Hindawi Publishing Corporation
Minimally Invasive Surgery
Volume 2012, Article ID 427803, 5 pages
doi:10.1155/2012/427803
Research Article
Bariatric Surgery in the Caribbean: Is It Safe in
a Low-Volume, Third World Setting?
Dilip Dan, Yardesh Singh, Vijay Naraynsingh, Seetharaman Hariharan,
Ravi Maharaj, and Surujpal Teelucksingh
Department of Clinical Surgical Sciences, The University of the West Indies, St. Augustine, Trinidad and Tobago
Correspondence should be addressed to Seetharaman Hariharan, uwi.hariharan@gmail.com
Received 16 November 2011; Revised 16 January 2012; Accepted 3 February 2012
Academic Editor: Kevin Reavis
Copyright © 2012 Dilip Dan et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Bariatric surgery is a well-recognized modality of management of obesity. In addition to obesity, it effectively controls diabetes
mellitus, and hypertension. It has been recommended that bariatric surgery should be done in “designated centers” of excellence
where there is a high volume of case turnover. Caribbean nations are not spared from the global spread of the obesity epidemic;
however, not many patients get the benefits of bariatric surgery. This study aimed to establish that bariatric surgery could be safely
and efficiently undertaken in a low-volume center outside the “designated centers” with comparable patient outcomes even in a
third world setting. Though “patient numbers” generally imply better outcome, in an environment where these numbers cannot
be achieved, patients should not be denied the access to surgery once good outcomes are achieved.
1. Introduction
Obesity has reached epidemic levels in many countries
around the world [1]. The prevalence of obesity has steadily
increased over the years irrespective of demographic factors
such as age, sex, race, ethnicity, or educational level [2]. It is
also increasing rapidly in both industrialized and developing
countries [3]. Worldwide, nearly 250 million people are
obese, and the WHO has estimated that in 2025, 300 million
people will be obese [4]. It is a well-known fact that obesity
is associated with increased morbidity and mortality.
There have been many published reports from several
Caribbean nations such as Jamaica, Barbados, Trinidad &
Tobago, and St. Lucia concerning the steady rise in the preva-
lence of obesity from primary school age through adoles-
cence and adulthood [5–8]. A recent PAHO/WHO report
suggests that more than half of the population in Trinidad &
Tobago fall within the parameters of being either overweight
or obese, which is indeed quite alarming [9].
The medical management of obesity has a poor track re-
cord, but bariatric surgery has demonstrated superior weight
loss and dramatic improvement in comorbidities in the
postoperative period.
In the developed world, bariatric surgery is usually per-
formed at designated centers of excellence on the basis that
this leads to better outcomes. However, it is debatable if bar-
iatric surgery should be limited to such high-volume centers
[10].
In addition to control of obesity, bariatric surgery is
also very effective in the management of diabetes mellitus
and hypertension, which commonly afflicts this population.
Since the prevalence of diabetes mellitus and hypertension is
also very high in the Caribbean nations, it may well be argued
that bariatric surgery should be commonly available com-
monplace in these islands regardless of the patient turnover
once results are acceptable.
With this background, this paper aims to investigate and
report the safety and effectiveness of bariatric surgery in a
low-volume center in a third world setting.
2. Methods
After necessary approval from Hospital Authorities, data
regarding patients who underwent bariatric surgery in a
single surgical unit (which offers the bariatric surgery service
in the whole island of Trinidad & Tobago) were prospectively
2 Minimally Invasive Surgery
recorded for a period of eight years (July 2003 through June
2011) and analyzed retrospectively.
Demographic data recorded included age, gender, weight,
height, and body mass index (BMI). Clinical data recorded
included preoperative biochemical parameters, comorbid ill-
nesses, drug and medication history, type of surgical pro-
cedure undertaken, surgical duration, postoperative com-
plications, repeat procedures, hospital stay, requirement of
High Dependency Unit/Intensive Care Unit admission, post-
operative biochemical parameters, postoperative medication
requirements, weight loss in the postoperative period, and
any other serious adverse outcome including mortality if any.
All patients were seen personally by the only trained
advanced laparoscopic bariatric surgeon on an individual
basis. The procedure was detailed and all risks and benefits
explained. The endocrinologist then coordinated the entire
metabolic and cardiac evaluation with a pulmonologist and
gastroenterologist used as needed. The nutritionist provided
pre- and postoperative counseling to the patient and family.
The services of a psychologist were used as determined by
the surgeon after the initial consult. After medical clearance
was obtained, the patient was again seen by the surgeon. This
multidisciplinary approach was used for all patients.
