Download CAGS Bariatric Surgery Working Group Report

CAGS Bariatric Surgery Working Group
Membership:
Dr. Dan Birch: Chair
Dr. Jim Ellsmere
Dr. Olivier Court
Dr. Mehran Anvari
Dr. Chris Andrew
Dr Shahzeer Karmali
Dr John Hagen
Dr Nam Nguyen
Terms of Reference:
For clarification, the following is an excerpt from the initial email from the president of
CAGS calling this group together:
“During the last CAGS executive and board meetings, as well as teleconferences, there
has been discussion surrounding the issues related to Bariatric Surgery and General
Surgery. Initially a proposed position paper was discussed and not supported due to lack
of clarity and necessity. In order to explore in more depth the concerns of Canadian
General Surgeons, with respect to both Bariatric surgery and surgery for the obese
patient, it was suggested that a Working group be formed to advise the executive and the
board.”
Therefore, the mandate of this group will be to advise the board upon the following
issues:
1. The relationship between CABPS and CAGS
2. The current status of Provincial Programs including a catalogue of programs
3. The educational needs of General Surgeons and General Surgery Trainees who
are not practicing Bariatric Surgery but must meet the needs of morbidly obese
patients requiring General Surgery procedures, and the needs of patients who
have had Bariatric surgery procedures.
4. The practice resources and standards for optimal care of the bariatric patient.
TOR 1: The relationship between CABPS and CAGS
As Mehran Anvari is VP of CABPS, he has drafted a statement that will be reviewed and
agreed upon by CABPS Exec. This initial statement is as follows:
The relationship between CABPS and CAGS
The Canadian Association of Bariatric Physicians and Surgeons (CABPS) represents Canadian
specialists interested in the treatment of obesity and severe obesity for the purposes of
professional development and coordination and promotion of common goals. CABPS was
founded 5 years ago and currently boasts close to 200 members. Currently a great proportion of
CABPS active members are also CAGS members, however the number of non-surgeon
membership is growing. Bariatric medical and surgical services across Canada is still
underdeveloped and it is expected that over the next 5 years we will see a sharp increase in
provincial funding for such services and to establish Bariatric Centres of excellence for provision
of care to an increasing population of Canadians requiring such services. As such the CABPS
membership is expected to double over the next three years. CABPS is run by a professional
management company Taylor Enterprises, and has a well functioning Board of Directors and
Committee structure. The presidency of CABPS is for period of three years and alternates
between a surgeon member and physician member.
CABPS and CAGS have many common goals and mandates (see CABPS mandate below) which
has facilitated a close working relationship between the two societies. CAGS has hosted a
CABPS symposium during it annual conference for the last three years with a resounding
success. In the last two years the CABPS symposium has drawn audience from across CAGS
membership, and there has been standing room only during the sessions. CABPS is hopeful to
continue to hold annual symposium during the CAGS conferences. In addition many of the
investment in infrastructure and services which CABPS is advocating for is also of importance to
CAGS members who find themselves caring for the surgical needs of an increasing population of
obese patients. It would therefore be important for CABPS and CAGS to issue a joint position in
the need for improved infrastructure and multi-disciplinary services for the increasing population
of Canadian patients who suffer from Obesity and morbid Obesity.
CABPS Mandate
The mandate of the Canadian Association of Bariatric Physicians and Surgeons follows:
 To bring together Canadian Physicians and Surgeons with a special interest in Bariatric
Medicine and Surgery in order to maintain and improve the standards of Bariatric care in
Canada.
 To support both primary and continuing educational programs in Bariatric Medicine and
Surgery.
 To advance knowledge in the field of Bariatric Medicine and Surgery.
 To facilitate and promote research in the field of Bariatric Medicine and Surgery.
 To develop policies and new ideas in the areas of clinical care, education, and research in
Bariatric Medicine and Surgery.
 To represent the views of the Bariatric Physicians and Surgeons of Canada.
 To facilitate communication between the public, the medical community and the
ministries of health at the provincial and federal level so as to promote awareness of the
health risks of obesity and severe or morbid obesity, the financial and health burden to
the individual and to society, and the efficacy of medical and surgical treatment options.
TOR 2: The current status of Provincial Programs including a catalogue of programs.
