(1)
Obesity Institute, Geisinger Medical Center, Southold, NY, USA
Abstract
Bariatric surgery is widely recognized as a powerful and preferred treatment for extreme obesity. The factors driving this recognition include the proven cost-effective improvement in health and quality of life as well as longevity for patients suffering from extreme obesity and the steady improvement in surgical outcomes. The steady improvement in surgical outcomes is related to the establishment of fellowship training programs and the exposure of junior resident learners to bariatric surgery, the development of minimally invasive surgical approaches, and the establishment of programs for the credentialing of bariatric surgeons and programs. The public awareness and improved outcomes have resulted in a rapid increase in bariatric surgical procedure numbers until the last several years when procedure numbers have stabilized, perhaps related to cost containment efforts by managed care insurance providers. At present, only a tiny fraction of the eligible patient pool actually receives bariatric surgery leaving millions of deserving patients without access to these procedures. The challenge to improve patient access to bariatric surgery is to improve the value of this treatment by improving outcomes and reducing costs. A major component of improving value is to improve the patient preparation and selection process by introducing evidence-based risk–benefit decisions in a setting of expanded comprehensive multidisciplinary patient evaluation.
Bariatric surgery has emerged as the optimal and preferred treatment for patients who suffer from health and quality of life afflictions related to extreme obesity. Considered experimental before 1991, bariatric surgery has now been widely embraced by patients and the medical community as the therapeutic potential of these procedures continues to be recognized.
During the last 15 years, this specialty, which was initially unrecognized by academic surgical societies, has emerged as an important service line for major academic and community medical centers. In addition, bariatric surgery has helped reverse the decline of general surgery and emerged as a major source of clinical material for resident training in gastric surgery.
The rapid rise in the popularity of bariatric surgery is multifactorial. The health benefits of these procedures, which provide patients with an opportunity to achieve lasting major weight loss and comorbid disease control, are now stimulating interest in studying the efficacy of these procedures as primary treatment for comorbid conditions like type 2 diabetes in patients with lesser degrees of obesity [1, 2]. Bariatric surgery has been shown to extend life expectancy and to be cost effective for those suffering from extreme obesity [3, 4]. Another important component in the emergence of bariatric surgery has been the improvement in surgical outcomes. In 1991, when bariatric surgery became an accepted treatment for extreme obesity, the best practice mortality was 0.5–1.5 % [5]. The current mortality rates derived from large clinical registries are 0.1–0.2 % [6–8]. These improved outcomes have been achieved despite the development of, and transition to, minimally invasive approaches to bariatric surgery.
Factors contributing to the improvement in surgical outcomes include the formulation of training and credentialing requirements for bariatric surgeons and the establishment of accredited centers of excellence. Current residency training in general surgery provides limited training in advanced laparoscopy, with a minimum of 25 cases required for board eligibility in surgery. During surgical residency training, the exposure of learners to bariatric surgery is also limited because most busy bariatric programs in academic medical centers have dedicated fellows and physician’s assistants who routinely participate in the surgical procedures in place of surgical residents. Laparoscopic bariatric surgery procedures are one of the more technically challenging advanced minimally invasive operations with a learning curve ranging from 75 to 100 cases [9, 10]. A case volume sufficient to master the learning curve is currently only available in the 130 current Minimally Invasive and Bariatric Surgery Fellowships [11]. The important learning elements of fellowship training in bariatric surgery are shown in Table 1.1. Despite concerns about patient safety in a training environment, several studies have demonstrated an association between fellowship training in bariatric surgery and improved outcomes [12, 13].
Table 1.1
Key elements of fellowship training in bariatric surgery
• Focused experience in minimally invasive bariatric surgical procedures by achieving the case volume equivalent to master the learning curve |
• Regular interaction with all members of the multidisciplinary team caring for extreme obesity to gain familiarity with evaluation and management of extreme obesity |
• Interaction with dedicated medical subspecialty consultants |
• Develop familiarity with the entire scope of bariatric surgery care as a result of involvement in all aspects of the bariatric surgery program |
In addition to the formalization of the training curriculum for bariatric surgeons, guidelines for granting privileges in bariatric surgery were developed in 2003 by the American Society for Metabolic and Bariatric Surgery (ASMBS) [14] and updated in 2005. In an effort to improve quality control, to coordinate a more disciplined development, and to establish outcome benchmarks for bariatric surgery, a Centers of Excellence program was launched by the ASMBS in 2003 as a mechanism for the accreditation of bariatric surgery centers. Similarly, the American College of Surgeons (ACS), hoping to extend the quality improvement processes originally developed for trauma and cancer care to bariatric surgery, instituted its own credentialing program for bariatric surgeons and programs.
Both of these programs evolved independently until April 2013, at which time they were combined to form the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP). Institutions, bariatric programs, and bariatric surgeons who meet the requirements apply for and receive provisional approval. This is followed by a site visit where surgical outcomes data, program policies and procedures, program personnel, and facility resources are reviewed in detail. Successful completion of the detailed site visit allows for final approval as a recognized center of excellence. The large clinical bariatric surgery registry, derived from the outcomes data submitted by each center, will provide benchmarks for quality assessment and improvement. The requirements for application for credentialing as a bariatric center of excellence are summarized in Table 1.2.
Table 1.2
The basic requirements for designation as a Center of Excellence in Bariatric Surgery
Criteria for accreditation as a Level I Bariatric Center |
|---|
Institutional requirements |
• Full service-accredited hospital |
• Established bariatric surgical program to provide outcome data |
• 125 primary weight loss operations during the preceding 12 months |
• Director of bariatric surgery |
• Bariatric surgery coordinator |
Surgeon requirements |
