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Bariatric surgery in the Caribbean: is it safe in a low-volume, third world setting?

Dan D, Singh Y, Naraynsingh V, Hariharan S, Maharaj R, Teelucksingh S.

Department of Clinical Surgical Sciences, The University of the West Indies, St. Augustine, Trinidad and Tobago.

Minim Invasive Surg. 2012;2012:427803. Epub 2012 May 8.


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.

{ 2 comments… add one }

  • admin October 22, 2012, 6:43 am

    When is low too low ?

    If volume were to become a decisive factor whether or not to provide various health services in the Caribbean the availability and access to such services would fall dramatically. This may not be easily accepted, but may be unavoidable in certain instances e. g. transplant surgery, surgery for congenital problems etc. Certainly, regionalization is a solution. If bariatric surgery is done by consensus in just one or two designated centers in the Caribbean, these may at least be “moderate” volume facilities. After all, this is elective surgery, so travel does not cause any detriment from a purely medical standpoint.
    “Too low” as related to the surgeon may be a mute point, provided that he or she has performed enough procedures in the past (e. g. during training, fellowship, previous practice locations) to have reached the flat part of their own learning curve. Technique and experience do not vanish, it is like riding a bicycle. That somebody can train in the Caribbean in a surgical subspecialty and reach that level is virtually excluded. So bariatric surgeons like plastic surgeons, spine surgeons, hand surgeons, transplant surgeons etc. should be trained outside the Caribbean in a high volume center in the US, Europe or Asia.
    The true problem of “too low” is the facility, where these low volume cases are performed. And bariatric procedures are dependent on a functioning facility, a controlled clinical pathway, ICU, OT/PT, competent dietician and so forth. Just imagine a transplant center which does ten transplants a year – even if one flies in a high volume surgical team for each procedure the system failure in the facility, possible lack, decay and loss of equipment, unfamiliarity with a clinical pathway used last two months ago, inadequate ICU management etc. will be detrimental. Sure, some are going to survive regardless, which may lead to the conclusion that it is safe to do such procedures at a low volume, third world setting or on the next, even smaller island. Besides, according to 2011 statistics of the CIA factbook (https://www.cia.gov/library/publications/the-world-factbook/geos/td.html) Trinidad and Tobagos GDP per capita ranks number 62 in the world, so hardly a third world country (although it may choose to behave like one). So a “third world” wand cannot serve as a perceived cause for higher complications, lower standards etc. Venezuela, Colombia and Cuba, popular destinations for government and citizens alike to receive highly specialized health care all show about 40 ranks behind Trinidad.

  • admin October 22, 2012, 1:41 pm

    Postbariatric Surgery

    Having bariatric surgery is one thing. What if it is successful ? Weight loss is stable after a year, but the skin usually does not retract. One hundred pounds lighter, but aesthetically and psychosocially the rehabilitation is incomplete. Body contouring is an integral part of designated bariatric surgery centers.
    In 2010 US high volume surgeons at Trinidad Institute of Plastic Surgery may have performed the first local lower body lift in Trinidad on a young woman after 120 pounds weight loss. Postbariatric surgery to complete rehabilitation of the patient is a multi staged process. Stage I – lower body lift +/- thigh lift and liposuction, stage II – augmentation mastopexy, bra line lift, +/- brachioplasty and liposuction, stage III – face and neck lift.