With reasonable geographic representation in our membership, each member of the working
group has been asked to submit a statement on the status of obesity/bariatric surgery of their
province/region of Canada (see below). This includes basic information suggest as number of
sites, surgeons, procedures offered and extent of private clinics offering surgery. The following
statements have been submitted:
 Nam Nguyen: BC
Known bariatric surgeons around the province polled:
Location
Surgeon
Bariatric Service(s) Provided
Burnaby
Delta
Kelowna
Richmond
Richmond
Surrey
Vancouver
Vancouver
Victoria
Victoria
Whiterock
Dr. Katherine Hsu
Dr. Robin Woodhead
Dr. Andy Kluftinger
Dr. Nam Nguyen
Dr. Sharadh Sampath
Dr. W.M. Leung
Dr. Cory Ming-Lum
Dr. Emil Woo
Dr. Brad Amson
Dr. Bao Tang
Dr. Jean Lauzon
Band
Band, Intragastric balloon
Band
Band, Sleeve Gastrectomy, Gastric Bypass
Band, Sleeve Gastrectomy, Gastric Bypass
Band
Band
Band
Band, Sleeve Gastrectomy, Gastric Bypass
Band, Sleeve Gastrectomy, Gastric Bypass
Band
It is estimated that 260 gastric bands are done per year in hospital and private surgery centres in
BC. The Victoria group is limited to about 50 bariatric procedures per year. The Richmond
Group previously offered bands and sleeve gastrectomy and will offer gastric bypass starting in
2011.
 Shahzeer Karmali: AB, Territories
The Alberta Obesity Program (AOP) builds on the Expanded Chronic Care Management model
in which the community and the health system act as collaborative partners with the
patient/family. This principle recognizes the vital role of both the community in providing a
supportive environment for obesity prevention and management at all levels, as well as the health
system in ensuring that clinicians and other service providers are well prepared to deliver
necessary services.
The Alberta Obesity Program model proposes services at three different levels – local
community, bariatric centres (within zones), and the Alberta Obesity Program. Its leadership and
governance structure will be instrumental in promoting excellence in bariatric care and
accountability for outcome measures.
The objectives of the Alberta Obesity Program are to:
 Provide a consistently high standard of obesity care for all Albertans based on need and
eligibility, taking into consideration the needs of diverse populations and being
responsive to AHS’ principles of patient-family-centredness.
 Ensure equitable access to obesity services, delivered as close as possible to where people
live, in a manner that is compatible with safety requirements, available expertise, and
existing or planned infrastructure.




Utilize a service delivery model that incorporates best practice, new approaches, local
successes, resource optimization, and promotes consistent provincial standards.
Implement strategies at the community level to support Albertans in achieving and
maintaining healthy weights and/or healthier lifestyles.
Monitor performance and analyze results to improve patient outcomes and service
delivery.
Reduce demands and economic pressure on the health system by treating obesity as a
chronic disease and a root cause of many other diseases.
Adult specialty care is delivered through four urban centres providing specialty services in
Edmonton, Calgary, Red Deer, and Medicine Hat. However, only Edmonton’s Weight Wise
program offers comprehensive bariatric care by an interprofessional team. The remaining three
specialty clinics are focused on bariatric surgery, and are not sufficiently staffed with
interprofessional teams to provide the range of bariatric care required for management of
complex obese patients. The Provincial Obesity Business Plan for Alberta suggests a
conservative target, which aligns with the National Institute for Health and Clinical Excellence4
and considers current surgical capacity. For Alberta, this means increasing the number of bariatric
surgeries from 261 in 2009 to over 2,000 surgeries/year. This target will take time to achieve; the
Provincial Obesity Business Plan outlines an incremental approach to achieving this international
benchmark for Alberta
The Weight Wise program is comprised of a medical director and clinic coordinator, as well as
specialist physicians (internal medicine, endocrinology, gastroenterology, psychiatry, and
surgery), nurses, psychologists, dietitians, physiotherapists, and occupational therapists.
