Irish Society of Gastroenterology 2018 Annual Winter Meeting

Amount of public bariatric surgeries being carried out is ‘totally inadequate for demand’

ewer than 100 bariatric surgeries are carried out in Irish public hospitals annually, when the number should be around 1,500 each year, one obesity surgery expert told the Irish Society of Gastroenterology (ISG) 2018 Annual Winter Meeting.

The ISG meeting, which took place in November, heard about the rise of obesity-related liver disease in Ireland, which is becoming a significant health issue, from a number of speakers.

Ireland is on track to become one of the most obese nations in the world if current trends continue, with approximately 39 per cent of Irish adults overweight and 18 per cent obese. This is leading to huge increases in diabetes, cancer and liver-related diseases (with non-alcoholic steatohepatitis becoming one of the leading indications for liver transplant), putting increased pressure on our health services, with inadequate awareness and dedicated resources to address obesity-related health issues, the meeting heard.

Bariatric surgery, including gastric banding or bypass, is only available publicly in Galway or Dublin, where the waiting lists are as long as four-to-five years, which is totally unacceptable, Mr Chris Collins, Consultant General and Upper GI Surgeon in Galway University Hospital, told the ISG meeting.

He said that the fewer than 100 surgeries a year being provided in the public system is nowhere near enough to meet growing demand. Given our current waiting lists and population size, Ireland should be carrying out 1,500 such surgeries a year in our public hospitals, but, according to Mr Collins, the capacity and beds to do this are not currently available.

However, following the work of the Taskforce on Obesity and the appointment of Prof Donal O’Shea to the role of HSE Obesity Lead, more dedicated funding for obesity services is due to be made available by the HSE next year.

This should lead to bariatric surgery being rolled-out in other regions, including Cork, Limerick and potentially Waterford, and an increase in the amount of operations being carried out to 150 next year, and up to 750 annually within the next five years, Mr Collins told the Medical Independent (MI).

During his presentation to the meeting, Mr Collins said that the current two preferred surgical choices in bariatric surgeries are sleeve gastrectomies, which remove part of the stomach, and the Roux-en-Y gastric bypass procedure, which involves creating a stomach pouch out of a small portion of the stomach and attaching it directly to the small intestine, bypassing a large part of the stomach and duodenum. “They both have benefits. The main benefit of the Roux-en-Y is for patients who have diabetes and they do better after surgery, and the main benefit of the sleeve gastrectomy from my point of view is, it is a shorter procedure with a lower complication rate… ” he told MI.

He added that the wide range of health risks of obesity are not discussed enough by clinicians, with many gastro complications, as well as sleep apnoea and fatty liver disease.

“When you look at the GI complications of obesity alone, they are quite significant; gastro-oesophageal reflux is significantly increased, the rate of oesophagitis is twice as common in obese patients. If you get Barrett’s oesophagus, you are two-and-a-half times more likely to develop oesophageal adenocarcinoma. Of course, these patients are then much more difficult to manage when it comes to considering surgery, as the risk of all their complications increase…

“These risks from obesity are carried into the stomach, with an increased risk of gastric cancer, and into the pancreas — you are more likely to get severe pancreatitis if you are obese… and into the colon. With every increase in BMI of five, your risk of colorectal cancer goes up by 18 per cent.”

Meanwhile, research presented at the meeting showed that alcoholic liver disease (ALD)-related hospital admissions in Ireland increased by 23 per cent over 10 years, while hepatocellular carcinoma (HCC)-related admissions increased by 300 per cent in the same period.

The full story on that research can be read on www.mindo.ie.

Upper GI bleeding mortality rates remain unacceptably high — international expert

he mortality rate in upper GI patients remains at approximately 10 per cent, not having changed significantly in the last 20 years, a leading expert in the field, Dr John Morris, Consultant Gastroenterologist, Glasgow Royal Infirmary, UK, told the ISG Winter Meeting.

Upper GI bleeding is one of the major emergencies gastroenterologists deal with in their daily practice, he noted. However, UK audits carried out by the British Society of Gastroenterology (BSG), the national blood transfusion service and other bodies identified several areas in the management of these patients that need improvement.