Procedures were performed at the same facility (with
adequate Intensive Care Unit back up facility) with a small
pool of locally trained operating room staff and the same
anesthetist. Patients were given heparin on induction and
compression stockings placed. Prophylactic Inferior Vena
Caval Filters were placed as determined to be necessary. The
patients were adequately secured on the operating table and
were placed supine for the bypass and in Lloyd Davis posi-
tion for the sleeve and band. A surgical assistant and camera
assistant were used in addition to the scrub nurse. All cases
were done laparoscopically using a 6-port technique for the
gastric bypass and a 5-port technique for the band and sleeve.
The gastric bypass was fashioned with a 15–20 cc gastric
pouch and a 120–200 cm Roux limb with a 50 cm biliopan-
creatic limb. An antecolic gastrojejunostomy was fashion-
ed using a linear stapler (ETHICON) and this was tested in-
traoperatively with dye and air. The sleeves were done using
the Echelon (ETHICON) stapler using a 38 Fr gastric tube
and the band used was the Swedish band (ETHICON).
The patients were nursed on the floor (one to one nursing
for 12 hours) and ambulated within 4 hours. Low molecular
weight heparin was given at this time. The nurses reported
directly to the surgeon who was readily available. A very low
threshold for return to the operating room was practiced. A
routine gastrografin study was done by the surgeon on day
1 prior to starting the liquid diet. The patient was seen in
1 week and then at 6 weeks, 3 months, 6 months, and then
yearly with a metabolic screen completed at the yearly visits.
Supplements used were chewable multivitamins, calcium,
vitamin D, and vitamin B12.
3. Results
Two hundred and eighteen patients underwent bariatric
surgery during the 8-year study period. Twenty-two patients
were lost to followup. The final analysis consisted of 196
Table 1: Resolution of comorbidities after bariatric procedures in a
low-volume center.
Comorbidities Resolution (%)
Diabetes mellitus 85.2
Hypertension 80.1
Obstructive sleep apnea 92.8
patients; 172 Roux-en-Y gastric bypass, 15 sleeve gastrec-
tomy, and 9 gastric banding.
Age ranged from 6 to 68 years (mean 49 years). There was
a female preponderance (60%) consistent with the reports of
higher prevalence of obesity in this gender in the Caribbean.
Preoperative body weight ranged from 79.5–234.5 kg. The
BMI ranged from 32–86 kg/m2 (mean 49 kg/m2).
Comorbidities included hypertension (80%), obstructive
sleep apnea (70%), diabetes mellitus (28%), significant back
pain (15%), osteoarthritis (13%), polycystic ovarian syn-
drome (35%), and female infertility (2%).
Actual weight lost in the postoperative period ranged
from 23.2 to 127.7 kg (mean 41.2 kg). Bariatric surgery is
usually considered successful if more than 50% of the excess
weight is lost postoperatively and maintained at that level. Of
the 172 patients who underwent gastric bypass, 134 main-
tained an excess weight loss of greater than 50% (mean 74%)
at a mean follow-up time of 3.4 years. Nineteen patients lost
less than 50% of the excess weight (mean 39%). Four patients
became pregnant (against advice and contraception) within
6 months after surgery and hence never lost significant
weight. Fifteen patients lost up to 82% excess weight but
regained weight after 1 year. This was secondary to poor
patient compliance with diet, exercise, and followup.
Diabetes resolved in 52 of 61 (85%) patients with the
remaining 9 patients having excellent control with decreased
medications (Table 1). Most patients’ diabetes resolved
within the first month following surgery. Hypertension
resolved in 70 of the 87 (80%) patients, and control became
relatively easier in the remaining 17 (Table 1). The majority
of patients had resolution of hypertension within 3 months.
Sleep apnea improved in 128 of 138 (93%) patients (Table 1).
All fifteen patients using continuous positive airway pressure
(CPAP) machines in the preoperative period were able to
discontinue its use within 1 month. Two patients with active
venous ulcers had them healed in 4months and the varicosity
related edema improved after bariatric surgery. Significant
improvement in the comorbidities was noted even for those
patients whose weight loss was not adequate. Average length
of stay for all patients ranged from 20 hours to 10 days (mean
1.9 days) with 92% patients discharged within 48 hours after
surgery. Length of procedure ranged from 46 minutes to 210
minutes (mean 75 minutes).
