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Weight loss surgery: what do we know about quality?

Weight loss is a constant struggle for millions of Canadians, with one in four Canadian adults classified as obese.

Losing weight is not easy. Many Canadians try to lose weight through diet, exercise, behavioral modification and medications.

Bariatric, or weight loss surgery is often the final effort for many on a long, difficult road to shed pounds and maintain weight loss.

Ontario announced the $75 million Bariatric Network in 2009 to increase capacity in the province from under 400 to over 2000 publicly funded bariatric surgeries per year.

Read Healthy Debate’s 2011 analysis on the need for, and access to bariatric surgery here.

Experts emphasize that bariatric surgery is not for everyone, and many who are referred for bariatric surgery and go through a rigorous screening process are found to be ineligible for the procedure.

Kenneth Reed, a surgeon at Guelph General Hospital and Bariatric Network board member notes that while about 24,000 patients have been referred through the Network since its inception, only about 7000 have had bariatric surgery.

However, there is an alternative to the Bariatric Network for those seeking weight loss surgery. Private centres across the province provide a type of bariatric surgery not funded through the public health care system, adjustable gastric banding, to patients for an out of pocket fee.

The bariatric surgery landscape is complex for patients to navigate. Healthy Debate reviews what is known – and unknown –  about bariatric surgery in Ontario.

Three weight loss surgery procedures

There are three main procedures for weight loss surgery.Each is different – with varying degrees of technical complexity, invasiveness, and reversibility.

They also differ in terms of clinical outcomes – the amount of  long-term weight loss  after surgery, and the frequency of  complications after surgery.

Adjustable gastric banding reduces the size of the stomach by placing a band around part of the upper stomach. This is a less-invasive surgical procedure, and is reversible because the band can be removed.  However, appetite is not affected by the surgery, and if patients overeat, the band can slip or stretch. Gastric banding has a lower rate of long-term weight loss than the other two procedures.

For these reasons, adjustable gastric banding is not publicly funded in Ontario. While it is publicly funded in Alberta, adjustable gastric banding is performed much less frequently than the other bariatric surgical procedures – sleeve gastrectomy and gastric bypass.

Ontario publicly funds sleeve gastrectomy and gastric bypass. Both these procedures are more invasive, and are irreversible. Intensive follow up is needed for patients who undergo these procedures. However, evidence shows that these procedures have better long-term patient outcomes than adjustable gastric banding.

Chris de Gara, an Edmonton surgeon, developed a video to educate patients and health care providers about the different bariatric surgery procedures. This video was funded by the Physician Learning Program of the Alberta Medical Association.

Private centres promising ‘easy’ weight loss surgery

Adjustable gastric bands are offered by private centres across Ontario as a relatively less-invasive weight loss surgical procedure. These centres market to obese patients with claims of sustained weight loss, non-invasive surgery and short wait times.

One website for such a centre tells patients they could “lose up to ½ of your excess weight within the 1st year!” Another claims adjustable gastric band surgery will help patients “lose weight safely and permanently.”

Yoni Freedhoff, a family doctor and obesity specialist in Ottawa says these clinics seduce potential patients with marketing claims.

These claims come at a cost. Healthy Debate spoke with three Ontario gastric banding centres who priced the procedure, including pre and after-care, at around $16,000.

Publicly funded bariatric surgery in Ontario

The Ontario Bariatric Network which does not perform adjustable gastric banding, was launched in 2009. It includes a Registry that collects standard information on every patient in the province referred for surgery  to four Bariatric Centres of Excellence. The Registry gathers information on wait times, follow up and patient outcomes.

Wait time information for bariatric surgery is publicly available through the Ontario wait times ‘Health Care Professionals’ page.

Recent papers published in two prestigious American journals have highlighted the importance of collecting high quality information on who bariatric surgery patients are, and what their long term outcomes are, including complication rates.

The latter paper documented a wide variation in the technical skill of the surgeons performing the surgery, and found that patients cared for by the most skilled surgeons had the fewest complications.

