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Specialists Without Borders Rwanda Seminar in Surgery - September 2010

12:00 18/01/11 | Owen Haskins | Editor in chief, Bariatric News

Specialists without Borders continued its medical education initiatives into Africa with a seminar in surgery over three days in Kigali, Rwanda. This was followed by teaching at the medical school in Butare. Thirteen Australasian surgeons participated as lecturers as well as, for the first time, five medical students, who were partly sponsored by Allergan, and two surgical Registrars. As this was a new experience for the medical students it is worthwhile, I think, to quote from one of the student’s experience, which bears reporting.


I am not exaggerating when I say the experience I gained from this trip has helped shape me as a person and as a future doctor. Specialists Without Borders student

“Although we only stayed there for a week, the eye-opening experience I gained there is invaluable. This was my first time to be in Africa, it amazed me how much Rwanda has developed since the 94 genocide, which was only 16 years ago. The cities were clean and people were very friendly. I visited a local African family, who showed us around their house and farm. They have very little materially compared to us, yet they are happy and work hard to provide for their children.

The Rwandan people are also very gentle – for example, in the local markets they do not push us to buy things despite the fact a lot of them struggle to make a living, unlike the scenes we commonly encounter in markets in other developing countries. As I am involved in the Surgical Students' Society of Melbourne, I am currently in touch with the head of Rwandan Students' Society, whom I have met there, to look at possible ways of us helping them financially to develop AIDS and hepatitis C prevention programs for the local Rwandan community. Our next step is also to set up a students exchange program for electives.

As personally I have learned enormous amount of clinical experience by tagging along the Rwandan doctors just for a day or so, I believe it would be extremely beneficial for more Australian medical students to see what it is like in Africa and for Rwandan medical students most of whom have never been abroad to see the Western system.


I am not exaggerating when I say the experience I gained from this trip has helped shape me as a person and as a future doctor. The surgeons from SWB have inspired me to pursue surgery as a future career and I would love to get involved with SWB in the long term.”


Seminar


The seminar in surgery was requested by the Rwandan Surgical Society, to which SWB has now become an official affiliate, and the National University of Rwanda/medical school as a way to continue the postgraduate medical education and to build on the successful seminar conducted in 2009 on medical and surgical emergencies
.

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Bariatric surgery – downsized

12:00 16/01/11 | Anonymous (not verified) |

Single Incision laparoscopic surgery, where the operation is performed through one small abdominal incision, is slowly emerging as a favourite option amongst patients and laparoscopic enthusiasts. To date, only a handful of surgeons are advocating this technique in general surgery, colorectal, urology and paediatrics. However, the world of weight loss surgery has been slow to adopt the single incision approach in part due to the technical challenges that larger patients pose, with hepatomegaly and central adiposity. 


In 2008, having first sought approval from the local new and novel committee, Mr Ameet Patel, a Consultant Surgeon at King's College Hospital, and Princess Grace Hospital, initially undertook single incision laparoscopic cholecystectomies, swiftly followed by single incision splenectomy, appendicectomy, and liver resections. In October 2008 he embarked on bariatrics and to date has performed single incision laparoscopic sleeve gastrectomies, and over 130 true single incision laparoscopic gastric band operations.


Having acquired considerable single incision surgical skills, the final frontier to be conquered was the Single Incision Laparoscopic Roux-en-Y gastric bypass, which was successfully undertaken on 5th September 2010. 


The procedure underway

In this initial experience the patient was a 24 year-old school teacher who had struggled with her weight for many years. At surgery her weight was 123kg with a BMI of 48. Her past medical history included one caesarean section, and a fatty liver confirmed on ultrasound. 


A single incision was made into the abdomen, through which a port with four working channels was placed. Through this port a 5mm camera and standard laparoscopic instruments were used. The chosen post device was able to accommodate all equipment required, including the hand held liver retractor, harmonic scalpel and 10mm stapling device. 


The operation itself was an exact replica of the laparoscopic approach, fashioning a 30ml gastric pouch, creating an anticolic gastrojejunostomy and entero-enterostomy and closure of mesenteric windows.

