CEMMS Gauteng - Centre of Excellence for Metabolic Medicine and Surgery

27/03/2025

I just love the variety of general surgery I still do in my practice. Even though I used to predominantly do bariatric surgery over the last eighteen years, I still love my general surgery procedures too. Head and neck cancer and endocrine surgery is where I started my career and I still thrive in doing cases related to this specialty. But with the advanced laparoscopic skills I developed through bariatric surgery I also enjoy other laparoscopic procedures including hernias (hiatal, incisional and inguinal), cholecystectomies, and colonic resections. I also do partial pancreatectomies and adrenalectomies laparoscopically as well. Recently, I have also gone back to doing vascular access procedures for dialysis patients. As the saying goes “variety is the spice of life”. 😊

21/10/2024

Chapter 6 Blog

Through the years of my profession as a general surgeon, I have been astounded by the behaviour of some of my colleagues. As health professionals we are obligated to adhere to an uncompromised standard of ethical conduct, not only to the patients we treat but to our colleagues as well. The HPCSA recognises this and insists that we attend yearly lectures and seminars on ethical behaviour as a doctor. This not only educates us on dealing with situations amongst patients and colleagues, but also includes our posts in social media.

Some of my colleagues and I have been publicly defamed and denigrated by a colleague using the platform of social media. I will not use this platform to retaliate or even defend myself. What I did instead is ask AI to discuss what it thought was the critical role of ethics and professional conduct in Medicine and this is what it came up with.

# The Critical Role of Ethics and Professional Conduct in Medicine: Building Excellence in Healthcare

In the complex world of modern medicine, ethical principles and professional conduct serve as the dual pillars supporting healthcare delivery. As medical technologies advance and healthcare becomes increasingly collaborative, maintaining strong ethical standards and professional relationships has become fundamental to successful practice.

# # The Fundamental Principles

At the heart of medical ethics lie four core principles that guide healthcare professionals in their daily practice:

1. **Autonomy**: Respecting patients' right to make informed decisions about their own healthcare
2. **Beneficence**: Acting in the best interest of patients
3. **Non-maleficence**: "First, do no harm"
4. **Justice**: Ensuring fair distribution of healthcare resources and treatment

# # Professional Conduct in Healthcare

# # # Collegial Relationships
Strong professional relationships among healthcare providers are crucial for optimal patient care. This includes:
- Respectful communication between colleagues
- Collaborative decision-making in patient care
- Constructive feedback and peer support
- Recognition of each team member's expertise and role
- Professional mentorship and knowledge sharing

# # # Building an Effective Healthcare Team
Professional conduct in healthcare requires:
- Clear role definitions and responsibilities
- Effective handoffs and transitions of care
- Regular team meetings and care coordination
- Conflict resolution protocols
- Support for junior colleagues and trainees

# # Why Ethics and Professionalism Matter in Healthcare

# # # Trust and Patient Care
The relationship between healthcare providers and patients is built on trust. When medical professionals maintain high ethical standards and demonstrate professional conduct, they create an environment where:
- Patients feel safe and respected
- Colleagues can collaborate effectively
- Care coordination improves
- Medical errors are reduced through open communication
- Team morale and job satisfaction increase

# # # Decision-Making in Complex Situations
Medical professionals frequently encounter situations where the right course of action isn't immediately clear. Ethical guidelines and professional protocols provide a framework for:
- Making difficult clinical decisions
- Resolving interprofessional conflicts
- Handling resource allocation
- Managing end-of-life care
- Balancing patient privacy with team communication

# # # Professional Integrity and Team Dynamics
Ethics in healthcare extends beyond patient care to professional conduct. Medical professionals must:
- Maintain appropriate boundaries
- Respect confidentiality
- Collaborate effectively with colleagues
- Support team members during challenging situations
- Contribute to a positive workplace culture

# # Modern Challenges in Medical Ethics and Professionalism

# # # Technological Advancements
As medicine advances, new challenges emerge:
- Digital communication and professionalism
- Social media boundaries
- Telemedicine etiquette
- Electronic health record documentation
- AI implementation and team adaptation

# # # Interprofessional Collaboration
Modern healthcare requires:
- Cross-disciplinary teamwork
- Clear communication channels
- Respect for diverse expertise
- Unified approach to patient care
- Professional development opportunities