Mehran Anvari, Clinical Lead and Chair of the Ontario Bariatric Network says the Bariatric Registry collects data for “internal quality control” and shares this information with the Bariatric Centres of Excellence. Registry data is used to “provide regular input to the sites doing bariatric surgery as to their outcomes and areas needing improvement” he says.

However, this information is not reported publicly, nor is it available at the provincial level.

Bariatric surgery is not a quick fix

Patient eligibility is an important part of determining who will have success with bariatric surgery, both in terms of low complication rates and sustained weight loss.

Kenneth Reed describes how he conveys to patients the major commitments necessary to ensure their surgery is successful.

Reed tells his patients to think of bariatric surgery as having a baby – with nine months spent prior to surgery preparing for the “major life altering event, very similar to introducing a child into the home, but you’re introducing an operation into the home that causes major behavioral changes.”

Reed likens the 9 months of pregnancy to a lengthy period of preparation for surgery. He says that this is time well spent where patients participate in education around changing diet and lifestyle behaviors, and putting in place appropriate psychosocial supports.

However, in spite of the need for advanced preparation, some argue that wait times for bariatric surgery are still too long.

And in fact, patients in both Ontario and Alberta, many frustrated with long preparation and wait times for publicly-funded bariatric surgeries are seeking surgeries through private centres within Canada or out of country.

Complications of private bariatric surgery

Chris de Gara says that many Albertans travel to centers in Ontario or abroad for adjustable gastric banding. de Gara notes that “there’s no difference between Mexico and Mississauga, you are a medical tourist in my mind.”

de Gara is the Medical Director for the Adult Bariatric Surgery Revision Clinic in Edmonton, which focuses on removing failed bands and trying to improve outcomes or complications in patients who have already undergone bariatric surgery. He says that the failure rate for adjustable gastric banding is around 40%.

Teodor Grantcharov, a general surgeon at St. Michaels Hospital in Toronto frequently sees patients experiencing complications from private bariatric surgery centres. He points out that it is “private enterprise, with little governance and no forum for quality control.”

A group of Alberta surgeons published a paper describing 10 patients who received gastric banding outside the province, and detailed the clinical and financial costs associated with managing these complications and removing failed bands. They estimate the total cost from these 10 patients to be over $160,000 to Alberta’s public health care system.

However, beyond a few case reports, there is no comprehensive information about how many Canadians are seeking gastric banding privately – either abroad, or at home.

There are no data around how many adjustable gastric band procedures have been safely performed, and what the long-term weight loss or complication rates are for patients paying for adjustable gastric banding at Ontario’s private centres.

Grantcharov emphasizes that “this is not a cosmetic procedure – it’s a medical and surgical procedure” and as such, it is important that quality is monitored.

More information needed

Patients and health care providers need high quality information about outcomes to support treatment decisions about bariatric surgery.

At the present time there is no public information about the outcomes after bariatric surgery, whether performed within the public health care system or privately. Neither do we know whether patients in different regions have equitable access to surgery.

“Data is done in a poor way” when it comes to bariatric surgery, says de Gara, With medical tourism happening between Canadian provinces, de Gara argues that collecting information on bariatric surgery patients “should be part of our DNA.”

Grantcharov echoes de Gara’s concerns, saying “no one has a comprehensive list of who is doing what” when it comes to bariatric surgery in Ontario.

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19 Comments
  • Shelby Dawdy says:

    How can I go about getting this sugery done? I am 5’4” and 185 pounds and definitely interested in having this done ASAP.

  • Leena says:

    Is this covers by ohip

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  • José Luis says:

    I changed into depressing the first couple of months after bariatric surgery,” she says. “I needed to adapt to eating the small quantities. My body became getting used to being rerouted. I felt lousy, tired. I was without a doubt being used to how my frame changed into operating. But searching returned, all of it resolved itself. It changed into now not a huge deal in particular thinking about how appropriate I feel now.

