Surgical Program

The Bariatric Surgical Program provides comprehensive pre-operative, peri-operative, and post-operative surgical care led by an interdisciplinary team. The focus of this program is the treatment of obesity and obesity-related health conditions, safe weight management, and healthy lifestyle changes.

In order to be referred to the Surgical Program, patients will require a physician's referral. 

Patients who meet the eligibility criteria are assigned to a Bariatric Centre of Excellence (BCoE) or Regional Assessment and Treatment Centre (RATC).

Eligible patients will be contacted directly by their assigned bariatric centre to attend an orientation session, followed by comprehensive screening and assessment by the interdisciplinary bariatric team to assess their appropriateness for surgery. Intensive education and nutritional counseling is provided prior to surgery. Following bariatric surgery, patients are monitored closely within the first year and then scheduled for routine follow up annually for a period of up to 5 years.

Surgical Program Eligibility

Eligibility:

  • 18 years of age and older
  • BMI greater than or equal to 40
  • BMI greater than or equal to 35 but less than 40. With at least one of the following comorbidities (as determined by your physician):
    • Coronary heart disease
    • Type II Diabetes mellitus
    • Hypertension
    • Diagnosed sleep apnea
    • Gastroesophageal Reflux Disease (GERD)

Ineligibility (not limited to):

  • Current drug or alcohol dependency (within 6 months of referral)
  • Recent major cancer (life threatening, within last 2 years)
  • Untreated or inadequately treated psychiatric illness
Types of Bariatric Surgery

The Ministry of Health and Long Term Care currently funds three types of bariatric surgery in Ontario, including Roux-en-Y Gastric Bypass, Vertical Sleeve Gastrectomy and Duodenal Switch. All three of these bariatric surgeries are done laparoscopically.

Laparoscopic Surgery, also called Minimally Invasive Surgery, involves several small incisions (approximately 5-12 millimetres in length) made by the surgeon. One incision is used to insert a small camera, and the others are for surgical instruments needed to perform the procedure. After surgery the incisions are closed with dissolvable stitches and special tape called steri-strips. This method creates minimal tissue damage, improves recovery time and has fewer complications. 

Based on a comprehensive surgical assessment done by the interdisciplinary bariatric team at each centre, patients may have one of the following bariatric surgical procedures:

Roux-en-Y Gastric Bypass (RYGB)

During Roux-en-Y Gastric Bypass Surgery the surgeon cuts the stomach and makes a small pouch at the end of the food tube called the esophagus. The surgeon goes further down the small intestine, cuts it, and attaches it to the pouch. Then the end of the small intestine that is still connected with the remainder of the stomach is attached to the bottom of the "Roux limb.” This allows the digestive juices produced by the pouch to meet up with the food in the intestines.

Having a small stomach is one of the keys to successful weight loss. Filling the small pouch with a few bites of food makes you feel the same "fullness” that you had before surgery after eating a large meal.

When you are eating less food it is important to make healthy food choices that are low in fat and sugar content to ensure you get the proper nutrients. You will need to take vitamin and mineral supplements every day after surgery for the rest of your life.

Vertical Sleeve Gastrectomy (VSG)

During Vertical Sleeve Gastrectomy Surgery the stomach is cut creating a long pouch that connects the esophagus to the small intestine. The pouch or "sleeve” is stapled and the rest of the stomach is removed.

The pouch can hold about 60 ml to 150 ml (2 ounces to 5 ounces); this depends on the surgeon doing the surgery. Normally a stomach holds up to 1000 ml (35 ounces). As shown in the picture, the way the food leaves the stomach does not change. The nerves are also left intact. Therefore the stomach is smaller but the function stays almost the same. None of the intestines are bypassed so food leaves the stomach and moves through the intestines normally.

Since the smaller stomach continues to function normally there are few restrictions on the food you can eat after surgery. Since the amount you can eat is less, it is important to make healthy food choices for weight loss and overall health.

VSG surgery is considered for people who already have medical problems such as anemia, stomach ulcer, inflammatory bowel disease, diverticular disease and other conditions that would place them at high risk for surgery involving intestinal bypass.

