Reviewed March 2013 – No Update Needed
The following position statement has been issued by the American Society for Metabolic and Bariatric Surgery (ASMBS) in response to numerous inquiries made to the Society by patients, physicians, society members, hospitals, health insurance payors, the media, and others regarding the role of bariatric surgeons in the care of patients with complications related to bariatric surgery. The intent of issuing such a statement is to provide a guideline derived from ethical standards and expert opinion on the topic of emergency care of bariatric surgery patients for bariatric surgeons, for general surgeons who do not perform bariatric surgery, and for hospitals (both those with bariatric surgery programs and those without such programs). The statement is not intended as, and should not be construed as, stating or establishing a local, regional, or national standard of care. The statement will be revised in the future should modifications be deemed necessary by the Society.
Ethical standards require that a surgeon who performs a surgical procedure on a patient provide appropriate postoperative care to that patient, including emergency care after hospital discharge. This is particularly pertinent in the early postoperative period when direct, procedure-related complications can occur. The ASMBS ethical standards indicate that bariatric surgeons have an bligation to provide appropriate postoperative bariatric surgery care to their patients, including the provision of an appropriately qualified surgeon to provide coverage for bariatric surgery patients in the absence of the primary operating bariatric surgeon. This is necessary because a specific knowledge base and skill set are required to provide optimal care to patients who have previously undergone bariatric surgery. Bariatric surgery incorporates concepts and anatomic reconstructions not traditionally a part of general surgery training. The physiologic effects of altering the intestinal limb lengths or gastric pouch size or performing intestinal resection can have nutritional and other consequences not anticipated by the general surgeon. Also, management issues germane to the numerous health consequences of morbid obesity might be less familiar to the general surgeon who does not practice bariatric surgery. Finally, under some circumstances, general surgeons unfamiliar with the management of complications related to a bariatric surgery procedure might choose to “reverse” a bariatric procedure when confronted with an emergent situation, whereas a qualified bariatric surgical specialist might decide a revision of the procedure would be more appropriate.
Bariatric surgery is primarily an elective specialty that allows hospitals and physicians the ability to decide whether to provide these services. This decision to offer bariatric surgical services should include the commitment to care for postoperative complications and provide the resources to do so, including the proper facilities, imaging and surgical equipment, intensive care unit and respiratory care, and anesthesia and surgical support, among others.
The scope of the current guidelines is directed at bariatric surgery-related complications that require emergency care. This position statement should not be misinterpreted to suggest that all surgical issues in morbidly obese patients or that all urgent conditions that occur in patients with a personal history of bariatric surgery require care by a bariatric surgeon. Routine surgical problems, including, but not limited to, conditions such as appendicitis, cholecystitis, or hernia, developing in a morbidly obese patient or in a patient who has previously undergone bariatric surgery are appropriately managed by a general surgeon who does not perform bariatric surgery. Because bariatric surgery-related complications can be confused with routine surgical problems (such as those listed above), general surgeons who do not perform bariatric surgery are encouraged to consult with a bariatric surgeon before treatment of a postoperative bariatric surgery patient when the patient’s presenting signs and/or symptoms appear to deviate from a typical presentation of the presumptive condition. Finally, it should be noted that bariatric surgeons are trained and credentialed in general surgery and are therefore qualified to participate in the care of non-bariatric general surgery patients, as well as routine surgical problems in bariatric surgery patients.
The ASMBS recommends the following guidelines for hospitals and physicians regarding the emergency care of patients with complications related to bariatric surgery procedures:
Hospitals are called on to recognize bariatric surgery as a surgical subspecialty and, similar to the emergency coverage arrangements hospitals provide for other surgical subspecialties, hospitals are required to recognize that a patient with bariatric surgery-related complications should ideally be treated by an appropriately qualified bariatric surgical specialist. Such treatment can be provided by an appropriately qualified and credentialed member of the medical staff in hospitals performing bariatric surgery procedures or by transfer to another facility. Life-threatening conditions that require immediate intervention are appropriately treated by an available general surgeon at hospitals that do not provide bariatric surgery services (see No. 3 below).
All hospitals in which elective bariatric surgery procedures are performed are called on to provide care to patients experiencing bariatric surgery-related complications. This is essential to provide a safe system of care, because issues such as relocation, insurance coverage changes, patient access issues, or the nature of an emergency situation can interfere with the provision of care by the primary bariatric surgeon who performed the procedure, their surgical practice, or hospital, as outlined above. Hospitals that provide emergency services to the community and perform bariatric surgical procedures should provide 24-hour emergency access to evaluation and treatment (e.g., by way of emergency room coverage) by qualified surgical specialists for all bariatric surgical patients. Hospitals that perform bariatric surgical procedures should also accept the transfer of patients with bariatric surgery-related emergencies from hospitals that do not provide bariatric surgery services.
Hospitals that do not perform bariatric surgery might not be equipped to take care of bariatric surgical emergencies and might need to transfer such patients to appropriately equipped centers with qualified bariatric surgical specialists who can treat bariatric surgery- related complications. However, this should only occur if the condition of the patient and specifics of the transfer arrangement will allow safe transfer. Bariatric patients who present with life-threatening surgical problems, whether related to the bariatric surgery or not, should not have their health jeopardized by efforts to arrange such a transfer if it is clear that urgent surgical intervention is indicated. In such circumstances (e.g., closed loop bowel obstruction threatening perforation or infarction), a general surgeon should perform the life-saving surgical intervention and avoid the delays inherent in transferring the patient.
