1. SUB-SAHARAN EXPERIENCE OF SURGICAL MANAGEMENT OF OBESITY
DR. RONALD MBIINE (MMED SURGERY)
PROF CHARLES IBINGIRA (MMED SURGERY)
MAKERERE UNIVERSITY, UGANDA

2. OUTLINE Understanding obesity in Africa
Existing treatment practices in Africa
Bariatric surgery
Experiences
Breaking barriers to surgical care of obesity in SSA

3. UNDERSTANDING OBESITY IN AFRICA
Last decade has seen a disproportionate increase in NCDs on the African continent. (New Epidemic in Africa)
Obesity is a key catalyst in the evolution of NCDs including
Hypertension
Diabetes Mellitus
Coronary Heart Disease
Obstructive sleep apnea
Obesity now described as a major cause for
premature death in Sub-Saharan Africa.

4. BACKGROUND …
Over 1.3 billion people globally are overweight ( 25 < BMI <30) and 600 million people are obese ( BMI > 30)
Over 340 million children and adolescents aged 5-19 were overweight or obese in 2016.
In Africa, the number of overweight children under 5 has increased by nearly 50 per cent since 2000.
Prevalence of obesity in Africa has increased over last 36 years by
1400% in Burkina Faso
500% in Ghana
Obesity is now responsible for more deaths globally than malnutrition

5. MIT Sloan 2015

6. DOUBLE BURDEN OF MALNUTRITION IN AFRICA

7. WHY SHOULD WE BE CONCERNED

8. COST IMPLICATION OF OBESITY ON HEALTH CARE

10. APPROACH TO TREATMENT OF Obesity
Conventional life style changes

11. Surgical management of obesity: BARIATRIC SURGERY
Refers to variety of weight loss surgical procedures
Most effective and Enduring treatment for
the morbidly obese patients.
In the 10-year Swedish Obesity Study:
Demonstrated that gastric bypass surgery
patients showed greater
long-term weight loss,
health-related quality-of-life improvement
Reduction in various risk factors compared with controls receiving conventional treatment. 

13. INDICATIONS FOR BARIATRIC SURGERY
BMI of >40 or Excess of more than 45kg(100oz) of BW
BMI >35 and at least one of: T2DM, HTN, Sleep apnea
Sustained failure to achieve weight loss despite all
non-surgical intervention.

14. Brief history of bariatric surgery
First document surgical treatment for obesity:
10th century in Spain by Jewish doctor Hasdai Ibn Shaprut.
on the King of Leon, D. Sancho who was morbidly obese.

15. BARIATRIC SURGERY- principles
Gastric restriction:
Sleeve
Band
Principle: Limit intake
Mal-absorption
Eg. Bilio-Pancreatic Diversion
Principle: Limit absorption

16. GASTRIC RESTRICTION Reduction in the capacity of the stomach
Simplest conducted for morbid obesity
Challenge: Patients learn to adapt to frequent high carbohydrate diet.
26% patients not happy with results
Include: AGB, Vertical sleeve gastrectomy(VSG)

17. Laparoscopic Adjustable gastric banding(agb)
Adjustable silicone band placed around first portion of the stomach. Balloon band has an inflatable port beneath the skin allowing for adjustments of the degree of gastric restriction
Weight loss is 45% of excess weight after one year
Advantage:
No permanent stomach resection
Adjustable
Disadvantage
Maladaptive eating behavior
Foreign body eroding into stomach
Stomach prolapse

18. VERTICAL SLEEVE GASTRECTOMY
Complications:
GERD, Gastric tube stricture, stenosis,
High risk for weight regain.

19. ROUX EN Y

20. Gastric bypass (ROUX & Y)
Effectiveness contributed by effects of
Dumping syndrome
Altered fat digestion by allowing down stream mixing of fat and bile.
Ghrelin produced by the distal gastric mucosa alters eating habits hence bypassed.
More effective technique with over 70% success rates in 9 to 14 months after surgery.

21. BILIOPANCREATIC DIVERSION with duodenal switch (BPD-DS)

22. Bpd-ds cont… Better and long lasting weight loss however
Higher risk for micronutrient and macro-nutrient deficiencies.
May be restricted to patients with severe morbid obesity as well as those who are extremely compliant
Less popular due to morbidity

23. Types & trends of procedures for bariatric surgery
Adjustable gastric banding
Roux en Y gastric bypass
Sleeve gastrectomy
Standard biliopancreatic diversion
Duodenal switch diversion
Gastric plication
Mini-gastric bypass
Vertical band gastroplasty

24. Comparison chart

25. EFFECT COMPARISON Key considerations
%Excess Body Mass Index Lost(%EBMIL)

26. FOLLOW UP after bariatric surgery
Carefully monitor for nutritional deficiencies
Iron, Calcium, Vitamin D, B12, Folic acid, PTH, Serum ferritin
Routine mineral and Vitamin supplementation
Ursodeoxycholic acid for first 6 months (Prevent gallstone formation)
Continuous Therapeutic patient education
Loose skin

27. REVISION PROCEDURES
REVISION: Defined as conversion, correction or reversal
INDICATION:
Severe side effects; Severe vomiting, severe dumping syndrome, intolerance to solid food.
Complications of procedure: Stricture, non-healing ulcers etc…
In-adequate weight loss

28. LATEST ADVANCES IN BARIATRIC SURGERY
Endoscopic Sleeve Gastroplasty
(ESG)- Accordion procedure
Endoscopic suturing device to reduce
stomach size
Endoscopic gastric balloon

29. EXPERIENCE AT OUR CENTER
Comprehensive Patient education
Open vs Laparoscopy Bariatric surgery
Cost implications for Laparoscopic
Capacity building in bariatric laparoscopic surgery
Commonly we do:
Vertical sleeve gastrectomy
Roux N Y bypass
Establishing subdivision of Bariatric surgery on GI unit

31. BREAKING Barriers to care
Absent organisational structures to support and advance the standard of bariatric surgery in Africa
Sporadic practices across the continent.
Need for Continental associations
Journals
Perception that Bariatric surgery is a cosmetic procedure:
Inclusion on insurance programs
Include Bariatric surgery on essential surgery list
Constrained capacity of suitably qualified staff
Linkages for advanced training in laparoscopy
Creation of high volume centers
Health Literacy
Inform patients about surgical options for treating obesity

32. TAKE HOME
Obesity is the key driver of the NCD epidemic in sub-Saharan Africa
Early life style adjustments are adequate in correcting disorder
Bariatric surgery is an essential component in treatment of obesity as well as other NCDs and not a cosmetic option
Advocacy for inclusion of surgical care in the NCD treatment package.

33. ASANTE SANA