surgical %EWL and VITD were correlated
with HbA1c 12-months post-SG (P<0.001, r=0.27, P<0.001, r=-0.16 and
P<0.005, r=-0.18, respectively). After controlling for cofounders, VITD
predicted HbA1c levels post-surgery. Within T2DM group, those who
were in remission 12-months post-SG had higher baseline VITD com-
pared to those remained diabetic (44.57±22 vs. 28.56±16, p=0.000), with
no significant differences in baseline BMI, hypertension, pre-op %EWL.
Patients with higher pre-surgical VITD levels had significantly lower
BMI (p<0.005) and higher %EWL (p<0.05) 12-months post-surgery.
Conclusion: Pre-surgical VITD levels appear to be an important indepen-
dent predictor for T2DM remission and weight loss, 12-months following
SG. Targeted support for patients with low baseline VITD levels may there-
fore enhance such patients to achieve better outcomes.
Perioperative management of type 2 diabetes mellitus around bariat-
ric surgery
Arpit Patel, Cara Frain, Karl Neff, Kirstin Carswell, Ameet Patel
King's College Hospital, London, United Kingdom
Background: Bariatric surgery can result in remission of type 2 diabetes
mellitus (T2DM) in up to 84% of patients, prior to discharge from hospital.
Shorter duration of T2DM, better preoperative glycemic control and signifi-
cant weight loss are factors associated with increased likelihood of T2DM
remission, and lower relapse rates. Patients with T2DM have increased hos-
pital length of stay and morbidity and mortality risks, when undergoing
surgery. Perioperative effects of bariatric surgery on glycaemic control are
unpredictable. Therefore, we have assessed a perioperative management pro-
tocol for T2DM, to optimise patient care, reduce hospital stay and minimise
morbidity around surgery.
Method: We performed a prospective compliance audit of our BProtocol for
adjusting insulin and diabetic medication before and after bariatric surgery^,
over a month. The results, together with our protocol, were presented to our
local team. Practice changes were identified and made. We then re-audited
our practice over a one month period to close the audit cycle. Sample popu-
lation included all patients with T2DM who underwent bariatric surgery
within this time. Datasets were grouped into: pre-operative, intra-operative,
post-operative and after discharge for analysis. Data was analysed using
GraphPad Prism, unpaired t-test was used for comparison, p< 0.05 was con-
sidered significant.
Results: A total of 27 patients met the inclusion criteria in October 2016
(cycle 1, n=12) and November 2017 (cycle 2, n=15). Adherence to the
perioperative management protocol was significantly better in the second
audit cycle (p<0.0001). Intra-operative management showed 100% compli-
ance with set standards during cycle two in terms of variable rate intravenous
insulin infusions being prescribed appropriately. There was also an improve-
ment in post- operative management with regards to appropriate change of
diabetic medication after surgery (p=0.0164). Care on discharge showed no
significant change and is open to improvement, in concert with the primary
care and hospital DM teams.
Conclusion: Prior to the implementation of the management protocol,
there was no standardised approach to perioperative management of
T2DM around bariatric surgery, in out unit. This audit improved our
S18 OBES SURG (2019) 29 (Suppl 1):S1S29
patientscare. In particular, there was an increased effort to educate staff from
different parts of the multi-disciplinary team and raise awareness regarding
difference in the bariatric surgical patientsmanagement. Complex multi-
disciplinary working is in itsinfancy for early elective surgical patients. As
bariatric surgery aims to bridge this gap, novel links with related hospital
teams and primary care providers should be reforged.
No critical care on site means no bariatric surgeryor does it?
Karl Foster, Numan Hamza, Jamie Brown, Keith Seymour, N Corbitt, M
Majid, Sean Woodcock
NSECH, Newcastle, United Kingdom
Background: Bariatric surgery should be performed with access to on-site
critical care (CC) facilities (BOMSS guidelines). The opening of our emer-
gency care hospital (ECH) in 2015, where our CC facilities are based, had a
negative impact on the number of bariatric operations performed due to lack
of elective beds. We took the decision to reinstate bariatric surgery, on appro-
priately selected patients, at our base site hospital (BSH) without on-site CC
facilities or out-of-hours emergency theatre access. This study describes the
changes in our practice we introduced and patientsoutcomes when com-
pared to the previous model that adhered to the BOMSS guidelines.
Method: Primary bariatric operations were identified from our prospectively
collected database and divided into three periods: 24 months prior to ECH
opening (Group 1, n=168), 6 months where procedures were only performed
at ECH (Group 2, n=35), and 28 months following re-introduction of bariatric
surgery at our BSH for low risk and at ECH for high risk patients (Group 3,
n= 202; BSH 170 + ECH 32). Mortality, CC requirements, unexpected
returns to theatre (URTT) during index admission, transfer rate, and length
of stay (LOS) were compared. Changes in practice to allow for BSH operat-
ing were noted. Chi Squared for comparisons.
Results: An anaesthetic/surgical MDT, change in thromboprophylaxis,
morning only bariatric operating at BSH, and a robust transfer policy from
BSH to ECH were established. Overall mortality 0% and (median) LOS was
35 (0%) vs. 5/202 (2.5%), respectively, with no statistically significant differ-
ence (P=0.535) between group 1 and group 3. URTT: Group 1 vs. Group 2
vs. Group 3; 5/168 (3%) vs. 0/35 (0%) vs. 6/202 (3 %) [BSH transfers 4/170
(2%), ECH 2/32 (6%)]. 7/170 (4%) patients operated on at BSH were trans-
ferred to the ECH.
Conclusion: Within our trust, bariatric surgery can safely be performed in
appropriately selected patients without CC or out-of-hours theatre facilities.
Our robust preoperative selection process, transfer policy, and multidisciplin-
ary approach have been key to this success, and we suggest BOMSS guide-
lines be reviewed.
Routine use of intra-gastric balloon in the management of the
) patients: An Obituary
Myutan Kulendran
, Maria Rivera Cartland
,Jun Yi Lau
Georgios Vasilikostas
, Marcus Reddy
, Omar Khan
St George's Hospital, London, United Kingdom;
Kingston Hospital
NHS Foundation Trust, London, United Kingdom;
Royal Surrey
County Hospital, Guildford, Surrey, United Kingdom
Background: Surgical management of BSuper-Super-Obese^patients
) presents a significant challenge. In our specialist quater-
nary bariatric institution, we had previously managed such patients with a
two-stage procedure with intra-gastric balloon insertion, followed by
sleeve gastrectomy. Since November 2011, we have changed our policy
to attempt a single-stage approach. The objective of this study was to
compare the outcomes of two-stage versus a single-stage procedure.