While there are a plethora of guidelines (NICE, ACG, BCG, etc) on how to manage upper GI bleeding, treatment is often suboptimal, both in resuscitation and treatment of patients in the early stages, Dr Morris explained. He said inadequate risk assessment means particularly sick patients who need immediate endoscopy are not recognised, and there is also a deficit in the skills needed to deliver the therapy. This can be seen in the fact that UK mortality rates for acute upper GI bleeding remain at around 10 per cent, a figure that has only marginally improved in the last 20 years, he stated.

Dr Morris is now leading a UK-wide quality improvement and training programme in upper GI bleeding to improve outcomes with regards to mortality, risk of re-bleeding, length of hospital stay and quality-of-life. “For the first time, we are seeing real enthusiasm from colleagues to actually address what is a hidden epidemic in terms of patient management,” he said.

“We are now seeing an emerging quality improvement programme that will address this for the first time. It will focus on the initial management of these patients, so the first 24 hours for young doctors in emergency departments and acute medical units, and it will also focus on upskilling the existing workforce.”

Key to improving upper GI bleeding outcomes, he believes, is appropriate resuscitation, including more careful consideration of blood transfusion usage. “It is now very clear that over-transfusion can be counterproductive and affects re-bleeding and mortality. So by using a care bundle, we hope to standardise care across healthcare organisations.”

Dr Morris added the timing of endoscopy and the skill set of practitioners in improving GI bleeding outcomes is key, citing data showing that compared to early endoscopy out-of-hours, waiting until morning and concentrating on adequately resuscitating the patients leads to better outcomes.

“We are so fixated on 24/7 endoscopy care, but there is good evidence now that early endoscopy doesn’t make a difference to the outcome of these patients… But patients who are adequately resuscitated do far better.”

This is particularly important in smaller, regional units. Thus, placing services into hub-and-spoke networks with clear treatment protocols and pathways and where only hospitals with 24/7 on-site endoscopy admit these patients out-of-hours will help ensure a higher-quality approach, he said.

The main causes of major upper GI bleeds remain peptic ulcer disease and varices, and Dr Morris explained that most current guidelines recommend that all patients should be risk-assessed with a Glasgow Blatchford Score (GBS) calculated pre-endoscopy, followed by a full Rockall Score post-endoscopy, which is not always practical.

The Rockall Score was initially created to predict risk of re-bleeding and mortality and requires endoscopy for full calculation.

Dr Morris stated the GBS is straightforward and practical and has been shown to successfully predict the need for intervention (blood transfusion, endotherapy and surgery) and mortality risk. In the UK now, they are moving towards using the GBS as standard practice, and moving away from the confusion of having more than one score, according to Dr Morris.

He added that it is also useful for deciding when patients are safe to discharge from emergency departments without the need for admission.

However, choosing the right techniques and technologies for individual GI bleeding patients remains a challenge despite ongoing advancements, such as the increased usage of Hemospray to achieve endoscopic haemostasis, with debate on clipping.

“So in terms of training our endoscopists of the future, we need endoscopy non-technical skills, as it is not only about how you deliver the therapy, but selecting the appropriate therapy for the patient that you’ve seen,” he stated.

Dr Morris told the Medical Independent that while there have been significant improvements in other key medical emergencies, “this is the largest standout cause of mortality in patients admitted acutely to our hospitals”.

“So it is something that we as gastroenterologists, nurses and specialists should really focus on and I am optimistic that using a combination of evidence-based bundles and training courses, we can really make a difference for our patients.”

Dr Morris stated that he had received a lot of interest from Germany in the improvement programme: “This is by no means a UK and Ireland problem; it is a worldwide issue and if we can improve patient care, then I will be delighted.”

His presentation was well received by attendees, who noted that Ireland also needs to restructure services and create set pathways to ensure all upper GI bleeding patients receive the best care.