VSG surgery is often the best surgery for people who are extremely overweight with medical conditions that rule out other forms of surgery. 

For some very obese people, vertical sleeve gastrectomy may be the first step to weight loss surgery followed by another form of weight loss surgery when it is safe to do so.

Duodenal Switch (DS)

During Duodenal Switch surgery the surgeon reroutes a lengthy portion of the small intestine, creating two separate pathways and one common channel. The shorter of the two pathways, the digestive loop, takes food from the stomach to the common channel. The much longer pathway, the biliopancreatic loop, carries bile from the liver to the common channel.

The common channel is the portion of small intestine, usually 75-150 centimeters long, in which the contents of the digestive path mix with the bile from the biliopancreatic loop before emptying into the largeintestine. The objective of this arrangement is to reduce the amount of time the body has to capture calories from food in the small intestine and to selectively limit the absorption of fat. As a result, following surgery, patients only absorb approximately 20% of the fat they intake.

The duodenal switch (DS) procedure is also known as biliopancreatic diversion with duodenal switch (BPD-DS) or gastric reduction duodenal switch (GRDS)

 

 

Surgical Program Features

The OBN has established standardized care paths based on current evidence and best practice that outline the minimal tests/assessments required pre-operatively for all bariatric patients in Ontario. Assessments may vary from person to person, depending on the individual and their health care needs in order to optimize health prior to bariatric surgery.

Before surgery, patients' care path includes:  

  • Program Orientation (Group Session) 
  • Interdisciplinary Bariatric Team Assessments which includes patient visits with:
    • Registered Dieticians
    • Social Workers
    • Registered Nurses and/or Nurse Practitioners
    • Medical Internists and other specialists (i.e. Psychology/Psychiatry) as deemed necessary
  • Pre-Operative Testing involving routine blood work and additional diagnostic testing based on patients' individual medical needs. These diagnostic tests may include: 
    • Ultrasound
    • Upper gastrointestinal series
    • Gastroscopy
    • Colonoscopy
    • Helicobacter Pylori Bacteria T
    • Pulmonary Function Tests
    • Cardiac Imaging
    • Cardiac Stress Test
    • Electrocardiogram
    • Sleep Apnea Study
  • Bariatric Surgery Education Sessions (usually done in group format)
  • Surgeon Consult and Consent
    • Patients may be on a low calorie meal replacement at patients' own expense for 2-3 weeks prior to surgery 
  • Aneasthesia Pre-Operative Assessment
  • Surgery scheduled

After surgery, patients' care path includes:

  • Post-operative visit at Week 1
  • Follow up assessments at the following time intervals:
    • 1 month post-op
    • 3 months post-op
    • 6 months post-op
    • 1 year post-op
    • Annually up to 5 years post-op

Note: Patients' pre-operative and post-operative care plan may also include additional one-on-one intervention or visits with interdisciplinary team members, based on individual needs. 

Pilot Metabolic Program

Program Background

Current evidence suggests that bariatric surgery for non-morbidly obese patients (BMI 28-35 kg/m²) with diabetes are associated with greater weight loss and better intermediate glucose outcomes when compared with non-surgical treatments.The Pilot Metabolic Surgical Program at St. Joseph’s Healthcare in Hamilton aims to confirm this evidence, and analyse the long-term results of diabetes resolution and weight loss post-procedure for these non-morbidly obese patients, ultimately providing improved and expanded services for this patient population.

Program Eligibility

Patients with complicated Type II Diabetes and a BMI of 28-35 kg/m² may be eligible for the Pilot Metabolic Surgical Program offered only at St. Joseph’s Healthcare Hamilton. Patients across the province can be referred to this pilot program; however they will be responsible for their own travel arrangements and expenses (Note: patients in Northern Ontario may be eligible for Northern Health Travel Grant Program). 

Program Features 

Patients referred to this program receive an orientation and comprehensive screening and assessment by the interdisciplinary  bariatric team to assess their appropriateness for bariatric surgery. Intensive education and nutritional counseling is provided prior to surgery. Following bariatric surgery, patients are monitored closely within the first year and then are scheduled for routine follow up for a period of up to 5 years.

