Pamela Davis, R.N., C.B.N.a, Lisa West-Smith, Ph.D., L.C.S.W.b,
Laura L. Baldwin, R.N.c, Karen M. Flanders, N.P., C.B.N.c,
Melissa M. Davis, M.S.N., A.P.R.N., B.C., C.N.S., R.N.F.A.c,
Lisa Rae Gergen, M.S.N., F.N.P., C.B.N.c, Paula R. Kilgore, R.N., C.B.N.c,
Terry L. McKenzie, R.N., C.B.N.c, Debra A. Proulx, R.N.c
a Chair, American Society for Metabolic and Bariatric Surgery Clinical Issues and Guidelines Committee, Gainesville, Florida
b Co-Chair, American Society for Metabolic and Bariatric Surgery Clinical Issues and Guidelines Committee, Gainesville, Florida
c Ad Hoc Member, American Society for Metabolic and Bariatric Surgery Clinical Issues and Guidelines Committee, Gainesville, Florida
Received August 22, 2012; accepted August 22, 2012
It is widely believed that appropriate aftercare is essential to the long-term success and outcomes associated with bariatric surgery [1,2], especially gastric banding procedures [3,4]. As part of this aftercare, periodic adjustments to the gastric band device are essential. Because of the exponential growth in aftercare visits, it is often necessary to use physician extenders to deliver aftercare to provide appropriate long-term access to care for patients. The intent of the credentialing guidelines for gastric band adjustments is to provide recommendations for appropriate education, training, and competency recognition for nonphysician providers.
Adjustments: The infusion of saline for device tightening or withdrawal of saline for device loosening via an access port to alter or adjust the size of the adjustable gastric restrictive device. The need for adjustments are based on clinical assessment of the patient’s hunger, satiety, dietary intake, portion size, weight loss/gain, and associated signs or symptoms of potential complications [5,6].
Physician Extenders: Although it is recognized that terms such as _nonphysician provider _and _physician extender _may not accurately convey the esteem in which these providers and their services are held, this terminology is consistent with facility and payor practitioner descriptions. For the purpose of this document, physician extenders are broadly defined as healthcare providers such as Supervised Registered Nurses, Clinical Nurse Specialists, Nurse Practitioners, and Physician Assistants.*
Experienced Provider: For the purpose of this document, it is defined as a bariatric surgeon or appropriately credentialed physician extender who has performed _200 gastric band adjustments and has attended a training course.
Scope of Practice
Adjustment of a band is a diagnostic and treatment decision by a licensed professional within the scope of their practice as defined by the state and the hospital [7–10]; however, Supervised Registered Nurses can perform this task as long as they are provided a band adjustment protocol by their covering physician. The protocol should be developed by the supervising physician(s). The practitioner cannot provide care outside of the scope of professional practice as mandated by their state and hospital.
Global Credentialing Requirements
To meet the Global Credentialing Requirements for performing gastric band adjustments, the physician extender new to the field should:
A. Attend didactic training through a gastric band training course that includes but is not limited to:
- Patient selection criteria
- Surgical preparation
- Surgical procedure
- Early postoperative management
- Assessment of postoperative patient/band adjustment considerations:
- Band size and type
- Current weight and weight loss/gain
- Dietary intake
- Number of meals per day
- Typical meal, including type and amount of protein, fruits, vegetables, starches
- Fluid intake, including type and amount
- Snacking, including type and amount
- Symptoms of hunger, dysphagia, dehydration, reflux, or vomiting
- Date of and response to last adjustment
- Review of current band fluid volume
- Determination of need for adjustment based on dietary intake, satiety, and weight loss/gain
- Identifying band-related and adjustment-related complications
- Adjustment protocols
- Determination of band adjustment volume using adjustment algorithm, adhering to the specific manufacturer’s guidelines regarding band volume
- Adjustment procedure steps
- Wash hands
- Explain procedure to patient
- Position patient
- Assess and palpate the port site
- Prepare syringe and saline
- Use Huber needle for adjustment
- Cleanse port site
- Perform the adjustment—insert needle into septum (center) of port
- Assessment of restriction after the adjustment
- Discharge instructions
- Diet recommendations/progression
- Complication signs/symptoms
- Long-term dietary and behavioral support
- Long-term complication recognition, assessment, and management
- Stomach prolapse
- Tubing leaks
- Tubing kinks
- Port site infection
- Practice of access port adjustment
B. Participate in clinical training in a preceptor program if available. If unable to participate in a preceptor program, then supervised clinical training with an experienced provider should include:
- Physician extender observation of a minimum of 10 aftercare visits and 20 gastric band adjustments
- Physician extender supervision on a minimum of 10 aftercare visits and 50 gastric band adjustments, to be completed before performing adjustments independently
- A method of performance evaluation to ensure patient satisfaction and monitor postadjustment adverse events
- Approval by the clinical supervisor responsible for training to allow a physician extender to manage aftercare and perform gastric band adjustments independently
C. For physician extenders currently performing gastric band adjustments, the following guidelines satisfy the credentialing requirements:
- Already performed adjustments in a bariatric surgery practice for a minimum of 6 months
- Documentation of 50 adjustments performed
- Documentation by an experienced provider of the physician extender’s ability to perform adjustments D. The practitioner cannot provide care outside of the scope of professional practice as mandated by their state and hospital.
