Bariatric News spoke to the current President of Bariatric, Metabolic Surgeons Society of Nigeria (BMSSN), Mr Abuchi Okaro (a consultant general, laparoscopic upper gastrointestinal (GI) and bariatric surgeon) about his career, his advice to young surgeons and the current status of bariatric surgery in Nigeria…
When you were growing up, did you always want to enter medicine?
I've always wanted to be a doctor as far back as I remember. In many ways having both of my parents being medical doctors and really as I recall spending a lot of time in my younger years in and around hospitals may have something to do with it. I vividly remember around the age of 11 or 12 saying: “I want to be a surgeon”. At the time of course I didn't know what type of surgeon.
Why did you become a bariatric surgeon?
To be honest, I came into my bariatric surgery phase of my career somewhat later. The main reason I say that is because during my specialist registrar surgically training on the London South West Thames deanery in the late 90’s and early 2000’s there were very few surgical units offering training in bariatric metabolic surgery (BMS). In fact, my initial preference for surgical specialisation was actually cardiothoracic surgery. However, at that time (in the early 1990’s) we witnessed a significant increase in the availability and spread of interventional cardiology and therefore a corresponding decline in open coronary bypass procedures. Thankfully for me, some of my then mentors impressed upon me that such a trend should prompt me to consider other specialist options for my future lifetime devotion to surgery. General surgery became my new specialist area of interest. Over time, I gravitated towards upper GI and laparoscopic surgery.
The various surgical units where I spent my years as a senior trainee surgeon meant that I eventually evolved into an upper GI oncological surgeon. I cemented that by undertaking a four months specialist surgical fellowship at The National Cancer Centre Tokyo, Japan, before my appointment as an NHS consultant Upper GI and laparoscopic surgeon in 2005.
My first exposure to BMS came In 2000, I was working at St George's Hospital (London, UK) as a junior registrar to Mr Alberic Fiennes, who was at that time one of the pioneers of BMS in the UK. I recall that Alberic was mostly performing RYGBs.
As an upper GI oncological surgeon, a good volume of my complex major workload involved procedures such as – oesophago-gastrectomies with extensive lymphadenectomies with splenectomy. As one may imagine, transitioning from such long and complex procedures to the field of BMS procedures like laparoscopic gastric sleeve or gastric bypass procedures was, not surprisingly, relatively straightforward.
In 2010, my interest and appetite to take BMS to West Africa began. By 2011, we opened up our 1st version of our MBS service in Lagos, Nigeria, and it's grown from there.
How much knowledge of bariatric surgery was there at that time in Nigeria?
In 2010, when our plans to open a BMS centre started, there were no centres in Nigeria where BMS was offered or available. This fact created an undeniable opportunity for us to blaze a trail in this region of the sub-Saharan continent and establish something novel and useful to the communities in the region. However, there loomed huge challenges in terms of manpower, resources, infrastructure etc that needed to be tackled directly through education, investment, partnerships and creating awareness. Looking back now, it’s no understatement when we say we have come a long, long way.
Now in 2024, most people are aware of BMS as a credible option for the management of obesity and its related diseases, and we are very grateful and appreciative of all those who have assisted us in making this positive impact. Presently, there are currently no less than five qualified surgeons offering high quality BMS services in the country. This is, frankly speaking, a drop in the ocean as far as potential demand is concerned as Nigeria has an estimated population well over 220 million people and, as such, has huge growth potentials for BMS services. However, many barriers to surgery still exist such as general awareness, surgical outcome fears, affordability etc. I will admit the expansion of BMS services in the country has been carried out with high levels of caution. The key reason for this is linked to ensuring it gains a solid and firm reputation as safe and dependable.
Who were the greatest influences on your career and what advice would you offer to young surgeons?
I will be the first to admit I have been very fortunate to have to have worked with several great surgeons and mentors both here in the UK and in Tokyo, Japan.
Firstly, to be an excellent surgeon, in a nutshell your procedural technique has to be so precise, surgery really is many ways is an art form. To any young surgeon, I would say concentrate on your surgical technique, understand the key and rate limiting steps of each procedure based on the anatomical fundamentals, seek out inspiring teachers and mentors and, most importantly, as you ascend your learning curve exercise patience, be deliberate and self-aware. In my opinion, another crucial component relates to your relationship with your patients. You have to make every effort to make them feel that they are in the presence of someone who genuinely cares. You just have to be a nice, caring doctor, focus on the detail and pay attention.
You are currently president of BMSSN, what are your aims and ambitions?
When we created the Society in 2020, our primary ambition was simply to bring clinicians involved in BMS services in Nigeria together. If you don't bring people together early, communicate and learn from each other, then there's going to be a lot of mistakes and clinicians are possibly going to unnecessarily struggle in their various locations by simply working in isolation. The other big gains through shared learning that’s particularly anchored on local and regional elements and adjustments with the quality and safety in mind.
What do you think the biggest challenges facing Nigeria and the wider West African region in regard to BMS?
I see this as related to three categories: patient-centred, facility-centred and surgeon-centred. From a patient-centred point of view, patients find it hard to get access to BMS services local to them. For instance, a patient in Ghana or Sierra Leone will have to come over to Lagos to have their procedure. There are also patient centred challenges when it comes to this form of medical tourism - such as good quality regular follow up, deciding on which centre to actually choose, currency and foreign exchanges factors also feature to mention a few. But even within that, they may have difficulties choosing who they go to, can they afford surgery and so on. The second category is related to facilities and healthcare providers. The healthcare provider space in Nigeria and the region is generally poorly regulated, this fact creates a huge host of potential negative consequences on the growth and development of BMS services when any conflicts arise between safety and profitability maybe concerned.
Finally, we need to develop and evolve a structured scheme with training pathway and guidelines to establish a highly professional BMS workforce. On the accreditation side, we need to define what best practise in the local region looks like. In summary, these are some of the challenges we are facing the region. Having said that, as you can see, none of these are unsurmountable. BMSSN is very keen to establishing our own patient database/registry, because this will help create minimum standards of patient care and outcomes. I would say it's also important because it ensures a degree of openness with our patients that says: “We are confident of what we do, we record the important elements real-time, you can look and see what we do.”
Away from surgery, what do you like to do in your spare time?
I’m really into physical fitness and do a lot of outdoor and indoor cycling. As a surgeon, you spend hours standing on your feet doing procedures, so it’s important to look after your physical health. It’s also important to looking after your mental well being, so I listen to a lot of podcasts and read books that focus on self-growth, the power of meditation and the study of stoic philosophy. I am of the age where I look at things through the lens of time. I don’t waste my time and energy and things that I can’t change. It’s easy to your waste time, isn't it? I spend my time focusing on what is important to me, both physically and mentally.