# # # Cultural Competency and Team Diversity
Healthcare teams must navigate:
- Various cultural perspectives
- Different communication styles
- Diverse professional backgrounds
- Multiple generational approaches
- International medical practices

# # Building a Culture of Excellence

# # # Professional Development
Healthcare organizations should promote:
- Continuing education programs
- Leadership development
- Mentorship opportunities
- Team-building activities
- Ethics and professionalism workshops

# # # Communication Standards
Effective healthcare teams maintain:
- Regular team meetings
- Clear reporting structures
- Open-door policies
- Constructive feedback mechanisms
- Professional documentation practices

# # # Conflict Resolution
Professional environments should have:
- Clear protocols for addressing conflicts
- Mediation services
- Fair grievance procedures
- Support systems for staff
- Regular team assessments

# # The Impact on Healthcare Outcomes

Strong ethical practices and professional conduct lead to:
- Better patient satisfaction
- Improved treatment adherence
- Higher quality of care
- Reduced medical errors
- Enhanced team collaboration
- Greater public trust
- Increased staff retention
- Better workplace satisfaction

# # Moving Forward

The future of healthcare depends on:
- Continuous ethical education
- Professional development
- Team-building initiatives
- Cultural competency training
- Leadership development
- Innovation in collaboration methods

# # Conclusion

Ethics and professionalism in medical practice create the foundation for excellence in healthcare delivery. As medicine continues to evolve, maintaining high standards in both areas becomes increasingly important. Healthcare professionals who prioritize ethics and collegial conduct not only serve their patients better but also contribute to a more effective, satisfying, and sustainable healthcare environment.

The commitment to ethical practice and professional conduct transforms healthcare from a mere service into a noble profession dedicated to human wellbeing. As we face new challenges and opportunities, these principles will continue to guide medical professionals in their mission to heal and serve, while fostering supportive and effective healthcare teams.

Nothing further needs to be said about this topic.

26/09/2024

Chapter 5 Blog.

I was watching the program on childhood bariatric surgery in the USA presented by Carte Blanche a few weeks ago. The story was centred around a thirteen-year-old girl Lexi and her failed laparoscopic gastric sleeve procedure 9 months after her surgery.

She happened to be one of those few children who was identified with an obesity gene called MC4R (melanocortin 4 receptor gene) found in 0.5 – 8.5% of children. Those children with this gene have about a 4,5% higher chance of developing obesity but keep in mind that today about 40% of Americans are classified as obese. The effect of this gene is a decreased sense of satiety by the hindbrain.

Lexi had an “insatiable appetite” and very little feeling of satiety and therefore, it did not surprise me that she rapidly “ate through” her operation within 9 months. Normally weight regain in majority of patients undergoing a laparoscopic sleeve gastrectomy procedure is only seen between 4 – 7 years after the surgery.

To understand why any surgery, diet or lifestyle adjustment fails with time one must understand the hindbrain and its function in regulating our appetite and weight.

The Appetite Center and Hindbrain: Regulating Our Hunger

The human body is a complex machine, with numerous systems working in harmony to keep us functioning. One of the most fundamental drives we experience is hunger, and at the heart of this sensation lies the intricate relationship between the appetite center and the hindbrain.

The Hindbrain: More Than Just Basic Functions

The hindbrain, also known as the rhombencephalon, is located at the base of the brain. While often associated with basic life functions like breathing and heart rate, it plays a crucial role in our eating behaviors.

The Appetite Center: Where Hunger Begins

Within the hindbrain lies a region called the appetite center. This area is responsible for regulating our food intake and energy balance. It's not a single, distinct structure but rather a network of interconnected regions working together.
Key components of the appetite center include:
1. The hypothalamus (Strictly speaking part of the forebrain but your hypothalamus, which is about the size of an almond, is located below the thalamus and above your pituitary gland. It sits directly above the brainstem at the base of your brain.) : This region houses important nuclei that regulate hunger and satiety.
2. The nucleus tractus solitarius (NTS): Located in the medulla oblongata, it receives signals from the gut about fullness.
3. The area postrema: A small region that can detect hormones and other substances in the blood related to hunger.

