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Virtual Education for Real World Challenges

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Session - ANZGOSA - 75.0 mins - ANZGOSA Room
This symposium will provide a forum for non-surgical members of ANZGOSA to discuss issues that may not be covered adequately in the main program. It is representative of the commitment of the ANZGOSA board to the multidisciplinary nature of management of diseases of the oesophagus and stomach and the need for inclusion of all relevant disciplines within ANZGOSA activities. 
Cate’s presentation will focus on the experiences and impacts of cancer care coordination in the oesophageal and gastric tumour streams within Alfred Health. The role of the Oesophago-Gastric Cancer Nurse Coordinator commenced in June 2018 following the implementation of the state-wide Oesophago-Gastric Redesign Program in which Cate was Project Coordinator alongside Project Lead, Mr Richard Chen (Upper GI Surgeon at the Alfred). The main objectives of the project at Alfred Health were to improve timelines of care from referral to multidisciplinary team meeting to treatment and to provide tailored, coordinated care to a group of patients with both poor survival rates as well as a significant morbidity burden. Having achieved notable impacts through fulfilment of the project’s objectives in patient care, which will be explored in further detail in this presentation, Alfred Health decided to fund the position on an ongoing basis. 
Australia and New Zealand Metabolic and Obesity Surgery Society (ANZMOSS) is a surgical society with an extensive multidisciplinary membership. The board consists of bariatric medical physicians, nurses, dietitians and psychologists. Furthermore the scientific program is comprehensive, multidisciplinary and inclusive. In this session Nazy Zarshenas, accredited practicing dietitian (APD) and a 15-year ANZMOSS member discusses the evolution of the integrated team in the society, its benefits for all team members, and the potential for the future.
Session - ANZGOSA - 150.0 mins - ANZGOSA Room
This outstanding session will address the current major challenges in oesophago-gastric malignancy and particularly areas in which progress and change has been observed. Highly credentialed local and international presenters will provide an overview of the latest updates and future directions in management of oesophago-gastric malignancy.
The optimal management of adenocarcinoma of the distal oesophagus and gastro-oesophageal junction (GOJ) remains unknown, with several treatment options available. The debate is also complicated by the spectrum of treatment paradigms for GOJ tumours, which include those for both oesophageal and gastric cancer. This presentation will describe the available treatment options, present the evidence for radiation therapy, and discuss ongoing clinical trials that will add to the evidence base.
Session - ANZMOSS - 105.0 mins - ANZMOSS Room
We will lead with perspectives on leadership and advocacy from the President-Elect of the ASMBS Teresa LaMasters and hear about the expansion of Sleeve Plus procedures in Asia and around the world as alternatives to Gastric Bypass before local Authors present the Best of submitted Free Papers.
Leading at home, leading at work, leading in advocacy. How to steer the ship during a crisis. The world as we know it has changed.  In this presentation I will discuss principles in leading through crisis.
Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong

With the increasing prosperity and Westernization of lifestyle, obesity has become an important health topic in Asia.  Compared to Caucasian, the Asian population is more likely to develop metabolic syndrome and type 2 diabetes at a lower BMI, which leads to a rapid upsurge of bariatric and metabolic surgery in the last 10 years.  In the past, Roux-Y gastric bypass (RYGB) used to be considered a gold standard of bariatric surgery in the west.  Although its popularity reduces after the introduction of sleeve gastrectomy (SG), it is considered superior to SG on achieving long term weight loss and diabetes remission.  However, the major drawbacks of RYGB in Asia are problems of dumping, stomal ulcers and the excluded gastric remnant.  In countries with a high incidence of gastric cancer (Japan & Korea), RYGB is not recommended by many gastric surgeons.  