Twelve patients underwent simultaneous cholecystec-
tomy and 8 underwent subsequent cholecystectomy. Prophy-
lactic ursodiol was used in 24 patients. Unexpected findings
at surgery included malrotation in 2 patients and jejunal
diverticulosis in 4 patients. Twelve patients had severe ad-
hesions; these were managed prior to doing the bariatric pro-
cedure.
Minimally Invasive Surgery 3
Table 2: Complications after Roux-en-Y gastric bypass, gastric
banding, and sleeve gastrectomy.
Bariatric
Proceduren
(total no. of cases)
Complications
No. of
patients
Percentage
Roux-en-Y gastric
bypass (172)
Haemorrhage 7 4.1
Intestinal obstruction 2 1.2
Deep vein thrombosis 2 1.2
Anastomotic leaks 0 0
Gastric banding
(9)
Band erosion 3 33.3
Band slippage 1 11.1
Portinfection 2 22.2
Sleeve gastrectomy
(15)
Gastroparesis 1 6.7
Blood transfusions were required in 7 patients (Table 2).
Three patients had postoperative bleeding on day 1, two
managed with relaparoscopy and control of the staple line
with clips. The third patient was managed conservatively and
settled. Four patients developed upper GI bleeding at the
gastrojejunostomy site and these occurred at day 2, week 6,
7, and after 1 year. All were managed with endoscopy and
cautery control.
Reoperations were performed in 7 patients (2 described
above). One patient was taken back on day-2 for laparoscopy
for persistent tachycardia to rule out anastomotic leak (neg-
ative). Two patients developed intestinal obstruction due to
adhesions (one due to previous myomectomy and the other
at the proximal Roux limb) (Table 2). Both were managed
laparoscopically. Another patient developed adhesions and
was managed by another surgeon with laparotomy and lysis
of a single band at the jejunojejunostomy. The last patient
developed a GI bleed on day 1 which caused clot obstruction
at the jejunostomy and a very small leak of the remnant
stomach’s staple line. A laparotomy was done to correct this;
the patient then developed an incisional hernia which was
repaired 2 years later during the abdominoplasty.
There was no mortality in this series. Prophylactic IVC
filters were used in 6 patients and 2 patients developed DVT
postoperatively (one in a patient with an IVC filter at 4
months and the other at 1 month) (Table 2). Symptomatic
hypoglycemia was found in 4 patients all managed with
dietary changes and 1 with acarbose. Four patients had a
preoperatively diagnosis of bipolar disorder and they all
underwent a gastric bypass. Weight loss was excellent in 3
and average in 1 but management of the psychiatric disorder
was very difficult in all with two even contemplating suicide.
All 9 patients having gastric banding lost >50% excess
body weight. However, weight regain occurred in all with
an average excess body weight loss of 33%. Three patients
developed gastric band erosions requiring removal and
conversion to sleeve gastrectomy. One patient developed an
early slippage and had the band removed by another sur-
geon. Two of the band erosion patients developed port site
Table 3: Proposed criteria for becoming a center of excellence
according to the American Society for Bariatric Surgery.
Proposed criteria for becoming a center of excellence
Institutional commitment to in-service education program
Perform >125 bariatric surgical cases per year
Bariatric medical director in decision loop
Full consultative staff and critical care services
Full line of equipment and instruments for the care of the surgical
patients
Bariatric surgeon with 51% of practice in bariatrics
infections requiring removal of the subcutaneous ports prior
to band removal. All bands were placed very early in the series
and this procedure has since been abandoned (Table 2).
Fifteen patients underwent sleeve gastrectomy with aver-
age followup of 8 months. Ages ranged from 6–68 years.
Average weight loss is 55.4% excess weight. One patient
developed a gastroparesis which required endoscopic place-
ment of a nasojejunal tube for feeding (Table 2). This was
removed after 8 days when the patient was able to swallow
again. This patient had lost 27.7 kg in a 6-month period. Two
patients had sleeves as the first part of a 2-stage operation
(due to super morbid obesity) one of whom required to be
converted to a gastric bypass.
4. Discussion
The major finding of the present study is that laparoscopic
bariatric surgery can be performed in a low-volume center
in a third world setting with low complication rates.
The American Society for Bariatric Surgery (ASBS) has
proposed categorization of certain bariatric surgical practices
into “Centers of Excellence” for bariatric surgery. Criteria for
becoming a center of excellence include a threshold volume
of bariatric surgical cases per year, operative outcomes, and
the presence of a multidisciplinary commitment to man-
agement of the morbidly obese (Table 3) [11].
