Laparoscopic Procedures for Morbid Obesity

[ST-34] Recommendations for facilities performing bariatric surgery

[by the American College of Surgeons]

The following recommendations were developed by the College's Committee on Emerging Surgical Technology and Education at the request of the American Society for Bariatric Surgery. These recommendations in the evolving field of bariatric surgery have been formulated to assist surgeons and institutions managing morbidly obese patients in providing excellence in surgical care and in developing a safe environment for their patients.

Background

Actuarial data demonstrate that 300,000 Americans die prematurely from obesity-related complications each year. The number of overweight Americans has increased steadily and will continue to increase because more than 25 percent of today's children are overweight or obese. Obesity costs the United States about $100 billion annually in direct health care expenses or in lost productivity.

Morbid obesity is defined as more than 100 pounds greater than normal body weight or a body mass index (BMI) > 40 kg /m2 (BMI > 35 kg /m2 if associated with significant comorbidities), and is present in 5 percent of the US population (10 million individuals). It is associated with many diseases and disorders including diabetes, hypertension, heart attacks, strokes, dyslipidemia, sleep apnea, Pickwickian syndrome, asthma, low back and disk disease, weight-bearing osteoarthritis of the hips, knees, ankles, and feet, thrombophlebitis and pulmonary emboli, intertriginous dermatitis, urinary stress incontinence, gastroesophageal reflux disease, gallstones, and cirrhosis and carcinoma of the liver. In women, infertility, cancer of the uterus, and cancer of the breast are also associated with morbid obesity. Taken together, the diseases associated with morbid obesity markedly reduce the odds of attaining an average life span and raise annual mortality tenfold or more.

Bariatric surgical procedures in current use have been reported to result in marked, lasting weight reduction in the majority of morbidly obese patients when assessed five years after operation. Studies of the health-related quality of life outcomes of these procedures have documented sustained significant improvements in all parameters measured. Diet or drug therapy programs have been consistently disappointing and fail to bring about significant, sustained weight loss in the majority of morbidly obese persons.

Currently, most (95%) morbid obesity operations are or include gastric restrictive procedures, involving the creation of a small (15 to 35 ml) upper gastric pouch that drains through a small outlet (0.75 to 1.2 cm), setting in motion the body's satiety mechanism. About 15 percent of morbid obesity operations done in the United States involve gastric restrictive surgery combined with a malabsorptive procedure, which divides small intestinal flow into a biliary-pancreatic conduit and a food conduit.

Potential long-term problems include not only those seen after any abdominal procedure, such as ventral hernia and small bowel obstruction, but also those specific to bariatric procedures, such as gastric outlet obstruction, marginal ulceration, protein malnutrition, and vitamin deficiencies.

Recommendations

Professional team
Surgeons practicing bariatric surgery are certified or in the process of certification by the American Board of Surgery or its Canadian equivalent within five years after completion of an accredited residency program in general surgery. In addition to obtaining the requisite primary technical expertise, bariatric surgeons acquire an understanding of morbid obesity as a disease and an intimate knowledge of the numerous diseases and conditions induced or aggravated by morbid obesity.

They develop skills in patient education and selection and are committed to long-term patient management and follow-up. There is active collaboration with multiple patient care disciplines including nutrition, anesthesiology, cardiology, pulmonary medicine, orthopaedic surgery, diabetology, psychiatry, and rehabilitation medicine. Appropriate technical skills in the performance of bariatric surgical procedures are acquired.

A dedicated dietician is helpful to patients during their adjustment to postoperative dietary guidelines. Patients participate in a program of behavioral adjustment, exercise rehabilitation therapy, and, if available, a patient support group.

Indications and prerequisites
Not all persons who are obese or who consider themselves overweight are candidates for bariatric surgery. These procedures are not for cosmesis but for prevention of the pathologic consequences of morbid obesity. The patient must be committed to the appropriate work-up for the procedure and for continuing long-term postoperative medical management, and understand and be adequately prepared for the potential complications of the procedure. Screening of the patients to ensure appropriate selection is a critical responsibility of the surgeon and the supporting health care team.

Hospital facilities and personnel
In health care institutions recognized as accomplished in bariatric surgery, there is a demonstrated commitment to provide adequate facilities and equipment, as well as a properly trained and funded appropriate bariatric surgery support staff. Minimal standards in these areas are set by the institution and maintained under the direction of a qualified surgeon, in charge of a bariatric surgery management team. This team includes experienced surgeons and physicians, skilled nurses, specialty-educated nutritionists, experienced anesthesiologists, and, as needed, cardiologists, pulmonologists, rehabilitation therapists, and psychiatric staff.

