Welcome to the Bariatric and Metabolic Institute Abu Dhabi

Welcome to the Bariatric and Metabolic Institute Abu Dhabi
Sheikh Khalifa Medical City
Abu Dhabi, United Arab Emirates

by Abdelrahman A. Nimeri, MBBCh, FACS, FASMBS

Dr. Nimeri is Director, Bariatric and Metabolic Institute (BMI) Abu Dhabi, Chief, Division of General, Thoracic and Vascular Surgery, Surgeon Champion, ACS NSQIP. Associate Program Director, ACGME-I Accredited Surgery residency program. Fellowship Program Director, MIS & Bariatric Surgery Fellowship Program, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates.

FUNDING: No funding was provided.

DISCLOSURES: The author reports no conflicts of interest relevant to the content of this article.

Bariatric Times. 2014;11(2):18–20.

The Bariatric and Metabolic Institute Abu Dhabi (BMI Abu Dhabi) at Sheikh Khalifa Medical City was established in June 2009 in close collaboration with BMI at Cleveland Clinic and Cleveland Clinic Florida. BMI Abu Dhabi is the main tertiary referral center for bariatric surgery complications and difficult bariatric surgery patients in Abu Dhabi.[1]

Our Staff
BMI Abu Dhabi is a comprehensive, multidisciplinary program comprised of surgeons, bariatric physicians, dietitians, psychologists, anesthesiologists, cardiologists, smoking cessation specialists, pulmonology, and endocrinology physicians (Figure 1). BMI Abu Dhabi is under the leadership of the founding director Abdelrahman Nimeri, MBBCh, FACS.

Our Facility
Sheikh Khalifa Medical City (SKMC) is a 693-bed hospital, accredited by Joint Commission International (JCI) with dedicated operating room suites for advanced laparoscopy. SKMC opened in 2000, and since 2007, SKMC is managed by the Cleveland Clinic. SKMC is the main tertiary referral hospital in the UAE and was the first multiscpecialty American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) outside of North America. SKMC joined ACS NSQIP in 2009.

Patient Assessment
Patients referred to BMI Abu Dhabi attend our monthly obesity public lecture. Here, they have the opportunity to meet the members of our team and receive a copy of our educational “Walk Away from Obesity” booklet. In addition, patients are given a questionnaire about their past medical and surgical history. Next, the patients are seen in our multidisciplinary clinic by both surgeons and dietitians. Each patient is given a two-page outpatient pathway that details an individualized plan for preoperative work up. On average, patients see our surgeons and dietitians 2 to 3 times prior to surgery. We follow the National Institutes of Health (NIH) criteria for bariatric surgery. The national insurance system (Thiqa) covers bariatric surgery for UAE nationals, and our employees of the healthcare system are covered as well. The rest of the insurance plans are evaluated on an individualized basis. Patients also have the option to self pay.

Procedure Statistics
Since 2009, more than 500 complex primary and revisional bariatric surgery procedures were performed at BMI Abu Dhabi. The outcomes of BMI Abu Dhabi were published in the Sheikh Khalifa Medical City Outcome book in 2013. In addition, the outcomes of BMI Abu Dhabi compared to the American College of Surgeons bariatric surgery programs were published in the Journal of the American College of Surgeons in May 2013 (Figure 2).[2]

BMI Abu Dhabi is unique in the types of bariatric procedures performed in the UAE and the Gulf region because laparoscopic Roux-en-Y gastric bypass (RYGB) represents our most commonly performed procedure (Figure 3). The bariatric procedures performed at BMI Abu Dhabi are RYGB, which represents 60 percent of our cases, followed by the laparoscopic sleeve gastrectomy (LSG), which represents 35 percent of our cases. Revisional bariatric surgery represents 20 percent of our bariatric surgery cases, and conversion from laparoscopic adjustable gastric banding (LAGB) to RYGB is our most common revisional bariatric procedure.

Our conversion to open in primary bariatric surgery is zero percent and revisional bariatric surgery is 2.5 percent. Our 30-day mortality is zero percent, leak in primary RYGB, 0.3 percent (1/273), revisional RYGB, 2.5 percent, and primary and revisional LSG is zero percent. Stenosis in primary RYGB is 0.3 percent (1/273), in revisional RYGB, 3 percent, and in primary and revisional LSG, zero percent.

We have noticed that our primary bariatric surgery patients fare better in terms of weight loss compared to our revisional bariatric surgery patients. Our average body mass index (BMI) for primary RYGB is 48.5kg/m2 (34–91), revisional RYGB, 41.5kg/m2 (17–71), and for primary LSG, 44.8kg/m2 (32–68). Our three-year EWL% for primary RYGB primary is 75 percent (11 patients), two year EWL% RYGB primary, 75.6 percent (34 patients), revisional RYGB, 53 percent (16 patients), and primary LSG, 81.4 percent (16 patients).