The relationship between volume and outcome has been
established in several complex abdominal operations [12,
13]. However successful procedure outcomes can be achiev-
ed by surgeons in low volume centers [14]. The concept of
centralization of surgery into specialized and superspecial-
ized centers may not apply to less populous nations [15].
Accreditation of Centers of Excellence in bariatric surgery
requires a hospital volume of more than 125 procedures/year.
Controversy exists about the perioperative safety of bariatric
surgery and the relationship between volume and outcomes.
There is no evidence-based rationale for this specific thresh-
old of 125 procedures/year [16].
There was no mortality in this series. The mortality
rate from a meta-analysis of 85, 048 patients was 0.28%
at 30 days after surgery and 0.35% between 30 days and 2
years [17]. The Longitudinal Assessment of Bariatric Surgery
(LABS) Consortium, a 10 center prospective trial involving
4 Minimally Invasive Surgery
4776 patients undergoing bariatric surgery, reported a 30-day
postoperative mortality of 0.3% [18].
Major complications in this series were hemorrhage, in-
testinal obstruction, deep vein thrombosis, band erosions,
band slippage, and delayed gastric emptying (Table 2). In the
multicenter LABS study of 4776 patients a major (90 day)
complication rate of 4.3% was reported [18]. In our series
the overall major complication rate for bariatric surgery
was 16/197 (8.1%). The 90-day complication rate was 9/197
(4.6%). There was no conversion to open and the majority of
operative complications were performed laparoscopically.
Resolution of comorbidities in the present study was
comparable to international data published in meta-analyses
[19, 20]. Diabetes Mellitus, Hypertension and Sleep Apnea
resolved in most patients in the present study (Table 1). In
a recent systematic review and meta-analysis by Buchwald
et al., which included 135, 246 patients, they demonstrated
a 78.1% complete resolution of diabetes and diabetes was
improved or resolved in 86.6% of patients [20]. In this
study, diabetes mellitus resolved in 85% of patients, while
the remaining 15% have excellent control on reduced medi-
cation.
Bariatric surgery decreases the prevalence of hyperten-
sion by 50% while another 25% of patients have a reduction
in the number of medications or their dosage [21]. Buchwald
et al. demonstrated a resolution of hypertension in 61.7%
of patients [19]. In the Swedish obese subjects trial, the
prevalence of hypertension decreased by 50% at 2 years (22).
Therefore, a significant proportion of bariatric surgical pa-
tients show resolution of hypertension. In this study, hyper-
tension resolved in 70/87 (80%) of patients.
Seventy percent of patients undergoing bariatric surgery
has sleep apnea syndrome [22]. Bariatric surgery is effective
in decreasing the severity in 100% patients with 80% of
patients using CPAP able to stop treatment [23]. Sugerman
et al. demonstrated in patients undergoing gastric bypass a
reduction of sleep apnea syndrome from 44% to 8% between
3 to 12months postoperatively [24]. In this study sleep apnea
was improved in 95% of patients with 100% of patients
weaned off CPAP machines.
Surgery is considered successful if more than 50% of the
excess weight is lost and maintained and if the comorbidities
resolve. In this study excess weight loss after surgery was
greater than 50%, 88.4% of gastric bypass patients, 55.4%
gastric sleeve, and 33% band with followup of 3.4, 0.9, and
6.4 years, respectively. In a meta-analysis by Buchwald et al.
excess weight loss after gastric bypass was 68.2% and gastric
banding was 61.6% [19]. In a systematic review of sleeve gas-
trectomy, excess weight loss was 55.4% [25].
Despite being a low-volume center (218 bariatric cases
over 8 years) and a low-volume surgeon (27 cases per year)
and not fitting the criteria for a center of excellence, we
have demonstrated that bariatric surgery can be performed
safely with acceptable morbidity and mortality. This is made
possible by having a well-trained vigilant surgical team, thor-
ough preoperative evaluation by a multidisciplinary team
and close personalized postoperative followup by the sur-
geon himself for all cases.
5. Conclusion
Obesity is highly prevalent in the Caribbean and bariatric
surgery is a safe and effective therapy for this modern
epidemic. Bariatric surgery provides effective weight loss,
dramatic resolution for many obesity-related diseases. This
study demonstrated that bariatric surgery is safe and effective
in this low-volume center in a third world setting. “Patient
numbers” should not be exclusively considered as a factor
to determine and/or predict safety of bariatric surgery
in surgical practice. Furthermore, patients should not be
deprived access to this most important treatment exclusively
based on number of procedures but rather on outcome.
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