What makes a bariatric surgeon? As of yet, the bariatric surgical community has no definite answer. There is no organization that credentials bariatric surgeons, so in theory, any general surgeon can perform bariatric surgery (see "A Voluntary Accreditation Program for Bariatric Surgeons"). But these procedures require specific surgical skills and training, an understanding of the disease of obesity and a willingness to follow patients for the long term. Before you grant bariatric surgery privileges to surgeons in your facility, here's what you need to know.

Initial surgical training
The best way for surgeons to learn bariatric surgery is to take a one-year fellowship course, which involves intensive, hands-on training, says Henry Buchwald, MD, PhD, a past president of the American Society for Bariatric Surgeons (ASBS) and a professor of surgery at the University of Minnesota. The University of Minnesota offers a bariatric fellowship program that attracts both new residents and physicians who've practiced for several years as general surgeons.

Although bariatric fellowship programs are rare, most surgeons-in-training receive some instruction in bariatric procedures. Dr. Buchwald discovered this when he designed a survey that was recently sent to all 251 accredited surgery programs in the United States (the response rate was 100 percent). He found that 74 percent of these programs perform and teach bariatric surgery, particularly open and laparoscopic gastric bypass. Furthermore, 90 percent of the 48 programs offering minimally invasive surgery fellowships also offer training in bariatric surgery.

Further training
The number of cases required to achieve proficiency in bariatric surgery varies, according to Dr. Buchwald. The ASBS has made the initial step toward defining this number by requiring its regular members to be board-certified general surgeons who have performed a minimum of 25 bariatric procedures within the past two years (if they haven't performed 25 procedures, they can join the ASBS as affiliate members).

The ASBS (www.asbs.org/html/guidelines.html) has developed credentialing guidelines for hospitals granting bariatric surgery privileges. Applicants must:

• have credentials at an accredited facility to perform gastrointestinal and biliary surgery;
• document that he 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 a program is in place to prevent, monitor and manage short-term and long-term complications; and
• document that a system is in place to provide follow-up for all patients, with the expectation that at least 50 percent of the patients who receive restrictive procedures and 75 percent of those with malabsorptive operations will be seen on a regular basis for at least five years.

It's important to remember, however, that it's up to the surgical facility to ensure that surgeons meet these requirements - the ASBS doesn't enforce the global credentialing requirements. It does, however, offer didactic and hands-on CME courses throughout the year, which cover everything from the essentials of bariatric surgery to advanced techniques. The organization is currently working on designing a preceptorship program, as well.

The American College of Surgeons (ACS) and The Society of American Gastrointestinal Endoscopic Surgeons (SAGES) have also released recommendations concerning bariatric surgeon credentials; the SAGES guidelines focus on laparoscopic procedures and the ACS recommendations include guidelines for developing a bariatric surgery facility. You can read the ACS recommendations at www.facs.org/fellows_info/statements/st-34.html and the SAGES recommendations at www.lapsurgery.com/BARIATRIC SURGERY/SAGES.htm.

In certain cases, surgeons must complete a company-sponsored course if they wish to perform surgery using a particular device. Surgeons who want to perform Lap-Band adjustable gastric banding surgery, for example, must complete a workshop the manufacturer, Inamed, offers and also commit to performing at least 25 procedures a year (www.inamed.com). Transneuronix, the manufacturer of the implantable gastric stimulator (currently in FDA trials), says surgeons wishing to perform this procedure will have to complete a similar course.

In 2003, the leadership of the ASBS, recognizing the need to set guidelines for and apply universal standards to bariatric surgery, created the Surgical Review Corporation (SRC), a not-for-profit organization that will evaluate and accredit both bariatric surgeons and bariatric surgery programs. Centers that win full approval from the SRC board's 12-member review committee and undergo a satisfactory site visit will be awarded the designation of center of excellence, which will last from one to three years. The SRC has already granted several facilities provisional status and plans to start site visits in July.

Surgeons and facilities must apply separately to demonstrate that the program has all the components to perform bariatric surgery, as well as good long-term and short-term outcomes. If a fully qualified surgeon is practicing in a facility that doesn't have the appropriate equipment, that facility can't qualify as a Center of Excellence. "We want to elevate the standards of bariatric surgery so that only the best people and the best centers are practicing it," says Walter J. Pories, MD, FACS, president of the SRC's Board of Governors. For more information, visit www.surgicalreview.org.

Do your homework
In the absence of one certifying body to credential bariatric surgeons, it's up to facilities to do their homework. Dr. Buchwald suggests ensuring, at a minimum, that surgeons meet ASBS standards and also checking the surgeons' short-term and long-term records. "Bariatric surgeons must make an effort to follow their patients long term, in addition to being good surgeons," he says. "Unfortunately, there are plenty of surgeons out there who shouldn't be doing these procedures."