Registered nurses complete in-depth initial assessments with patients and serve as case managers
to oversee, coordinate, and monitor patient participation and progress in the program. Multidisciplinary team members provide input into comprehensive management plans in consultation
with patients; the roles and contributions of team members are determined by their specific
disciplines. The program addresses mental health barriers such as emotional and binge eating
patterns, depression, anxiety, self-esteem, and body image issues through individual and group
management options involving therapies such as brief psychotherapy and cognitive behavioural
therapy. Dietitians focus on establishing healthy eating patterns to support weight loss and
maintenance. They develop tailored nutrition interventions, including nutrition support for
surgical patients to address malnutrition and reduce post-surgical complications.
An ‘outreach’ Weight Wise program has been developed in Whitehorse to serve the population of
Yukon. Bariatric surgeons from Edmonton will consult on patients attending these clinics by
visiting Whitehorse to assess readiness for surgery.
 Chris Andrew: SK, MAN:
Status of Bariatric Surgery in Manitoba
Prior to 2008: no activity in Bariatric surgery. Since Jan, 2008 two surgeons (John Bracken,
Chris Andrew) began performing laparoscopic gastric banding at a private facility (Maples
Surgical Centre). This is ongoing, at a rate of approximately 75 cases per year (100% private). To
my knowledge, there is no plan for MB Health to fund the bands.
Since the summer of 2010, there are 4 bariatric surgeons in Winnipeg (the above named surgeons,
plus Ashley Vergis and Krista Hardy). We are currently doing 4-5 gastric bypasses and 2-3 sleeve
gastrectomies per month. There is a proposal in the works (just submitted to MB Health) for a
fully funded program, with the initial goal to be approximately 200 cases per year (mix of
bypasses and sleeves). Until that program is approved, we are operating within the confines of the
current surgery budget. As such, we are limited to 8 cases per month. This has all been surgeoninitiated. We have had innumerable meetings with the regional health authority to plead and beg
them to fund a proper bariatrics program. We have received upwards of 600 referrals for the
public program (from within MB) since March, 2010 (which is when we “announced” that we
would be offering bariatric surgery within the region).
 John Hagen: ON
Organizational Structure
The Ontario Bariatric Network (OBN) was established in 2009 as part of the Ontario Bariatric
Strategy initiated by the Ministry of Health and Long-Term Care of Ontario (MOHLTC). The
Network is comprised of clinical and administrative specialists from each of the Bariatric
Programs within the province, as well as representatives from the MOHLTC. Dr. Mehran Anvari
is the Surgical Lead and the OBN Advisory Board Chair.
Within the OBN are various sub-committees such as the; Referral Task Force, Surgical Task
Force, Medical Task Force and Mental Task Force. These groups meet regularly to offer advice
to the OBN Advisory Board and to action solutions. The goal of these committees to create a
high standard of care that is consistent across the province providing all patients with the same
experience.
Referral Process
All Referring Physicians / clinicians interested in referring a patient to the Bariatric Program must
register and create an account for themselves at www.bariatricregistry.ca. Once registration is
complete, they can log into the Registry to print of a Referral Form, fill it out with their patient’s
information, and fax it into the Central Database. Patients are assigned to a Bariatric Centre of
Excellence (BCoE) that is closest to their Postal Code.
Once sorted and assigned to the appropriate Centre, the centre initiates contact to begin the
patient’s journey for Bariatric care. This journey begins with an invitation to a mandatory
Education Orientation Session, followed by assessment appointments where the patient is seen by
a Bariatric Team of specialists, including a consultation with the surgeon. These assessments
determine if the patient is a suitable candidate for surgery.
The timelines for the Referral Process are as follows:
1. Referral Request to Orientation Session = 3 months
2. Orientation Session to 1st Assessment = 3 months
3. 1st assessment to Surgery Date = 3 months (maximum 6-months)
The total care process to surgery date should be about 9 months (1 year maximum). These
timelines were outlined and agreed upon as a ‘guide/tool’ by the Referral Task Force.
Follow Up
It is expected that the bariatric center will have a 90% follow up of the patients. All of the
demographic parameters and results are registered through the bariatric Registry including weight
loss, relief of comorbidities and mortality rates. This data is entered by each of the bariatric
centers.
Bariatric Centers
There are a total of six (6) centres across the province. Of these there are four (4) Bariatric
Centres of Excellence (BCoE) and two (2) Regional Assessment Treatment Centres (RATC).
