Published June 2013

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Background

The field of bariatric surgery continues to grow, attracting surgeons with expertise in laparoscopic, gastrointestinal, and bariatric surgery. With the implicit goal of ensuring that surgeons have met minimum criteria to safely perform bariatric surgery, 3 national surgery associations—American Society for Metabolic and Bariatric Surgery (ASMBS), American College of Surgeons (ACS), and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES)—independently created credentialing guidelines to guide hospitals and institutions in the credentialing process for bariatric surgery [1], [2], [3]. The guidelines were thoughtfully written to assist local credentialing committees in the evaluation of an applicant’s qualifications and were not developed to become a standard of care.

Both the ASMBS Bariatric Center of Excellence program (ASMBS BSCOE) and the ACS Bariatric Surgery Center Network (ACS BSCN) were developed to improve the quality of patient care and have been recognized by the Centers for Medicare and Medicaid Services (CMS). By creating a culture of data collection and outcome tracking, these 2 novel programs have fostered a dramatic improvement in outcomes and a significant reduction in patient mortality. In 2012, under the leadership of the ASMBS in partnership with the ACS and in collaboration with members of the Michigan Bariatric Surgery Collaborative (MBSC), a unified bariatric surgery quality improvement and accreditation program—the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP)—is being developed.

With the quest for unification, a joint task force (members listed in Table 1) with representation from the key societies was created to develop a set of credentialing guidelines consolidating the 3 existing credentialing guidelines into 1 document. The guidelines have been endorsed by the leadership of the ASMBS, SAGES, ACS, and the Society for Surgery of the Alimentary Tract (SSAT).

Table 1. Joint Task Force Members

ASMBS ACS SAGES MBSC SSAT
William B. Inabnet III, M.D. (chair) Ronald Clements, M.D. Kevin Reavis, M.D. Arthur M. Carlin, M.D. Matt Hutter, M.D.
Eric Bour, M.D. John Morton, M.D. William S. Richardson, M.D. Jonathan Finks, M.D.
Christopher Joyce, M.D. Shean Satgunam, M.D.
Kim Marley, M.D.
Joe Moran, M.D.

Purpose

The purpose of this document is to recommend guidelines to local credentialing committees for the credentialing of surgeons to perform bariatric surgery. These guidelines aim to ensure that bariatric surgeons have undergone appropriate training and have achieved a certain minimum level of skill to safely perform bariatric surgery and to recognize and treat complications. These guidelines offer recommendations to institutional credentialing bodies regarding surgeon experience and training for surgeons seeking bariatric surgery privileges. It is acknowledged that special circumstances may apply to an applicant surgeon’s training background, and thus, guidelines must allow for some flexibility. Ultimately, the decision to provide credentials for a surgeon resides with the local institution credentialing committee or their appointee. Credentialing recommendations should be stringent enough to ensure patient safety but not so stringent as to compromise access to care by limiting the number of surgeons credentialed to perform bariatric surgery. Credentialing guidelines also should address and reinforce the quality metrics/parameters that have been established with the specialty for safe practice.

It is strongly recommended that all the facilities in which the surgeon performs bariatric surgery participate with the MBSAQIP, including compliance with data entry of all bariatric procedures into the national outcomes registry. Requirements in this document as they pertain to the MBSAQIP also can be fulfilled by participation in an equivalent approved statewide or national bariatric quality improvement program. It is important to have institutional support for data management, bariatric surgery infrastructure, and personnel. All surgeons practicing bariatric surgery in accredited facilities are required to participate with the MBSAQIP or an equivalent regional/national quality improvement program, which involves submission of all bariatric surgery cases performed at the accredited institution and periodic review of outcomes.

Recommended bariatric surgeon requirements include the following:

  • Completion of an accredited general surgery residency.

  • Certified or eligible to be certified by the American Board of Surgery or equivalent (American Osteopathic Board of Surgery, Royal College of Physicians, and Surgeons of Canada). Exceptions to the board certification requirement can be made on a case-by-case basis.