As more bariatric surgeons are familiar with sleeve gastrectomy, the concept of Sleeve-Plus surgery is getting increasing attention in recent years.  With excision of the greater curve and preservation of antrum and pylorus, it obviates the issue of remnant gastric cancer and adds the potential benefit of reducing dumping symptoms. In addition the PLUS procedure, usually a bypass component, enhances the anti-diabetic effect which is important for diabetes patients.  We have recently performed a randomized control study in comparing the anti-diabetes effect as well as the gastrointestinal side effects between RYGBP and Sleeve Gastrectomy plus loop duodenojejunal bypass (SGDJB).  Our preliminary results showed that anti-diabetes effect and gut hormone profile are similar between these two operations.  Although SGDJB resulted in longer operating time, higher short-term morbidity and more GERD symptoms after surgery, they have less anastomotic ulcers, less severe dumping symptoms and lesser degree of iron deficiency. 

In order to overcome the complexity of SGDJB but retain its superior anti-diabetes effect, more variant of “plus” procedure is being investigated, by either a gastro-intestinal bypass (gastric bipartition) or  jejunojejunal bypass.    However, none of these novel procedures should be recommended as a “better” procedure before its safety and efficacy are tested under ethics-approved studies and surgeons who perform these novel procedures have the responsibility in following up and evaluate them in the long term. 

**We would like to acknowledge the Research Grant Council, Education Bureau, Hong Kong SAR Government in supporting our research work. 

Purpose. To explore  general practitioner attitudes, perceptions, treatment  patterns and barriers to referrals for obesity specialist services, including both public and private obesity and/or bariatric metabolic surgery (BMS) clinics.  
 
Methods. 810 general practitioners with a specific interest in obesity management (GPwSIO) were invited to participate in an online survey.
  
Results.  15.3% completed the survey.  55% of GPwSIO reported that “patients lacked motivation or interest in adopting healthier lifestyle habits”. GPwSIO viewed “the society we live in and eating habits” as most important contributors to serious obesity.  55.2% of GPwSIOs initiated treatment for obesity including dietary advice, very low calorie diets (VLCDs), and pharmacotherapy in less than 10 patients in the preceding 3 months.  GPwSIO report referring patients with severe obesity to private BMS obesity management clinics (42.1%), to allied health practitioners -dieticians mainly  (39.5%) and to endocrinologists (14.9%). 
 
65% of GPwSIO stated that BMS is effective long term treatment. 68.3% would consider referring patients for bariatric surgery, however only 34% GPwSIO s are referring eligible patients for BMS. GPwSIO referred < 5 of patients within the past 3 months to a public bariatric clinic (41.7%) vs private BMS clinic (68.8%). 
 
Only 57.9% of GPwSIO were comfortable in providing ongoing care for their bariatric patient.  GPwSIO’s reported being not well supported in the both the medical and/or surgical problems post BMS from either their private (43.5%) or public (49.5%) bariatric clinic respectively. Communication between the bariatric clinic and the GPwSIO was reported “good to adequate” by only 54.9% of GPwSIO’s. 
 
Conclusions.  There is a lack of understanding of the physiological and genetic basis of obesity, with an emphasis on obesity being a “lifestyle choice” even by GPwSIO. This is manifested by inertia in the utilisation of treatments such as VLCDs and obesity pharmacotherapy. GPwSIOs report a lack of confidence in referring and managing the long term care of the bariatric patient. Further education and up-skilling are required. 
BACKGROUND
Gastro-esophageal reflux (GERD) post-SG is a critical issue due to symptom severity, impact on quality of life, requirement for re-operation, and potential for Barrett’s esophagus. The pathophysiology is incompletely delineated. We aimed to to evaluate the mechanisms associated with reflux events following sleeve gastrectomy (SG).
 
METHODS
Post-SG patients, stratified into asymptomatic and symptomatic, underwent protocolized nuclear scintigraphy (n=83), 24-hour esophageal pH monitoring, and stationary manometry (n=143) to characterize reflux patterns. Ten patients underwent fasting and post-prandial concurrent manometry and pH for detailed analysis of reflux events.
 