How the Appetite Center Works

The appetite center functions through a complex interplay of hormones, neural signals, and sensory input. Here's a simplified breakdown:
1. Hormonal signals: Hormones like ghrelin (which stimulates appetite), leptin (which suppresses it) and cholecystokinin (CCK) released in the small intestine and promoting feeling of fullness interact with the appetite center.
2. Neural signals: The vagus nerve sends information from the digestive system to the brain about the hormones released during digestion, nutrient composition of food and stomach distension.
3. Nutrient sensing: The brain can detect levels of glucose and other nutrients in the blood.
4. Integration: The appetite center integrates all these signals to determine whether we feel hungry or full.

Role of neurotransmitters

Several neurotransmitters in the hindbrain play crucial roles in appetite regulation:
1. Serotonin: often associated with mood, it also influences satiety.
2. Norepinephrine: helps suppress appetite.
3. GABA (Gama-Aminobutyric Acid) can stimulate feeding when activated in certain hindbrain areas.

The Hindbrain and Energy balance:

Maintaining energy balance is crucial for overall health and the hindbrain plays a significant role in this process. The hindbrain helps maintain a stable body weight by adjusting appetite based on energy expenditure or by influencing metabolic rate. Through its connections to other brain regions and the endocrine system, the hindbrain contributes to blood sugar regulation and fat storage and utilization as well.

Disorders affecting the hindbrain can have profound effects on eating behaviour.

The Bigger Picture:

The hindbrains influence on eating goes beyond just telling us when we are hungry or full. By processing satiety signals the hindbrain helps determine how much we eat in a single sitting and how often we feel the need to eat.
Understanding the role of the appetite center and hindbrain in regulating hunger has important implications for health and medicine. Research in this area could lead to new treatments for obesity, eating disorders, and other metabolic conditions.
As we continue to unravel the mysteries of the brain, the appetite center stands as a testament to the intricate and fascinating ways our bodies maintain balance and ensure our survival.

1. Medical Advancements:
Obesity Treatment: By understanding how the appetite center works, researchers can develop more targeted therapies for obesity. This could include drugs that mimic satiety signals or block hunger signals.
Eating Disorders: For conditions like anorexia or bulimia, treatments could be developed that help normalize appetite regulation.
Metabolic Disorders: Conditions like diabetes, which involve disrupted energy metabolism, might benefit from therapies that target the appetite center.
2. Nutritional Science:
Personalized Diets: Understanding individual variations in appetite regulation could lead to more effective personalized nutrition plans.
Food Design: The food industry could develop products that more effectively trigger satiety signals, potentially aiding in weight management.
3. Neuroscience Research:
Brain-Gut Connection: Studies on the appetite center contribute to our broader understanding of the brain-gut axis, which is increasingly recognized as important in overall health.
Neural Plasticity: Research in this area provides insights into how the brain adapts to changes in diet and metabolism.
4. Public Health:
Education: Better public understanding of how appetite works could lead to more informed dietary choices.
Policy: Insights from this research could inform public health policies related to nutrition and obesity prevention.
5. Aging and Longevity:
As we age, appetite regulation can change. Understanding these mechanisms could help in developing strategies to maintain healthy eating patterns in older adults.
6. Psychological Health:
The link between mood disorders and appetite disturbances could be better understood, potentially leading to improved treatments for conditions like depression.
7. Evolutionary Biology:
Studying the appetite center provides insights into how human metabolism evolved, potentially shedding light on why certain eating patterns are so ingrained in our biology.
8. Artificial Intelligence and Machine Learning:
Models of appetite regulation could be used to create more sophisticated AI systems for personalized health management.

By exploring the appetite center and hindbrain, we're not just learning about hunger – we're gaining insights that could revolutionize how we approach nutrition, health, and even our understanding of human behavior. This research sits at the intersection of neuroscience, endocrinology, psychology, and public health, making it a rich area for interdisciplinary study and innovation.

The next time you sit down at a meal, take a moment to appreciate the intricate work your hindbrain is doing to keep your eating behaviors in check! Don’t ignore that sudden satiety check.

11/09/2024

Chapter 4 Blog

Under what circumstances is appropriate to do a sleeve gastrectomy?

Some of you reading this website have probably read about laparoscopic sleeve gastrectomy (LSG) and have heard such good reports about the operation. Yet on my website I have indicated that it is an operation that does not stand the test of time in most patients. And this is true. Statistics don’t lie.

