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.
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.