Bariatric Surgery: Credentialing

Introduction

With the rapid increase of bariatric procedures performed though the last two decades, there has been increasing focus by societies, insurance providers, and other organizations on credentialing guidelines to assure best practices are being  followed.

Along side its 15 other clinical practice guidelines, the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) has developed bariatric credentialing guidelines. In 2003, the Board of Governors of SAGES approved the Guidelines for Institutions Granting Bariatric Privileges Utilizing Laparoscopic Techniques. This was done jointly with the American Society of Bariatric Surgery (ASMBS).

SAGES Bariatric Credentialing Guidelines

The SAGES bariatric guidelines establish both laparoscopic and open weight loss procedures as appropriate treatments for morbid obesity based on 1991 National Institutes of Health Consensus Conference for the surgical management of morbidly obese patients. They stipulate weight loss surgery should be practiced by appropriately trained surgical teams within programs that provide perioperative and long-term management.

In 2003, experts met at the SAGES Appropriateness Conference and established the duodenal switch, banded gastroplasty, laparoscopic adjustable band, and laparoscopic gastric bypass as appropriate operations for weight loss based on current evidence.

Overview of SAGES Bariatric Credentialing Guidelines

Other societies such as the ACS, ASMBS, and the Betsy Lehman report use volume criteria to recommend credentialing surgeons. These range between 25-50 procedures annually. In contrast, the SAGES guidelines places the impetus for privileging on the provider institutions recommending input from a committee and the chief of surgery.

For surgeons without formal training in weight loss surgery (fellowship), preceptorship and/or formal courses are offered as alternatives. Any such courses should meet category 1 Continuing Medical Education requirements, and involved both didactics and hands-on experience with inanimate labs or tissue labs.

Minimum Requirements

• Formal residency training in general surgery within an accredited program with subsequent certification by the American Board of Surgery if required by the institution

• Documentation that there exists adequate follow-up of patients including nursing care, dietary care, counseling, support groups, exercise training, psychological care if needed, and a method of identifying and managing complications

• If the surgeon has formal training only in open bariatric surgery, SAGES recommends having a second surgeon who is trained in laparoscopic bariatric surgery, and is therefore complementary to their expertise. Alternatively, the surgeon may participate in a proctored experience deemed adequate by the chief of surgery.

Fellowship Training

If the surgeon has documented formal training in laparoscopic bariatric surgery, SAGES recommends that the volume of open and laparoscopic cases be demonstrated for the type of procedures to be done, and that a complementary surgeon experienced in open procedures be available if needed. The adequacy of case volume/experience is to be determined by the chief of surgery.

If the surgeon has no documented formal residency training in either laparoscopic open bariatric surgery, they are expected to take a formal course AND be proctored by a qualified surgeon who is approved by the institution of practice.

Institutional Support

Adequate equipment and staff training are expected to be in place prior to starting a bariatric program. Two skilled surgeons are recommended for laparoscopic bariatric procedures, or a surgeon and a skilled first assistant.

Maintenance of Privileges

SAGES recommends that the chief of surgery or appropriate institutional body should determine the criteria for provisional privileges, monitoring of performance and outcomes, and continuing education requirements (meetings and courses). The guideline states that outcome data should be reviewed after 6 months of the granting of privileges, and regularly thereafter as compared to published national benchmarks. Any denial of privileges should have an appeal process in place.

References

1. Schirmer BD, Schauer PR, Flum DR, Ellsmere J, Jones DB. Bariatric Surgery Training: Getting Your Ticket Punched. Journal of Gastrointestinal Surgery. 2007;11:807-812.
2. ASBS Bariatric Training Committee. American Society for Bariatric Surgery Guidelines for Granting Privileges in Bariatric Surgery. Surgical Obesity and Related Diseases. 2006;2(1):65-67.
3. SAGES. Guidelines for Institutions Granting Bariatric Privileges Utilizing Laparoscopic Techniques. Surgical Endoscopy. 2003;17:2037-2040.
4. Guidelines for the Clinical Application of Laparoscopic Bariatric Surgery. https://www.sages.org/sagespublicationprint.php?doc=30. Accessed June 25,2006.
5. Jones DB, DeMaria E, Provost DA, Smith CD, Morgenstern L, Schirmer B. Optimal management of the morbidly obese patient: SAGES appropriateness conference statement. Surgical Endoscopy. 2004;18(7):1029-1037.