With more than 50,000 operations each year in France, bariatric surgery is considered to be the only effective class III treatment allowing a significant improvement in the quality of life for many patients.
Interview with Dr. Grégoire de Courville who talks about the development of bariatric surgery activity within the Digestive Surgery Department of Foch Hospital:
Tell us about your bariatric surgery activity within the Digestive Surgery Department.
The bariatric activity was born two years ago now, with the implementation of a whole course by a multidisciplinary team. This course is entirely carried out at Foch Hospital, with a preoperative follow- up, as recommended by the High Authority of Health (HAS), of at least 6 months before surgery. This follow-up is carried out by two bariatric surgeons in the department, Dr Frédéric Kanso and myself, as well as a team of nutritionists, psychiatrists, psychologists and dieticians, in cooperation with the anaesthesia team, of course, to assess patients before the operation.
We perform several operations, including the sleeve gastrectomy, which is currently the most performed surgery in France, and the Y gastric bypass. We do not perform a ring, as experience in France shows that it is currently the source of more failures than other operations.
What are the indications for bariatric surgery and the co-morbidities that can be improved after the operation?
Medical, nutritional and dietetic treatment, within a team used to the management of obesity, must be carried out as a first line of treatment. Bariatric surgery is only considered if this treatment fails after about a year. Moreover, the indications are quite simple, they are validated by the HAS, and we must stick to them. It is a BMI greater than 40, or greater than 35 in patients with obesity comorbidities, notably arterial hypertension, type II diabetes, hepatic complications (NASH, steatosis), dyslipidemia, sleep apnea syndrome, or disabling osteo-articular diseases such as knee, ankle pain, etc.
You pay particular attention to the post-operative follow-up of your patients. How do you proceed?
The follow-up after surgery is a bit of an Achilles’ heel of the management, since we now know that after two years only 50% of patients are still being followed up. This is not always a lack of follow-up by a medical team. Sometimes it is patients who want to forget their old illness and who no longer want to hear about the doctors or the hospital, which is understandable.
We are therefore very vigilant on this point. We have a highly protocolised post-operative follow-up programme with surgical, nutritional and dietary consultations, and a schedule given to the patient as soon as the operation is performed. At each consultation, we fix the next appointment, which allows us to limit the “lost of sight”. We also have a reminder system for those lost to follow-up, with an annual review of the patients who have undergone surgery. Did they come to the consultation? If not, we call them back, to insist on the importance of the follow-up.
Follow-up must be lifelong. It is denser at the beginning, with appointments close together (four surgical appointments in the first year), then spaced out little by little (two appointments in the second year, then an annual appointment) in the absence of problems (nutritional deficiency, surgical complications).
You perform bariatric surgery with robot assistance. You are also developing robotic surgery forvarious operations such as hiatal hernias or stomach cancer. What benefits do you derive from this in your practice?
It is a very interesting surgical tool, since it allows mini-invasive surgery, in the same way as laparoscopy, but with additional comfort for the surgeon in terms of quality of dissection and 3D vision. It really gives the impression of moving inside the abdomen. We have a magnified image, dissection tools with joints so that the instruments can be used in all three planes of space. We manage to do things which are difficult to do with laparoscopy today.
The indications for this technology must therefore still be weighed, and its use reserved for complex surgery. For example, in bariatric surgery, for bypass surgery, especially in patients who have already been operated on once, we will need all the advantages of the robot.
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