Method: A prospectively collected, single institution database of patients
between BMI60kg/m
and <75kg/m
was analysed on an intention to treat
basis. Outcomes in patients who underwent single-stage and two-stage bar-
iatric surgical procedures between July 2010 and April 2015 were compared.
Results: 21 consecutive patients per group were compared. The initial BMI
was 66.1±4.0kg/m
and 63.7±3.9kg/m
in the two-stage and single-stage
groups respectively. At one year following definitive surgery, there was no
significant difference in %Excess Weight Loss (44.7±13.2 vs 42.9±20.2,
p=0.74) and BMI (47.4±6.3 vs 46.9±9.0, p=0.84). Total inpatient stay was
greater in the two-stage group (4.6 ±2.4 vs 2.3±0.7, p=0.0002) with three
complications due to the balloon (ulcer, vomiting) and two complications
following sleeve gastrectomy (abdominal pain, bowel obstruction); two pa-
tients required readmission. The single-stage group had two peri-operative
complications (atrial fibrillation, hypotension) but no readmissions.
Conclusion: Single-stage bariatric surgery in BSuper-Super-Obese^pa-
tients (BMI60kg/m
and <75kg/m
) is a feasible strategy with compa-
rable outcomes to a two-stage approach. It is associated with shorter
hospital stay, fewer complications and fewer readmissions.
Bariatric complaints snapshot from a Bariatric Centre
Biborka Bereczky Ph.D., Ashok Bohra MS FRCS
East-Midlands Bariatric & Metabolic Institute (EMBMI), University
Hospitals of Derby & Burton NHS Foundation Trust, Derby, United
Background: The complaints and litigations in the Bariatric world are on the
rise. We set out to audit the nature of the official complaints received by our
centre and the responses. Since the introduction of the Tier 3 and 4 systems as
per NHS England guidance, in 2014, we have seen a change in the weight
management programme, resulting in mandatory waits of a year for those
patients with a BMI <50 and of 6 months for those with BMI >50.
Method: All complaints and responses which were received by the Trust
over the past 5 years, were reviewed. The nature of each complaint (both
clinical- and non-clinical) and the resolution was analysed. Data were
taken from the PALS (Patient Advice & Liaison Service) Office.
Results: Over the past 5 years 12 official complaints were placed. Weve
received 3 complaints due to waiting list delay or cancellation of admission/
surgery/appointments; 4 complaints where bariatric surgery was not offered
due not meeting the eligibility criteria - mental health issues (2), low BMI (1)
or unrealistic expectations (wanted PEG tube insertion for weight manage-
ment); 3 gastric band related (port leakage, band erosion, and inadequate
weight loss), one post sleeve gastrectomy stricture; 1 due to poor understand-
ing of medical priorities (patient insisted to have hernia repair prior to weight
loss surgery). All written complaints were investigated and answered.
Conclusion: Only 1/3 of the complaints were due to postoperative compli-
cations. Most of these were Band related. The remainder of complaints were
due to poor understanding of NHS guidelines or the MDT process, unrealistic
expectations, communication gaps, long waiting time, or mental health issues.
The Role of Routine Contrast Study Post Bypass: a Hard Truth to
Sean Henderson, George Mori, Ben Rees, Emma McCabe, Emily Futers,
Tamir Salih, William Ainslie, Pedro Ballester, Mark Peter, Brian
Dobbins, Arin Saha
Huddersfield Royal Infirmary, Huddersfield, West Yorkshire, United
Background: Anastomotic leak is perhaps the most feared early compli-
cation after Roux-en-Y gastric bypass for morbid obesity. Many surgeons
routinely request a water-soluble contrast swallow after surgery to
OBES SURG (2019) 29 (Suppl 1):S1S29 S19
exclude a leak though this practice often leads to a delay in discharge and
increased cost. This study aimed to describe the practice of routine post-
operative swallow in our unit.
Method: All patients who had a Roux-en-Y gastric bypass for morbod
obesity between October 2009 and November 2018 at our unit were
identified from a prospectively maintained database. Prior to 2017, stan-
dard practice was to perform a post-operative water-soluble swallow.
After 2017, the unit introduced a number of efficiency measures and
standardised pathways and stopped performing post-operative swallow.
The incidence of leaks, time of detection and outcomes were recorded and
compared between the two groups.
Results: There were 328 patients. There were no post-operative deaths.
254 patients (77%) underwent routine contrast swallow; this occurred
between 1 and 3 days after surgery. Leaks were confirmed in 3 of these
initial swallows; these were taken back to theatre and had re-operation
and revision of the gastro-jejunal anastomosis with successful outcome.
Five patients had a swallow that was equivocal for leak; none of these
patients exhibited clinical evidence of leak and were managed conserva-
tively with success and without any requirement for any re-intervention.
After the change in policy, median length of stay fell from 3 days to 1 day
Conclusion: Routine contrast swallow following RYGB did not increase
detection of post-operative leak or influence or hasten associated man-
agement and outcomes. Removal of a water-soluble contrast swallow
from a routine post-operative management planis safe and the test should
be reserved for patients who exhibit deviation from standard post-
operative recovery.
Conversions to Roux En Y Gastric Bypass from One Anastomosis
Gastric Bypass: Causes & Outcomes
Nayer Rizkallah
, James Latimer
, Kamal Mahawar
, William Carr
Neil Jennings
, Norbert Schroeder
Sunderland Royal Hospital, Sunderland, United Kingdom;
University Hospitals, Cairo, Egypt
Background: One Anastomosis Gastric Bypass (OAGB) is gaining more
popularity amongst bariatric procedures. Although the scientific literature
is rich in studies outlining the outcomes of this procedure, the data in-
volving conversions to Roux En Y Gastric Bypass (RYGB) is still limit-
ed. This study is designed to focus on causes of conversions to RYGB and
postoperative outcomes.
Method: Data was analyzed retrospectively from a prospective electronic
database of 565 OAGB performed from October 2013 till October 2018.
Pre-operative weight and endoscopy were recorded. The timing & cause
of conversion were identified along with the performed investigations.
The surgical technique of conversion was noted from operative report.
Clinical outcomes and complications of initial and later procedure were
looked into. Weight loss achievements were calculated in the form of
Excess Weight Loss% (EWL%) & Total Weight Loss% (TWL%).
