I am one of only four bariatric surgeons in the country, so people come from afar. More than half my patients are from outside Munster. Patients regularly travel from Dublin, Galway and Limerick for surgery.
Bariatric surgery is a most rewarding surgical discipline, because the majority of the patients are absolutely delighted with the results of surgery. No other surgical procedure can cure the majority of the patients’ medical conditions, greatly improve how they look in the mirror and make them feel so much happier in themselves.
Women in particular are delighted to be able to drop a few dress sizes. They often relate how they can buy off the peg in “normal” clothes shops when previously they had to get clothes tailormade or buy from special sites online.
Surgery is last hope
Men tend not to be so image conscious and, for many, surgery is their last hope to have medical conditions such as diabetes or high blood pressure cured or improved. As there is a very significant improvement or cure in the rate of diabetes, hypertension or sleep apnoea as well as the obvious cosmetic benefits from significant weight loss, the patients tend to be very happy with the results.
The most common bariatric surgical intervention is the gastric sleeve followed by gastric bypass. Bariatric surgeons are moving away from gastric band surgery as the long-term results are not as good as other procedures. I’ve taken out more bands in the past year than I have put in, and the commonest obesity operation in France – where they put in thousands of bands – is removal of gastric bands.
The gastric sleeve procedure involves removing four-fifths of the patient’s stomach, leaving a narrow, banana-shaped tube or sleeve. The patient can’t eat as much after the surgery and has to start on a diet of yogurt and milky porridge before moving on to smaller amounts of solid food, which they must chew well. As I tell my patients, their starter becomes their main course after surgery.
Patients lose one to two stone in the first couple of months after surgery and 90 to 95 per cent lose a total of between five and eight stone. The more motivated a patient is, the better they do. Surgery breaks the cycle of weight gain, but it’s not a magic bullet. Once they get down to a certain level, the patient has to eat healthily and exercise, ideally for an hour a day, to keep the weight off.
The causes of obesity are multifactorial. Many morbidly obese patients suffered some sort of trauma in their childhood and turned to food as a result, and there are some people whose satiety centre in the brain is probably set higher.
I do the operation that helps my patients to lose the weight but, at the end of the day, keeping the weight off is in their own hands. In many ways, an operation is not the best way to treat obesity, but it’s the best we have. Someday they may invent a pill that will suppress appetite without any side effects but I don’t think it will happen without the patient working on their diet and exercise as well; there will always have to be an element of patient self-control.
Centre of Excellence Award
The surgical unit at the Bon Secours Cork has recently obtained a Centre Of Excellence award from the International Federation for Surgical Obesity. We are the first unit in Ireland to obtain such an award and I am delighted for the hospital and the team that we have been given the credit for the high standard of care we provide for our patients.
I work as part of a large team including dietitians, physiotherapists, nursing staff, endocrinologists, cardiologists, radiologists, anaesthetists and respiratory physicians.
This wide medical team is very important for the management of morbid obesity, which can be associated with very complex medical conditions such as diabetes, hypertension and sleep apnoea. These patients also require regular psychological input.
The hospital has invested significantly in refurbishing a dedicated ward of individual rooms for bariatric surgical patients. Beds, chairs, doors and washing facilities are specially geared towards larger patients. Theatre equipment is all designed to deal with patients weighing up to 350kg.
I enjoy teaching the medical students. It keeps me on my toes. I have at least two final-year medical students attached to my team in any week. During their time with my unit, I will teach them how to treat general surgical and bariatric patients. They attend my endoscopy and theatre lists and come on ward rounds. As postgraduate tutor, I also regularly give lectures to the junior doctors and nursing staff to help them gain a better understanding of surgery so I am continuously teaching.
I am an examiner for final medical examinations for UCC. I am a member of the teaching faculty for the Royal College of Surgeon’s (UK) minimally invasive surgical skills course. I regularly commute to London to teach on this course.
My gatekeeper
My working week begins and ends with invaluable support from my PA, Caitríona O’Sullivan, who is the link between my patients and my service. After eight years working with me, she has acquired the skills of secretary, gatekeeper, counsellor, nurse, diagnostician and data manager, all in one.