    Today, she says, “I feel perfectly healthful. I do not miss the meals. If there is something I’m craving, if I even have a little little bit of it, I’m excellent. That’s the reality. I do not suppose you ought to deprive yourself of anything, however, element size is a big aspect.”

  • Bryan Johnston says:

    Bryan Johnston I am 48years old with a lot of health problem now what I need is a surgeon who is not scared to do a gastric bypass on someone who is considered to be hi risk my BMI is 67 I am type two diabetic I am currently on a alot of different meds for many different types of sickness not I am willing to sign a waiver for any Dr that is willing to do the surgery because the complacations outweigh the negatives of having the surgical procedure

  • Karen Parker says:

    I wish I knew all this prior to having a lapband procedure done in Toronto. It has been a problem for me from the beginning but I stuck with it, even though I had to have surgery to fix a hernia caused by the pressure of coughing when the ban wrapped around an area of my stomach and caused me aspirate into my lungs which caused nonstop coughing and dark spots on my lungs to which I had a lung biopsy looking for cancer.
    I was glad to hear I did not have cancer but it was a very stressful time as I had test after test only to find out it was the band that caused my issue.
    I won’t get into how hard it was to get the clinic that did the original operation did not want to deal with me. I did get them to refer a doctor who was a surgeon and who knew about the bands worked out a hospital and finally did the hernia repair and move the wires of the band but did not remove it.
    Now three years later I have pain and my stomach looks like a 7 months pregnant woman. In the mean time my husband left me for another woman, for which he tolds friends he got tired of me always being sick. I am not back to work as I had a break down when my marriage failed after 27 years and I now have depression and anxiety.
    I phoned the doctor who did the hernia repair and his assistant phoned me back I told her the issue and that I wanted the doctor to recommend a surgeon in my area as I cannot drive to toronto as I can only drive short distances and not on any 400 series highways because of panic attacks. I’ve not heard back from the doctor or his assistance.
    My psychiatrist told me about the stomach sleeve that is covered by OHIP and the surgeon would remove the band and replace it with the sleeve but I had to get a referral from my family doctor. I spoke to my family doctor about this and he said he would give me a referral but he had not heard about this. He advised me to research it, get a doctors name an fax number and he would send a referral.
    I have been researching and found information on the sleeve but cannon find a doctors name in Oshawa where I live. Most of the information is in the Unite States.
    Can you give me information on doctors in Oshawa or Durham region who could help me. Presently, I receive CPP Disability once a month and still waiting for spousal support from my ex-husband. I also live with my daughter and my two grandchildren. So I do not have the money to pay for this surgery like I did not first one that I took out a loan for.

  • Patrick says:

    I have struggled with obesity for nearly 20 years. I was diagnosed with Type 2 diabetes in 2000 and was initially able to control his blood sugar with diet and exercise. I was able to lose weight at the time of that diagnosis, but over time regained all that weight. In 2008, I entered a 26-week hospital-based lifestyle modification education program. However, for all that effort, my weight loss was minimal. As an aside, following the lifestyle modification course, I embarked on and completed a research-based Master of Education studying the use of distance education technology for lifestyle modification, particularly obesity.

    Routine blood tests in mid-2013 began to indicate my kidney function was rapidly deteriorating. In early 2015, I was on the precipice of renal failure which, in the near future, would require dialysis and/or a transplant. I was advised that I might avert or delay kidney failure if I could lose sufficient weight to substantially reduce my hypertension and reduce or eliminate the effects of his diabetes.

    In February 2015, my wife and I attended an information session on Roux-en-Y Gastric Bypass (RYGB) surgery—the only bariatric procedure covered by OHIP. At that session, I learned that it would be a minimum of 12-18 months before the surgery would take place due to patient backlog. Furthermore, there is no triage: medical necessity will not advance your surgery date. At the same time, my nephrologist indicated that kidney failure was imminent, and would likely occur well before any potential surgical date, resulting in the need for dialysis and/or transplant. Placement of the gastric band was the only medical procedure/treatment available to me that could be performed in time to potentially avoid or delay renal failure.