Results: During this period, 16(2.8%) patients were converted to RYGB.
One patient was excluded (giving history of conversion from gastric band
to OAGB to RYGB). Females accounted for 60% (n=9). Mean age was
51.1(21-62) years. Mean initial weight was 142.3(94.2-239) kg. Mean
EWL% was 73.7%. Mean follow up was 42.7 months. Only one patient
had esophagitis on pre-operative endoscopy. Causes of conversion were
reflux 13(2.3%) & marginal ulcer 2(0.3%). Pre-conversion endoscopy
revealed reflux (11) and marginal ulcer (2). Mean timing of conversion
was 22(6-44) months. All patients showed improved clinical symptoms
except one with recurrent ulcers.
Conclusion: In our unit, conversion to RYGB from OAGB has mainly
been done to relieve reflux symptoms. This study has clearly outlined the
success achieved by conversion to RYGB in controlling the patients
symptoms. However, patients with marginal ulcers might still experience
recurrent ulcers with RYGB. The predominant surgical technique was
simple Roux conversion. Revision of gastro-jejunostomy was only
required where perforation/stricture was found. This study reflects our
experience with conversions to RYGB.
Establishing the Current Usage of Smartphone Technology in
Bariatric Surgery Patients
Richard Newton, Oliver Clough, William Hawkins, Christopher Pring,
Guy Slater, Andrew Currie, Deepti De Araujo, Madeleine Bates, Lorraine
St Richard's Hospital, Chichester, West Sussex, United Kingdom
Background: Personal technology is being increasingly used in
healthcare. This study aimed to establish the current usage of health,
fitness and weight loss (HFW) mobile phone apps, activity monitors
and online peer to peer support groups amongst the bariatric patients
served by a high volume bariatric service.
Method: All adult patients engaging with the bariatric department be-
tween 5/11/18 and 16/11/18 were asked to complete a 15 part question-
naire about technology engagement, and about their interest in a compre-
hensive, fully integrated, dedicated bariatric app. 61 patients completed
the questionnaire (19 perioperatively on the ward; 42 from clinic). 72%
were female. Patients had a mean BMI of 43, were aged 18-71, and 89%
were White British.
Results: Patients used daily: smartphones (92%), tablets (57%), HFW
apps (36%), and activity monitoring (31%). 64% had downloaded
HFW apps. The primary focusses were calorie counting, activity moni-
toring, and weight tracking. Of 23 different HFW apps used, the most
popular daily ones were BMy Fitness Pal^(13%) and BFitbit^(10%), and
weekly BMy Weight^(10%). Online HFW peer-to-peer support groups
were used by 52% (women F=64%, M=25%; p=0.008). Patients de-
scribed five local forums (32 mentions) more frequently than twelve
national/international forums (13 mentions). 85% of all patients would
use a dedicated bariatric app, 64% would pay, most commonly £2-5/
Conclusion: Most of the responders use smartphones, and a growing
minority are harnessing technology for an explosion of both HFW apps
and (especially local) HFW peer-to-peer support groups. Only one patient
in the study used a bariatric centred app (Baritastic), but with most pa-
tients prepared to pay a subscription to support a useful, dedicated,
evidence-based and fully integrated patient centred bariatric app, perhaps
bariatric clinicians should be harnessing these technologies more readily.
Symptomatic Gallstone Disease Development Following Bariatric
Surgery 2 Year Follow Up Data
Karim Jundi, Giordano Perin, Michael Pellen
Hull and East Yorkshire Hospitals, Hull, United Kingdom
Background: Obesity and weight loss both increase the risk of gallstone
formation. Access to the biliary tree is altered by certain bariatric proce-
dures with implications for managing future symptomatic gallstones. The
aim of this study is to evaluate the rate of development of symptomatic/
complicated gallstone disease following bariatric surgery
Method: We retrospectively reviewed all patients undergoing a bariatric
surgical procedure (Gastric Bypass, Sleeve Gastrectomy or duodenal
switch) in the year 2015. We collected data concerning preoperative
BMI, weight and diagnosis of gallstone disease, 12 months and 24
months follow up. For patients being diagnosed with gallstone disease
during the follow up period we collected data concerning admission rate,
reason for admission, decision to perform cholecystectomy.
Results: Overall 66 patients underwent a bariatric surgical procedure in
the analysed period (mean age 45y, median preoperative BMI 51). Three
S20 OBES SURG (2019) 29 (Suppl 1):S1S29
out of 66 patients had a cholecystectomy before being referred to our
services. During the follow up period 9/63 patients developed symptomatic
gallstone disease (mean age 42y, median preoperative BMI 55). Seven of
those 9 patients had an elective laparoscopic cholecystectomy performed
within the follow up period, 2 were on the waiting list. Overall we recorded
5 emergency admissions for gallstone disease during the follow up period.
We recorded 3 cases of biliary colic and 2 cases of cholecystitis.
Conclusion: At 2 year follow up following bariatric surgery
symptomatic/complicated gallstone disease can affect up to 14% of pa-
tients with no pre-operative history of gallstone disease.
Safety of switching from Roux-en-Y to single anastomosis gastric
bypass: A single surgeon experience
Chanpreet Arhi, Debasish Ghosh, James Bartram, Sonia Ike, Yashwant
Homerton University Hospital, London, United Kingdom
Background: Although several reports describe the single anastomosis
gastric bypass (SAGB) as a valid alternative for the laparoscopic Roux-
en-Y Gastric Bypass (LRYGB), experience in the UK is relatively limit-
ed. Here we describe the experience ofa single surgeon after switching to
a predominantly SAGB service.
Method: The first consecutive one hundred SAGB were compared with
the last consecutive one hundred LRYGB in terms of patient demo-
graphics, co-morbidities (diabetes, OSA, hypertension, cardiovascular)
ASA grade and BMI before surgery. Outcomes of interest were length
of stay (LOS) and the odds ratio of a complication within 30 days after
accounting for the above factors.
Results: The last LRYGB was carried out in 2016, with 14, 48, 38 SAGB
in 2016, 2017 and 2018respectively. There was no significant difference
in co-morbidities, ASA or mean BMI (46.9 kg/m
LRYGB vs 44.5
SAGB), although SAGB patients were significantly older (median 50vs
47 years p=0.04) and female (81.8%vs 68.1% p=0.03). The median LOS
was significantly shorter following SAGB (1vs 2 days p=0.03). There
was one leak treated conservatively after a SAGB and no deaths in either
cohort. No significant difference in overall complications was noted in
univariate (SAGB 7.1%vs LRYGB 4.1% p=0.25) or regression analysis
(OR 0.36 95%CI 0.691.91 p=0.23).