Despite hopes to have a long-mooted HSE clinical programme for gastroenterology in place at this stage, there was little progress in 2018 but it is hoped an appointment will be made in 2019, ISG President Prof Laurence Egan told MI. Organising the management of acute GI bleeding would be a key priority for the programme. “The way it is managed is very variable around the country, with a big difference between the larger and small hospitals in how it is managed, as well as availability of expertise. As Dr Morris pointed out, proper care pathways are equally as important in the management of upper GI bleeding as having 24/7 services, so that is something that could be implemented relatively easily across all the hospitals in the country,” Prof Egan commented.

Challenges for specialty outlined during meeting

he planned extension of BowelScreen must come with increased resources and staffing, a number of gastroenterologists warned at the ISG Winter Meeting.

During his presentation, Dr Eoin Slattery, Consultant Gastroenterologist, University Hospital Galway, raised concern about the dramatic increase in workload the age extension of BowelScreen will bring.

Currently, the national bowel cancer screening programme screens eligible people from the ages of 60-to-69 years, but this is being extended to cover the ages of 55-to-74 years within the next two-to-three years, “and whilst that is only 10 years, it increases the workload three-fold”.

“Most units are struggling to cope with their current workload as it is, so to triple the workload without real investment in terms of infrastructure and capital is going to be an extraordinary challenge,” Dr Slattery told the Medical Independent. “We want to do the work but we need the funding to do it and need more people and facilities to do that.”

During his presentation, Dr Slattery explained how BowelScreen has “been a rip-roaring success — it will save lives unequivocally”.

“In many ways, it has been a victim of its own success because we’ve managed to recruit so many patients and stop cancer in its tracks. But for it to continue to be a success and to expand it, the facilities that we work in, the infrastructure that we work in has to go with that too.”

He noted that as BowelScreen is quite a new programme compared to many existing programmes internationally, one key benefit was that it started when faecal immunochemical testing (FIT) was standard, replacing less-accurate faecal occult blood tests used in other bowel cancer screening programmes.

The first round of screening under BowelScreen picked up a significant amount of cancers and adenomas, creating a corresponding workload, Dr Slattery commented.

According to published data, in its first screening round, BowelScreen invited 488,628 eligible people for screening, completed screening in 196,238, performed 8,062 colonoscopies and detected 521 cancers. This represents a screening uptake rate of 40.2 per cent and a cancer detection rate of 2.65 per 1,000 people screened.

“Most of the cancers were at an early stage with an adenoma detection rate of 54 per cent….About 10 per cent of those were classified as advanced adenomas, which are just simple ‘snip-off’ polypectomies, but a lot of these were advanced procedures that need an advanced skill set.”

Dr Slattery said the evolution of endoscopy techniques and the advent of endoscopic mucosal resection (EMR) has been a great benefit for BowelScreen patients.

“I think mucosal resection has changed the pathway for patients with advanced colorectal lesions so surgery is no longer a necessity for those patients and they can be managed endoscopically, by and large very successfully. All that based on the work of BowelScreen, which identifies these patients earlier,” he told MI.

Dr Slattery also praised the quality of the “cutting-edge” equipment (high-definition scopes and ScopeGuide) in use in the BowelScreen centres, saying all units should have the latest technology.

However, he said there was a need for more rooms to carry out endoscopy and noted he is the only public gastroenterologist providing EMR services in the west of Ireland, covering Galway, Roscommon, Mayo and Sligo, with increasing demand.

EMR takes longer, about an hour compared to about 20 minutes with colonoscopies, and is more complex, so that has to be factored into future planning, he explained.

Dr Slattery also stressed the importance of appropriate stratification of patients (ie, whether they are fit for EMR), and referral pathways for those outside the remit of the programme, ie, polyps over 2cm and those of difficult pathology who need surgical management.

Speaking to MI following the endoscopy session, ISG President Prof Laurence Egan said that while gastroenterologists in Ireland are currently facing many challenges, foremost among these is the challenge of meeting increasing “practically insatiable” demand for endoscopic services. “As well as that, there are increased advanced endoscopic techniques, and risk of complications and increased scrutiny in key performance indicators at individual endoscopist level, so all those factors contribute to making endoscopy an extremely exciting field, where we can really help patients a lot, but, as many things go, we don’t quite have the resources to match demand and that has to be addressed.”

