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2nd Gore Expert Obesity Meeting

The experts have their say…

The key issues concerning the obesity epidemic, emerging trends in bariatric/metabolic surgery, how the bariatric community needs to respond to these changes...

The 2nd Gore Expert Obesity Meeting was held at WL Gore and Associates’ Feldkirchen-Westerham location, in Germany, from September 19-20, 2018. The meeting provided surgical specialists from around the world the opportunity to interact, debate and share their experiences with European experts in bariatric and metabolic surgery. Topics under discussion included sleeve gastrectomy, gastric bypass, SADI-S, revisional surgery and staple line reinforcement, as well as how to manage obesity-related condition such as gastroesophageal reflux disease, Hiatal hernia and abdominal wall repairs. After the meeting, Bariatric News asked several experts to give us their thoughts on the key issues concerning the obesity epidemic, emerging trends in bariatric/metabolic surgery, how the bariatric community needs to respond to these changes, the key take home messages of the meeting and if Staple Line Reinforcement is the future ‘gold standard’ for sleeve gastrectomy? Here’s what they had to say…

Professor Antonio Torres - Madrid, Spain

In my opinion, the most relevant issue is to properly inform society about the great epidemic we are facing with. Then to try to fight against all the adiposity related diseases as IFSO mission has stablished.

The increasing number of LSG is the most relevant point from the surgical point of view and, as a consequence the high percentage of revisional surgery dur the fact that some of the LSG will fail in the future. Other important issue will be the multidisciplinary approach after surgical failure, including medications.

Antonio Torres

The bariatric community needs to be more open to society and try to get enough resources to improve data collection, improve the present guidelines, and to increase the number of multidisciplinary teams that can perform bariatric and metabolic surgery with the highest quality.

The key take home message of the meeting is the need to define the most suitable patients to indicate LSG in their multidisciplinary approach to metabolic/bariatric surgery. It would be also essential to standardise LSG technique, although it is not an easy matter.

In my opinion, a shift from a DRG system based on budget (€) per procedure to a Quality System would take a lot of time, but it would be ideal. In this scenario, there is no doubt that staple line reinforcement would be more commonly implemented.

Dr Patrick Noël - Abu Dhabi, United Arab Emirates

The obesity epidemic is today worldwide, interesting everyone in developed countries independently of the social level of the people. Education of young people is one thing. Information on this disease is another important thing, like raising awareness on the benefits of physical activities.

Regarding patients already obese, a greater access to treatment is something really important in our societies. Only 1 % of the candidates for surgery benefit from it today, which means that 99% of the morbidly obese patients are excluded from the picture. A better awareness of this way of treatment is needed. The economic impact of this surgical approach is something beneficial for our societies in term of saving money.

Patrick Noël

LSG accounts today for over 60 % of all bariatric procedures performed worldwide with some isolated resisting countries like in Northern Europe. Almost 2 patients on 3 operated today are for a LSG. In 2 years, the percentage of MGB performed globally increased by 265 % except in North America. At the same time the number of LAGB is still decreasing and very few procedures are now performed.

The number of RYGB decreased slowly year after year but this procedure remains important in the surgical landscape. The rate of revisional procedure is increasing each year with the first cases of revisional sleeves following the previous peak of band failure. Endoscopic procedures are more and more used thanks to marketing, but do not have the same efficiency for morbidly obese patients. Their number will meanwhile increase with time and a greater access to these minimally invasive approaches. They will take a part of the market for low BMI.

We need to reinforce the use of the data with a better registry of all complications and results will allow to respond to all these changes with an accurate analysis of the data. A large spreading of this with a better respect of guidelines which should as well be re-evaluated at some points will be the key points of a greater success of the surgery as part of the armamentarium to fight against the obesity epidemic. A continual training of the surgeon will be the last piece of the cake.

The key take home messages of the meeting were surgery is safer and safer with the increasing experience of the surgeons, with a better selection of the patients and of the indications. The use of reinforcement devices now makes the severe postoperative complications we know about very rare. Data and randomised clinical trials are now essential to build an algorithm of the best indications for the patients depending on their conditions, BMI and history.

