American Society for Metabolic and Bariatric Surgery
GUIDELINES FOR GRANTING PRIVILEGES
IN BARIATRIC SURGERY
RATIONALE
Bariatric surgeons, like
those in other sub-specialty areas of surgery, should be
responsible for demonstrating a defined experience and
exposure to the discipline’s unique cognitive, technical,
and administrative challenges. The following guidelines
define the degree of experience, exposure, and support
considered as minimally acceptable credentials for general
surgery applicants to be eligible for hospital privileges to
perform bariatric surgery. These guidelines are intended to
be an update of the original guidelines enacted in 2003 (see
reference 1 below). The updated changes are based on
recently published evidence from the medical literature as
well as consensus expert opinion of ASMBS members of the
Bariatric training and credentialing committee and Executive
Council.
CATEGORIES OF PROCEDURES
For the
purpose of this document, bariatric procedures are divided
into procedures which involve stapling /division of the
gastrointestinal tract to achieve weight loss or procedures
that do not involve stapling/division of the
gastrointestinal tract.
GLOBAL CREDENTIALING REQUIREMENTS
To
meet the Global Credentialing Requirements in bariatric
surgery the applicant should:
- Have credentials at an accredited facility to perform
gastrointestinal and biliary surgery.
- Document that he or she is working within an
integrated program for the care of the morbidly obese
patient that provides ancillary services such as
specialized nursing care, dietary instruction, counseling,
support groups, exercise training, and psychological
assistance as needed.
- Document that there is a program in place to prevent,
monitor and manage short-term and long-term complications.
- Document that there is a system in place to provide
and encourage follow-up for all patients. Follow-up visits
should either be directly supervised by the Bariatric
surgeon of record or other health care professionals who
are appropriately trained in perioperative management of
bariatric patients and part of an integrated program.
While applicants can not guarantee patient compliance with
follow-up recommendations, they should demonstrate
evidence of adequate patient education regarding the
importance of follow-up as well as adequate access to
follow-up.
EXPERIENCE IN BARIATRIC SURGERY REQUIRED TO TRAIN
APPLICANTS
For the purposes of this document,
experienced bariatric surgeons serving as trainers for
applicants should meet Global Credentialing Requirements and
have experience with at least 200 bariatric procedures in
the appropriate Category Of Procedure in which the applicant
is seeking privileges prior to training the applicant.
DEFINITION OF OPERATIVE EXPERIENCE
For the purposes of this privileging guideline,
operative experience is defined broadly to include not only
procedure performance but also global care of the bariatric
patient that encompasses preoperative and postoperative
management. . Specifically, preoperative management
experience must include patient evaluation and preparation
for surgery. Postoperative management experience must
include inpatient postoperative management and outpatient
management extending beyond the 90 day global period (i.e. 6
month and or annual follow-up visits). Documentation of
perioperative management should reflect” hands-on”
experience in the outpatient clinic or office as well as
hospital ward corresponding to the same patients (or
equivalent) that underwent surgery by the applicant.
Procedure performance experience is defined as “hands on”
performance of a significant portion of the operation under
the direct supervision of an experienced Bariatric surgeon
as defined above.
OPEN BARIATRIC SURGERY PRIVILEGES INVOLVING
STAPLING OR DIVISION OF THE GASTROINTESTINAL TRACT
To obtain “open” bariatric surgery privileges,
the surgeon must meet the Global Credentialing Requirements
and document an operative experience of 15 open bariatric
procedures (or subtotal gastric resection with
reconstruction) with satisfactory outcomes during either 1)
general surgery residency, or 2) post residency training
supervised by an experienced bariatric surgeon. Surgeons who
primarily perform laparoscopic Bariatric surgery may obtain
open Bariatric surgery privileges after documentation of 50
laparoscopic cases (see below) and at least 10 open cases
supervised by an experienced Bariatric surgeon.
LAPAROSCOPIC BARIATRIC SURGERY PRIVILEGES
FOR PROCEDURES INVOLVING STAPLING OR DIVISION OF THE
GASTROINTESTINAL TRACT
To obtain laparoscopic
bariatric surgery privileges that involve stapling the GI
tract the surgeon must meet the Global Credentialing
Requirements and:
- Have privileges to perform “open” bariatric surgery at
the accredited facility
- Have privileges to perform advanced laparoscopic
surgery at the accredited facility.
- Document 50 cases with satisfactory outcomes during
either 1) general surgery residency or 2) post residency
training under the supervision of an experienced Bariatric
surgeon.
BARIATRIC SURGERY PRIVILEGES FOR PROCEDURES THAT
DO NOT INVOLVE STAPLING OF THE GASTROINTESTINAL TRACT
To obtain laparoscopic bariatric surgery
privileges for procedures that do not involve stapling or
division of the GI tract the surgeon must meet the Global
Credentialing Requirements and:
- Have privileges to perform advanced laparoscopic
surgery at the accredited facility.
- Document 10 cases with satisfactory outcomes during
either 1) general surgery residency or 2) post residency
training under the supervision of an experienced bariatric
surgeon.