    Because I was at a much higher risk than patients who normally get the gastric band, my operation was done in a hospital. The post-operative care has from the clinic in Mississauga has been exemplary, caring, and professional. They really want me to succeed.

    In the three months following my surgery, I have made remarkable strides:
    – I have lost 30 pounds
    – my insulin requirements have gone from 80 IU/day to 12 IU/day
    – my blood pressure has stabilized at around 134/73
    – all of the edema is gone from my legs
    – the hemorrhaging in my retinas has cleared
    – my creatinine levels are in steady decline

    My point here is that, in some desperate cases, the gastric band may be the only available treatment. In such a case, OHIP should consider reimbursing at least a portion of the cost. In my case case, it has probably saved my life. Moreover, how much expense have I saved the medical system for the cost of dialysis for the rest of my life and/or the cost of a transplant.

    • Judy says:

      Hi Patrick

      I am think of getting the gastric band also…less intrusive…..I will be happy to lose 75-100 lbs. I love healthy foods, chicken, salads, vegetables but I know I eat very large portions. What did you have to do after surgery to loose weight…example..eat less, exercise….if you ate too much did you get sick? Just curious….. I am not in a huge rush to loose the weight (so I don’t care if I lose 30 pounds a month) just want help to lose it….what could you eat for supper? Thank you and good luck with your weight lose surgery.

  • Gary Moore says:

    Howdy! I am currently looking for VGS surgery thru the Red Deer clinic (Alberta). I am overweight BUT my purpose in the surgery is to control or eliminate my Diabetes. I have just hung up the phone with the clinic. My app for the clinic was accepted in Aug 2014. I was told that I should have the surgery in November 2014. As of today, I am told my first intake will not be before March 2015. If all goes well, I might have surgery a YEAR later.
    Studies have shown that over 83% of people that are type 2 diabetics that have the surgery go into TOTAL REMISSION! Why is this surgery still called “elective”? The health risks associated with metabolic syndrome far outweigh the so called benefits of the go-slow system that is in place.

    I wonder if this program is more of a make-work project than it is concerned with patient’s health.

    I am actively seeking a resolution in Mexico. This is a very sad statement for our much vaunted health care system.

    • Linda Gendron says:

      I had the RNY surgery eight weeks ago. I waited a year and a half from referral. It was publicly funded. The professionals who work at the bariatric clinic are essential in the process. I rely on the advice of the dietitian. I made use of the social worker’s advice and have private counseling in place since I live far from the bariatric clinic. I found and joined a local support group which has also echoed the advice of the clinic in a timely manner. I learned before surgery that the surgery is a tool to help, not the be all and end all solution.
      I know how hard it is to wait for something that is very likely going to help improve your health. Making the adjustments in habits beforehand really helps. Being impatient will not help if you have not learned to make healthy choices, eat slowly, to chew your food well, to give up gum, coffee, carbonated beverages, drinking through a straw or the myriad of other habits strongly recommended by the bariatric clinic which reduce the risk of complications. Even something as simple as getting my blood work done a year before surgery resulted in a substantial increase in the amounts of vitamins I was taking, which is monitored by the nurse.
      I changed as I prepared for surgery. I could have hurried things along by calling the clinic regularly, but I didn’t. The time I took to prepare for surgery helped me adjust to the changes. There are also changes required for VGS
      I have heard that some private clinics are awesome, and others are suspect. To me the advantage of the publicly funded system is they are dedicated to ensuring results with minimal complications, so ensure they educate and support the entire person in the process, not just the surgery. I wish you well in your journey.