  • State medical licensure in good standing.
  • Completion of an accredited bariatric surgery fellowship. For nonfellowship trained surgeons, documentation of previous bariatric surgery experience and formal didactic training in bariatric surgery (such as that provided by the ASMBS Fundamentals of Bariatric Surgery Course) is recommended. Supporting documentation, including a case log list or bariatric surgery training certificate, should be provided to allow the credentialing committee to assess the applicant surgeon’s bariatric surgery experience.

  • Participation within a structured bariatric program that provides or coordinates comprehensive, interdisciplinary care of the bariatric patient.

  • Commitment to use bariatric surgery clinical pathways.

  • Privileges to perform gastrointestinal surgery.

  • Privileges to perform advanced laparoscopic procedures if laparoscopic bariatric surgery privileges are being requested.

  • The surgeon will actively participate with the MBSAQIP and adhere to its standards by implementing changes in practice in accordance with feedback from the MBSAQIP or an equivalent regional/national quality improvement program.

Recommended criteria for surgeons with no or limited experience in bariatric surgery or advanced laparoscopy include the following:

  • Applicant surgeon must complete a structured training curriculum in bariatric surgery and advanced laparoscopic surgery as reviewed and approved by the bariatric medical director.

  • The applicant surgeon must have completed a general surgery residency.

  • The applicant surgeon’s initial cases should be performed with a co-surgeon who is a fully credentialed bariatric surgeon. The absolute number of proctored cases is left up to the local credentialing committee. However, the local credentialing committees may wish to delineate separate requirements for those procedures that require gastrointestinal stapling versus those that do not. It is advisable that the first cases be of lower technical difficulty with carefully determined lower risk patients as determined by the bariatric medical director.

  • The surgeon will actively participate with the MBSAQIP program and adhere to its standards by implementing changes in practice in accordance with feedback from the MBSAQIP or an equivalent regional/national quality improvement program.

Types of procedures

The following procedures qualify as bariatric procedures (open or laparoscopic) under these credentialing guidelines: adjustable gastric banding, biliopancreatic diversion with duodenal switch, biliopancreatic diversion without duodenal switch, revisional bariatric surgery, Roux-en-Y gastric bypass, sleeve gastrectomy, and vertical banded gastroplasty.

  • Investigational procedures should be performed under an IRB-approved protocol.

  • Local credentialing committees may wish to delineate separate requirements for those procedures that require gastrointestinal stapling versus those that do not.

  • Endoluminal bariatric procedures are not covered by these guidelines and should be credentialed under endoscopic privileges. It is recommended that practitioners performing endoluminal bariatric procedures should be credentialed to perform bariatric surgery and if not, they should be an active member of an accredited, structured bariatric surgery program.

Recommendations for maintenance and renewal of privileges

  • Privileges to perform bariatric surgery should be renewed at a minimum of every 2 years.

  • Maintenance of certification by the American Board of Surgery or its equivalent.

  • Continued active participation within a structured bariatric surgery program. Ongoing participation with the MBSAQIP program or an equivalent regional/national quality improvement program.

  • The surgeon must demonstrate continued critical assessment of his/her outcomes as determined by periodic review of outcomes from an acceptable regional or national outcomes registry.
  • The chief of surgery or his/her designee should verify that these criteria have been met.

References

  1. Clements R, Saber A, Teixeira J, et al. Guidelines for institutions granting bariatric privileges utilizing laparoscopic techniques. Society of American Gastrointestinal and Endoscopic Surgeons Guidelines Committee. Surg Endosc. 2011;25:671–676

  2. American College of Surgeons Bariatric Surgery Center Network Program Manual, V4.03–01–11.

  3. American Society for Metabolic and Bariatric Surgery, Guidelines for granting privileges in bariatric surgery, October 2005.