FAQ

What is the definition of obesity?

Overweight: 10% to 20% above the person's "desirable" body weight

Obesity: 20% or more than the person’s "desirable” body weight. It is an increase in body weight beyond the limitation of skeletal and physical requirements, as the result of excessive accumulation of body fat.

Super Obesity: 
40% or more than the person’s "desirable” body weight. It is an excess of body fat, or weight of 45.4 kilograms (100 pounds) over ideal body weight, that increases the risk of developing cardiac and endocrine disturbances, including coronary artery disease and diabetes mellitus, as well as some kinds of cancer.

What is Body Mass Index (BMI)?

Body Mass Index (BMI) is a measurement of weight in relation to height. BMI is calculated by dividing your weight in kilograms by the square of your height in meters.

Excess Body Weight (EBW) is a measurement of current weight in relation the ideal weight which is based on age and height. The amount of weight in excess of one's ideal body weight is the calculated EBW.

What is bariatric surgery?

Bariatric surgery, also known as weight loss surgery, is a surgical procedure that serves as an option for some people who have not been able to lose weight through traditional means such as diet and exercise. There are several different kinds of bariatric surgery; the bariatric surgeries funded by the MOHLTC and offered through the OBN Surgical Program are outlined in the 'Types of Bariatric Surgery' section. 

Are you eligible for the Surgical Program?

Eligibility:

  • 18 years of age and older
  • BMI greater than or equal to 40
  • BMI greater than or equal to 35 but less than 40. With at least one of the following comorbidities (as determined by your physician):
    • Coronary heart disease
    • Type II Diabetes mellitus
    • Hypertension
    • Diagnosed sleep apnea
    • Gastroesophageal Reflux Disease (GERD)

Ineligibility (not limited to):

  • Current drug or alcohol dependency (within 6 months of referral)
  • Recent major cancer (life threatening, within last 2 years)
  • Untreated or inadequately treated psychiatric illness

Are there age restrictions for bariactric surgery?

You must be at least 18 years old to be considered for the Surgical Program. Please refer to the 'Surgical Program Eligibility' tab for more information.

Is weight loss surgery right for everyone?

No, bariatric surgery is not the solution for everyone. The interdisciplinary bariatric team will help determine whether surgery is right for you after a complete evaluation and discussion with you. Bariatric surgery is a life-altering procedure and you need to be committed to making the lifestyle changes needed for successful outcomes.

What types of assessments will I need before bariatric surgery?

The OBN has established standardized care paths based on current evidence and best practice that outline the minimal tests/assessments required pre-operatively for all bariatric patients in Ontario. Additional pre-operative assessments may vary from person to person, depending on the individual and their health care needs to optimize health prior to surgery.


This is a general list of tests that you may have before surgery. You may have some or all of these tests. Other tests may be needed as well.

You may need to prepare for some tests; your bariatric team will explain these to you and tell you how to prepare for them.

Abdominal Ultrasound

Other names for this are ultrasound imagining, scanning or sonography. Abdominal ultrasound involves using high-frequency sound waves to produce pictures of the inside of your body. The pictures show the structure and movement of your body’s internal organs as well as the blood flowing through blood vessels.

Upper Gastro-Intestinal Series (Upper G. I.)

This is an x-ray of the esophagus, pharynx, stomach, and first part of the small intestine called the duodenum. For this test, you swallow a special liquid dye called barium; as the barium moves through your body pictures are taken.

Cardiac Imaging

Cardiac imaging tests check your heart, heart valves, blood vessels and other structures of the heart. They pick up previous heart attacks, heart disease, blocks from plaque build-up or other problems that you may have with your heart, as well as provide measurements of the heart, chambers and function. There are many kinds of cardiac imaging tests such as a cardiac stress test, cardiac magnetic resonance imaging, cardiac MIBI, and cardiac perfusion scan.

