Christophe, nurse coordinator of therapeutic patient education (ETP) at the Ora ora day hospital. ©MB/Radio1
Bariatric surgery, which is part of the management of obesity, will be subject to authorization in Polynesia, as announced by the Council of Ministers on August 24, to ensure ” optimal safety conditions, following deaths. Although the criteria for this authorization remain to be specified, part of this new treatment lies in the development of the activity of the Ora Ora centre, which will open in 2020, which will welcome 10 additional patients, specifically suffering from morbid obesity (BMI greater than 40). Within the framework of “therapeutic patient education”, the nurses of the structure insist on the importance of an individualized intraoperative follow-up of this pathology.
Obesity is a disease whose treatment is complex and often tedious, as specialists and patients agree, and in 2010 it affected 40% of the population in Polynesia, among the 70% already overweight. Figures that have increased in the twelve years since, and whose gravity has been highlighted by the Covid-19 pandemic. To remedy this, bariatric surgery operations, which modify the digestive tract, are a very popular solution. According to the figures of the CPS their number in Polynesia amounts to 350 in 2019; 250 in 2020 and more than 200 in 2021.
It is however « d’interventions lourdes » and they require a specific framework that the country intends to tighten. The Council of Ministers announced on August 24 that the surgical operations of “bypass”, the “sleeve” and the fitting of gastric bands would be subject to authorization by the health organization commission of French Polynesia so that they are “carried out under optimal safety conditions and that surgery remains reserved for patients who require it”. A decision that comes after serious consequences of this lack of regulation have resulted in deaths, according to the Health Department.
The Council of Ministers stated: “The operative consequences can be serious: fistulas, haemorrhages, psychic (decompensation), digestive (occlusions, ulcerations, hiatal hernia) and deficiency (deficiency in iron, calcium, vitamin D, malnutrition, poor functioning of the surgical assembly). Medical monitoring of patients is essential after the operation, organized by the attending physician in coordination with the medical-surgical team to avoid post-operative consequences. It is extended for life and includes consultations with the medical and surgical team (surgeon, endocrinologist) and regular consultations with the attending physician. »
The criteria for this authorization remain to be clarified, but we already know that more complete support will be developed to be integrated into the framework conditioning this authorization.
Neither a miracle solution, nor “a solution of last resort”
Useless and impossible to identify causes and general factors of the disease, for the professionals of the day hospital in care and rehabilitation in Polynesia (SSRP) Ora Ora which opened its doors in 2020. Among the four guaranteed care – obesity, respiratory, orthopaedics, neurology – that of morbid obesity should soon be developed there. The establishment has received authorization to open 10 additional places dedicated to people with a body mass index (BMI) greater than 40 to offer them a personalized course of up to three years. For a few days a year – 18 days the first year, 12 days the second and 6 the third – the sessions are organized on the patient’s free time, according to his availability. General practitioner, psychologist, social worker and nurse coordinators develop a care pathway adapted to each patient.
Eating habits are indeed at the heart of the pathology, but they are linked to psychological and social factors that vary from person to person. Trauma linked to violence, unhealthy pace and lifestyle, limited income are all possible causes. Once the person is overweight, it is his metabolism that is modified. “Obesity is a disease of the adipose tissue, and there comes a certain stage where we are no longer able to lose weight”, explains Fleur Deshogues. In summary, fat cells “self-sustaining” and losing weight takes a lot more effort than gaining it. At this moment ” the best recommended treatment is surgery, it is not necessarily the last resort” indicates the nurse. “You shouldn’t wait until the disease is too advanced, there really is a window where it is indicated, beyond that the intervention is too dangerous for the patient”.
“Helping patients get well, not just lose weight”
The first results of the follow-up of the 32 patients who have reached the end of the first year are encouraging. The mean BMI at the start of treatment is 49.65. Then in April 2022 it is 47.7 or 3.9 points less in the surgical course. And even if at the start it is the loss of extra pounds that is evaluated, for Christophe, nurse coordinator at Ora Ora, it is simply a question of helping patients “to be well”. They sometimes suffer from knee or back pain, sleep apnea, and breathing problems. “As part of therapeutic patient education (TPE), we work on behavior and acceptance of the disease” because the gaze of others and their judgment does not help patients to take charge of themselves. Again the question is “How such a person will manage to put in place changes and it will not be the same as the neighbor”.
The other difficulty of the treatment of obesity is to hold over time, according to the nurses. Patients’ over-ambitious goals are disappointed because they know little about the disease. Professionals insist that weight stabilization is already an encouraging victory. A patient who loses 5% of his weight reduces the risk of hypertension and diabetes by 50%. Some end up giving up surgery, presenting risks and with consequences throughout the patient’s life.