RESULTS
Baseline demographics between cohorts were similar: Age 47.2±11.6 vs. 44.1±11.3 years (p=0.121); females 73.2% vs. 90.8% (p=0.005); excess weight loss (EWL) 53.8±28.1% vs. 57.4±25.5% (p=0.422), follow-up duration 12.3 vs. 7.4 months (p=0.503). Nuclear scintigraphy delineated bolus-induced deglutitive reflux events (29.6% vs. 62.5%, p=0.005) and post-prandial reflux events (4(IQR2) vs. 4(IQR 3) events, p=0.356). Total acid exposure was significantly elevated in the symptomatic population (7.7% vs. 3.6%, p<0.001), especially fasting acid exposure (6.0% vs.1.3%, p<0.001). pH/manometry analysis demonstrated acute elevations of the gastro-esophageal pressure gradient (>10mmHg) underpinned most reflux events. Swallow-induced intragastric hyper-pressurization was associated with individual reflux events in most patients (90% in fasting state and 40% post-prandial).
 
CONCLUSIONS
We found reflux to be strongly associated with SG and identified three unique categories. Bolus-induced deglutitive and post-prandial reflux occurred in most patients. Elevated fasting esophageal acid exposure mediated symptoms.  Frequent, significant elevation in the gastro-esophageal pressure gradient was the mechanism of reflux and appeared to relate to the non-compliant proximal stomach.
BACKGROUND
Revisional malabsorptive procedures are indicated when primary bariatric operations have failed, particularly multiple times. There are significant surgical risks and potential for severe nutritional deficiencies if follow up is inadequate. There is limited data available on long term nutritional parameters and attrition rates in this cohort of patients.

METHODOLOGY
Analysis of prospectively recorded data for all patients who had a revisional biliary pancreatic diversion (BPD) +/- duodenal switch (DS) over a 16 year period at multiple centres.

RESULTS
A total of 102 patients were identified who had undergone a revisional BPD +/- DS, with a mean of 2.5 (range 1-7) prior bariatric procedures. Median follow up was 7 years (range 2-17 years). There were 23 (22.5%) patients permanently lost to follow up at a median of 5 years postoperatively. At the time of revisional BPD +/- DS mean BMI (SD) was 46.4m²/kg (8.7). Mean percentage total weight loss (SD) of 22.95% (13.37), 20.06% (10.47), and 17.55% (5.66) was recorded at 5,10 and 15 years respectively. At baseline, 24 patients had diabetes and 16 had hypercholesterolaemia with remission of these occurring in 20 (87%) and 7 (43%) patients respectively. Minor nutritional deficiencies occurred in 82 (80.4%) patients, with 10 (9.8%) patients having severe deficiencies requiring periods of parenteral nutrition with 6 patients requiring limb lengthening procedures. 16 (15.7%) patients experienced a complication within 30 days, which included 3 (2.9%) anastomotic leaks. Elective surgery was required in 42 (41.2%) patients for late complications.

CONCLUSION
Revisional malabsorptive bariatric surgery induces significant long term weight loss and comorbidity resolution. Patients lost to follow up is of major concern, given the high prevalence of nutritional deficiencies. The risk of serious perioperative complications remains low, however the overall risk of requiring further surgery is high. This data is of relevance to any procedure that incorporates a malabsorptive component.
Session - ANZGOSA - 75.0 mins - ANZGOSA Room
This session will address new patient management paradigms, in particular, Enhanced recovery after surgery and its role in the Australasian setting. 
Another presentation will cover the rapidly emerging concepts of sarcopaenia in oesophago-gastric malignancy and whether it is ready to be incorporated into routine clinical staging systems. 
The ANZGOSA free paper abstract scored highest will also be featured.
BACKGROUND
Leaks post sleeve gastrectomy remain morbid and resource-consuming. Incidence, treatments and outcomes are variable, representing heterogeneity of the problem. A predictive tool available at presentation would aid management and predict outcomes. we aimed to develop and validate a classification of sleeve gastrectomy leaks able to reliably predict outcomes, from protocolised CT findings and readily available variables.
 
METHODS
From a prospective database (2009-2018) we reviewed patients with staple line leaks. A Delphi process was undertaken on candidate variables (80 to 20).  Correlations were performed to stratify 4 groupings based on outcomes (salvage resection, length of stay, and complications) and predictor variables. Training and validation cohorts were established by block randomization. 
 