Clinical privileging for the physician extender
The facility or facilities in which the individual practices should establish a process to grant clinical privileging to the physician extender, which should include:
A. Verification of current license to practice as one of the following:
- Registered Nurse
- Clinical Nurse Specialist
- Nurse Practitioner
- Physician Assistant
B. Verification of current certification to practice in an advanced role
- American Academy of Nurse Practitioner
- American Nurses Credentialing Center
- National Commission Certification of Physician Assistants
- Certified Bariatric Nurse (for Registered Nurses)
C. Verification that supervising physician, if applicable, is a bariatric surgeon or bariatric physician D. Continued oversight of the Supervised Registered Nurse
Other facility/program considerations
It is recommended that the program be managed by either an existing Bariatric Surgery Center of Excellence (BSCOE) or a facility that is in the process of obtaining accreditation by the American Society for Metabolic and Bariatric Surgery (ASMBS)/American College of Surgeons (ACS) Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP). It is further recommended that written policies and procedures exist for (1) the proper technique of a gastric band adjustment and (2) the training of physician extenders to perform gastric band adjustments. The provider or program administrator should maintain documentation of acquisition of education, demonstration of competency, and any other documents necessary to ensure that practice is in compliance with the standards of safe practice.
Adoption of consent forms for gastric band adjustment procedures should be discussed with the program’s risk and liability carrier to determine necessity.
It is the responsibility of the program administrator to determine appropriate billing, documentation, and supervision guidelines for the use of physician extenders.
Additionally, it is the responsibility of the program administrator to determine appropriate use of fluoroscopy by physician extenders, as regulations may vary by state and by hospital.
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 expert opinion, are offered only as guidelines, nd are specifically not intended to establish a local, regional, or national standard of care for any gastric band adjustment procedure. Although the ASMBS views these guidelines as important to successful weight loss outcomes and to the provision of safe patient care, it does not warrant, guarantee, or promise that compliance ensures positive surgical outcomes for any single procedure. It is the responsibility of the program to determine appropriate billing, documentation, and supervision guidelines for the use of physician extenders.
The authors wish to acknowledge ASMBS Executive Council Liaisons Jaime Ponce, MD and Emma Patterson, MD and ASMBS Staff Liaison Barbara Peck for their assistance in the development of these guidelines.
 Shen R, Dugay G, Rajaram K, Cabrera I, Siegel N, Ren CJ. Impact of patient follow-up on weight loss after bariatric surgery. Obes Surg 2004;14:515–9.
 Gould J, Ellsmere J, Fanelli R, Hutter M, Jones S, Pratt J, Jones DB.
Panel report: best practices for the surgical treatment of obesity. Surg Endosc 2011;25:1730–40.
 Dugay G, Ren CJ. Laparoscopic adjustable gastric band (Lap-Band) adjustments in the office is reasonable—the first 200 cases. Obes Surg 2003;13:537.
 Watkins BM, Montgomery KF, Ahroni JH. Laparoscopic adjustable gastric banding: early experience in 400 consecutive patients in the USA. Obes Surg 2005;15:82–7.
 Realize [Internet]. Cincinnati: Ethicon Endo-Surgery, Inc.; c2007–2012. About band fills. [cited 2012 October 3]. Available from http://www.realize.com/band-fills-adjustments.htm/.
 LapBandCentral [Internet]. Irvine: Allergan, Inc.; c2007–2011. The art of adjustments with the Lap-Band AP system. [cited 2012 October 3].  AORN [Internet]. Denver: Association of Perioperative Registered Nurses; c2010–2012. AORN position statement on RN first assistants. [cited 2012 October 3]. Available from http://staging.aorn.org/
 ASMBS [Internet]. Gainesville: American Society for Metabolic and Bariatric Surgery; c2005–2012. Guidelines for granting privileges in bariatric surgery. [cited 2012 October 3].  AZBN [Internet]. Phoenix: Arizona State Board of Nursing; c2002–2012. Advisory opinion laparoscopic adjustable gastric band (LAGB) fill. [cited 2012 October 3]. Available from http://www.azbn.gov/documents/advisory_opinion/AO%20LAPARASCOPIC%20ADJUSTABLE%20GASTRIC%20BAND%20LAGB%20FILL%20Mar%202010.pdf/.
 Nursing [Internet]. Columbus: Ohio Board of Nursing; c2010–2012. Role of the registered nurse in providing bariatric care by filling and unfilling a client’s surgically established gastric banding system. Guidelines for registered nurse. [cited 2012 March 22]. Available from http://www.nursing.ohio.gov/PDFS/Practice/GastricBand_IG072011.pdf/.