A London-based Consultant Laparoscopic and bariatric Surgeon, Dr Abuchi Okaro and his team were recently in Euracare Multi Specialist Hospital, Lagos on a working visit where he successfully performed Nigeria’s first Single Anastomosis Gastric Bypass, a weight loss procedure. In this interview, in this interview with Martins Ifijeh and Ayodeji Ake, he spoke on challenges of laparoscopic surgery in Nigeria and options available to citizens
What is Laparoscopic Surgery all about?
The term laparoscopy means looking in or visualising through small holes and telescopes the contents of the abdominal cavity. It is an extension of that process, using various instruments inserted through small hole to perform surgical procedures that would have otherwise been performed through large cuts or incisions to allow the hand into the cavity to perform the surgery.
What are the benefits of the surgery?
The patient does not need large cuts in order to do the surgery, and this translates into less post-operative pain after the procedure. Another big advantage is that with less pain, the patient recovers faster and so can go home even on the day of the surgery. Another advantage is that the surgery is projected on a large TV screen so you get a bigger image or picture allowing those present in the theatre to follow and learn more about what is done via the video system.
Laparoscopic or keyhole surgery has been in Nigeria for longtime, in fact gynecologists were the first to use laparoscopic techniques in Nigeria as with other parts of the world. It’s only much later that we general surgeons got involved. What is relatively novel or new for us in Nigeria is performing highly complex and advanced laparoscopic upper gastro-intestinal procedures such bariatric or weight loss surgery
The factors hampering the spread of intermediate and advanced laparoscopic gastro-intestinal surgery in our region are firstly the lack of adequate training and expertise of medical and nursing personnel up to a level of proficiency to permit independent practice, secondly the required laparoscopic equipment and other tools are very expensive and therefore require specific and sizable investment as part of the setup costs. Lastly, but not least is the significantly higher cost of performing the same procedure but with the laparoscopic or keyhole method.
Bariatric or metabolic surgery is a rapidly expanding branch of Upper Gastro-Intestinal surgery around the world. The ability to surgically adjust the upper digestive tract and cause over time significant weight losses for the patient has transformational impact on weight which affect diseases like Type 2 Diabetes, Hypertension, sleep apnea etc. It is predicted that as high as 30 per cent of Nigerian adults are obese
Can you share some of your personal experiences?
I performed my first bariatric surgical procedure which was a Lap Sleeve Gastrectomy in Lagos in 2011. Since then I am pleased to say we have made significant progress over the years in terms of building the team and partnerships that have allowed us put together a fully functional service that comprises high quality infrastructure, personnel and system. The workload and referrals have slowly but steadily increased year on year. Our main challenges remains public awareness, this is not just limited to knowing that the service exists but also its potential benefits. Another frequent challenge is the general apathy and fear of patients having any complex surgery performed in Nigeria.
We are confident that by creating the right awareness, and backed by the right positive messages that highly skilled medical services such as bariatric surgery will have a definite place and an exciting future in Nigeria.
The benefits of bariatric surgery can be both medical, like treating diabetes, improving fertility, and curing hypertension and psychological issues like improving self-confidence and overall productivity. The road towards healthy eating and living is more like a journey than a trip and requires all members of the team, surgeon, physician, anesthetist, dietitian and nurses working together on a multi-disciplinary platform for the benefit of the patient and community.
We would like to see our centre and other centres like it, to make patients planning to travel long distance overseas for medical treatment reconsider and re-evaluate such plans and consider visiting local units like ours where their healthcare needs can be assessed and treated locally. Particularly in bariatric surgery, continuity of care (follow up) delivered at international standards locally, offers the best long term outcomes and solutions for patients.
Don’t you feel cost or affordability is part of the reasons why metabolic surgery or gastric by-pass is not used broadly in Nigeria?
Everyone in healthcare globally must consider affordability of services if such services are to become sustainable. I am sure affordability has some impact on its wider acceptance in the short term, I however feel that the medium to long term benefits in terms of improving overall health, treating diabetes, preventing certain cancers to mention a few, will go a long way in further demonstrating the value of such services in our communities in Nigeria.
Are there other cost-effective solutions or options that Nigerians can embrace to tackle obesity?
There are a number of procedure options we offer in the weight loss and metabolic surgery clinics. Our usual practice is upon full appraisal and patient assessment we base our recommendation on the patients’ age, current weight, eating and overall lifestyle and let the patients choose what suits them. We are continuously striving to broaden the range of options available locally. For instance, in modern day cancer treatment you have options like surgery, chemotherapy, and radiotherapy. Something similar applies in treating obesity and there is a range of treatments, surgery is one of the options, probably the best option. However, the priority remains proper and effective counseling. Then the patient can pick the preferred choice.