Let’s take a deeper look at how the LSG evolved. This was not a common operation when I embarked on my journey in bariatric surgery in 2007. In fact, at that time most of the operations being done for obesity were Roux-en-Y gastric bypass surgeries (RYGB): about 60 – 65%. The “stomach only” operation popular at that time was the Laparoscopic adjustable gastric band (LAGB), done in about 30% of patients. The rest were having other types of procedures including LGS and LBPD-DS procedures, but a minority.

Why this trend? The public are not always aware that not all surgeons have the same abilities to perform certain procedures. Not everyone is good at playing computer games and in the same way not all surgeons are good at doing open surgery let alone laparoscopic surgery. Surgeons rated the technical difficulty of all surgical procedures on a scale of 1 – 10. For instance, an inguinal or umbilical hernia would be rated as a 1/10 difficulty generally although even then I have done some hernias that could be classified as a 5/10 difficulty on the odd occasion. A gallbladder or hiatus hernia operation for heartburn is generally considered a difficulty level of 2 to 3/10.

Now when it came to obesity operations, a LAGB and LGS were rated as no more than a difficulty of 2/10. Basically, just about every surgeon could be taught how to do these procedures relatively safely and competently. Furthermore, what attracted surgeons to do these procedures is that these patients generally did not become malnourished or require supplements as we see in the LRYGB and LBPD-DS patients.

LRYGB technical difficulty was at least a 5/10. Fewer surgeons were competent enough to do this surgery safely and soon those with higher than acceptable complication rates and higher mortalities than expected were reverting to the safer “stomach only” procedures. What we saw world-wide between 2007 and 2014 was more and more LAGB long-term complications and very poor long-term weight loss compared to the LGS patients. More and more surgeons converted to doing LGS procedures during this time and around 2015 the most common operation was no longer the LRYGB operation but the LGS, despite most surgeons still agreeing that the LRYGB was much more successful for weight loss and treatment of chronic diseases such as diabetes, than the LGS was.

The LBPD-DS procedure has a technical difficulty of 10/10, often quoted in the medical surgical literature as being one of the top 10 most difficult operations to perform. Since 2007 to date, the number of surgeons performing this type of operation on their patients has almost always been less than 1% world-wide. Not just because of the technical difficulties and much higher potential peri-operative complications, but also because of the long-term nutritional complications (this will be discussed in another blog).

So back to the LGS…

Now performed as the procedure of choice world-wide in more than 70% of cases! Recent 10-year outcome data of 10’s of thousands of patients showing a weight loss of more than 20% from where the patient started, is seen in less than 13% of patients. Let’s not kid ourselves, that’s better than a nearly 0% success with diet and lifestyle modification over the same period. But why are weight loss surgeons persisting in doing these operations?

IFSO, one of the international surgical organisations, endorses the operation because it has the least overall mortality and complication rates compared to the LRYGB and LBPD-DS, in particular. Their philosophy is that with newer medications coming onto the market that perhaps combining these medications with the LGS, we may see better long-term results. May be so but the cost of these medications is exorbitant. Secondly, the philosophy of IFSO was that should the patient have a failed LGS they could be converted to a RYGB or BPD-DS procedure. (Revision of the same operation NEVER works). There is a huge cost factor involved here for “redo” surgery and in South Africa medical aid funders do not pay for revision or redo surgery.

Do I believe there is a place for LGS procedure in South Africa and in my practice? ABSOLUTELY.

I will never refuse a patient requesting this operation if that is what they believe in. It is still a very good option in the less than 35 BMI patient or any patient under BMI 50 who only has financial means for a LGS but can still come back in 5 – 10 years if the procedure fails and they have the financial means to now convert to a LRYGB or LBPD-DS procedure. It is a good option in children until they reach the informed consent age of 16 – 18 years of age to decide on a more powerful surgical solution. I still think it should be the procedure of choice in patients over 65 years of age who have a BMI of less than 45, for multiple reasons.

Statistics don’t tell the whole story. Every patient is different, and one size does not fit all. Often as a bariatric multidisciplinary team, we will only decide and advise the patient as to what operation we think will work best after 2 months of working with the patient (before the day of surgery). And even then, we get it wrong sometimes.

11/09/2024

CEMMS Gauteng August 2024 Blog

Who are the professionals in GAUTENG CEMMS?

In part 2 of the CEMMS blog, I want to introduce you to my team.