  • Patricia Armstrong says:

    Good read. I had the lapband procedure in ON in 2010. I found the weight loss immediate but 4 almost 5 years on although I have kept some of the weight off I struggle with the mental changes i.e. emotional eating that I think needs to have more of a focus on prior to the procedure. I agree, that a national database would be great and perhaps soliciting this information through a national forum i.e. newspaper, internet, etc. would encourage people to share their experiences. I now live in SK and a friend of mine in ON sent me your article. The power of the media. Thank you.

  • Lisa says:

    I am one of the 40% failure with the banding. I spent 5 years and nearly 20k (with credit medical financing) and have only lost 39 lbs. I still am unable to eat solid food consistently and have received very little help from the private clinic I was banded at. The surgeon that banded me has had so many patient complaints he was orders to step down and was told he must attend ethics classes…
    I’m now looking into GB as a last resort… I’m still out my $20 000 and the 5 years but hopefully this will be the change that helps me reach my WL goal.

    • C Almond says:

      I was banded 6 years ago, lost 100 lbs, it’s a tool. You still have to eat healthy for it to work properly. But I get your frustration because I have lost and gained and even gone to other weight loss programs for help, only to continue to struggle to keep it off. Looking into the Gastric Sleeve. A lot of my band friends have had the band removed and gone for the sleeve with amazing results. The sleeve is covered by OHIP in Ontario now.

      • Melanie says:

        Do you have any more information regarding the sleeve being covered by OHIP? I was going to go to Mexico to have it done recently but got scared and cancelled. Do you know the criteria to be covered like BMI or other conditions.

  • David L. Schiavone says:

    Thanks! It was a good read! Thanks for the details on bariatric surgery. It’s nice to hear about the complications of bariatric surgery too. I’m looking to do the laparoscopic gastric band surgery at Credit Valley Clinic. I ‘m not sure how good it is when compared to bariatric surgery.

    • C Almond says:

      Hi David,
      I had gastric banding done by this clinic 6 years ago and lost 100 lbs in 8 months, the problem is over time the weight can come back on and I found it difficult to eat solid protein without getting stuck. The clinic is amazing, the care top notch. I am happy with my weight loss and have kept it off, but I still need to lose about 75 lbs and have not reach my goal in 6 years. Good Luck!

    • Karen says:

      How was the surgery at the credit valley clinic?

  • Christopher Sutton says:

    The continuing rise in national rates of obesity makes the issue of bariatric surgery a relevant and priority topic for many jurisdictions across Canada. In 2010, CIHI released an article in HealthCare Quarterly (http://www.longwoods.com/content/21682) providing an overview of in-patient bariatric surgery delivery in Canada between 2004–2005 and 2008–2009. We are now working on a new project to update and expand this work to include not only a patient profile and overview across jurisdictions, but also a look at selected outcomes. Look for its release spring 2014.

  • The College of Physicians and Surgeons of Ontario says:

    The College of Physicians and Surgeons of Ontario agrees that access to information about the outcomes of bariatric surgery would help to support treatment decisions.

    It’s important to note that oversight of private clinics where surgery is performed has vastly improved since 2010 when the College was given the authority to inspect them. Each premises now regularly undergoes an inspection to ensure it is a safe environment for the types of procedures performed in it, and the physicians are assessed to determine whether they are qualified to perform the procedures in question.

    A two-tier framework for the reporting of adverse events is also now in place at these surgical premises. Tier 1 adverse events (such as a death within the premises; and transfer of a patient from the premises directly to a hospital for care) must be reported to the College within 24 hours. Tier 2 events (such as the number and type of infections occurring in the premises; and an unscheduled treatment of a patient in a hospital within 10 days of a procedure performed at a premises) must be tracked and reported annually to the College.

Authors

Karen Born

Contributor

Karen is a PhD candidate at the University of Toronto and is currently on maternity leave from her role as a researcher/writer with healthydebate.ca.

Andreas Laupacis

Editor-in-chief Emeritus

Andreas founded Healthy Debate in 2011. He is currently the editor-in-chief of the Canadian Medical Association Journal (CMAJ)

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