Electrocardiogram (ECG or EKG)

This is a test that records the electro activity of your heart. It is used to diagnose some heart problems. This test is non-invasive and requires a few minutes of relaxation. While laying down sticky pads are placed on your chest, stomach, arms and legs; these are attached to a machine by thin wires. The machine is then turned on and records your heart activity during rest.

Sleep Apnea Studies

This is also called Polysomnography (PSG); it is a test that may require a few visits to complete. Sleep apnea tests help identify a variety of sleeping disorders such as sleep apnea (when you stop breathing several times when sleeping), narcolepsy (when you fall asleep any time, anywhere), restless leg syndrome and other sleep problems.

You will stay overnight for this sleep apnea testing. You are attached to a monitor and watched closely while you sleep. During the exam many body functions are monitored including, eye movement, brain waves, heart waves, muscle movement, snoring, breathing air flow and effort.

Cardiac Stress Test

A Cardiac Stress Test is also known as an Exercise Stress Test or a Treadmill Test. A Cardiac Stress Test helps the health care team find out how well your heart handles work. As your body works harder during the test, it needs more oxygen, so the heart pumps more blood.

This test shows if the blood supply is reduced in the arteries that supply the heart. It also helps the health care team know the kind and level of exercise appropriate for you. A medical professional is always present throughout the test. You start by walking slowly on a treadmill, then the speed of the treadmill is increased and the treadmill is tilted to produce the effect of walking up a small hill.

Gastroscopy

A gastroscopy is a test where a long flexible tube called a gastroscope is passed through your mouth, down your throat into the upper digestive tract. It allows the doctor to look at the lining of the esophagus, stomach and first part of the small intestine called the duodenum. A sample of tissue called a biopsy may be taken to check for H.Pylon.

Colonoscopy

A colonoscopy is a test that looks at the lower end of the intestine, colon and rectum. You need to prepare for this test the day before by emptying the bowel; This process will be explained to you beforehand.

On the day of the test, after you have medication to make you relaxed and sleepy, a small flexible tube scope is inserted into your rectum. The end of the scope has a light and is attached to a screen similar to a television, allowing the doctor see the inside of your lower bowel.

Blood Tests

Blood tests are also done to look your health and well being. Some of the common tests are: complete blood count (CBC), blood glucose (sugar), different vitamin and mineral levels such as iron, calcium, B vitamins and vitamin D.

Helicobacter Pylori (H. Pylori) Bacteria Test

H. Pylori is the name of a common bacteria that can cause problems such as stomach ulcers and stomach cancer. If you have H. Pylori you must be treated with antibiotic medication to make sure the bacteria is gone before you have bariatric surgery. It is important to note that ulcers can also be caused by other diseases or from smoking, drinking alcohol and caffeine use after surgery.

Tests used to determine the presence of H. Pylori infection may include:

  • Blood test : A blood sample may reveal signs of an H. pylori infection in your body
  • C-14/13 breath test: During this test, you drink a solution that contains radioactive carbon molecules. If you have an H. pylori infection, the radioactive carbon is released when the solution is broken down in your stomach. Your body absorbs the radioactive carbon and releases it when you exhale. You exhale into a bag and your doctor uses a special device to detect the radioactive carbon.
  • Gastroscopy : a gastroscopy is a test where a long flexible tube called a gastroscope is passed through your mouth, down your throat into the upper digestive tract. It allows the doctor to look at the lining of the esophagus, stomach and first part of the small intestine called the duodenum. A sample of tissue called a biopsy may be taken to check for H. Pylori.

Pulmonary Function Tests

These are a group of tests that measure how well your lungs take in air, release air and move oxygen from the air into your body’s blood. These tests help diagnose lung diseases such as asthma, bronchitis, emphysema or find the cause of shortness of breath.

For some tests, you breathe normally and quietly. For other tests, you force air in or force air out during testing.

What do I need to stop doing before bariatric surgery and why?