Conclusion: Switching to SAGB is a safe alternative to LRYGB for a
surgeon with experience in the latter. The reduced LOS for SAGB reflects
not only on the surgeon, but also the bariatric unit as a whole.
Laparoscopic Roux-en-Y Gastric Bypass versus Laparoscopic Sleeve
Gastrectomy for Obstructive Sleep Apnoea resolution
Hussein Al-Rubaye
, Emma Rose McGlone
, Borna Farzaneh
, Mae Johnson
, Caroline-Louise English
, Marcus Reddy
Omar Khan
St. George's, University of London, London, United Kingdom;
Imperial College London, London, United Kingdom;
St. George's
Hospital, London, United Kingdom
Background: Bariatric surgery is an effective treatment for obstructive
sleep apnoea (OSA), leading to high rates of long-term resolution. The
mechanism through which this occurs is not well understood, although
weight loss via non-surgical means is also associated with improvement
in OSA. The aim of this systemic review and meta-analysis was to com-
pare the efficacy of laparoscopic sleeve gastrectomy (LSG) and Roux-en-
Y gastric bypass (RYGB) leading to resolution of OSA.
Method: A comprehensive search of MEDLINE, Pubmed, Embase, and
OVID was performed. Eligible studies compared rates of OSA resolution
in obese patients following RYGB or LSG. Randomised controlled trials,
comparative prospective and matched cohort studies were included.
Resolution of OSA was defined as no longer requiring night-time contin-
uous positive airway pressure (CPAP). Meta-analyses were performed
using fixed or random effects models depending on statistical heteroge-
neity. Risk of bias within and across studies was assessed using validated
scoring systems.
Results: Five studies (309 participants) were included: 4 cohort studies
and 1 randomised controlled trial; all with low risk of bias. LSG was
associated with a better rate of OSA resolution than RYGB, although this
was not statistically significant at 12 or 36-month follow-up (OR 1.24,
95% CI [0.64 to 2.41]; p=0.52 and OR 1.27, 95% CI [0.51 to 3.12];
p=0.61 respectively). In contrast, within the selected studies LSG was
associated with less percentage excess weight loss at both time points,
and this was significant at 36 months (SMD 8.25, 95% CI [2.91 to 13.58];
Conclusion: LSG trends towards providing better resolution of OSA than
RYGB, despite poorer weight loss. This would suggest that the underly-
ing mechanisms responsible for OSA resolution following bariatric sur-
gery are not entirely weight loss dependent. Further good quality random-
ized controlled trials areawaited to further evaluate the relative efficacy of
these procedures in leading to OSA resolution.
The first Irish Metabolic Surgery Pilot
Zsolt Bodnar, Paul O'Connor, Amjed Khamis
Letterkenny University Hospital, Letterkenny, Donegal, Ireland
Background: Until not long ago the diabetes was a medical disorder. The
first results of the bariatric surgery that was capable to reach a good
control of the type 2 diabetes mellitus came from the 90's.
Unfortunately, the Irish population has the highest BMI in the European
Union and the total number of diabetic patients has doubled during the
last two years. Based on these data the first Irish metabolic surgery pilot
study was organized and carried out last year in our hospital.
Method: The authors present in detail the first pilot study of Irish
Metabolic Surgery with the first year follow-up results. Fifteen diabetic
patients were included meeting the following criteria: more than two
years of diabetes, age under 70, HbA1C>8% duringat least one year with
the failure of adequate antidiabetic therapy. All the patients wereoperated
in the same hospital and laparoscopic Roux-en -Y gastric bypass surgery
was performed in each case. The first operation was performed on 22nd
May and the last was on 18th December 2017.
Results: Authors present the one-year follow-up results. During the first
year, complete diabetes remission was achieved in 80% of this patient
cohort. Of 15 patients, 12 had stopped taking all hypoglycemic drug
treatments and 3 patients' drug dose was reduced by more than 50%
compared to pre-surgical values.
Conclusion: The gastric bypass surgery has a great and important
effect on type 2 diabetes treatment; therefore metabolic surgery
should be included in the next national surgical program in
Evaluating a potential role for community pharmacists in post-
bariatric nutrient support (VITAMINS)
Yitka Graham
, Charlotte Earl-Sinha
, Lindsay Parkin
, Peter Small
, Nim de-Alwis
Catherine Hayes
University of Sunderland, Sunderland, Tyne and Wear, United
Sunderland Royal Hospital, Sunderland, Tyne and Wear,
United Kingdom
OBES SURG (2019) 29 (Suppl 1):S1S29 S21
Background: Patients are under the care of the bariatric multi-
disciplinary team for two years before discharge into General Practice
for long-term follow up. Guidelines advocate annual monitoring of nutri-
tional status and supplementation, but no consensus exists on what this
should entail. Findings from our recent study showed a patient-reported
need for further post-surgical vitamin and mineral supplementation sup-
port. Currently, community pharmacists do not have a defined role in
post-bariatric support but have skills and accessibility that could support
patients long-term. The aim of this study was to explore a potential role
for community pharmacists in post-bariatric surgical nutrient support.
Method: Participants were recruited from a bariatric surgical unit in a
large NHS hospital and a public list of community pharmacies selected
through analysis of geographical referrals to the unit and approached in
writing. Individual, semi-structured interviews, assisted by a topic guide
were carried out in person or by telephone and audio-recorded.
Anonymised data was transcribed verbatim and analysed through a qual-
itative constant-comparative framework to understand participantsper-
spectives, identify common themes and develop a conceptual framework
with which to construct a framework for a potential community pharmacy
role in bariatric patient support. Recruitment took place between June
August 2018.
Results: Twenty-five participants were recruited to the study. Bariatric
staff (n=9) reported negligible interaction with community pharmacists,
but felt establishing communication and a potential pathway to embed
community pharmacists as part of patient care would provide additional
support, resource and potentially improved compliance with supplemen-
tation. Community pharmacists (n=16) reported poor knowledge of bar-
iatric surgery and were not able to identify bariatric surgery patients in
routine practice, but understood issues with absorption of vitamins. With
appropriate training and a pathway created in collaboration with the bar-
iatric team, pharmacists felt this would benefit patients and extend the role
of community pharmacists.