BCoEs Include: St Joseph Healthcare Hamilton, Guelph General Hospital, The Ottawa Hospital
and University of Toronto Collaborative (Toronto Western Hospital, Humber River Regional
Hospital). RATCs Include: Thunder Bay and Windsor Regional Hospital. The RATC are
involved with assessing the patients only (no surgery) and the BCoEs assess patients and perform
surgery.
Surgical Procedures Performed
The majority of the bariatric procedures are the laparoscopic Roux-en-Y gastric bypasses.
Laparoscopic gastric sleeve resections are performed in the circumstances where it is not possible
to do a Roux-en-Y gastric bypass. The circumstances included patients with previous surgery
such as previous liver transplants, massive ventral hernias, and multiple adhesions preventing
formation of the Roux-en-Y limb. Laparoscopic gastric sleeve resections can also be done in the
circumstances of massive obesity (BMI> 60). Laparoscopic gastric banding is not covered by the
provincial healthcare plan. Gastric banding is being performed in private clinics outside of the
provincial plan.
Surgical Centers
Center
Number of procedures 2010
Surgeons
Toronto HRRH
450
Toronto St. Joseph
180
Toronto UHN
240
Toronto SMH
120
Toronto TEGH
120
Hamilton
300
Ottawa
300
Guelph
220
John Hagen
Laz Klein
Mikki Sohi
Quoc Huynh
David Starr
Lloyd Smith
David Lindsay
Paul Sullivan
David Urbach
Todd Penner
Allan Okrainec
Tim Jackson
Teodor Grantcharov
Ori Rotstein
Jamie Cyriac
Mariann Aarts
Mehran Anvari
Dennis Hong
JD Yelle
Joe Mammaza
Ken Reed
Jules Foute-Nelong
The total number of cases for 2010 is expected to be 1930. The number of cases for 2011 will be
an additional 350 cases spread out throughout the centers. The number of laparoscopic gastric
bands is more difficult to predict because it is done in private centers. Likely, each year there are
approximately 1000 gastric bands been done in private clinics.
 Olivier Court: QUEB
Bariatric surgery has been performed in Quebec since the 1970’s. In response to growing
demand and the demonstration of clear benefits for the patient (Quality of life, comorbidities
and mortality) and for the healthcare system (reduced longterm costs), the Quebec
government announced in 2009 additional funding to increase the volumes of bariatric
surgery performed in the province from 840 cases in 2009 to an expected 3000 cases in 2012.
This is achieved by the designation specific centres for bariatric surgery. There are at the
moment 2 Centres of Excellence and 5 Regional Centres. The 2 Centres of Excellence are
Institut Universitaire de Cardiologie et de Pneumologie de Quebec (Laval University) and
McGill University Health Centre. The 5 Regional Centres are CSSS de la Vallee de l’Or,
Hopital Sacre-cœur, Hopital Pierre Boucher, Centre Hospitalier Universitaire de Sherbrooke
and Hopital Sainte-croix.
The need to train more surgeons in Bariatric Surgery has been recognized and McGill
University started in 2010 the first Bariatric Surgery Fellowship in Canada.