Pre- and Postoperative Patient Care
Our preoperative workup includes psychological and dietitian evaluation for all patients. We perform EGD/UGI study and colonoscopy on selective parients.[3] We allow the patients to decide which procedure they want to undergo and we advise patients who have gastroesophageal reflux disease (GERD), type 2 diabetes mellitus (T2DM), or previous LAGB to undergo RYGB. All patients have intraoperative endoscopy at the end of surgery. We do not place drains or perform UGI studies, and patients are started on clears liquids once they are awake.

Patient Adherence
The UAE nationals make up 80 percent of our patient population and their care is covered by insurance, including postoperative care and vitamin supplementation. Initially, we were facing several misconceptions about how bariatric surgery works, the importance of changing how a person eats, and the importance of exercise. We have found that adherence to vitamin supplementation is not great in our patient population and we are in the process of evaluating our three-year data post bariatric surgery.

Patient and Staff Education
BMI Abu Dhabi conducts a monthly obesity educational public lecture to educate the public about the dangers of obesity and the metabolic syndrome, and the potential complications of bariatric surgery (Figure 4). Our motto is, “Walk away from obesity.” We emphasize to patients the importance of participating in our multidisciplinary program and the need to change the way a person eats and exercises. We also emphasize that bariatric surgery is a life-saving, effective tool that needs to be used properly to get effective long-lasting results.

This month marks our 48th monthly obesity public lecture. Furthermore, BMI Abu Dhabi features several educational and training endeavors, including a bariatric fellowship program, which started in February 2013; an annual obesity symposium (Figure 5) that is in its sixth year; and several bariatric surgery courses and workshops for physicians, residents, and surgeons.

Emerging Trends
We have found that patients are interested in the sleeve gastrectomy procedure because of perceived simplicity and the false perception that a patient does not need vitamin supplementation after sleeve gastrectomy. In addition, our patients are interested in the greater curvature plication and mini gastric bypass, two procedures that are done in the UAE. We have found that LAGB has fallen out of favor. In the last three years, BMI Abu Dhabi has placed six LAGBs and removed 100 LAGBs for weight recidivism or complications of LAGB.

Patient Cases
BMI Abu Dhabi is the main tertiary referral center for bariatric surgery in the UAE. The following highlights three interesting patient cases that were referred to us.
Case #1. A young woman was referred to us with a chronic fistula 18 months after sleeve gastrectomy after failed operative repair, and multiple endoscopic stents. When she came to us, she was wheelchair bound and her weight was 120Lbs. After a five-week period of enteral feeding, she was laparoscopically managed with a Roux-en-Y esophagojejunostomy. This proved to be a succesful treatment for the patient.
Case #2. We received a referral for a patient who presented with a BMI of 64kg/m2, gastrocutaneous fistula from a leak after sleeve gastrectomy, high output enterocuteneous fistula (ECF) after she had failed laparoscopic jejunostomy tube, acute renal failure on hemodialysis, pancytopenia, and severe sepsis requiring mechanical ventilation. After a two-week period of resuscitation, she was treated openly by resecting her ECF and performing wide drainage of the abdomen. This proved to be a succesful treatment for the patient.
Case #3. A young woman who underwent laparoscopic RYGB presented with obstruction of the bilio-pancreatic limb, which required reoperation. At the time she came to us, she was malnourished on total parenteral nutrition (TPN), wheel chair bound,  and had severe nutritional deficiencies. Operative exploration noted a distal gastric bypass with a 75cm blind loop with bacterial overgrowth. She improved after surgical correction and delivered a healthy baby boy one year later.

A Unique Facility
SKMC is unique in having the second ACGME-I accredited surgery residency program outside of North America after the program in Singapore. In addition, SKMC has the first multispeciality accredited center outside of North America. Furthermore, BMI Abu Dhabi is unique in the fact that we are the only bariatric surgery program in the UAE and the Gulf region that primarily performs laparoscopic Handsewn RYGB.

References
1.    El Hassan E, Mohamed A, Ibrahim M, Margarita M, Al Hadad M, Nimeri AA. Single-stage operative management of laparoscopic sleeve gastrectomy leaks without endoscopic stent placement. Obes Surg. 2013;23(5):722–726.
2.    Nimeri A, Mohamed A, El Hassan E, McKenna K, Turrin NP, Al Hadad M, Dehni N. Are results of bariatric surgery different in the Middle East? Early experience of an international bariatric surgery program and an ACS NSQIP outcomes comparison. J Am Coll Surg. 2013;216(6):1082–1088.
3.    Al Hadad M, Dehni N, Alakhras A, Ziaei Y, Turrin NP, Nimeri A. Screening colonoscopy in the initial workup of bariatric surgery patients: guidelines are needed. Surg Endosc. 2014 Jan 8. [Epub ahead of print]

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Category: Bariatric Center Spotlight, Past Articles