Conclusion: There are opportunities to involve community pharmacists
in post-bariatric patient support for vitamin and mineral supplementation.
Pharmacists possess knowledge around absorption, distribution, metabo-
lism and excretion of vitamins and minerals meaning that education
around the mechanisms of bariatric procedures and nutritional recom-
mendations for patients would be straightforward. Communication be-
tween bariatric units and community pharmacies is needed to discuss
logistics of support in practice and construct a framework to ensure pa-
tients are aware of pharmacist support, their needs are met and recom-
mendations followed. The issue of payment to carry out a service needs to
be agreed for it to be financially viable.
2 Year Resolution Rate of Obstructive Sleep Apnoea Syndrome and
Type 2 Diabetes Mellitus Following Bariatric Surgery
Giordano Perin, Karim Jundi, Michael Pellen
Hull and East Yorkshire Hospitals NHS Trust, Hull, United Kingdom
Background: Obstructive Sleep Apnoea Syndrome and Type 2 Diabetes
Mellitus are conditions commonly affecting morbidly obese patients and
may be undiagnosed or untreated. Preparation for bariatric surgery can
identify undiagnosed comorbidity and offer potential remission. The aim
of this study is to evaluate the effect of bariatric surgery on the natural
course of Obstructive Sleep Apnoea Syndrome (OSAS) and Type 2
Diabetes Mellitus (T2DM).
Method: We retrospectively reviewed all patients undergoing a bariatric
surgical procedure (Gastric Bypass, Sleeve Gastrectomy or duodenal
switch) in the year 2015. We collected data concerning preoperative
BMI, weight and diagnosis of OSAS and T2DM, 12 months and 24
months follow up.
Results: Overall 66 patients underwent a bariatric surgical procedure in
the analysed period (mean age 45y, median preoperative BMI 53).
Twelve patients were identified as having undiagnosed OSAS. 2/12 did
not require treatment before or after surgery; 3/10 patients were still
requiring non-invasive ventilation treatment at 24 months; 7/10 patients
had a full remission of OSAS at 12 and 24 months. Twelve patients had a
preoperative diagnosis of T2DM. At 24 months2/12 patients were still on
medical treatment while 9/12 had a complete remission. One 30 day
mortality case was recorded in the T2DM group.
Conclusion: Bariatric surgery significantly reduces the long term impact
of both OSAS and T2DM and can induce remission in up to 70% and
75% of the patients respectively.
Management of failed and complicated Gastric Band: personal ex-
perience and proposed management plan
Ahmed Marzouk
St. George's University Hospital, London, United Kingdom. Faculty of
Medicine, Cairo University, Cairo, Egypt
Background: Obesity has become a worldwide epidemic disease, in turn,
weight loss surgery has progressed markedly in last decades since late
1990s laparoscopic adjustable gastric band (LAGB) surgery has become
a popular surgery with wide application. However, recently a rise in the
number of patients who have either failure of weight loss maintenance or
band-related complications has been noticed. In turn, the need for
revisional surgery post gastric band is progressively increased.
Method: In this study a review of 37 cases presented with gastric band-
related complications, with an investigational plan including imaging and
endoscopic evaluation was adopted for patients evaluation, accordingly
after discussion in a bariatric multidisciplinary team and the patients,
management was done for each individual patient which ranged from
adjustment of the band up to band removal with or without conversion
to other modality of weight loss surgeries simultaneously or staged.
Results: 37patients, mean age 36 years, Mean BMI 37.7, mean post band
surgery duration 34 months. 24 (64.86%) presented with weight regain,
19 (51.4%) have reflux and regurgitation not responding to medical man-
agement, 10 (27%) had vomiting and food intolerance. All had radiolog-
ical and Endoscopic evaluation, 28 (75.67) had an evident hiatus hernia
and oesophageal dilatation, 5 of them (17.9%) low-grade dysplasia
(Barret's oesophagus), 5 (13.5%) various degrees of band slippage, and
2 band-migrating. Accordingly, band adjustment in 8 patients (21.6%),
Band removal (including trans gastric band removal) in 12 (32.4%), and/
or conversion (sleeve-gastrectomy 3/17, RYGB 10/17 or SAGB 4/17)
Conclusion: Management of failed or complicated gastric bandmandates
a meticulous evaluation and assessment in order to have a proper decision
making to ensure best patient outcomes.
How well are bariatric surgery patients being monitored after dis-
charge? Lessons learned from an inner-city GP practice, and pro-
posed strategies for improvement
Ghazaleh Mohammadi-Zaniani
, Pipin Singh
Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle
Upon Tyne, Tyne & Wear, United Kingdom;
The Village Green
Surgery, Newcastle Upon Tyne, Tyne & Wear, United Kingdom
Background: NHS patients who have undergone bariatric surgery are
discharged from theirsecondary care department 2 years post-operatively,
provided there are no interim issues. Thereafter their annual monitoring is
taken over by their GP. It is well known that bariatric surgery patients
remain at risk of clinically significant nutritional deficiency post-opera-
tively, and the release of BOMSS guidance of nutritional status monitor-
ing in 2014 clarifies what is required in primary care. We aimed to assess
S22 OBES SURG (2019) 29 (Suppl 1):S1S29
whether this was being adhered to in a relatively large and well-
performing inner-city GP practice.
Method: A search of the 10,504 registered patients identified 26 patients
as having undergone either Sleeve Gastrectomy, Laparoscopic Assisted
Gastric Band (LAGB), or Gastric Bypass. We assessed whether patients
had undergone biochemical monitoring in adherence to BOMSS guide-
lines. The patient record was checked to assess whether appropriate elec-
tronic alerts were in place to advise healthcare providers of the need for
biochemical monitoring. Due to the project findings, discussion was had
with the local laboratories for the provision ofa bariatric-specific order set
of bloods aimed at the gastrectomy and bypass patients, to prevent in-
complete monitoring in the future.
Results: Of the 26 patients, 12 underwent Gastric Bypass, 6 LAGB, and
8 Sleeve Gastrectomy. One patient had their LAGB reversed and was
excluded from analysis. Only 3 patients (12%) were fully compliant with
monitoring, and 9 patients (36%) had no monitoring after their secondary
care discharge. The remainder had irregular monitoring and often an
incomplete panel of tests. This was despite 17/25 having correct electron-
ic alerts on file. 19 patients requiring recall were identified and invited for
blood tests. At time of writing 10 were successfully recalled with 5 new
nutritional deficiencies identified, requiring discussion with secondary
care and treatment.
