Surgical Task Force Recommendations Ken Reed MD, FRSCS Committee Chair, and Staff Surgeon, Guelph General Hospital Clinical Associate Professor of Surgery, McMaster University Dennis Hong MD, MS.c, FRCSC, FACS Assistant Professor, McMaster University, St. Joseph s Healthcare John Hagen MD, FRCSC Assistant Professor of Surgery of U of T, Minimally Invasive Surgery Group, Surgical Director, Bariatric Surgery, Humber River Regional Hospital Jean Denis Yelle BA, MD, FRCSC, FACS Assistant Professorr Surgery, University Ottawa Foregut and MIS Surgery Trauma Director, The Ottawa Hospital Teodor Grantcharov MD, PhD, FACS Associate Professor of Surgery, University of Toronto Scientist, Keenan Research Centre of the Li Kaa Shing Knowledge Institute Minimally Invasive Surgery David Urbach MD, MSc, FRCSC, FACS Staff Surgeon, University Health Network Covidien Chair in Minimally Invasive Surgery Professor of Surgery and Health Policy, Management and Evaluation, University of Toronto
Tracking of Biennial Review and Approval: Review Year Complete Approved Released 2013 February 17, 2015 February 27, 2015 OBN Advisory Board March 25, 2015 2015 2017 2019 2021 2023 Overview (Core Values) Laparoscopic Roux en Y gastric bypass is the gold standard. All patients referred for bariatric surgery should be assessed at one of the Ontario Bariatric Network (OBN) bariatric centres (BCoE or RATC) before having surgery either in province or out of province. Complete evaluation of each patient is the responsibility of the multidisciplinary team at each of the bariatric centres. The OBN will develop and maintain clinical evidence based guidelines for use by the bariatric centres multidisciplinary teams in order to promote consistency across the network (see Appendix). Some patients may be identified as requiring a procedure other than the Laparoscopic Roux en Y gastric bypass to meet their health needs. Indications 1) Presence of morbid obesity that has persisted for at least the preceding 2 years, defined as: a. Body Mass Index (BMI) exceeding 40; or b. BMI greater than 35 in conjunction with one of the following severe co morbidities i. Coronary heart disease ii. Type II Diabetes mellitus iii. Clinically significant obstructive sleep apnea (i.e. patient meets the criteria for treatment of obstructive sleep apnea) iv. Medically refractory hypertension (blood pressure greater than 140 mmhg systolic and/or 90 mmhg diastolic despite optimal medical management) v. Gastroesophageal Reflux Disorder requiring medical therapy 1
2) The patient's bone growth is completed (18 years of age or documentation of completion of bone growth) 3) The patient has attempted weight loss in the past without successful long term weight reduction Contra indications 1) Active uncontrolled pathology of stomach or intestines 2) Reversible endocrine pathology causing obesity 3) Current drug (including nicotine in all forms) or alcohol abuse 4) Uncontrolled or inadequately treated psychiatric illness 5) Lack of comprehension of risks, benefits, expected outcomes, alternatives, and lifestyle changes required with bariatric surgery Recommended Procedures 1) Laparoscopic Gastric Bypass Gold standard 2) Laparoscopic Vertical Sleeve Gastrectomy Restrict this procedure to patients who have pathology of the intestine that would prevent the gastric bypass Procedure could be done as stage one of a two step process to Roux en Y for super obese Can be performed as an alternative if surgeon determines intra operatively patient is at risk if Roux en Y performed No high quality long term data on the benefit of this procedure. As stated in JAMA. 2014; 312(9):934 942, insufficient evidence exists regarding long term outcomes for gastric sleeve resections 3) Laparoscopic Bilio Pancreatic Diversion with Duodenal Switch Best performed in a BCoE of high volume Super super obese (BMI >60) are most likely to be considered for this procedure Higher rate of morbidity and mortality Needs the most comprehensive follow up through a BCoE to ensure appropriate nutritional support (mandatory) Avoid if long term follow up is difficult 2
Procedures Not Recommended (or funded by OBN) 1) Laparoscopic Adjustable Band See OHTAC Recommendation Revised Sept. 2010 http://www.hqontario.ca/english/providers/program/ohtac/tech/recommend/rec_lagb_20091204.pdf As stated in JAMA. 2014; 312(9):934 942, Gastric bypass has better outcomes than gastric band procedures for long term weight loss, type 2 diabetes control and remission, hypertension, and hyperlipidemia 2) Mini Gastric Bypass Not recommended due to complications & outcomes 3) Vertical Banded Gastroplasty (VBG) Revision/Conversion Bariatric Surgery Surgical Task Force Report on Revision/Conversion Bariatric Surgery approved by OBN Advisory Board (February 2015) and released by task force (March 2015) Surgical Skill Set Minimal recommended surgical skill set to initiate a laparoscopic bariatric surgery practice by a recent graduate: Completion of an accredited general surgery program FRCS(C) certification Completion of a laparoscopic fellowship with training in the fundamentals of weight loss surgery including pre op, peri op, and post op care of the weight loss surgical patient and an experience of a minimum of 50 weight loss surgery procedures Minimal recommended surgical skill set to initiate a laparoscopic bariatric surgery practice within an established surgical practice: Completion of an accredited general surgery program FRCS(C) certification Established mastery of advanced laparoscopic skills Documentation of training in the fundamentals of weight loss surgery including pre op, periop, and post op care of the weight loss surgical patient Proctored for a minimum of 25 cases by an experienced bariatric surgeon 3
Minimal recommended activity to maintain bariatric surgical skill set: Maintenance of an outcomes database Demonstration of acceptable rate of perioperative complications Perform a minimal annual volume of 50 cases Minimum institutional annual volume of 120 cases 2 surgeons per site See Appendix for: 1) Age Criteria 2) Cancer Survivorship 3) Current Drug Use (NSAIDs) 4) Patients with dual anti platelet therapy with fresh stent 5) Pregnancy 6) Surgery Specific Investigations 7) Post Operative Monitoring and Reporting 4