To be recognized as a “Centre of Excellence” internationally, the centre has to do around 100 cases a year, with each surgeon at least 50 cases a year and with the senior surgeon having a life-time experience of more than 250 cases. In South Africa there are unfortunately very few surgeons who can get to these numbers, mainly because the surgery is very expensive, and most patients simply cannot afford it. What I can say though is that the more experienced centres will always attract the most patients. The reasons we accredit these centres is because data captured shows these centres have 2 to 3 times lower complication rates and the lowest mortality risk. Furthermore, follow up of patient care is much more professional and effective, due to the experience and knowledge of all the professionals in the team.

In the Gauteng CEMMS team, we have two bariatric surgeons and one specialist surgeon assistant (who can deal with any possible complication). I, Dr Gary Fetter, am the senior surgeon, with more than 17 years’ experience in this field of surgery. I have done over 3000 primary surgeries and done over 250 revision operations during my career. All I can say is that I am still learning and evolving into what I consider a better, more effective, bariatric and metabolic surgeon. One can never stop learning and improving, no matter how old you are.

Dr Sudha Naidoo is the other surgeon in the team, with excellent laparoscopic and robotic skills. When he has complex cases, we do them together because we all understand this is best for patient care and outcomes. Dr Martin Lebos is a general and hepatobiliary/ gastrointestinal surgeon, who has been working as an associate with me for the last 4 years at Netcare Waterfall City hospital. We assist each other in all the major surgical cases we do, including most of the bariatric cases I do, and where his assistance is of great value is picking up any potential mistakes I might make during surgery and visa versa. Having assisted at hundreds of procedures with me, he knows almost as much as I do about the bariatric surgical procedures and complications.

Dr Leeann Spoolder is the Specialist Physician that Dr. Naidoo and I work with, to prepare our cases for surgery and to address the long-term follow up of our patients. She has recently completed the SCOPE course and other exams required by the board of SAMMSS to become a qualified and accredited bariatic physician of our team. She is in the process of bringing other young physicians on board and educating them as well. Her dedication to the field of obesity and associated medical diseases is admirable and I am honoured to have such an accomplished physician on our team.

Dr Adrian Webb (14 years), Dr Tanya de Roubaix (6 years), Dr Dawn Keightley (4 years), are the experienced anaesthetists in our team and also help other bariatric centres when required. I cannot tell you as patients, how safe you are in their expert hands.

David Goncalves is the psychologist who has more than 20 years of experience in this field of medicine. His wife, Irene Goncalves (20 years) and her team of physiotherapists provide exceptional post-operative physiotherapy for our patients too. Nicola Drabble (16 years) and other experienced dieticians in this field of medicine are part of our very experienced team and are always training new dieticians as well.

My theatre staff have been with me for over 14 years. They make the operations run very smoothly cutting down on at least 30 to 60 minutes of time wastage during these very complex procedures. The ICU nurses and ward nurses have been with me for a very long time as well, some since 2011 when we opened the hospital.

I cannot even begin to explain to you how privileged and honoured I am to have all these people around me who have remained loyal to me, and all these people have only one directive; to give the patient the best treatment.

The Gauteng CEMMS team is all about the best care for you as the patient.

12/08/2024

Chapter 2 Blog

What is CEMMS?

Many of you reading this website are probably asking what CEMMS entails.

Internationally we recognise that surgery of obesity needs a team of very experienced medical professionals to look after the holistic care of the patient deciding to have the surgical option of treatment. This also includes the institution or hospital where you might undergo your surgical procedure.

Firstly, let us address the facility that does your procedure. Usually this is a hospital but can also be a day care centre. Internationally the requirements for accreditation of these facilities are strict but fair. Primarily, the accredited facility should have double doors going into even the examination room of your treating doctors. This is to allow large “double-sized” wheelchairs and beds to have easy access to all facilities for the patients. The wards should also have double door access to the bathroom particularly and the toilets and washbasins should be floor mounted to allow easy access and stability for the patient. Open showers for easy access to the patient should he or she collapse. I can mention many more requirements before the facility is accredited for bariatric/ obesity surgery. So, if you, as the patient, go into a hospital and doctors’ rooms and don’t notice these basic fundamentals of basic care, ask to see how the facility was accredited for this complex type of surgery.

My team is affiliated to SAMMSS (South African Metabolic Medicine and Surgery Society). This organisation of medical, endocrinologist and surgical professionals are responsible for helping you as the patient getting medical aid reimbursement for your surgical procedure (when you qualify for the benefits). The responsibility of this society, with a board of specialists is not only to get the surgeon and his team accredited with the medical aid but also the facility or hospital where the procedure will be performed.