RESULTS
A 4-tiered classification was developed based on CT appearance and duration post-surgery. Inter-observer agreement was high (κ=0.85, p<0.001). There were 59 patients, (training:30, validation:29). Age 42.5±10.8 vs. 38.9±10.0 years (p=0.187); female 65.5%vs.80.0% (p=0.211), weight 127.4±31.3 vs. 141.0±47.9kg, (p=0.203). In the training group, there was a trend towards longer hospital stays as grading increased (I=10.5days; II=24days: III=66.5days; IV=72 days; p= 0.005). Risk of salvage resection increased (risk ratio grade4=9; p=0.043) as did complication severity (p=0.027).  Findings were reproduced in the validation group: risk of salvage resection (p=0.007), hospital stay (p=0.001), complications (p=0.016). 
 
CONCLUSION
We have developed and validated a classification system, based on protocolised CT imaging that predicts a step-wise increased risk of salvage resection, complication severity and increased hospital stay. The system should aid patient management and facilitate comparisons of outcomes and efficacy of interventions. 
AUTHORS
YATES M(1)^, CABALAG CS(1)^, CORRALES BENITEZ M(1), YEH P(1,4), WONG SQ(1,4), CHONG L(2, 3), HII M(2, 3), DAWSON SJ(1,4,5), PHILLIPS WA(1), CLEMONS NJ(1), DUONG CP(1)
 
^Authors contributed equally to this work
1-Peter MacCallum Cancer Centre, Melbourne VIC
2-Department of Upper GI and Hepatobiliary surgery, St. Vincent’s Hospital, Melbourne VIC
3-Department of Surgery, St Vincent’s Hospital, University of Melbourne 
4-Sir Peter MacCallum Department of Oncology, University of Melbourne
5-Centre for Cancer Research, University of Melbourne

PURPOSE
Circulating tumour DNA (ctDNA) has clinical utility in monitoring treatment response and in the detection of disease recurrence in breast and colorectal cancer.  The aim of this study was to explore the role of ctDNA in the management of patients with oesophageal cancer (OC).  
 
METHODOLOGY
Blood samples and tumour biopsies were collected from 52 patients after diagnosis of OC.  In patients planned for surgery, blood samples were taken before and after neoadjuvant treatment, and during the surveillance period.  Blood samples were analysed for the same mutations present on pre-treatment tumour biopsy using a custom targeted amplicon-based approach to cover mutational foci across 9 of the most commonly mutated genes in OC.
 
RESULTS
Somatic mutations in treatment-naïve OC tumour biopsies were detected in 45 out of 51 (88%) patients.  Out of these 45 cases, 19 (42%) had detectable tumour-informed ctDNA in their plasma.  The majority (79%) of patients who were ctDNA positive had either locally advanced or metastatic disease.  In locally advanced nodal negative patients who were ctDNA positive, there was a trend towards inferior disease specific survival.  After treatment, the emergence of new somatic mutations in serial surveillance blood samples was associated with recurrent disease (p = 0.038).  
 
CONCLUSIONS
This study demonstrates that ctDNA may have clinically utility in the management of patients with OC by providing additional prognostic information.  Assessment of ctDNA in post treatment blood samples may lead to the detection of early recurrent disease.
Radiological assessment of low skeletal muscle mass (myopenia) and density (myosteatosis) have been identified as potential predictors of postoperative complications, recovery and survival after oesophago-gastric cancer surgery. This presentation will provide a summary of the relevant evidence to date, pros and cons of available tools to assess muscularity and future direction of incorporating these measures into preoperative risk stratification tools.  
Session - ANZGOSA, ANZMOSS - 30.0 mins - ANZMOSS Room
Objectives:
Understand factors that increase risk in bariatric patients
Discuss approach to assessing and improving risk factors to improve outcomes with bariatric patients
Understand Bariatric surgery patients are optimal for implementation of prehabilitation or optimization
Understand Components of improved post operative outcomes
Session - ANZGOSA - 65.0 mins - ANZGOSA Room
There will be two complementary and detailed presentations on the technical and physiological aspects of oesophageal reconstruction. 
Carel Le Roux from Dublin will detail physiological changes associated with reconstruction of the oesophagus. 
Jon Shenfine will provide an overview of the technical aspects of optimally constructing a conduit in oesophageal surgery.
Session - ANZMOSS - 60.0 mins - ANZMOSS Room
With a focus on interdisciplinary care Arya Sharma will reflect on how COVID-19 has changed obesity management and Teresa LaMasters will drill down into how to maximise the benefits from interdisciplinary teams.
The ideal bariatric practice. How to maximize an interdisciplinary team to get the most from your patient. In this session I will discuss the Key Aspects of an ideal and successful bariatric practice and discuss how these components impact patient outcomes.
Session - ANZMOSS - 60.0 mins - ANZMOSS Room
Surgical Speed Dating. 12 presenters of Free papers in rapid-fire defence of their presentations against an expert panel and the conference attendees.

