Are all surgeons doing bariatric surgery in Pakistan competent & experienced enough to undertake these surgical procedures?

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 POSE is an OPD procedure still in experimental phase

Are all surgeons doing bariatric surgery in
Pakistan competent & experienced enough
to undertake these surgical procedures?

Registration, monitoring of results and accreditation of
all HCPs undertaking interventional procedures is
essential to ensure patient safety

KARACHI: Are all the surgeons doing bariatric surgery well trained, competent and experienced enough to undertake such surgical procedures? In the absence of any accountability, registration and monitoring of all those healthcare professionals who undertake interventional procedures i.e. bariatric surgery as well as laparoscopic surgery, interventional cardiac procedures besides those involved in assisted reproductive techniques running IVF Centers, infertility clinics is extremely important to ensure patient safety. There have been reports of serious complications following these procedures, hence till such time that we have some state control, the senior and well trained professionals and the respective professional specialty organizations should start registering of all such healthcare professionals who are undertaking interventional procedures. Their results should be closely monitored and their registration, accreditation will also help generate local data as to the number of procedures being performed and their results.
Patient safety has become an important issue these days and even in highly developed countries in the West are reported to have documented numerous medical errors, “Near Misses”, un-necessary surgical procedures some of which are influenced by materialistic attitude of the doctors. Bariatric surgery in particular is a very new specialty in Pakistan and appropriate measures are needed to ensure patient safety so that they are not fleeced by greedy physicians and surgeons.
In Pakistan we seem to have no approved guidelines for undertaking bariatric surgery. At how many centers in the country it is being practiced and what is the total number of surgeons undertaking these surgical procedures, what is their surgical experience and expertise, nothing is documented. In the absence of any such guidelines, the patients who wish to avail of these facilities are left at the mercy and sweet will of the medical centers and surgeons. It is essential that all those who wish to undertake any interventional procedures must have had adequate training followed by experience of assisting and then independently doing about at least fifty procedures under supervision of experts before they can independently start practicing. This is what is practiced in all the civilized countries but we are nowhere near having formulated such guidelines.
According to a recent report the Health Authority of Dubai has decided to introduce standards to protect people seeking bariatric surgery for weight reduction and other weight related problems. These rules will cover which patients are eligible for surgery besides qualifications and experience of the surgeons. The new rules will standardize diagnosis, treatment and ways of reporting data by the end of each month to the central registry. Their decision follows a few cases of serious complications with bariatric surgery, hence the health authority decided to introduce these rules and guidelines to ensure patient safety. It may be recalled that according to WHO, 67% of men and 72% of women in UAE are overweight or obese. International criteria requires a person’s body mass index (BMI) to be more than forty or more than 35 if there is an associated illness such as diabetes. Since hospitals in UAE has set their own standards, at times it is difficult to hold the doctors accountable. Dubai Health Authorities are working with local and international experts including Emirates Obesity and Metabolic Surgery Interest Group and American Society of Metabolic and Bariatric Surgeons. Many studies have shown the benefits of bariatric surgery for chronic diseases. Statistics from a 2004 study published in JAMA has shown remission rate of 77% in type 2 diabetes patients while hypertension was eliminated in 62% of patients. According to Dr. Faruq Badiuddin obesity is a metabolic disease. It includes complications such as diabetes and hypertension. These complications are usually present in one third of the patients in his practice. Bariatric surgery is not done just to reduce weight. He was of the view that bariatric surgery should be named as metabolic surgery which is surgical procedure designed to correct the metabolic defects in the body.
Dubai Health Authorities move will set minimum requirements for bariatric surgeons. According to Dr. Fawaz Torab President of Emirates Group of Experts, some of the new requirements might include surgeon’s complete training and performing between fifty to hundred operations depending on the type of surgical procedure. UAE University and Tawam Hospital introduced Fellowship in bariatric surgery last year is expected to address these problems like high demand for surgery and few surgeons. In Pakistan there is no Fellowship in Bariatric Surgery so far. Surgeons doing bariatric surgery will be obliged to undertake training courses to improve their skills and then get accreditation. At present many patients are being treated by inexperienced surgeons leading to serious complications.
Dr. Faisal Badri, Head of general surgery at Rashid Hospital feels that all surgeons doing bariatric surgery should get a license. At present it is an open market and all the surgeons are doing bariatric surgery. Rashid Hospital is one of the biggest bariatric surgery units in UAE operating on over eighty patients a year. “It is not unusual for doctors there to get patients who have had botched surgeries at other facilities, sometimes as many as ten a year” says a report appearing in The Nation published from Dubai. Rashid Hospital has a waiting list of about three hundred for the surgery, hence many patients go to other private hospitals. Rashid Hospital offers surgical facilities free to Emirates Nationals and at subsidized rates to expatriates. A gastric bypass could cost about ten thousand US dollars as compared to fifteen to twenty thousand US dollars at other private healthcare facilities. Hospitals affiliated with Dubai Health Authority work on privilege basis which means that doctors must complete a number of supervised operations before they are approved and accredited to work within a specialized department. However, private hospitals operate more freely.
Dr. Badiuddin says they are in contact with Dubai Health Authorities to develop unified guidelines for the whole of UAE. It is extremely important to have clear guidelines which should be well promoted to the to the UAE surgeons. When amateur surgeons who are not appropriately trained start doing bariatric surgery, we see lot of problems and complications in patients which have been now well documented.
According to yet another report Dr. Fiasal Badri, Head of general surgery at Rashed Hospital says that incision less treatment is not reversible. Less invasive operations are now available and some are under trial but they have not yet been approved by the FDA. Procedures like primary obesity surgery endoluminal (POSE) is an outpatient procedure performed under general anaesthesia. It involves stitching the stomach where the hunger receptors are located. Dr. Tarek Saleh consultant gastroenterologist at Medcare Hospital Dubai who first performed it in UAE has so for treated twenty patients. It is a good procedure for people who wish to lose some weight without resorting to more invasive, laparoscopic bariatric procedures that require longer recovery time. During this procedure a tube is inserted orally and lands in the spongy part of the stomach that stretches out to accommodate large meals. This portion of stomach is also responsible for the secretion of hunger hormones that can lead to overeating, Dr. Saleh stated. Surgical tools are moved through the tube and used to grasp the stomach tissue and deploy suture anchors to create tissue folds in the stomach wall, reducing the capacity upto to 25%. This procedure works best for the patients who need to lose between ten to thirty Kg with a body mass index between thirty and forty. Patients must not be diabetic or have a history of being treated with insulin. However, this procedure is still in experimental phase. We do not recommend this procedure because we do not know the long term results. We tell the patients clearly; look this is an experimental procedure. If you want to take your chances, please go ahead but get it done in a place where someone is experienced in doing it. Possible complications associated with this procedure (POSE) are bleeding and infection which can result from perforation of the gastric wall. Clinical trials began in 2007, so far no death has been reported from this procedure and it has a complication rate of less than 1.4%.
Coming back to the situation in Pakistan, speakers at various medical conferences have highlighted the importance of registration, accreditation of all those undertaking various interventional procedures and having central registries. A large number of un-necessary angiographies, endoscopies and even stenting of healthy arteries have been reported. Similarly many of the so called Infertility Clinics and IVF centers run by unqualified and inexperienced people continue to fleece patients and there is no body to check these unethical practices. When will the government and health authorities wake up to have some guidelines for registration, monitoring and accreditation to ensure patient safety is not known?

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