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.
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.
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
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
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.
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
- Bariatric surgery team of experienced and committed surgeons, anesthesiologists, nurses, and nutritionists
- Recovery room staff experienced in difficult ventilatory and respirator support
- Floor nurses experienced in respiratory care, management of nasogastric and abdominal wall drainage tubes, and ambulation of morbidly obese patient; knowledge of common perioperative complications and ability to recognize intravascular volume, cardiac, diabetic, and vascular problems
- Availability of specialists in cardiology, pulmonology, rehabilitation, and psychiatry.
- Special operating room tables and equipment to accommodate morbidly obese patients
- Retractors suitable for bariatric surgical procedures
- Specifically designed stapling instruments
- Appropriately long surgical instruments
- Other special supplies unique to the procedure
- Recovery room capable of providing critical care to obese patients
- Available intensive care unit with similar capabilities
- Hospital beds, commodes, chairs, and wheelchairs to accommodate the morbidly obese
- Radiology and other diagnostic equipment capable of handling morbidly obese patients
- Long-term follow-up care facilities including rehabilitation facilities, psychiatric care, nutritional counseling, and support groups
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Reprinted from Bulletin of the American College
Vol.85, No. 9, September 2000