The chairs are larger than usual and so are the blood-pressure cuffs and even the weigh scales. That’s because the Royal Jubilee Hospital’s weight-loss surgery clinic is designed for patients struggling with morbid obesity and the health risks that come with it.
Up-sizing the surroundings and equipment plays into the respect patients deserve before and after surgery, says program medical director Dr. Ali Zentner.
The clinic is on the ground floor of the Memorial Pavilion, near the hospital parkade to minimize the steps needed to get there. The clinic is integral to the marked increase in surgeries over previous years. In 2013, there were 260 surgeries done in B.C., 120 of them at Royal Jubilee. This year, Royal Jubilee alone will perform from 170 to 180, with another 200 taking place at Richmond Hospital.
“I’m really proud of the program that we offer,” says Zentner, a specialist in internal medicine affiliated with the American Board of Obesity Medicine. “These are not patients who come to us as beggars, so to speak, which I think was what the old model was like.
“You had a bunch of stragglers asking for surgery; they had to advocate [they had] no support, they had to ask for everything. This is now a formalized program with a clear plan of action.”
The clinic isn’t just about open-abdomen surgery to reduce the size of the stomach.
It’s about intensive preparation for success for 35 weeks — the usual wait time between acceptance to the program and the operation. Medical professionals from respirology, endocrinology and cardiology, along with a dietitian, are involved with boosting the success of clinic patients.
The current wait list for surgery is only 44 patients, said Alison Dormuth, director of surgical services for Island Health. “But that is a bit misleading. Those are the patients that have been cleared through the [35-week] program and they’re absolutely ready for surgery.”
A much longer wait ensues from the time GPs refer patients to their acceptance in the program — an estimated 15 to 18 months.
“There is undeniably a backlog to getting into the program, and that’s something that we need to continue to work on,” Dormuth said. “But we’re giving patients a much better service.”
The clinic has tackled some serious inefficiencies in the way gastric-bypass surgery worked until recently.
Previously, a family doctor would refer an obese patient to a general surgeon, and when the appointment rolled around, the patient could be unprepared psychologically or suffering from a heart condition that ruled out surgery.
Wait lists grew as general practitioners kept making referrals for desperately obese people, and combined with a shortage of surgeons doing weight-loss procedures, “it could be years and years” before a patient got a turn, Dormuth said.
Now GPs refer directly to the Jubilee program, and every applicant gets plenty of education and support about their condition upfront. It’s only when that patient is “ready, willing and able” to have surgery that they see the surgeon, Dormuth said. “It’s a much better use of surgeons’ time.”
At one point, Dr. Brad Amson was the only Victoria surgeon performing the procedures. Now there are two surgeons attached to the program — Amson and Dr. Samaad Malik, who has completed a fellowship in advanced laparoscopic surgery — and a rotating part-time surgeon.
The weight-loss surgery performed at Royal Jubilee involves gastric bypass or gastric sleeve procedures that greatly reduce the size of the stomach, meaning far less food can be eaten and absorbed.
Weight-loss surgery requires an adjustment to lifestyle issues, including significantly reduced food, Dormuth said, and the program acknowledges there is a kind of grief involved with that. Some candidates opt not to go ahead.
Patients are asked to quit smoking, try to lose weight before surgery and take other lifestyle steps that might improve their prognosis.
Patients with conditions commonly associated with obesity such as diabetes, high blood pressure, sleep apnea or heart disease must have those under control before becoming eligible for surgery.
“Nutrition counselling is a huge thing,” she said. “It really is a complete change in how you live your life and you need to be able to make that commitment and understand that there’s going to be a longer term recovery in terms of follow up care.”
That patients who have felt marginalized by the health system now have a clinic run with their interests in mind and staff to follow them through the process and throughout their lives is “hugely valuable,” Zentner said.
“These people feel safe the minute they walk in the door; they feel understood and they really feel cared for and that’s before they even have the surgery.” The new program provides patients with extensive pre- and post-surgical education and coaching on food intake, meal-planning, triggers that lead to overeating, as well as stress management and exercise.
The health system is over-taxed, but this program is definitely one thing that gets it right, Zentner said.
“They just need to keep getting it right. I think it’s a huge service, not just to the people of British Columbia, but to the health system,” said Zentner, who comes to the clinic from Vancouver on Fridays.
Five years after gastric bypass surgery, 60 per cent of recipients have been cured of diabetes, she said.
“The cost-benefit to the system is massive, never mind the quality of life issues. It makes sense financially and it makes sense medically.”
Bypass surgery costs about $13,000 per patient, and a heart bypass costs upward of $150,000, she estimated.
“As a society, we struggle with the challenge of excessive weight and the enormous personal toll it takes on people, their families, as well as on the health-care system as a whole,” said Health Minister Terry Lake in a news release about the new clinic.
“We want to make sure patients who have bariatric surgery gain the best possible benefit from it, with the lowest possible risk, and are fully supported to getting back to improved health and a better quality of life,” added Island Health president Dr. Brendan Carr in the same release.
Zentner said she would love to see more surgeries done and the addition of one or two psychologists to the program, along with another medical specialist to follow people through life.
“I want to see this program grow and develop and continue to serve the people on the Island and the people of British Columbia.”
By the numbers: Royal Jubilee a hub for weight-loss surgery
• In 2010, there were only 52 weight-loss surgeries performed in B.C. hospitals, all of them at Royal Jubilee Hospital. This year, the number will total about 400, about 180 at Royal Jubilee.
• The Ministry of Health says the wait time is 4.7 weeks provincewide and 7.1 weeks in Island Health. That is calculated from the date when a patient’s operating-room booking information is received at the hospital to the date of the surgery.
Island Health calculates the wait time at about 35 weeks, based on when the patient enters the bariatric clinic program at Royal Jubilee.
• Body mass index must be 35 or higher to qualify, combined with high risk of serious health problems as a result. Health Canada deems a healthy BMI to be 18.5 to 24.9.
• Patients are assessed by the bariatric program team at one month after surgery and again at three months, six months and 12 months.
• 70 to 80 per cent of weight-loss surgeries at Royal Jubilee are deemed successful by Island Health.
• Gastric bypass surgery costs about $13,000. It is funded provincially, but health authorities contribute to Royal Jubilee based on the number of referrals.
• About $3,000 in funding is for non-surgical aspects of patient care to optimize long-term success.
• Roughly half of the patients who have bariatric surgery at Royal Jubilee are from the Mainland.
• Only 44 patients paid for their own less-invasive laparoscopic band procedures at B.C. private surgery clinics in the past year, says the College of Physicians and Surgeons of B.C. The province does not cover lap-band surgery. A joint ministry-health authority committee “concluded the evidence shows lap banding is not as effective over the long-term as other forms of bariatric surgery, according to international scientific studies,” said Ministry of Health spokeswoman Laura Heinz.