I really think that in the current state of the art, a staple line reinforcement for the LSG is something validated for the bleeding condition and probably as well for the risk of leakage. Furthermore, we all agree that a bleeding can secondarily give a leak. The choice of the right cartridge is as well an important factor in the decreasing rate of complications and yes, the right cartridge associated with a SLR will be the future Gold Standard of a good LSG.

Professor Gianfranco Silecchia – Rome, Italy

We need to increase awareness of the obesity epidemic. Educational programmes are mandatory for different targets: general practitioner, paediatrics, teacher and students etc. The community does not know the correlation and cause effect relation between obesity and its severe complications.

The so-called ‘alimentary diabetes’ in the general opinion is related to the type of food, cooking, nutrition non to the obesity conditions. On the other hand, the knowledge of proper treatments for obesity is lacking. The internet, media, social media etc are confusing and the message is: “Hi we have the magic treatment to change your life!”

Gianfranco Silecchia

I want to underlie the more or less abandoned procedures - vertical banded gastroplasty and adjustable gastric banding. OAGB is an emerging procedure and huge data are coming from several researchers worldwide demonstrating at least mid-term sustainable effect on weight loss and co-morbidities control. The latter is not considered a standard validated technique, however, it is gaining popularity and acceptance by the scientific community.

Endoscopic primary treatment of obesity is an unmet issue. On the other hands, endoscopy is a valid approach for the treatment of several acute and long-term complications of laparoscopic bariatric procedure.

Revisional surgery is a chapter of bariatric/metabolic surgery. The patients must be informed that lifelong a revision of the procedure could be necessary. The safety and effectiveness of revisional surgery has been demonstrated by several studies.

The surgical societies should have a primary role in the education, training and validation of new and emerging procedures as well as for technical innovation. Guidelines, recommendations for good clinical practice, statements, update of previous guidelines are mandatory to offer the best care options to our patients.

The training of the young surgeons in laparoscopic bariatric/metabolic surgery is another hot topic. Accreditation rules are different in European and Nord American Countries as well as the training program incorporated into the residency program in general surgery. A standardised training programme and greater access to lab, virtual reality etc are needed.

The key take home message of the meeting was sleeve gastrectomy remains the most popular procedure worldwide. A great attention should be paid to the tip & tricks to avoid perioperative and long-term complications, and all the technical details should be considered crucial for a proper surgical treatment. Bleeding and leak are the most important issues and absorbable buttress material are considered a safe and effective options to decrease complications. For me the staple line reinforcement is today a Gold Standard for sleeve gastrectomy.

The need of concomitant repair of the hiatal defects is accepted as standard of care. The issue how and when to reinforce the cruroplasty is a matter of discussion. The experience from the different centres is crucial in sharing skills and knowledge.

Ahmed Ahmed - London, United Kingdom

The answer to the obesity epidemic really depends on the country concerned. In the United Kingdom, there are over 2.2 million people eligible for bariatric surgery. The average number of operations performed in the NHS per year is around 5000 and actually going down! In my view the main reasons for this are (i) barriers to referral of eligible patients from commissioning bodies (known as STPs or CCGs in UK healthcare system) (ii) lack of understanding of metabolic surgery effectiveness by primary care physicians (iii) lack of awareness of the treatment in the eligible patient population (iv) poor financial incentive for NHS hospitals to develop bariatric surgery centres as remuneration poor based on DRG and (v) most UK NHS hospitals are running at full capacity with frequent cancellation of elective benign surgical cases – my own waiting list is now over two years long!

Ahmed Ahmed

Laparoscopic sleeve gastrectomy is really popular and likely to overtake the bypass in the UK. MGB or OAGB is rising in popularity especially for revisional surgery (from failed band/sleeve) due to its added malabsorption effect. In my unit, we are currently commencing a ESG programme and have NIHR funding to research bariatric embolization from next year in a sham controlled RCT.

In the UK setting, I think we will have no other option than to empower patients and provide legal support for those that are refused funding for bariatric surgery. Once we increase demand for the surgery from commissioners this in turn will drive the supply and more hospitals will provide the surgery and training opportunities and fellowship programmes in turn will be created.

The key take home messages of the meeting are clearly the staple line is king and using buttressing really helps ensure that the staple line is optimised. In my opinion, using SLR should be considered not a gold standard but a minimum standard when performing LSG. There is excellent data supporting its usage and the price of the product can be offset against the potential cost of having to treat LSG complications of staple line leak and bleed.

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