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Bariatric surgery in...

...Qatar

The dramatic rise of diabetes in Qatar has resulted in an increase in the number of bariatric procedures. We discuss development of the specialty with Dr Michel Gagner...

On November 14th 2011, the International Diabetes Federation launched the 5th edition of the ‘Diabetes Atlas’ to coincide with World Diabetes Day. The new figures indicate that the number of people living with diabetes is expected to rise from 366 million in 2011 to 552 million by 2030. Nowhere is the increased expected to be more marked than in the Middle East and North Africa Region. Currently, 32.6 million people (9.1% of the population) have diabetes and this number is expected to double in less than 20 years.

By 2030, 59.7 million people (11% of the population) will be living with diabetes with more millions undiagnosed. Moreover, six out of the world’s top ten countries with the highest prevalence of diabetes are in the region. The new regional figures also show that the prevalence of type 2 diabetes in the region for younger age groups is substantially higher than the global average.

Qatar and obesity

According to International Association for the Study of Obesity’s 2012 statistics, Qatar ranks sixth globally in the prevalence of obesity and has the

highest rate of obesity (36.5%) among boys (and 23.6% of girls) aged 12–17 Qatar is also ranked 5th for having the highest percentage of people between 20 and 79 with diabetes. Currently 16% of the population is diabetic.

The Hamad Medical Corporation (HMC) is the premier non-profit healthcare provider in Doha, Qatar. The HMC has an expressed mission to provide the best quality care for all patients irrespective of nationality, in order to create ‘Health For All’ healthcare programme, as pledged by the State of Qatar. Providing a ‘Health For All’ healthcare programme has resulted in a huge investment in all areas of public health, including diabetes and obesity. Part of the fight against these debilitating condition will be by a team of bariatric surgeons and specialists at HMC, headed by Dr Michel Gagner (Professor of Surgery in Montreal, Canada).

“I first came to Qatar when I was Chief of laparoscopic Surgery at Cornell University in New York (2003-07), and I was invited by Dr Abdulazim Abdul Wahab Hussain (now Consultant General Surgeon and Medical Director of Al-Ahli Hospital in Doha, Qatar) to assist him with complex cases. I was visiting Qatar two or three times each year,” explained Gagner. “After Dr Hussain left HMC, the hospital was looking to re-engineer the bariatric programme and I arrived in February 2011 with the objective of re-establish the HMC’s bariatric programme as a centre of excellence in the region.”

There are many reasons for such high rates of obesity in the country including a lack of exercise and poor diets, as well as cultural traditions. “Lifestyle choices have the greatest impact on a patient’s health. We need to educate the population on the consequences of not exercising regularly and inform people of the dangers of eating foods that are high in calories and carbohydrates, and of the benefits of eating fruits and vegetables,” he said. “These choices are more influential than a person having genetic pre-disposition to obesity.”

There are also cultural influences as in Qatari society food is often consumed communally, making it difficult to ensure proper portions and it is also perceived as normal within society to be obese, with no stigma associated with obesity.

In the 18 months Gagner has been operating in Qatar, the HMC team have managed to train local surgeons and specialised bariatric team to perform several bariatric procedures. In fact, the HMC team have performed over 500 procedures with a zero mortality rate. With obesity and diabetes rates some of the highest in the world, he argued that the population required and deserved a dedicated bariatric programme. “In our team there is one senior consultant, one junior consultant, a specialist with a couple of finishing general surgery residents, who are probably going to join the bariatric programme. We are not the only hospital in the region performing bariatric surgery, but I believe we are performing more complex cases, such as revisions.”

Different procedures

As well as a lack of education and awareness of the causes of obesity, he acknowledged that there is also a general lack of education in the general population about obesity and in particular bariatric surgery. As a result, most people thought that the Lap-Band was the procedure of choice however, the procedure does have a high rate of failure in the region due to poor patient compliance (poor exercise and dietary compliance results in the patient returning to hospital to have their band adjusted).

“As a result, each day we removed bands as they just do not have the desired effect. The patients eat a lot, become ill and have regained weight,” he explained. “Therefore, there has been a big change in the types of procedures we perfrom. I think in the last year there have been two Lap-Band procedures the rest were either bypass or sleeve gastrectomy. In fact, over the last few months we have seen more sleeve than bypass procedures.”

Sleeve gastrectomy is preferred due to the compliance of the patient to the post procedure regime. Bypass requires supplements and patients do not always stick to this regime, whereas sleeve the intestine routing is not affected and mineral absorption stays the same. Gagner explained that there is also the consideration of pregnancy. “If young women are planning a pregnancy in the future then bypass will reduce the amount of folic acid produced and could cause certain neurological deficiencies for the child so we would strongly advise against bypass.” Although sleeve gastrectomy can cause some vitamin 12 deficiencies in certain cases, it does not have a detrimental effect on the mother or child. 

He emphasized that there is a lot to do in terms of educating the patients in regard to other types of bariatric procedures, the associated risks and complications (leaks and bleeding), as well as dietary, exercise and other life-style changes required. 

“We have to make patients aware that although bariatric surgery can resolve metabolic problems such as diabetes, if they do not comply with their dietary regime they may develop micro-nutrient deficiencies (iron, calcium),” said Gagner. “There is also need to create and develop bariatric patient support groups so they can help each other before and after surgery, as well as the more general need to educate the public about the importance of regular exercise.”

Children

Of course bariatric surgery for children should be a last resort, but Gagner described a vicious cycle in which adolescents unable to lose weight become withdrawn, trapped, bullied, do not play with other children, spend more time on computers and less time exercising. “When we speak about bariatric surgery for children, then we have an obvious problem,” he lamented. “More needs to be done to address children’s consumption of breakfast cereals, snack foods, dairy products, carbonated beverages, chilled desserts and restaurant foods.” 

Registry

There are currently over 1,000 patients on the waiting list for bariatric surgery at the HMC and given the volume of procedures, the HMC is looking at collecting patients’ data in a clinical database that will be populated through monitoring their outcomes, treatment efficacy, safety and complications.

“We are looking to employ a registry in Qatar similar to the one utilised by bariatric surgeons in the UK. This was a well designed and developed database that permitted surgeons to collect their data prospectively. If we were to adopt such a system it would allow us to identify outcomes, complications and failures and see how we could improve,” he added. “We could also match our outcomes with the UK data and see how we compare. There is also the possibility of putting the data into a larger international registry and see how bariatric surgery in Qatar compares country to country and region to region, to the benefit of surgeons and patients.”