Surgical Centres
Centers
Institut Universitaire de Cardiologie
et Pneumologie de Quebec
Procedures
Laparoscopic Sleeve Gastrectomy
Laparoscopic BPD/DS
Open BPD/DS
Revisional Surgery
McGill University Health Center
LAGB
Laparoscopic Sleeve Gastrectomy
Laparoscopic Gastric Bypass
Laparoscopic BPD/DS
Revisional Surgery
Laparoscopic Gastric Bypass
CSSS de la Vallee de l’Or
Hopital Sacre-cœur
Hopital Pierre Boucher
Centre Hospitalier Universitaire de
Sherbrooke
Hopital Sainte-croix
LAGB
Laparoscopic Sleeve Gastrectomy
Open BPD/DS
LAGB
Laparoscopic Gastric Bypass
LAGB
Laparoscopic Gastric Bypass
LAGB
Surgeons
Dr. Simon Biron
Dr. Simon Marceau
Dr. Stephane Lebel
Dr. Frederic Hould
Dr. Laurent Biertho
Dr. Fady Moustarrah
Dr. Nicolas Christou
Dr. Olivier Court
Dr. S. Demyttenaere
Dr. Jose Mijangos
Dr. Denis Brouillette
Dr. Ronald Denis
Dr. Henri Atlas
Dr. Pierre Garneau
Dr. Pierre Jette
Dr. Steven Miller
Dr. Emilie Comeau
Dr. Anne Meziat
Dr. Mathieu Lalancette
Dr. Richard Laplante
 Jim Ellesmer: NB, PEI, NS, NFLD
New Brunswick:
 M. Savoie, bathhurst, lap trained in quebec, 1 1/2 years program, band and sleeve 50/50,
plan to do switch, 100/yr, diabetes clinic, wt list 900 pts
 S. Beausoeil, moncton, lap trained in mcgill, 5 years program, bypass, band, sleeve 50/50
less bypass, 150/yr, gp runs clinic, wt list big one code - gastroplasty code, no pre
approval, hospital pays for LAGB band reimbursed by government
Nova Scotia:
 J. Ellsmere, halifax, lap trained in Harvard
 D. Klassen, halifax, lap trained in mcgill, 3 year program, sleeve, diabetes clinic, together
do 100 year, wt list > 10 years gastroplasty code, requires pre approval
PEI
no service currently
NFLD
no service currently in
TOR 3: The educational needs of General Surgeons and General Surgery Trainees who
are not practicing Bariatric Surgery but must meet the needs of morbidly obese patients
requiring General Surgery procedures, and the needs of patients who have had Bariatric
surgery procedures.
Obesity has an impact on both the General Surgeons performing general surgical operations as
well as being aware of issues of patients undergoing bariatric surgery.
Obesity impact on General Surgical Care:
Etiologies: Obesity demonstrated association with surgical diseases
Gallstone disease
Colorectal Carcinoma
Hernias-incisional, umbilical, inguinal
Preoperative issues: Obesity related co-morbidities
Sleep Apnea
Diabetes
Hypertension
Intraoperative issues:
Access/Entry to Abdomen in Morbidly obese patient
Liver size
Managing intra-abdominal adiposity
Abdominal wall closure
Post-operative issues:
Managing bariatric patient on ward-sleep apnea, mobility, diet
Risks of post-surgical infection, dehiscence
Incisional hernia risk
Managing the bariatric patient:
Goals:
Understanding of the commonly performed bariatric operations in Canada and their effect on the
digestive tract
Managing complications:
Gastric Bypass:
Immediate: Leak, Bleed, Bowel obstruction
Delayed: Internal Hernia, Stricture, Marginal Ulcer, Bowel Obstruction, Nutritional Deficiencies
Adjustable Gastric Banding
Immediate: Dysphagia, Perforation
Delayed: Band slip, Band erosion, Port site infection
Sleeve Gastrectomy:
Immediate: Leak, Bleed
Delayed: Leak, Abdominal abscess, stricture, ulcer, Nutritional Deficiencies.
TOR 4: The practice resources and standards for optimal care of the bariatric patient.
Introduction
It is clear that when morbidly obese patients present for consideration of a surgery for control of
their disease, they have exhausted all other options. The care of these patients exceeds simply
immediate pre and postoperative considerations. The positive impact of surgery on long term
morbidity and mortality as well as the demand on the health care system has been wellestablished. For the benefits to be of any impact, satisfactory long-term results (>5 years) is the
goal. The general guidelines from the National Institute of Health (NIH) consensus conference
statement published over two decades ago are still highly relevant. Bariatric surgical procedures
should be offered in carefully selected patients with acceptable operative risks after assessment
by a multidisciplinary team with medical, surgical, psychiatric and nutritional expertise. The
operation should be performed by a surgeon with substantial expertise with these procedures and
who is working in a clinical setting with adequate support for all aspects of management and
assessment. Appropriate lifelong medical surveillance after surgery is also necessary. Each of
these key points is addressed in further detail below.
