Clinical Service Line 02 - UGI & Bariatric, Colorectal, Gastro & Endo, Surgery wards

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    Bariatric-metabolic surgery for NHS patients with type 2 diabetes in the United Kingdom National Bariatric Surgery Registry
    (2023-06) Currie, Andrew; Bolckmans, Roel; Askari, Alan; Byrne, James; Ahmed, Ahmed R.; Batterham, Rachel L.; Mahawar, Kamal; Miras, Alexander Dimitri; Pring, Chris M.; Small, Peter K.; Welbourn, Richard
    Aim Bariatric-metabolic surgery is approved by the National Institute of Health and Care Excellence (NICE) for people with severe obesity and type 2 diabetes (T2DM) (including class 1 obesity after 2014). This study analysed baseline characteristics, disease severity and operations undertaken in people with obesity and T2DM undergoing bariatric-metabolic surgery in the UK National Health Service (NHS) compared to those without T2DM. Methods Baseline characteristics, trends over time and operations undertaken were analysed for people undergoing primary bariatric-metabolic surgery in the NHS using the National Bariatric Surgical Registry (NBSR) for 11 years from 2009 to 2019. Clinical practice before and after the publication of the NICE guidance (2014) was examined. Multivariate logistic regression was used to determine associations with T2DM status and the procedure undertaken. Results 14,948/51,715 (28.9%) participants had T2DM, with 10,626 (71.1%) on oral hypoglycaemics, 4322 (28.9%) on insulin/other injectables, and with T2DM diagnosed 10+ years before surgery in 3876 (25.9%). Participants with T2DM, compared to those without T2DM, were associated with older age (p < 0.001), male sex (p < 0.001), poorer functional status (p < 0.001), dyslipidaemia (OR: 3.58 (CI: 3.39–3.79); p < 0.001), hypertension (OR: 2.32 (2.19–2.45); p < 0.001) and liver disease (OR: 1.73 (1.58–1.90); p < 0.001), but no difference in body mass index was noted. Fewer people receiving bariatric-metabolic surgery after 2015 had T2DM (p < 0.001), although a very small percentage increase of those with class I obesity and T2DM was noted. Gastric bypass was the commonest operation overall. T2DM status was associated with selection for gastric bypass compared to sleeve gastrectomy (p < 0.001). Conclusion NHS bariatric-metabolic surgery is used for people with T2DM much later in the disease process when it is less effective. National guidance on bariatric-metabolic surgery and data from multiple RCTs have had little impact on clinical practice.
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    Implementation of a digital therapeutic to support physical activity within existing multi-disciplinary weight management services for severe obesity.
    (2023) Williams , O; Zalin, A; Atkinson, L
    Introduction Physical activity (PA) behaviour change is an essential element of Tier 3 and 4 obesity care pathways, with increased PA prior to bariatric surgery linked to more positive patient outcomes. Clinical staff within bariatric services advise patients to increase PA, however few have the specific knowledge needed to create personalised PA plans, and services often have limited access to exercise specialists. Digital therapeutics have the potential to provide accessible, scalable PA behaviour change support, but have not previously been implemented within a multi-disciplinary weight management service. Methods A digital PA prescription service was implemented into the Tier 3 and 4 weight management services within two NHS Trusts. Delivered to patients via a smartphone app, the service automatically creates a safe, progressive PA plan, based on NICE guidance and Exercise is Medicine protocols. Plans are personalised to the patient's health conditions and current PA status. Clinical staff are able to monitor patients' adherence to their prescription, and self-reported health metrics, via a secure data portal. Patients were additionally supported by a specialist practitioner. Results Through a collaborative learning process, methods for integrating the service into existing pathways, including staff training and awareness, and onboarding and supporting patients, were iteratively refined. Once established, on average 40 patients per month initiated the service. Overall improvements in service users' active minutes, steps, and physical function were observed, and positive feedback was received from both patients and staff. Conclusions An innovative, digital PA prescription service was successfully integrated into existing weight management services.