Monday morning begins with a unit ward round at 8am with the junior doctors, medical students and nursing staff. This is followed by my endoscopy (scope) list. I regularly perform endoscopic procedures for bariatric patients before surgery to rule out ulcers or identify undiagnosed hiatus hernias.
Monday afternoon is my bariatric clinic for new referrals, where I see patients who are contemplating bariatric surgery for the first time. I usually spend up to an hour discussing the various options with the patients. Patients are often very emotional as it takes great courage to admit that you need an operation to lose weight. Many have been thinking of having surgery for years but have not been able to pluck up the courage to see someone.
Most patients have tried everything possible to get their weight down, including every diet and every diet pill on the market.
Many actually cry at finding someone who is empathetic and who can “cure” the condition they have battled all their lives.
I usually ask the patients to bring a relative with them. I give them booklets explaining the surgery and take them through a presentation explaining the benefits of having it.
I give them the contact details of patients who have had surgery in the past and who are willing to chat with them. I advise them to go to the patient support group meetings [at Bon Secours Hospital in Cork on the first Tuesday of every month], where patients who have had surgery and patients who are thinking of having surgery sit around and have an informal chat. Many patients make long-term friends with others when they go through the surgery together.
After that clinic, I carry out an evening ward round and review all the patients who have come in to have bariatric surgery on the following day.
Operating list
On Tuesdays at 7am I do paperwork followed by an early-morning pre-operative ward round. After this I attend the hospital radiology meeting, where all the medical staff meet and review complex (non-cancer) cases as a group. This is followed by my bariatric operating list, which may finish any time up to 8pm. I will perform between one and four bypass/sleeve procedures during the day.
During and between operations, I will teach the medical students and junior doctors who are attached to my service. I also tend to do my general surgical on-call on a Tuesday. After operating I will do a ward round with the team and review the postoperative patients and see any emergency general surgical patients who have been admitted to the hospital that day.
If any patients need emergency surgery, I will perform this during the day or that night. I work with three other general surgeons. One day in four I am on call for a continuous period of 24 hours for acute surgical admissions and any emergency surgical condition that may arise in the hospital.
Wednesday morning begins at 7.30am with a post-take ward round. I review and assess all the patients who have been admitted as an emergency during the previous 24 hours. If anyone needs surgery, I will try to arrange this for Wednesday afternoon or sooner. This is followed at 8am by surgical journal club/case presentations; an important meeting which is largely run by the surgical SHOs and registrars, and attended by all the surgical consultants. I then attend my general surgical clinic followed by my general surgical theatre list on Wednesday afternoon. This usually finishes at 6pm and I carry out a postoperative ward round and post-take review of all the acute admissions and the investigations that the patients have had during that day.
Multidisciplinary meetings
Thursday morning begins at 7.30am with a ward round. After that we have the cancer multidisciplinary team meeting, during which all physicians, surgeons, radiologists and pathologists involved in cancer surgery review all cancer cases. This is one of the most important meetings in the week.
After this meeting I have my bariatric review clinic. I review all patients undergoing weight-loss surgery. Many of the patients I have treated go from being claustrophobic, immobile and sometimes bedridden to ultimately running marathons once they have lost a significant amount of weight. The improvement in their quality of life is really quite dramatic.
It is amazing to see some people change their lifestyles from being TV addicts and agoraphobics to committed athletes in love with the outdoors.
I might have an operation to perform on a patient who was admitted during the week, or a course or conference to attend. I use any spare time to carry out paperwork or surgical research.
I am currently involved in a number of research projects. My particular interests are the benefits of surgical weight loss on medical conditions such as diabetes, hypertension, sleep apnoea and urinary incontinence. I regularly attend national and international meetings and present our research at these meetings. We have submitted two scientific papers to international journals for publication. And our team has published a bariatric book entitled Weight-loss surgery: A comprehensive medical team approach.
Out of hours
My favourite time is spent with my wife, Ursula, our four children, and Davis, our Labrador, near Sliabh Laig in Donegal at the northern part of the Wild Atlantic Way, where we love to swim, kayak, fish and mountaineer. We also all have a keen interest in scuba diving and I am working towards a Divemaster qualification. I have season tickets for Munster and Ireland rugby matches and travel to Thomond Park and the Aviva Stadium whenever possible.