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Bariatric Training is now SORTED

05:37 19/04/10 | Owen Haskins | Editor in chief, Bariatric News

As a surgical registrar with a specialist interest in Upper GI and Bariatric surgery, I was frustrated by the lack of a formalised training programme in Bariatrics in the UK. I was also a little disappointed that courses in bariatric surgery were slightly confused about their target audience, with delegates ranging from junior trainees to senior consultants. I decided to address these problems and designed SORTED!


S.O.R.T.E.D (Surgery for Obesity – Registrar Training and Educational Development) is a unique modular course, designed specifically for senior trainees within two years of a consultant post. Its aim is to provide operative training in addition to enhancing multidisciplinary skills necessary to practice in this specialty. Full sponsorship was generously offered by Ethicon Endo-Surgery after a “dragon’s den” style pitch at head office and the pilot course was setup in the South West region.

Six delegates were selected from open competition using a combination of CVs, letters of support from trainers and personal statements. The course programme was as follows:


Module 1 (Feb18th/19th2010)


European Surgical Institute, 
Hamburg, Germany.


Faculty: Mr David Hewin, Mr David Mahon, Mr Peter Sedman


This two day module was held at the state-of-the-art facility in Germany, owned and run by Ethicon Endo-Surgery. The programme included:


Simulator session – using computer simulation to revise basic laparoscopic skills such as knot tying and suturing. Hand-eye coordination and manipulation exercises were included with time trials to encourage competition between the delegates and faculty. The faculty were not always the fastest! Each delegate and faculty had their own individual simulator.


Dry laboratory session – each delegate had their own laparoscopic station with a porcine prosection. This was excellent as all the organs were in their correct anatomical positions and was a welcome change to a dried out stomach and bowel pinned out on a corkboard. We then trialed a new perfusion prosection model (unique to Ethicon Endo-Surgery) in which red liquid was continuously pumped through a cannula in the splenic artery. This meant that the tissues were engorged and “bled” if you made a mistake. A truly excellent experience for all and great preparation for the wet labs.


Supervised sleeve gastrectomy in the dry labs, Hamburg

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Extreme obesity

03:12 06/02/10 | Anonymous (not verified) |

The management of patients with BMI >60 is a challenge undertaken regularly by few centres worldwide. Literature review reveals a variety of series of such patients with varying degrees of success in technique and outcome. Unfortunately, despite demand for intervention, this patient group is often poorly managed by general healthcare professionals, due to reluctance to intervene, or a belief that they are ‘beyond help’. Ongoing care in the community or hospital setting is extremely costly, and early demise is the norm. 


"Our experience shows that with attention to detail, these patients (heaviest BMI 131) can be safely managed through surgical intervention" Shaw Somers

The complex aetiology of such extreme obesity demands comprehensive multidisciplinary assessment. All patients require the involvement of the extended bariatric team in order to manage the physical and psychological preparation for intervention. Most will require a prolonged period of preparative treatment that might include a temporising weight-loss intervention, such as an intra-gastric balloon.

Co-morbidities are often challenging and sometimes unexpected in nature. Their intensive correction is the cornerstone of safe surgical intervention.Familiarity of the entire Bariatric team with the needs of this patient group is vital. Patient mobilisation and handling protocols are taken to a ‘special level’ in order to ensure patient and staff safety. Infrastructure issues, such as furniture, toileting and operative equipment need to be addressed.


Over the past 12 years, our centre has accumulated experience of surgery in over 300 patients with BMI >60. Our experience shows that with attention to detail, these patients (heaviest BMI 131) can be safely managed through surgical intervention. Application of the same operative decision algorithms can result in similar outcomes of percentage excess weight loss as for standard Bariatric patients. We have undertaken RYBG (open or laparoscopic) in 93%, LAGB in 5% and Sleeve gastrectomy in 2% patients.

Mortality occurred in 3 patients, all secondary to advanced co-morbidity. Complications occurred in 11%, mostly co-morbidity related (cardio-respiratory). Hospital stay was a median of 7 days, but this was skewed due to mobilisation / discharge issues rather than true post surgical recovery. Post discharge, all patients had primary care management plans including prolonged DVT prophylaxis.


Plastic surgery should be considered an essential part of Bariatric management in this group of patients." Shaw Somers

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