CONTINUED ASSESSMENT OF OUTCOMES
It
is recommended that the local facility review the surgeon's
outcome data within 6 months of initiation of a new program
and after the surgeon’s first 50 procedures (performed
independently) as well as at regular intervals thereafter,
to confirm patient safety. In addition, the surgeon should
continue to meet Global Credentialing Requirements for
bariatric surgery at the time of reappointment.
Documentation of continuing medical education related to
Bariatric surgery is also strongly recommended.
DISCLAIMER
The American Society for
Metabolic and Bariatric Surgery (ASMBS) is established as an educational
professional medical society. It is not intended to
be, nor should it be viewed as a credentialing body.
The above recommendations are based on members' experience
and are offered only as guidelines and are specifically not
intended to establish a local, regional or national standard
of care for any bariatric surgical procedure. While
the ASMBS views these Guidelines as being important to
successful surgical outcomes, it does not warrant, guarantee
or promise that compliance assures positive surgical
outcomes for any single procedure.
REFERENCES:
1. American Society
for Bariatric Surgery. Guidelines for Granting Privileges in
Bariatric Surgery. Obes Surg. 2003;13:238-240.
2. Cottam DR , Mattar S, Lord J, Schauer PR. Training and
Credentialing for the Performance of Laparoscopic Bariatric
Surgery. Laparoscopy and SLS Report 2003; 2 (1): 15-21.
3. Watson DI, Baigric R, Jamieson FG. A learning curve
for laparoscopic fundoplication: definable, avoidable, or a
waste of time? Ann Surg. 1996; 224:199-203.
4. Chevallier JM, Zinzindohoue, F, Elian N, et al.
Adjustable gastric banding in a public university hospital:
prospective analysis of 400 patients. Obes Surg.
2002;12:93-99.
5. O’Brien PE, Brown A, Smith PJ, et al. Prospective
study of a laparoscopically placed, adjustable gastric band
in the treatment of morbid obesity. Br J Surg. 1999;
85:113-118.
6. Favretti F. Cadiere GB, Segato G, et al. Laparoscopic
banding: selection and technique in 830 patients. Obes Surg.
2002; 12: 385-390.
7. Schauer P, Ikramuddin S, Hamad G, Gourash W. The
learning curve for laparoscopic Roux-en-Y gastric bypass is
100 cases. Surg Endosc. 2003;17(2):212-215.
8. Higa KD, Boone K, et al. Laparoscopic Roux-en-Y
gastric bypass for morbid obesity: technique and preliminary
results of our first 400 patients. Arch Surg.
2000;135:1029-1033.
9. DeMaria EJ, Sugerman HJ; Kellum JM, Meador JG, Wolfe
LG. Results of 281 consecutive total laparoscopic Rous-en-Y
gastric bypasses to treat morbid obesity. Ann Surg.
2002;235(5):640-645.
10. Witttrove AC, Clark G. Laparoscopic gastric bypass: a
five year prospective study of 500 patients followed from 3
to 60 months. Obes Surg. 1999;19:123-143.
11. Oliak D, Ballantyne P, Weber P, et al. Laparoscopic
Roux-en-Y gastric bypass: defining the learning curve. Surg
Endosc. 2003;17(3):405-408.
12. Park A, Witzke D, Donnelly M. Ongoing deficits in
residents training for minimally invasive surgery. J
Gastrointest Surg. 2002;6(3)L501-507.
13. Wolfe BM, Szabo Z, Morgan ME, Chan P, Hunter JG.
Training for minimally invasive surgery. Need for surgical
skills. Surg Endosc. 1993;7:93-95.
14. Rossser JC; Rosser L, Savalgi RS. Skill acquisition
and assessment for laparoscopic surgery. Arch Surg.
1997;132:200-204.
15. Rosser JC, Rosser L, Savalgi RS. Objective evaluation
of a laparoscopic surgical skill program for residents and
senior surgeons. Arch Surg. 1998;133:657-661.
16. Mori T, Hatano N, Maruyama S. et al. Significance of
“hands-on-training” in laparoscopic surgery. Surg Endosc.
1998;12:256-260.
17. JCAHO. The 1995 Joint Commission Accreditation Manual
for Hospitals. Oakbrook Terrace, IL: JCAHO;1994.
18. Dent T. Training and privileging for new procedures.
Surg Clin North Am. 1996;76:615-621.
19. American Society for Bariatric Surgery, Society for
American Gastrointestinal Endoscopic Surgeons. Guidelines
for laparoscopic and open surgical treatment of morbid
obesity. Obes Surg. 2000;10(4):378-379.
20. American College of Surgeons. Recommendations for
facilities performing bariatric surgery. Bull Am Coll Surg.
2000;85(9):20-23.
21. SLS Training and Fellowship Opportunities. Society
for Laparoendoscopic Surgeons Website. Available at:
http://www.sls.org/services/fellowship.html#gen.
22. Available Fellowships in Surgical Endoscopy and
Laparoscopy. Society of American Gastrointestinal Endoscopic
Surgeons Website. Available at:
http://www.sages.org/fellowships/index.php.
Revised
October 2005
Requests for reprints should be sent to:
American Society for Bariatric Surgery
100 SW 75 th
Street, Suite 201
Gainesville , FL 32607 USA
Phone:
(352) 331-4900
Fax: (352) 331-4975
E-mail:
info@ASMBS.org
