Bariatric Surgery in Qatar: An Interview with Dr. Michel Gagner

Since 2003, Michel Gagner, MD, FRCSC, FACS, FASMBS, FICS, AFC (Hon.), has been flying to and from Qatar, performing bariatric surgery on the most complex patient cases. In 2007, he was invited to take on the task of restructuring the bariatric program at Hamad General Hospital in Qatar’s capital city, Doha. He accepted the challenge and has since seen improvement in the program and the care of people with obesity in Qatar.

Bariatric Times interviewed Dr. Gagner to learn more about obesity in the Middle East, his experiences there, and his hope for the future.Bariatric Times. 2012;9(12):10–11

Dr. Gagner with the medical staff at Hamad General Hospital

Photos of Doha, Qatar, Hamad General Hospital, and Dr. Gagner performing surgery.
Dr. Gagner, could you start by explaining how you got involved working in Qatar?

In September 2003, I took a position with Weill-Cornell University in Manhattan and was given the task of building a Center of Excellence (COE) there. At that time, Cornell was setting up a medical college in Qatar and invited Cornell faculty members to teach through telemedicine. I was invited to give a talk at Hamad General Hospital (HGH) because the chief of surgery there was very interested in bariatric surgery. After that, I was invited to fly to Qatar to perform surgery for the most complex cases. I developed a relationship with the staff at HGH and, after leaving Weill-Cornell (Manhattan) in 2007 and taking a Chief of Surgery position with Mount Sinai Medical Center in Miami, Florida, HGH offered me a contract to restructure their bariatric program. The aim was to create a COE modeled after the accreditation standards for COEs followed in the United States. HGH is the largest and main medical center in Qatar, so the opportunity and need were great.

It sounds like there was a need for quality care of patients with obesity in Qatar. Could you give some background on the obesity problem there and what, including bariatric surgery, should be done to tackle it?

Yes, the countries in the Middle East—Saudi Arabia, Kuwait, and Qatar—struggle with an obesity epidemic as prevalent as in the United States. Qatar, the wealthiest country on the planet, is also one of the fattest (top 5 in the world). Seventeen percent of the population suffers from diabetes. The obesity rate is 80 percent among women and is also very high among children. To begin to understand contributors to obesity in this area, it is important to examine the culture and lifestyle there, which changed from tribal to western in two generations. First, summers are very hot and many people do not go outside to walk let alone exercise. There are indoor facilities and a lot of malls, but everything is spread out so most people use cars. In addition, the food there is high in fat, which means the typical individual’s diet is not very nutritious to begin with. This in turn contributes to low adherence to diet and exercise plans even after bariatric surgery. Adjustable gastric bands are not performed often in Qatar because patients are often nonadherent to after-care plans and often do not return for follow up. We perform a lot of sleeve gastrectomy procedures, as this operation does not require as much follow up. Other considerations in after care include addressing nutritional deficiencies. Since women in Qatar dress with clothing covering their bodies, they are often deficient in Vitamin D and require more supplementation.

It is important to tackle obesity on all fronts, and bariatric surgery is but one aspect of tackling obesity in the Middle East. I would like to see it become a country where exercise is encouraged. Maybe that would mean redesigning the city to implement pathways with air conditioning or underground tunnels where people could walk and cycle.

How did you go about restructuring the bariatric program at Hamad? What did you have to consider in creating a plan of action?

In restructuring the program at Hamad General Hopital, almost every aspect of a successful center had to be considered. First, it was important to establish a multidisciplinary approach. Surgeons had to be trained in caring for patients with obesity through all stages of the weight loss surgery journey. Nurses and other allied health team members also had to be trained on how to work with this unique patient population. Staff members in Qatar come from nearby countries, such as Egypt, and therefore may come to Hamad with different training. This meant we had to make certain that training and communication was consistent among all staff members. Although many employees speak different first languages, the primary language at Hamad is English. All staff members also needed to learn consistency in patient protocol and preoperative care methods as well as postoperative and follow-up processes. We had to make changes to the equipment changes throughout the bariatric facility and also consider other areas of the hospital that would be seeing bariatric patients. For instance, we looked at the anesthesia and radiology departments. Chief Operating Officer (COO) Ms. Colene Daniel and Chief Executive Officer Dr. Hanan Alkuwari were both on board. After evaluating and changing all of these areas, we were able to turn things around there in a matter of a couple of months.

Have you seen results proving that this model has worked?

In the instance of Qatar, there was a will and need to create high standards in bariatric surgery. We recorded data there and were proud to show that in two years, there were no deaths, no leaks, and the complication rate was two percent. This shows that you can go to a place and re-engineer a program to achieve success, just as companies can go from debt to profit. What really shows the impact this project has made in Qatar is that they have now reached a completed 3,000 surgeries, which means they have operated on one percent of the entire Qatari native population (of 300,000). How many countries can you say have operated on one percent of the population (in regards to bariatric surgery)? The United States has a population of around 350 million, so to operate on one percent of the country, we would have to operate on 3.5 millions Americans not to mention the fact that there are new patients in need of bariatric surgery every day. It is difficult to make an impact on disease prevalence, such as hypertension and diabetes, but bariatric surgery could be the key to starting to alleviate metabolic syndrome. This could justify bariatric surgery on a larger scale, which is why this model is so important.

What have you learned from this project and what is your hope for the future? Will you continue your work in restructuring other bariatric programs? Will you enlist the help of other surgeons around the world?

This has been an interesting, challenging, and very rewarding experience for me. It was my first time working on a project like this and now I am being asked to do the same in other countries, including Australia and Kuwait. I have learned that undertaking the same project in other areas of the world will mean considering other geographical, cultural, and lifestyle aspects of that patient population, so future plans will have to be adjusted from the Qatar model. For instance, Australia has shown high patient adherence to aftercare, so more gastric band procedures might be performed there.

Now that international centers will no longer be accredited under the Surgical Review Corporation’s International Centers of Excellence program, I predict that individual international bodies and societies will begin to organize their own accreditation programs. For the future, I envision an international expansion of bariatric-accredited programs and databases. For instance, in Qatar the data are recorded in both United States and United Kingdom databases, so we can compare ourselves to both countries.
My hope is that describing my experiences in Qatar will help to inspire readers and colleagues. In order to continue this important work, we need a critical team of experts to help. My message is that it is absolutely possible to go into a program, identify the problems and fix them, and create a renewed, successful program.

Dr. Gagner, thank you for taking the time to speak with us about this very interesting and important endeavor.

FUNDING: No funding was provided for the preparation of this interview.

DISCLOSURES: Dr. Gagner reports no conflicts of interest relevant to the content of this interview.

AUTHOR AFFILIATION: Dr. Gagner is Clinical Professor of Surgery; Chief, Bariatric and Metabolic Surgery, Hamad General Hospital, Doha, Qatar.

Category: Interviews, Past Articles