Upper gastrointestinal training in the UK and Ireland: a Roux Group Study

INTRODUCTION

Surgical training programmes in the United Kingdom and Ireland (UK&I) are in a state of flux. This study aims to report the contemporary opinions of trainee and consultant surgeons on the current upper gastrointestinal (UGI) training model in the UK&I.

METHODS

A questionnaire was developed and distributed via national UGI societies. Questions pertained to demographics, current training evaluation, perceived requirements and availability.

RESULTS

A total of 241 responses were received with representation from all UK&I postgraduate training regions. The biggest discrepancies between rotation demand and national availability related to advanced/therapeutic endoscopy and robotic surgery, with 91.7% of respondents stating they would welcome greater geographical flexibility in training. The median suggested academic targets were 3-5 publications (trainee vs consultant <3 vs 3-5, p<0.001); <3 presentations (<3 vs 3-5, p=0.002); and 3-5 audits/quality improvement projects (<3 vs 3-5, p<0.001). Current operative requirements were considered achievable (87.6%) but inadequate for day one consultant practice (74.7%). Reassuringly, 76.3% deemed there was role for on-the-job operative training following consultant appointment. Proficiency in diagnostic endoscopy was considered a minimum requirement for Certificate of Completion of Training (CCT) yet the majority regarded therapeutic endoscopy competency as non-essential. The median numbers of index UGI operations suggested were comparable with the current curriculum requirements. Post-CCT fellowships were not considered necessary; however, the majority (73.6%) recognised their advantage.

CONCLUSIONS

Current CCT requirements are largely consistent with the opinions of the UGI community. Areas for improvement include flexibility in geographical working and increasing national provisions for high-quality endoscopy training.

O106 Maximising the benefits of bariatric surgery through targeting ghrelin: a randomised, double-blind, placebo-controlled crossover study in people with suboptimal weight loss after bariatric surgery

Introduction

One in 5 people have a suboptimal weight-loss (WL) response to bariatric surgery. The causes are unclear, but patients report resumed hunger and increased food intake, eating behaviours driven by the orexigenic hormone, ghrelin. This proof-of-concept study aimed to evaluate the impact of reducing circulating acyl-ghrelin, the biologically active isoform, on appetite and energy intake in people with suboptimal WL and aberrant ghrelin profile after bariatric surgery.

Methods

Thirty-five patients with &lt;20%WL from 12 months after Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) and aberrant circulating ghrelin profile underwent 10 days of treatment with a novel, highly-selective ghrelin o-acyltransferase inhibitor, GLWL-01, and placebo. The primary endpoint was within-person change in ad libitum energy intake during a test meal on day 10. Secondary endpoints assessed subjective appetite, food cravings, macronutrient intake, gut hormones, cardiometabolic profile and body composition. Ethical approval was obtained.

Results

Thirty-one participants (26 RYGB, 9 SG) completed both cycles. GLWL-01 produced a 58.9±27.2% decrease in fasting plasma acyl-ghrelin and 29.3±27.1% increase in desacyl-ghrelin after 10 days. Marked reduction in subjective hunger, food cravings and hedonic influence on appetite was observed with GLWL-01, however objective appetite measures – ad libitum and free-living energy intake – did not change. Circulating levels of cardiovascular risk-conferring lipoproteins significantly improved and no adverse impact on glycaemic control was observed.

Conclusion

Pharmacological modulation of the ghrelin system may be used as part of a personalised therapeutic approach to optimise clinical outcomes in patients with suboptimal WL after bariatric surgery.

Take-home message

This first-in-human mechanistic study shows that pharmacological modulation of the ghrelin system is a promising therapeutic strategy for maximising weight loss response to bariatric surgery.

High-resolution CINE MRI allows estimation of 3D regional atrial strains

Introduction

It is increasingly evident that atrial function is an important marker of cardiovascular health. Impaired global left atrial strain has been associated with risk of thromboembolic events, atrial fibrillation and heart failure. When performed at high spatial resolution, CINE MRI allows the estimation of regional atrial strains, which may facilitate earlier identification of atrial disease and improved (non-contrast) characterisation of atrial fibrosis. Nevertheless, to date, high resolution regional atrial strains has not been assessed using CINE MRI.

Purpose

We introduce a novel rapid 2.2-mm isotropic atrial CINE MRI protocol used to image healthy subjects and patients with cardiovascular disease (CVD). We additionally present a dedicated image analysis pipeline to estimate regional 3D atrial strains from these images.

Methods

We imaged 10 healthy subjects (5 female, 24–36 years old) and 6 patients referred for cardiac MRI due to known or suspected CVD (2 female, 25–80 years old). All subjects were scanned in a 1.5T Philips Ingenia MRI scanner in a single breath-hold (&lt;25 s), using a short-axis 3D bSSFP protocol (flip angle: 60°, TE/TR: 1.6/3.3 ms) with retrospective cardiac gating, SENSE = 2.3 (along both phase encode directions), typical FOV: 400 x 270 x 70 mm3, isotropic acquisition resolution of 2.2 mm3. Images were reconstructed to 20 cardiac phases with 55% view sharing.

The left atrium (LA) was manually segmented in atrial diastole. We tracked the position of evenly spaced points along the LA contour across all phases of the cardiac cycle using the Medical Image Tracking Toolbox. This was used to create a series of deforming smooth triangular meshes, from which Lagrange strain tensors were estimated.

Results

Figs a-c show 3 orthogonal views of the proposed high-resolution atrial CINE MRI scans for a representative CVD patient, with the LA segmentation overlaid in red. Representative LA principal strain directions (as arrows) with the colour indicating the amount of strain observed along this direction are shown in Fig d for active atrial contraction (posterior view). The calculated strain directions varied smoothly in space and time, as expected, and were largest in amplitude in the regions closest to the mitral valve.

Overall, principal strains were larger in healthy subjects (AC strains: 0.12±0.06) than in the CVD cohort (AC strains: 0.04±0.01). This difference was statistically significant during AC (p-value: 0.02), but not during atrial diastole (p-value: 0.06).

Conclusions

We present a novel high-resolution CINE-MRI protocol for estimating regional atrial strains in 3D, with pilot data from 10 healthy subjects and 6 cardiovascular patients. Future studies will compare regions of abnormal atrial strain with fibrosis identified in late gadolinium enhanced MRI to assess whether regional strains can provide a better characterisation of atrial tissue and improved stratification of patients at risk.

Figure 1

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): British Heart Foundation, EPSRC/Wellcome Trust Centre for Medical Engineering