Conclusion: The experience of this practice indicates that inadequate
biochemical monitoring of bariatric patients has the potential to lead to
patient harm. Recalls also identified a lack of patient compliance with
nutritional supplements. This otherwise successful practice is struggling
to monitor its bariatric patients adequately, a fact potentially compounded
by the fact that bariatric surgery follow-up does not fall under the Quality
and Outcomes framework (QOF) indicators. This may merit future dis-
cussion on the structure in which primary care follow-up is organised and
funded for chronic health conditions, and a wider audit of primary care
monitoring would be beneficial.
Utility of the Apollo OverStitch Device for the endoscopic revision of
the gastro-jejunal stoma in patients with weight regain after Roux-
en-Y gastric bypass (RYGB)
Vasha Kaur, Devinder Bansi, Marta Mano Lopes, John Cousins, Ahmed
Imperial College, London, United Kingdom
Background: Roux-en-Y gastric bypass (RYGB) can achieve up to 60%
weight loss 2 years after surgery but 30% of patients will regain their
weight within 2 years. The options for this group of patients are limited;
redo surgery can be challenging with a greater risk of complications.
Endoscopic revision of the gastro-jejunal anastomosis using the Apollo
OverStitch device now offers an alternative option in these patients to
achieve further weight loss. Here we report our experience using this
device, which is the largest patient cohort in the UK to date.
Method: Between April 2017 and Nov 2018 we have used the Apollo
OverStitch device in 20 patients who had regained weight after an initial
RYGB. All patients were discussed initially at our bariatric MDT. All
patients underwent a prior gastroscopy to ensure a stoma size of at least
2cm. All cases were done under general anaesthetic.
Results: Here we report on the 3 month data for our first cohort of 13
patients.11 patients were female. 10 managed to lose weight at 3 months,
with an average weight reduction of 7kg. One patient had a re-do proce-
dure, having dropped from 104kg to 95kg and then further to 88.8kg.
Conclusion: Endoscopic revision of the RYGB stoma using the Apollo
OverStitch device is an effective method of achieving further weight in
these patients. Although the results in our patient series so far have been
relatively modest, other reports have achieved an average of 11.7kg at 6
months. We arenow revisingour technique to incorporate more 'bites' for
each suture placed, as well as following the first line of sutures with a
second in order to achieve a tighter effect on reducing the stoma size. We
have since done a further 7 patients making our cohort the largest in the
Nathanson versus PretzelFlex: which is better?
Sumit Midya
, Aishah Hakim
, Jessica Toombs
, Sandra Katswere
Gregory Jones
, James Ramus
, Marianne Sampson
Royal Berkshire Hospital, Reading, United Kingdom;
Royal Berkshire
Hospital, Reading, United Kingdom
Background: Retraction of the left lobe of liver to access the proximal
stomach, is an important step in any bariatric procedure. Nathanson Liver
Retraction System (Cook Medical) and PretzelFlex Surgical Retraction
(Surgical Innovations) are the commonly used liver retractors
in most centres. The aim of this study is to compare these two instruments
and find out which of them is better in bariatric procedures.
Method: This is a retrospective study of patients undergoing gastric
bypass and sleeve gastrectomy in the last eighteen months at our centre.
We did not include patients undergoing gastric band surgery or non-
bariatric procedures like anti-reflux surgery. The type of retractor used
in each procedure, was dependent on the surgeon's choice and availability
of instruments. We collected the following data: operating time, postop-
erative pain score, presence or absence of postoperative nausea/vomiting,
postoperative liver function tests (LFT) and C-reactive protein (CRP).
Results: We have included 211 patients, of whom 174 underwent gastric
bypass and 37 had sleeve gastrectomy. Nathanson was used in 126 pa-
tients, while PretzelFlex was used in 85 patients. The meanoperating time
was similar in both the arms. The mean postoperative pain score was
higher with Nathanson and postoperative nausea/vomiting was also more
common in these patients. The serum ALT (Alanine aminotransferase)
level which is a marker of hepatocellular damage was significantly in-
creased after use of Nathanson as compared to PretzelFlex (mean 208 vs.
87). The mean CRP levels were also elevated in patients where
Nathanson was used.
Conclusion: Both Nathanson and PretzelFlex produce adequate retraction
of the left lobe of the liver and our surgeons found them equally effective.
Nathanson produced more hepatocellular damage as evidenced by the
marked increase in ALT but this was entirely reversible. In our study, use
of Nathansons retractor was associated with increased levels of postoper-
ative pain, nausea and higher levels of postoperative CRP; but these were
not found to be statistically significant. We would recommend randomised
studies with larger number of participants to gain further evidence.
Evaluating inpatient perceptions of body weight, the associated
health effects and achieving body weight goals
Tim Gardner
, William Norton
, George Ramsay
, Lorna Aucott
, Alison
Ave n ell
, Shayanthan Nanthakumaran
Aberdeen Royal Infirmary, Aberdeen, United Kingdom;
University of
Aberdeen, Aberdeen, United Kingdom;
University of Aberdeen,
Aberdeen, United Kingdom
Background: Obesity is an international pandemic. Obese individuals
have increased risks of comorbidities and associated health detriment. In
order to reduce obesity related health problems, individual patient moti-
vation is key for weight loss. However, it remains unclear if patients with
co-morbidities who are admitted to hospital perceive their illness to be
attributable to their weight or if they are aware of available risk reducing
and weight loss strategies. We seek to assess inpatient perceptions of
weight, its health impact, barriers to weight change and awareness of
available weight management programmes.
OBES SURG (2019) 29 (Suppl 1):S1S29 S23
Method: This was a questionnaire-based pilot project. Patients admitted
to emergency general surgery or acute medicine were invited to take part.
Ethical permissions were obtained through proportionate ethical review
and the project was supported through NHS Grampian Research and
Development. Informed consent was obtained from all patients who
agreed to take part. Paper questionnaires were given to each patient in
which patients were asked to estimate their weight, explore their knowl-
edge of obesity associated co-morbidity and motivators/ barriers to
weight loss.