Guidelines for Patient Selection
 1991 NIH consensus guidelines provide valid but incomplete patient selection criteria for
contemporary bariatric procedures.
o BMI > 40 kg/m2
o BMI 35-40 kg/m2 with high-risk co-morbid conditions such as coronary artery
disease, obstructive sleep apnea, obesity hypoventilation syndrome, nonalcoholic steatohepatitis, hypertension, dyslipidemia, pseudotumor cerebri,
asthma, venous stasis disease, severe urinary incontinence, and debilitating
osteoarthritis
 Other well-selected patients may benefit from laparoscopic bariatric surgery
o BMI >60 kg/m2
o Patients > 60 years

Adolescent bariatric surgery (age < 18 years) has been proven effective but should be
performed in a specialty center.
o Patient selection criteria should be the same as used for adult bariatric surgery.
Surgical Options
 Roux-en-Y gastric bypass, biliopancreatic diversion with/without duodenal switch and
laparoscopic adjustable gastric band are effective and validated bariatric procedures.
 The laparoscopic approach is preferred over open.
 Laparoscopic sleeve gastrectomy is validated as providing effective weight loss and
resolution of co-morbidities up to 3-5 years.
Bariatric Program and Facility
Bariatric Program
 Bariatric surgery programs should include a multi-disciplinary team with appropriate
training and experience.
 The treatment team should include:
o Dietician
o Psychiatrist/psychologist
o Anesthetist
o Nurses
Preoperative Evaluation
 Psychological evaluation is commonly part of the preoperative work-up of bariatric
patients.
 Treated psychopathology does not preclude the benefits of bariatric surgery.
 All patients should undergo an appropriate nutritional evaluation before any bariatric
surgical procedure.
 Preoperative weight loss may be useful to reduce liver volume and improve access for
laparoscopic bariatric procedures, but mandated preoperative weight loss does not affect
postoperative weight loss or comorbidity improvement.
Hospital facilities
 Any hospital with a bariatric surgery program must have a full range of surgical and
medical specialties, including radiology, for consultation and management of
complications; access to an intensive care unit is essential.
 Physical space design (patient room layout, doorways, etc…) should comply with the
Facilities Guideline Institute (FGI) recommendations for bariatric patients.
 Equipment to accommodate morbidly obese patients including scales, beds, wheelchairs,
lifts and bathrooms must be available.
Postoperative follow-up
 A protocol-derived staged meal progression, based on the type of surgical procedure,
should be provided to the patient.
 Nutritional supplementation (vitamins +/- minerals) appropriate to the type of surgical
procedure must be provided to the patient.
 Medications for comorbidities (diabetes, hypertension, etc…) must be appropriately
adjusted postoperatively.
 Routine metabolic and nutritional monitoring is recommended after all bariatric surgical
procedure. The frequency of follow-up depends on the procedure performed and the
severity of comorbidities.
Nutritional or metabolic
Procedure
comorbidities
VBG
LAGB
RYGB
No
Yes
No
Yes
No
First 6
months
q 3-6 mo
q 1-2 mo
q month prn
q month prn
q 2-3 mo
Second 6
months
Once
Twice
Once
Twice
Once
Next
year
Annually
q 6 mo
Annually
q 6 mo
q 6 mo
Thereafter
Annually
Annually
Annually
Annually
Annually
Yes
No
Yes
BPD/DS


q 1-2 mo
q 2-3 mo
q 1-2 mo
q 3-6 mo
Twice
q 6-12 mo
q 6 mo
Annually
q 3-6 mo Annually
q 6-12 mo q 6-12 mo
Inadequate weight loss should prompt evaluation for:
o Surgical failure (pouch size, anastomosis, etc…)
o A poorly adjusted gastric band
o Development of maladaptive eating behaviors or psychological complications
Bariatric surgeons have an obligation to provide both emergency and elective care to
their own postoperative patients.
References
1. American Association of Clinical Endocrinologists, The Obesity Society, and American
Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice for
the Perioperative Nutritional, Metabolic, and Nonsurgical Support of the Bariatric
Surgery Patient. Surg Obes Relat Dis. 2008 Sep-Oct;4(5 Suppl):S109-84.
2. SAGES guideline for clinical application of laparoscopic bariatric surgery. Surg Endosc.
2008 Oct;22(10):2281-300.
3. 2006 Canadian clinical practice guidelines on the management and prevention of obesity
in adults and children. CMAJ. 2007 Apr 10;176(8):S1-13.