Bariatric surgeons, as recognized surgical subspecialists,have an obligation to maintain their familiarity with the various bariatric surgical procedures and inherent complications of these procedures as a part of their obligation to provide care to all patients requiring emergency treatment of bariatric surgery-related complications.
Bariatric surgeons have an obligation to provide both emergency and elective care to their own postoperative patients, to educate their patients that they are available to provide such care, and to inform their patients how to access this care.
Bariatric surgeons must maintain privileges at a hospital with appropriate facilities for bariatric patients that also provides emergency services accessible 24 hours daily to care for their bariatric surgery patients who develop complications. Bariatric surgeons who practice exclusively in an outpatient-only facility will not be able to satisfy this obligation and must, therefore, satisfy one of the following criteria:
- Have in place an approved transfer acceptance emergency care agreement with an appropriate hospital that performs bariatric surgery with emergency services accessible 24 hours daily with a qualified bariatric surgeon or surgeons practicing at that facility who will accept their patients and provide emergency care to them, or
- Join the medical staff of an appropriate hospital that performs bariatric surgery and provides emergency services accessible 24 hours daily to provide emergency care to their patients who develop bariatric surgery-related complications.
The ASMBS has recognized that these guidelines raise a number of potential concerns. For example, the various relationships that exist between medical staff and hospital systems are too diverse to provide specific guidelines regarding how these objectives should be accomplished. Thus, each institution is charged with determining how such coverage is best provided. Financial arrangements between hospitals and qualified bariatric surgeons might be required to ensure appropriate coverage.
In some hospital environments, emergency call coverage requirements could lead to an unacceptable coverage burden for bariatric surgeons. Thus, it might be appropriate to train and credential general surgeons who do not perform elective bariatric surgery procedures to provide emergency care to patients experiencing bariatric surgery-related complications. It has been recommended that general surgeons who become qualified to provide emergency care for patients with bariatric surgery-related complications should be credentialed to provide gastrointestinal surgery at the facility and meet the facility’s minimal credentialing criteria for bariatric surgery. Ongoing continuing medical education regarding bariatric surgery and the management of bariatric surgery-related complications is also recommended for such general surgeons who provide coverage for bariatric surgery emergencies, including documentation of a minimum of 8 Category I credit hours annually.
Furthermore, some bariatric surgeons offer only a single elective procedure option for patients desiring bariatric surgery. However the ASMBS has called on all surgeons practicing bariatric surgery to recognize their responsibility as surgical subspecialists to provide care in an emergency setting for bariatric complications beyond the scope of their typical elective surgical practice. Underlying this is the reasonable assumption that a practicing bariatric surgeon provides a better option for providing care to a patient with a bariatric surgery-related complication requiring emergency care than would a general surgeon who is unfamiliar with the bariatric surgery procedures and their complications. Thus, bariatric surgeons have an obligation to maintain their familiarity with the various bariatric surgical procedures and their inherent complications to provide reasonable emergency care to patients who could develop a wide range of bariatric surgery-related complications.
Bariatric program hospitals and bariatric surgery specialists who accept the burden of providing emergency care to unfamiliar patients who present with bariatric surgeryrelated complications likely represent the best available option to provide care in an emergency situation. They do so for the benefit of the patient experiencing an emergency condition, mandating the best available care, often as a life-saving intervention. The ASMBS calls on third-party payors to reimburse the costs for emergency care delivered by physicians and hospitals to bariatric surgery patients who carry any form of health insurance coverage. Finally, the ASMBS recognizes that bariatric surgery specialists and hospitals that provide emergency care to bariatric surgery patients from other practices often do so under difficult circumstances (including, but not limited to, a lack of reliable medical information, unfamiliar or nontraditional surgical procedures, poor follow-up care, patient non-compliance and psychological issues, and so forth), and that such extenuating factors can have a negative impact on the outcome of care rendered in an emergency treatment situation should not be subject to liability for providing such care.
Emergency Care Position Statement and Standard of Care
This Position Statement is not intended to provide inflexible rules or requirements of practice and is not intended, nor should it be used, to state or establish a local, regional, or national legal standard of care.
The American Society for Metabolic and Bariatric Surgery cautions against the use of this position statement in litigation in which the clinical decisions of a physician have been called into question. The ultimate judgment regarding the appropriateness of any specific procedure or course of action must be made by the physician in light of all the circumstances presented. Thus, an approach that differs from the position statement, standing alone, does not necessarily imply that the approach was below the standard of care. To the contrary, a conscientious physician might responsibly adopt a course of action different from that set forth in the position statement when, in the reasonable judgment of the physician, such a course of action is indicated by the condition of the patient, the limitations of available resources, or advances in knowledge or technology. All that should be expected is that the physician will follow a reasonable course of action based on current knowledge, available resources, and the needs of the patient to deliver effective and safe medical care. The sole purpose of this position statement is to assist practitioners in achieving this objective.