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    The surgical management of obesity
    (2023) Askari, Alan; Jambulingam, Periyathambi; Gurprashad, Roy; Al-Taan, Omer; Adil, Tanveer; Munasinghe, Aruna; Jain, Vigyan; Rashid, Farhan; Whitelaw, Douglas
    Abstract: Obesity has reached pandemic levels globally. Surgical management of obesity aims to establish metabolic control, weight loss and resolution of multiple health conditions and to improve quality of life. Here, we examine the role of surgery in the management of obesity within the context of a multidisciplinary team involving a variety of healthcare professionals. We highlight the importance of patient selection, perioperative care, the various types of bariatric surgery currently available as well as emerging procedures. In addition to clarifying the different types of procedure, we also examine the potential complications and issues of weight regain and failure to lose weight. Ultimately, bariatric surgery remains comparatively safe and with generally excellent results in terms of control of existing obesity-related conditions; with the ever-increasing number of patients living with obesity, the scope of bariatric surgery is thus likely to increase.
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    A systematic review of outcomes and quality of life after ileorectal anastomosis for ulcerative colitis
    (2023) Al-Rashedy, Mohammed; Mukherjee, Tanmoy; Askari, Alan; Gurjar, Shashank
    Background and study aims Ileorectal anastomosis (IRA) is one option for restoring bowel continuity in patients who have undergone subtotal colectomy for ulcerative colitis (UC). This systematic review aims to assess short- and long-term outcomes after IRA for UC, including anastomotic leak rates, IRA failure (as defined by conversion to pouch or end stoma), cancer risk in the rectal remnant, and quality of life (QoL) post-IRA surgery. Materials & methods The Preferred Reporting Items for Systematic Reviews and Meta-Analysis checklist was used to demonstrate the search strategy. A systematic review of PubMed, Embase, Cochrane library, and Google Scholar from 1946 to August 2022 was undertaken. Results This systematic review included 20 studies, representing 2538 patients who underwent IRA for UC. The mean age ranged from 25 to 36 years and the mean postoperative follow-up ranged between 7 and 22 years. The overall leak rate reported across 15 studies was 3.9 % (n = 35/907) ranging from 0 % to 16.7 %. The failure of IRA (requiring conversion to pouch or end stoma) as reported across 18 of the studies was 20.4 % (n = 498/2447). The risk of developing cancer in the remaining rectal stump following IRA was reported by 14 studies and was accumulatively 2.4 % (n = 30/1245). Five studies reported on patient QoL using a variety of different instruments and 66.0 % of patients (n = 235/356) reported a “high” QoL score. Conclusion IRA was associated with a relatively low leak rate and a low risk of colorectal cancer in the rectal remnant. However, it does carry a significant failure rate which invariably requires conversion to an end stoma or the formation of an ileoanal pouch. IRA provided a QoL to most of the patients.
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    A systematic review of outcomes and quality of life after ileorectal anastomosis for ulcerative colitis
    (2023) Al-Rashedy, Mohammed; Mukherjee , Tanmoy; Askari , Alan; Gurjar , Shashank
    Abstract Background and study aims Ileorectal anastomosis (IRA) is one option for restoring bowel continuity in patients who have undergone subtotal colectomy for ulcerative colitis (UC). This systematic review aims to assess short- and long-term outcomes after IRA for UC, including anastomotic leak rates, IRA failure (as defined by conversion to pouch or end stoma), cancer risk in the rectal remnant, and quality of life (QoL) post-IRA surgery. Materials & methods The Preferred Reporting Items for Systematic Reviews and Meta-Analysis checklist was used to demonstrate the search strategy. A systematic review of PubMed, Embase, Cochrane library, and Google Scholar from 1946 to August 2022 was undertaken. Results This systematic review included 20 studies, representing 2538 patients who underwent IRA for UC. The mean age ranged from 25 to 36 years and the mean postoperative follow-up ranged between 7 and 22 years. The overall leak rate reported across 15 studies was 3.9 % (n = 35/907) ranging from 0 % to 16.7 %. The failure of IRA (requiring conversion to pouch or end stoma) as reported across 18 of the studies was 20.4 % (n = 498/2447). The risk of developing cancer in the remaining rectal stump following IRA was reported by 14 studies and was accumulatively 2.4 % (n = 30/1245). Five studies reported on patient QoL using a variety of different instruments and 66.0 % of patients (n = 235/356) reported a “high” QoL score. Conclusion IRA was associated with a relatively low leak rate and a low risk of colorectal cancer in the rectal remnant. However, it does carry a significant failure rate which invariably requires conversion to an end stoma or the formation of an ileoanal pouch. IRA provided a QoL to most of the patients.