To prepare for surgery and be in the best health possible to recover, you need to make some lifestyle changes before surgery. Your interdisciplinary bariatric team will advise you as to your plan before surgery. As general guidelines, you must stop:

  • Smoking
  • Using non-prescription or illicit drugs
  • Drinking alcohol, beer and wine
  • Consuming caffeine
  • Drinking carbonated beverages

Smoking is unhealthy for many reasons. It can delay wound healing due to poor blood flow and lead to marginal ulcers after surgery. You need to stop smoking 6 months prior to surgery and cannot smoke at all after your surgery
For help to quit smoking, contact Smokers’ Helpline:

Non-prescription or illicit drugs are unhealthy for many reasons. They can cause problems with medications you need to take before, during and after surgery. Some also increase appetite, imparing your ability to follow the required diet. You need to stop non-prescription medication drug use 6 months before surgery and cannot use them at all after your surgery.

Alcohol irritates the lining of the stomach and can cause liver damage. When you lose weight quickly, your liver takes up waste products and toxins produced in your body. This puts stress on your liver and can cause many problems. If you drink alcohol, you will feel the effects very quickly. Alcohol may also cause Dumping Syndrome if you have Roux-en-Y Gastric Bypass surgery. You must stop drinking alcohol, beer and wine 2 months before surgery and cannot drink for at least 3 months after. After surgery, alcohol irritates the lining of your stomach pouch. It is also high in calories and sugar. After surgery, your stomach pouch is not able to break down the alcohol and your blood absorbs it very quickly. This means that you feel the effects more quickly and more intensely, and can become intoxicated after consuming a very small amount of alcohol. This is not safe for many reasons. Your doctor or dietitian will tell you if/when you can have alcohol again.

Caffeine irritates the lining of the stomach. It is a diuretic, and it can inhibit iron absorption. Caffeine also increases acid production.

Carbonated beverages can cause problems after bariatric surgery, as they produce gas in the small stomach pouch. Most people find this very painful. You need to stop drinking carbonated drinks 2 months before surgery to get used to not drinking carbonated beveragesafter your surgery.

How long does it take to schedule surgery?

It takes several months to meet with the bariatric team for various assessments and testing. During this time it is important for you to continue to focus on your health and weight loss to prepare for surgery.

What is the length of time that I will stay in the hospital after surgery?

On average, patients stay in the hospital for 2-3 days following bariatric surgery (longer if needed). It is important to talk to the members of the interdisciplinary bariatric team about this before surgery. The length of stay also depends on whether you develop any complications after surgery.

When can I return to work or school after surgery?

On average, patients usually return to work/school within 4-6 weeks following bariatric surgery; this may vary depending on the individual.

Will I need to take supplements post-operatively?

Yes, most patients will have to take a multivitamin every day. Other vitamins and/or supplements may also be needed depending on your nutritional status; your blood will be checked several times in the first year to determine if you require any other vitamins or supplements. Your bariatric team will work closely with you to ensure that you get the best nutrition possible in order to stay healthy.

If I have diabetes, will bariatric surgery help?

Weight loss surgery has been shown to improve Type II diabetes, but not Type I.
In Type II diabetes, the degree of change depends on the type of bariatric surgery. Talk to members of the bariatric team about this when you are thinking about surgery.

How quickly does surgery improve type 2 diabetes?

For some people diabetes disappears almost immediately within days of surgery. For others, blood sugar levels begin to fall soon after surgery, becoming completely normal within a year. Each person is different.

Will I have to follow a special diet after bariatric surgery?

Over the first 6 to 8 weeks after surgery, your diet will gradually increase from liquids to semi solid foods. This helps you heal. In the long term, you need to eat healthy in order to lose weight and maintain a healthy weight. You will follow guidelines provided to you by the bariatric team that include eating at mealtimes only, avoiding sugary foods, drinking enough fluids throughout the day, and avoiding overeating and overfilling your stomach.

Will I be able to eat only small amounts of food?

The amount of food you can eat depends on the type of bariatric surgery you had. Your stomach is smaller, which means you will feel full and satisfied with less food. Your interdisciplinary bariatric team will educate you about your diet before and after surgery; you will need to continue to follow this diet for the rest of your life.