Results: 50 participants, median BMI 28.6 (range 19.4 - 49.7). 31.9%
were of healthy weight and 68.1% overweight. Of normal weight partic-
ipants, 20% overestimate their weight, 13.3% underestimate. In the over-
weight category, 6.3% overestimate their weight, 28.1% underestimate (p
= 0.25), 61.8% were concerned their weight was too high. Weight
Management Programme use was low (17 individual uses in 32 over-
weight participants). Barriers to engagement were pain (30%), time
(34%) and physical health (36%). Motivators included improving fitness
(60%), health (56%) and self-confidence (46%). 35% of overweight pa-
tients did not feel they were adequately informed of ways to optimise their
Conclusion: Two thirds of our patient cohort were overweight. Just under
30% underestimated their weight and approximately 40% were not con-
cerned their weight was too high. Therefore, in this pilot study, there is a
lack of patient perception. Use of nationally-run and NHS-funded weight
management programmes must be encouraged by healthcare profes-
sionals, along with guidance and support on weight management. This
pilot study will be used to develop further strategies on enhancing en-
gagement with these weight management programmes. With the mean
BMI of the population increasing, the NHS must be prepared to face this
issue head-on, with adequate funding and support.
Evaluating attendeesperceptions of attending a bariatric patient sup-
port group
Lisa Wilde
, Arun Sekhar
, Catherine Hayes
, Yitka Graham
Sunderland Royal Hospital, Sunderland, Tyne and Wear, United
University of Sunderland, Sunderland, Tyne and Wear,
United Kingdom
Background: A regional bariatric support unit delivers a monthly patient
support group, via specialist nurse facilitation, supporting an open and
ongoing invitation to both pre- and post-surgical bariatric patients. The
rationale for the group is threefold; to provide an active community of
peer support, to facilitate further interactions with the bariatric multidis-
ciplinaryteam, and to provide an inclusive forum for the context of shared
experience and the co-construction of knowledge surrounding both ex-
pectations of and the lived experience of bariatric surgical intervention.
The specific aim of this study was to evaluate attendee perceptions of the
value of attending the support group.
Method: Participants (pre- and post-operative) were recruited from two
nurse-led monthly bariatric patient support groups at an NHS hospital.
Participants were invited to voluntarily undertake an anonymous printed
survey, distributed during the support group meeting and returned to staff
in sealed envelopes, thus protecting patient confidentiality. The survey
consisted of 7 questions focusing on participant perceptions of attending
the support group. Most responses scored the maximal 10 points on a
Likert scale (Graded 1-10 on perceived value). Free text boxes were also
incorporated to capture qualitative commentaries. Recruitment took place
across two months May (21 attendees) and June (15 attendees).
Results: The survey elicited a 64% response rate (n=23). All participants
reported feeling welcome at the two meetings, finding it educational and
helping to maintain long-term focus in both pre-and post-operative con-
texts. Staff interaction was rated highly, especially in relation to the ap-
proachability of nurses regarding specifically requested information.
Participants were asked to describe an experience in their day to day lives
which had been handled differently as a consequence. All participants
reported that their pre/post outcomes had perceptibly improved as an
unintended consequence of attending the support group.
Conclusion: The patient support group was perceived as a safe and wel-
coming space for patients, which was highlighted as having a positive
impact on their pre- and post-operative lives, both promoting and
supporting positive behaviours in their lives. The opportunity to interact
with staff in a less formalised environment encouraged attendees to ask
questions and openly seek advice which was reported as helpful and
increasing confidence. A longitudinal study into participation with sup-
port groups both pre- andpost-surgically is recommended to facilitate the
long-term support afforded to all bariatric patients.
A Prospective Study of Erectile Function in Morbidly Obese Male
Patients Undergoing Bariatric Surgery using IIEF-5 Score
Ashish Ahuja, Jagdeep Choudhary
Dayanand Medical College & Hospital, Ludhiana, Punjab, India
Background: Obesity is a worldwide epidemic. It is one of the leading
preventable causes of death worldwide with increasing prevalence in both
adults & children. Neuroendocrine & sexual aberrations are common in
obesity & severity is compared to long term effects of aging. Erectile
dysfunction(ED) is inability to attain erection for sexual activity& is
common in obese patients which has been attributed to serum testosterone
levels & endothelial dysfunction associated with pro inflammatory state
of obesity.
Method: The study was conducted at our hospital on male obese subjects
undergoing bariatric surgery over One & half years who consented for the
study. Evaluation by Andrologist regarding counseling, hormonal evalu-
ation & secondary assessment of secondary sexual characters was done.
Pre operative evaluation done by bariatric surgeon, dietician, psychiatrist,
anaesthesiologist, chest physician & cardiologist. The outcome of the
study was assessed from improvement in IIEF-5 score, patient having
increased confidence & improvement in sexuality.
Results: This study was conducted between January 2014-June 2015. A
total no. of 17 patients who underwent bariatric surgery & gave consentto
participate in the study were included. Mean Age (yrs) 43±7.624, Mean
height(m)172.47±6.09, Mean weight(kg)138.71±17.51, Mean BMI(Kg/
)46.67±6.230. Significant weightloss was observed at 4 weeks & 3
months when mean weight was 130.47±14.77kg &116.53±15.64kg re-
spectively. Pre operative mean IIEFS-5 score was 10.71±17.51Kgs.
Substansial improvement was seen in score at 4 weeks & significant at
3 months with mean values ofIIEFS-5 score as 12.76±5.27 & 17.24±4.89
Conclusion: Significant weight loss after bariatric surgery in men
results in improved clinical outcomes. With patients acting as their
own controls, this study demonstrates that bariatric surgery improves
male erectile function, evident by an improvement in IIEFS-5 score
& overall feeling of sexual wellness. This study also showed im-
provement in Sex hormonal profiles as seen with better serum tes-
tosterone levels, LH &FSH levels. Lipid profiles & Glycemic control
also improved in patients over follow up time. The improvement in
Erectile function &metabolic parameters may serve as motivators for
obese men considering bariatric surgery.
The accuracy of Respiratory Rate measurement using the novel
Respirasense device compared to gold-standard capnography a
useful tool for the bariatric unit?