So, before you let yourself have any surgical procedure, it is your right to ask for a certificate of accreditation and if one is not provided you can always go to the SAMMSS website and see if the facility and doctor is accredited or not.

Our endeavour as caring doctors towards our patients is always “to do no harm”.

In my next blog I will address the multidisciplinary team.

17/07/2024

As I contemplate my journey as a surgeon over the last 30 years or so, I remember a few valuable life lessons along the way. My career pathway was not easy, but I was very fortunate that along the way doors were opened to help my career prosper. Even then, being a surgeon, and a competent surgeon, only comes with endless hours of dedication and hard work. Nobody succeeds in any profession over a lifetime without putting in those extra hours every day. Initially my interests in surgery when I had just qualified, were in the super-specialities of endocrine and breast cancer surgery.

I still do a lot of endocrine related surgeries up to the present time but steered away from breast cancer surgery when I went into private practice in 1997. As part of my experience and training I also got very involved with kidney and pancreas transplantation which I performed from 1994 till 2016 when obesity/ bariatric surgery consumed most of my time. The unit I trained in in 1994 to 1997 at the Johannesburg Hospital also had a head and neck cancer department and I was asked to head this department up as well, toady I still perform complex head and neck cancer operations, something I used to dislike but grew very fond of in the last 2 decades.

The challenges of these head and neck operations are as complex as the laparoscopic BPD-DS surgery we do for metabolic and weight loss surgery. Of course, I did and still do all the other fields of general surgery including cholecystectomies, all kinds of hernia repairs, colorectal and upper gastrointestinal surgery and skin cancer surgeries including melanomas. A vast diversification of interests and experience, most of which I continue to perform on a regular basis, even today.

To do laparoscopic metabolic and obesity surgery with minimal intraoperative and postoperative complications, requires advanced laparoscopic skills. In simple laymen’s terms, you need the talent and skills of a professional sports person to perform some of these extremely intricate operations. Techniques and skills that are not learned overnight, but over many years. Even after doing 1000 cases I felt, I was still learning to perfect my skills. I learned quickly that I was certainly not competent after doing 50 or 100 cases.

Statistically, worldwide, we know that in this field of surgery, skills are only really fully evolved after about 250 to 500 cases and where the surgeon is performing at least 50 cases a year to keep their skills honed. There are very few weight loss or bariatric surgeons who can claim this degree of life-time experience, but everyone who wants to do this surgery has to start somewhere as I did.
In 2000 I was first approached to do this type of surgery and I declined as I was already extremely busy in my own practice. Secondly, the reputation of this surgery done around the world was tarnished by poor governance and poor outcomes with even less long-term care of these patients.

I wanted nothing to do with it. But internationally surgeons and physicians got together and started looking at the good outcomes of the operations being done at the time. Proper scientific research, governance and accountability was being introduced into this field of medicine and surgery and when I was approached again in 2006, I was satisfied that surgery had an exceptional benefit for patients suffering from diabetes, hypertension, cholesterol and severe obstructive sleep apnoea amongst many other medical conditions including the prevention of cancer.

I then started honing my skills as an advanced laparoscopic surgeon, including training by those already doing the surgery in South Africa. My first few cases were extremely challenging, but it was only after doing 500 cases that I realised, with experience, the surgeries became a lot safer for the patients. Yes, along the way we had complications, but the vast majority of the patients over the last 17 years I have done this surgery, have only had extreme gratefulness and appreciation for the massive change it caused in their lives; not only the sustained weight loss over many years but also greatly improved general health, mobility and energy in their lives.

It is for these reasons that I continue to do this type of surgery, learning from all my patients what works and what doesn’t after their surgery. I have modified the surgical procedures over the years as it is not as important to me or the patient what happens in the short-term of a few years but what happens to them in the long-term over 10 to 15 years.

I always keep reminding patients, before and after the surgery, success of any of these operations we do, depends to the largest extent on the sustained lifestyle changes the patients make after their surgery. Self-discipline is essential for success of these operations in most cases (not all). Surgery has never been a “quick fix” and never will be.

Yours in Good Health,
Dr Gary Fetter

A multidisciplinary medical centre aimed at providing expert advice and experience for obesity