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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.