The operating room environment required for performance of bariatric surgery has special operating room tables and ancillary equipment available to accommodate patients weighing up to 750 lbs. Appropriate bariatric retractors, staplers, and long instruments are available.

Anesthesia for bariatric surgical procedures is performed by individuals specially trained in this area and regularly assigned to bariatric procedures as a member of the bariatric surgery team. Specialized operating room staff familiar with the equipment, instruments, and procedures are identified as members of the bariatric surgery team. The staff of the recovery room and intensive care units is expert in the immediate postoperative care of the morbidly obese patient and their special needs, particularly for ventilatory support. The facilities conform to standards mandated by the Joint Commission on Accreditation of Health Care Organizations.

The preoperative assessment of morbidly obese patients may require special radiology equipment. The perioperative care of morbidly obese patients requires special beds, chairs, and commodes. Nursing personnel are trained and skilled in giving respiratory care, assisting with ambulation, and recognizing potential intravascular volume, cardiac, diabetic, and vascular problems.

Systematic long-term follow-up after obesity surgery is essential and includes dietary instruction, vitamin and mineral supplementation, exercise therapy, and, where feasible, patient support groups.

Conclusions

Morbid obesity is effectively treated with established surgical procedures, achieving substantial weight reduction and improved quality of life in the majority of patients with acceptable rates of mortality and morbidity. The optimal environment for achieving good outcomes includes a well-prepared and committed surgeon, an established and experienced bariatric surgical team of health professionals, appropriate institutional resources and equipment, and a system for patient evaluation and follow-up.

Recommendations for Facilities Performing Bariatric Surgery

 Staffing

Operating Room

Hospital Facilities

References

1. Begg CB, Cramer LD, Hoskins WJ, Brennan MF. Impact of hospital volume on operative mortality for major cancer surgery. JAMA 1998;280:1747-51.
2. Brolin RL, Robertson LB, Kenler HA, Cody RP. Weight loss and dietary intake after vertical banded gastroplasty and Roux-en-Y gastric bypass. Ann Surg 1994; 220:782-90.
3. Campos CT, Buchwald H, Bourdages H. Gastric surgery for obesity. In: Digestive Tract Surgery: A Text & Atlas. Eds RH Bell, LF Rikkers, MW Mulholland,JB Lippincott Co, Philadelphia, PA. 1995; 281-294.
4. Centers for Disease Control and Prevention: Number and percentage of children and adolescents who were overweight by gender and race/ethnicity: United States NHANES III, 1988-1994. Morb Mortal Wkly Rep, 1997.
5. Choban PS, Onyejekwe J, Burge JC, Flancbaum L. A health status assessment of the impact of weight loss following Roux-en-Y gastric bypass for clinically severe obesity. J Am Coll Surg 1999;188:491-497.
6. Foley EF, Benotti PN, Borlase BC, et al. Impact of gastric restrictive surgery on hypertension in the morbidly obese. Am J Surg 1992; 163:294-7.
7. Health Implications of Obesity. NIH Consensus Development Conference Statement. Ann Int Med,103:1073-1077, 1985.
8. Kellum JM, DeMaria EJ, Sugerman HJ. The surgical treatment of morbid obesity. Curr Probl Surg 1998-1 35:795-858.
9. Lew EA, Garfinkel L: Variations in mortality by weight among 750,000 men and women. J Chronic Dis, 32:563-576, 1979.
10. McGinnis JM, Folge WH: Actual causes of death in the United States. JAMA, 1993;270:2207-2212.
11. Manheim LM, Sohn MW, Feinglass J, Ujiki M, Parker MA, Pearce WH. Hospital vascular surgery volume and procedure mortality rates in California, 1982-1994. J Vasc Surg 1998;28:45-56.
12. Naslund I, Agren G. Social and economic effects of bariatric surgery. Obes Surg 1991-1 1:137-40.
13. NIH conference: Gastrointestinal surgery for severe obesity. Consensus Development Conference Panel. Ann Intern Med, 115:956-961, 1991.
14. Pories WJ, Swanson MS, MacDonald KG, et al. Who would have thought it? An operation proves to be the most effective therapy for adult-onset diabetes mellitus. Ann Surg 1995; 222:339-50; discussion 350-2.
15. Rosenbaum M, Leibel RL, Hirsch J: Obesity. N Engl J Med, 337:396, 1997.
16. Wolf AM, Colditz GA: Current estimates of the economic cost of obesity in the United States. Obes Res, 6:97-106, 1998.

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Reprinted from Bulletin of the American College of Surgeons
Vol.85, No. 9, September 2000