Proton pump inhibitors should continue to be used

atients with a proven indication for proton pump inhibitors (PPIs) should continue to receive them in the lowest effective dose, despite recent concerns about their long-term safety, the ISG Annual Winter Meeting was told by a US expert in the area.

Dr Colin Howden, Gastroenterologist Specialist, University of Tennessee, Memphis, US, discussed how safety issues associated with PPIs have recently attracted widespread media and lay attention and noted that gastroenterologists are now being frequently asked about the appropriateness of PPI therapy for specific patients.

Furthermore, some patients may have had PPI therapy discontinued abruptly or inappropriately due to these safety concerns.

Reviewing the evidence on the proposed adverse consequences of PPI therapy, Dr Howden maintained that it is inadequate to establish causal relationships between PPI therapy and many of the proposed associations.

Residual confounding related to study design and the over-extrapolation of quantitatively small estimates of effect size have probably led to much of the current controversy about PPI safety, he said. In turn, this has caused unnecessary concern among patients and prescribers. That said, PPI dose escalation and continued chronic therapy in those unresponsive to initial empiric therapy is discouraged, he added.

Speaking to the Medical Independent (MI), Dr Howden reiterated his key point that PPIs are generally safe when correctly indicated, and remain key to the management of a number of conditions affecting the upper gastrointestinal tract, including gastroesophageal reflux disease, Barrett’s oesophagus, eosinophilic oesophagitis, and dyspepsia.

“PPIs are very useful drugs and a number of patients take them for very good reasons and generally derive a lot of benefit from them. They have been linked to a whole host of possible adverse outcomes, but the level of evidence for many of these associations is very weak. I think if physicians or patients have concerns, they should make sure they are on the PPI for a valid reason, as many patients take these medications inappropriately. If the patient is on PPIs for a valid reason and is doing fine, then as long as the drug is being taken in the lowest effective dose, there is really no need to be concerned.”

Meanwhile, speaking during the inflammatory bowel disease (IBD) session, Dr Anthony O’Connor, Consultant Gastroenterologist, Tallaght University Hospital, Dublin, said quality-of-life issues in IBD patients are not being adequately considered by clinicians and researchers.

He pointed out that IBD severely impacts quality-of-life across a number of domains, including fatigue, depression, pain and changes in body image and argued that trying to ensure the best quality-of-life for patients should be key in the treatment approach. However, he contended that clinicians, while focusing on disease scores and measurable outcomes often do not ask simple yet vital questions, like how is the patient’s social and sex life. He said treat-to-target and mucosal healing must not be at the exclusion of quality-of-life.

“A multidisciplinary, multimodality approach is required to address the quality-of-life issues our patients face.”

Dr O’Connor is now working on furthering Irish research into this area. 

At the end of the meeting, there was an update on the work of INITIative, the first collaborative research network for IBD in Ireland. The network is open to clinical and scientific investigators with an interest in Crohn’s disease and ulcerative colitis throughout the island of Ireland.

Speaking to MI, Network Chair Prof Glen Doherty said INITIative has been recruiting for a number of trials and studies over the last year and is on track to meet its recruitment targets.

These include the I-CARE study, which is the first observational European prospective cohort study that will provide unique information (safety, efficacy, risk-benefit ratio and healthcare costs) on the long-term use of recommended therapy in IBD, using a predefined, standardised follow-up. This real-world data will be used to guide clinicians as well as healthcare authorities to provide the best care for IBD patients by optimising available therapies.

“Recruitment began in Ireland in May 2017 and we have recruited almost 400 patients from Ireland and we have our own clinical trial, GOAL-ARC [a nationwide, multi-centre, investigator-initiated, randomised, controlled trial to evaluate the use of personalised golimumab (GLM) dose adjustment in ulcerative colitis], which has been recruiting successfully, and we are at nearly 50 per cent recruitment for that study. So our focus now, going forward, is trying to involve other disciplines who are interested in IBD to collaborate and thus improve the impact of IBD research being done in Ireland.”