Panel: Dr. Grant Beban, Dr. George Hopkins, Professor Wendy Brown, Dr. Michael Hatzifotis, Dr. Reza Adib, Adam Skidmore, Dr. Michael Talbot, David Schroeder, Dr. Nick Williams, Dr. Michael Booth
Panel: Dr. Grant Beban, Dr. George Hopkins, Professor Wendy Brown, Dr. Michael Hatzifotis, Dr. Reza Adib, Adam Skidmore, Dr. Michael Talbot, David Schroeder, Dr. Nick Williams, Dr. Michael Booth

Please view these presentations prior to the session.

The banded sleeve gastrectomy revisited: long-term experience from a single centre.
Miss Mavis Orizu

Cohort study comparing gastrointestinal quality of life (GIQOL) post single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) versus Roux-en-Y gastric bypass (RYGB)
Dr. Janindu Goonawardena

Long-term outcomes of sleeve gastrectomy
Dr. Megan Alderuccio

Long Term Outcomes of Sleeve Gastrectomy as a Revisional Procedure
Dr. Prem Chana
Session - ANZMOSS - 60.0 mins - Integrated Health Room
Looking at the important area of Stress and trauma for the bariatric patient and the specialist interest area of how to provide nutrition to the bariathelete.
This presentation will provide an explanation of how psychological trauma manifests in bariatric patients, drawing from case material, diagnostic guidelines, recent research, and theories of aetiology. Some of the challenges faced by surgeons and clinic directors looking to integrate psychological support for bariatric patients are described, followed by some rationales for including psychological support or interventions for patients as a potential adjuvant to bariatric surgery.
Whether at elite or recreational level, the bariathlete presents a huge nutritional challenge to ensure nutritional needs are met to maximise performance.  Nick will explore the most important dietary challenges for the bariatric surgical patient turned exercise machine as they strive to get through their arduous training sessions and then perform on that big day.  Nick’s presentation will mainly focus on achieving adequate energy, protein and carbohydrate intake for the bariathlete with very small eating capacity and the massive challenges this is to the Dietitian to meet these macronutrient targets. Nick will use a real life case study of a bari-triathlete to show how training diet, race preparation and race day can all be maximised with sound dietary preparation. 
Session - ANZGOSA - 15.0 mins - ANZGOSA Room
Session - ANZMOSS - 15.0 mins - ANZMOSS Room
After 3 years of meetings and stakeholder engagement the ANZMOSS Public Bariatric Surgery Framework document will be released on the 15th October.

Followed by a warm up to the welcome reception with awarding of the best free paper and peoples choice awards for posters and presentations.
Session - ANZGOSA - 30.0 mins - ANZGOSA Room
Only relevant  members ANZGOSA are permitted.

Agenda can be found here
Session - ANZGOSA, ANZMOSS - 60.0 mins - ANZMOSS Room
This is a great chance to get social and join with others in your ‘bubble’ for a wine and relax. 

If you would like to use your camera, it will be the perfect chance to see everyone on screen and join in some fun with our MC Darren Isenberg as he hosts a very social and interactive welcome reception. Virtual live networking with aperitifs and beverages (BYO).
#ANZMOSS - ANZGOSA 2020 Virtual Conference
ANZMOSS – ANZGOSA 2020 Virtual Conference
#ANZMOSS - ANZGOSA 2020 Virtual Conference
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