Lorraine Albon
, Sonia Baryshpolec
, Samantha Cowpe
, Denise
, Jayne Longstaff
, Anoop Chauhan
S24 OBES SURG (2019) 29 (Suppl 1):S1S29
Western Sussex Hospitals NHS Foundation Trust, Chichester, United
St Marys NHS Treatment Center, Portsmouth, United
Portsmouth Hospitals NHS Trust, Portsmouth, United
PMD Solutions, Cork, Ireland
Background: Respiratory complications are more common in obese pa-
tients even in the absence of lung disease, and a change in the respiratory
rate (RR) is frequently the first observation that may indicate clinical
deterioration in medical and surgical settings. Despite its importance,
manual counting can be difficult to routinely and frequently measure in
obese patients, thus it can potentially underestimate clinical deterioration
especially following bariatric surgery. A noveldevice has been developed
for use at the bedside which continuously and wirelessly transmits RR to
a smart-tablet for clinical tracking. We compared real-time RR measure-
ment between gold-standard capnography and the RespiraSense device.
Method: Patients with a BMI > 35 kgs/m
were recruited from a UK Pre-
surgical Bariatric Clinic and RR was measured simultaneously over 60
minutes with both the novel device and capnography. The primary end-
point was analysed using a Bland Altman analysis to measure the limits of
agreement between methods.
Results: Data from 12 patients with a mean BMI of 52.2 (SD 9.64) kgs/
were evaluated. All 12 patients had a BMI > 40 kgs/m
, placing them
in the Obesity III BMI classification as per the NICE clinical guideline
CG189. The maximum BMI was 66.8 kgs/m
. A mean RR of 17.3 bpm
(SD 2.8) for capnograph measurements compared to a mean RR of
16.9 bpm (SD 2.3) with the novel device were recorded. The novel device
has a bias of -0.34 and limits of agreement of -2.57 to 1.88 bpm when
compared to the capnography derived RR.
Conclusion: The novel device is accurate in measuring RR when com-
pared to gold standard for RRs within the normal range in severely obese
patients. It represents a feasible method of reliably monitoring RR in
obese patients and may help identify early clinical deterioration on the
Bariatric unit. Further investigations comparing the accuracy of the de-
vice at low and high RRs is now required.
Colorectal cancer in Obese Patients - Is There a Role for Bariatric
Miriam Adebibe
, Debasish Ghosh
, Anupam Dixit
, Manisha Sharma
, Abdul Quddus
, Adnan Alam
, Kalpana Devalia
Homerton Hospital, London, United Kingdom;
Worthing Hospital,
Worthing, United Kingdom
Background: Obesity is seen in 20% of patients with all types of cancer,
complicating it's diagnosis and treatment by way of challenges in screen-
ing, surgical options, chemotherapy dosing, and post-treatment care. The
role of bariatric surgery in managing obesepatients with cancer is not well
defined. Rapid weight loss may benefit outcomes, but must not delay
oncological treatment. In colorectal cancers (CRC), it is possible to target
weight loss whilst patients complete neoadjuvant chemoradiation if ser-
vices can be coordinated. We present our experience of managing obese
patients with colorectal cancer at a UK centre providing colorectal cancer
and bariatric surgery services.
Method: This is a retrospective case series from a high volume single
centre delivering National Health Service in the UK. The data was com-
piled from searches of Colorectal and Bariatric multi-disciplinary team
(MDT) meeting outcomes from January 2016- October 2018.
Results: 5 patients with colorectal malignancy were referred to bariatric
surgery : 2 rectal, 2 sigmoid, 1 caecal cancer. Laparoscopic Sleeve
Gastrectomy (LSG) was performed in 3 patients (2 were unfit) who sub-
sequently underwent 1 laparoscopic low anterior resection with
defunctioning loop ileostomy for low rectal cancer and 2 laparoscopic
anterior sections for sigmoid cancer. Patients' (2 females, mean age 51yrs)
BMI pre-LSG ranged from 47.4-57.4kg/m2. All patients lost weight rap-
idly with average loss of 24.8kg (range: 18.8kg-35.2kg) between surger-
ies (4-6 months). All surgical resections were complete. Length of hos-
pital stay was 6-8 days with no reported complications following bowel
Conclusion: Our internal referral rates of obese CRC patients for consid-
eration of LSG before cancer resection is low. Referral was considered
when BMI exceeded 45kg/m2 and a stoma was indicated at index proce-
dure (eg in low anterior resections to protect the anastomoses below the
peritoneal reflection due to higher risk of leak) or deemed likely due to
high risk of complications. Criteria for bariatric referral at different cen-
tres will depend on operative approach for cancer surgery. A lower BMI
in open cases may benefit tumour resection and wound management. In
laparoscopic cases, it makes stoma formation possible rather than im-
prove access.
A comparison of medium-term excess weight loss in super obese
patients following laparoscopic sleeve gastrectomy and laparoscopic
roux-en-y gastric bypass
Muhammad Ali Karim, Fahad Mahmood, Amir Khan, Salman Mirza,
Mushal Naqvi
Manor Hospital, Walsall, United Kingdom
Background: With the NHS currently having to withstand considerable
financial constraints, bariatric surgery is often reserved for the highest
risk, super obese patients (BMI 50). A variety of operations are avail-
able, but this study aims to compare weight loss achieved by super obese
patients at two years following the laparoscopic sleeve gastrectomy
(LSG) and the laparoscopic roux-en-y gastric bypass (LRYGB).
Method: Demographical data, pre-operative weights/BMIs and two-year
post-operative weights were collected from a prospectively maintained
database for patients undergoing LSG and LRYGB between October
2011 and October 2015 within a single UK level 4 bariatric centre.
Percentage excess weight loss (%EWL) at two years post-operatively
were compared using Mann-Whitney U test.
Results: 149 patients were included. 103 were female. 110 underwent LSG;
39 LRYGB. Male:Female ratios were 1:1.75 and 1:5.5 for LSG and LRYGB
respectively. Median age for LSG was 47 (22-70) years and 44 (20-65) years
for LRYGB. Median pre-operative BMIs were 56.8 (50.0-79.2) and 53.9
(50.1-78.5) for LSG and LRYGB respectively. Median two-year post-oper-
ative BMIs were 40.8 (23.1-57.0) and 37.7 (26.8-57.9) for LSG and LRYGB
(p=0.09) respectively. Median two-year %EWL was 51.4kg (20.9-125.1) for
LSG and 60.0kg (14.7-93.1) for LRYGB. There was no significant difference
in BMI or %EWL (p=0.3) between study groups.
Conclusion: LSG and LRYGB have comparable medium-term weight
loss results in the super obese.
Should we routinely OGD all bariatric patients as part of their pre-
operative work up?
Ruth Edmonds, Nichola Coleman, Alfonso Antequera, Christina Macano
St Bernards Hospital, Gibraltar, Gibraltar