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 cannot 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 Applicant
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 Gastointestinal 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 Gastointestinal 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.
Laparoscopic Bariatric Surgery Privileges for Procedures that do not Involve Stapling or Division of the Gastointestinal 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.
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.
- American Society for Metabolic and Bariatric Surgery. Guidelines for Granting Privileges in Bariatric Surgery. Obes Surg. 2003;13:238-240.
- 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.
- 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.
- 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.
- 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.
- Favretti F. Cadiere GB, Segato G, et al. Laparoscopic banding: selection and technique in 830 patients. Obes Surg. 2002; 12: 385-390.
- 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.
- 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.
- 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.
- 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.
- 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.
- Park A, Witzke D, Donnelly M. Ongoing deficits in residents training for minimally invasive surgery. J Gastrointest Surg. 2002;6(3)L501-507.
- 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.
- Rossser JC; Rosser L, Savalgi RS. Skill acquisition and assessment for laparoscopic surgery. Arch Surg. 1997;132:200-204.
- 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.
- Mori T, Hatano N, Maruyama S. et al. Significance of “hands-on-training” in laparoscopic surgery. Surg Endosc. 1998;12:256-260.
- JCAHO. The 1995 Joint Commission Accreditation Manual for Hospitals. Oakbrook Terrace, IL: JCAHO;1994.
- Dent T. Training and privileging for new procedures. Surg Clin North Am. 1996;76:615-621.
- American Society for Metabolic and 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.
- American College of Surgeons. Recommendations for facilities performing bariatric surgery. Bull Am Coll Surg. 2000;85(9):20-23.
- SLS Training and Fellowship Opportunities. Society for Laparoendoscopic Surgeons Website. Available at: http://www.sls.org/services/fellowship.html#gen.
- Available Fellowships in Surgical Endoscopy and Laparoscopy. Society of American Gastrointestinal Endoscopic Surgeons Website. Available at: http://www.sages.org/fellowships/index.php.
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