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Canadian study

Bariatric surgery can be performed safely in secondary HCCs

Overall mortality and centre-specific mortality are well within accepted values

Laparoscopic bariatric surgery can be performed safely in secondary health care centres (HCCs) with a dedicated service corridor to an affiliated tertiary health care centre, according to a study published in the Canadian Journal of Surgery.

“With proper patient selection, a dedicated health care team and a service corridor to an affiliated tertiary health care centre, laparoscopic bariatric surgery, including gastric bypass can be performed safely in secondary health care centres,” wrote study author, Dr Nicolas Christou, Section of Bariatric Surgery, Division of General Surgery, McGill University, Montréal, Canada. “Further study is needed to determine whether the model can be applied across Canada.”

As in many countries around the world, access to bariatric surgery is difficult and limited by a number of factors including insurance coverage, funding and hospital resources. In 2006, a unique pilot project was started to determine whether laparoscopic bariatric surgery can be safely performed in smaller hospitals, designated as secondary health care centres, and linked via a dedicated service corridor to a full service tertiary health care centre.

The model was proposed by l’Agence d’évaluation des technologies et des modes d’intervention en santé (AETMIS) in a report to the Quebec Minister of Health and Social Services as a means of increasing bariatric surgery capacity in the province. The paper presents the outcomes from pilot project. 

The 534-bed McGill University Health Centre (MUHC), which has more than 40 years of bariatric surgery experience, is fully equipped with an intensive care unit (ICU) and has dialysis capability, was selected as the secondary health care centre. The tertiary health care centre was the Centre Métropolitain du chirurgie, a fully accredited 17-bed private hospital with a “Specialized Medical Centre” designation from the Ministry of Health and Social Services.

The study included 830 patients: 676 treated at the affiliated secondary health care centre and 154 at the affiliated tertiary health care centre. Gastric bypass was performed in 85.4% of patients, gastric band in 11.1% of patients and gastric sleeve in 3.5% of patients. BMI was significantly higher in the patients treated at the tertiary health care centre, than at the secondary health care centre (mean 54.4 vs. 47.5).  

The same surgeon performed all procedures with the same dedicated operating room team, ward nurses and support staff over the duration of the study. Patients with potentially life-threatening complications were transferred to the tertiary healthcare centre via a special ambulance using a priori determined protocol (service corridor). 


There were significantly more women treated at secondary than tertiary health care centre, and these patients were also younger (by about one year). However, patients treated at a tertiary centre were heavier and their BMI significantly higher (p=0.001). Gastric bypass was the predominant procedure because gastric banding was not publicly funded in Quebec until recently.

There were two deaths at the tertiary centre and no deaths at the secondary centre (overall mortality was 0.2%). Logistic regression analysis failed to identify any variables (age, sex, location of surgery, starting BMI, ASA score, OS-MRS) contributing to the risk of death owing to low incidence of death. 

Complications recorded within the first 30 days after the surgery were slightly higher at the tertiary centre and obesity surgery mortality risk scores and ASA score were also significantly higher at the tertiary centre (Table 1). 

Table 1: Patient stratification and complications recorded within the first 30 days after surgery at each site

The major complication rate was 2.3% (n=16) at the secondary centre and 5.8% (n=9) at the tertiary centre (p=0.036), and minor complications were significantly more frequent in the tertiary centre (p=0.003). Seven patients (1%) required direct transfer to the tertiary centre and all were treated successfully.

Weight loss in kilograms and the percentage of total weight loss were equivalent between the two centres. Although a comparison of the excess weight loss between the centres regarding the surgical procedure was not possible due to insufficient data, gastric bypass was associated with significantly better weight loss results than the gastric band and gastric sleeve procedures. 

Whilst he acknowledges that the current study represents the personal series of one experienced bariatric surgeon, and a less experienced surgeon may not be able to duplicate these results, Christou believes that appropriate selection of a secondary health care centre and adequate training of the preoperative, perioperative and postoperative teams, remains imperative.

“We have now collected sufficient statistics to suggest that, with proper patient selection, this approach could be feasible,” claims Christou. “Patient selection criteria allow for safe surgery to be delivered at secondary health care centres with acceptable mortality and short- and long-term complications. Overall mortality and centre-specific mortality are well within accepted values.”  

To access the article, please click here

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