What exactly do you do in weight loss surgery? Is it to reduce the stomach or suppress appetite?
The principles of healthy weight reduction treatments are centered around sensible dieting, regular exercise, and portion control. Where diet is concerned, we analyse things in terms of calories consumed. When trying to reduce that amount of calories a patient consumes, we take a lot of things into consideration. One is appetite, which is the desire to consume more; it is a physical, psychological and emotional process. Another key issue is the feeling of fullness during meals otherwise called Satiety. You know that in Nigeria we have the culture of eating till we are full. In our culture we are made to believe that as a visitor, if you leave ‘left-over’ in the plate, it is disrespectful of your host. This is now an outdated belief and directly leads to overeating and obesity. You also cannot talk about overeating without looking at how active we are. In the country now, we are compelled to live sedentary lives because of some factors including our culture. Our roads have no good walkways, no parks for people to walk around and we are always jumping in cars and buses. Obviously, we rarely burn enough energy even as we consume food massively.
In metabolic surgery, the key thing is to make people feel full quicker, so the patient has a reduced appetite or is satisfied quicker. What is done to the stomach tends to reduce its volume (restrictive). Another thing is to change how the intestines and other parts of digestive system function. So that when you eat, the bulk of the food is not absorbed, so most things just pass along till they are excreted in the waste movement. This is called Malabsorption. These are the two major aspects of bariatric surgery. All these must be taken with good education on the best choice of food and drinks. Regrettably our food culture is carbohydrate led and we eat big meals. Beer and juice consumption is on the increase. These things have consequences. The way one eats can kill gradually: diabetes, obesity, hypertension, infertility to mention a few.
What is the level of obesity in Nigeria and the UK, and at what level of obesity would bariatric surgery be required?
There are globally acceptable guidelines based on the Body Mass Index (BMI). It is based on the ratio of one’s weight to height. It estimates what amount of the body weight is made up of fat. One can easily identify the level of one’s obesity. On the question about prevalence of obesity in Nigeria, nobody can state specifically because no detailed study has been done but one can comfortably state that in the adult age bracket of 30 years and above, the estimated percentage would be about 30 per cent. The range might differ from those averagely obese to those who are very huge in size. Also, there are cultural elements that can move a person from being slightly obese to morbidly obese.
Do you do liposuction, tummy tuck and other things involved in cosmetic surgery?
Not at all! We need to make a clear distinction between cosmetic surgery and bariatric or weight loss surgery. Cosmetic surgery is purely for the change of appearance to look better. In this case the surgeon suck fat from different positions of the body to make it look good. The impact is superficial. In weight loss surgery the changes are deeper. The way various parts function – intestines, pancreas etc are fundamentally influenced. It is not that there would be no changes in image or looks, but those changes were not the primary purpose of the surgery.
Can bariatric surgery be done on young people with tendencies of being fat so that obesity will not occur in future?
That is not advisable. Obesity in children is a global issue and the message should be healthy consumption and more exercise. The responsibility is on the parents, schools and the entire community. Surgery cannot be recommended at this level. Non-surgical options should be the relevant choice until the stage of obesity. There are indeed genetic factors to obesity but if you eat right and exercise well, you can improve your health and reduce your weight to live longer and better.
You specialise in Single Anastomosis Gastric Bypass? What edge does it have over these other options?
Gastric bypass is an operation that combines the reduction of the volume and size of the stomach with changing the functionality of the digestive system so that when you eat, the bulk of the food is not absorbed so most things just go out as waste. The Single Anastomosis Gastric Bypass is a refinement of the old style Roux-En-Y Proximal Gastric Bypass Surgery that has been available for some time. This modified operation does not create blind channels and alleys like the existing one. It is a bit more comfortable for surgeons, and it’s seen as superior in terms of weight loss and control of things like diabetes. This is undoubtedly the first time it is done in Nigeria.
What are the risks involved in this surgery?
The first is that the patient will have full anesthesia. That has its risks. The second risk is the bleeding. The body is made of blood and vessels and in surgery you cut tissues and some parts out, so there is bleeding at the time of surgery and sometimes after, although this is not common. Another risk that does not happen often is leakage after the stitch. The cutting and stitching can be as long as 18cm and everything must heal perfectly. Any leakage can be very risky but it does not happen often. Thankfully, we have treated over 250 patients without any serious complications or deaths.