SLEEP SPECIALISTS Anesthesia providers must be airway management masters and skilled at limiting post-op pain and PONV risks.

As the administrator of an ASC that has hosted more than 3,000 gastric banding surgeries — about 460 each year — since launching the program in 2005, I know what it takes to run a successful bariatric program. Here are a few insights you can use to do the same.

1. Expected excellence
You don't necessarily need to be a Bariatric Center of Excellence (www.asmbs.org) to host gastric banding procedures, but most commercial payors require outpatient facilities to earn the certification for reimbursement. Also keep in mind that bariatric patients are generally well-educated about the procedure and will seek centers of excellence when deciding where to go for their surgeries. Even if you decide against the designation, create a gastric banding program with the guidelines in mind, which require your facility to host 125 cases in the 12 months before seeking certification. (That number is based on current regulations, which are expected to be updated this month, and likely to be reduced.) You must also have a director of bariatric surgery and bariatric surgery coordinator on staff and work with surgeons experienced in weight-loss surgery who are associated with inpatient bariatric programs. Finally, you must have designated services such as anesthesia and imaging in place, and a patient transfer agreement with an inpatient facility able to handle bariatric patients in the event of an emergency.

2. Equipment and staff
A surgical team trained in general surgery can become proficient in gastric banding procedures rather quickly. One additional requirement: Scrub techs must prime the gastric band before surgery, which involves additional training often provided by the implant manufacturers. The priming essentially involves injecting sterile saline solution into and removing air from the band to ensure it's a fluid-filled, rather than air-filled, reservoir.

Required capital investments include longer versions of basic laparoscopic instrumentation. You'll also want longer standard instrument sets in the event surgeons must open the patient after failed laparoscopic approaches. Needlescopic instrumentation is best suited for single-incision lap bands, which we offer to patients with body-mass indexes on the low end of the obesity spectrum, ranging from 30 to 35.

Two companies — Allergan and Ethicon — manufacture gastric bands. The designs are basically the same. Which one you stock will depend largely on surgeon preference. Both companies market the bands for a comparable price, about $3,200 each.

You'll need an OR table that supports 700 to 1,000 lbs. Our surgeons prefer to place patients in the supine position with a footboard, but some programs use specialty beds with split-leg braces and stirrups to position patients in the lithotomy position, for physicians who like to stand between patients' legs while operating.

Patient transfer devices such as air-filled mats and air-filled lifts, which can lift patients from the floor to stretcher height, are essential pieces of equipment for ensuring the safety of your staff. Many anesthesia providers use foam wedges to ramp up patients' upper bodies to ease difficult intubations. Your nursing team must ensure patients' pressure points are padded correctly, an especially important precaution when operating on obese individuals. The positioning devices you'll need are based on surgeon preferences, but you likely won't need to buy beyond what you're already using for general surgery patients.

Know, too, that patient comfort is extremely important. Ensure waiting room furniture and restroom facilities can accommodate bariatric patients and stock adequately sized patient gowns, robes and socks.

3. Patient selection
Centers of excellence guidelines limit the age, weight and BMIs for outpatient bariatrics. We follow those guidelines, limiting eligible candidates for surgery to individuals with BMIs of 55 or less. As with any procedure performed in the outpatient setting, it's best to perform gastric banding on patients able to ambulate soon after surgery. In fact, getting patients up and moving as quickly as possible is essential to the procedure's success. Patients should be walking circuits around the PACU 30 to 60 minutes after the procedure's conclusion, be ready for discharge within a couple hours, and be committed to walk for 40 minutes every day for 10 minutes at a time during the first 2 weeks post-op.

4. Anesthesia expertise
Difficult airways are always a concern in obese patients due to excess neck tissue that can collapse on the airway after sedation. Keep a difficult airway cart on hand filled with the tools needed to manage challenging intubations such as bronchoscopes and video laryngoscopes. Providers must be skilled in managing medication administration to obese individuals, specifically to control PONV. That's an unpleasant side effect after any surgery, but it's particularly important to limit its risk in these patients because retching and vomiting can cause band-related complications. To that end, avoid the use of narcotics to control post-op pain and give all patients the same anti-emetic regimen, which has kept our PONV rate at a low 2%: scopolamine patches, Zofran (ondansetron), Reglan (metoclopramide) and Decadron (dexamethasone).

Proceed with caution
Gastric banding case volumes appear to be leveling off after a significant 5-year growth. More insurance plans are covering the procedure that clearly benefits patients, but it's been a challenging development for surgery centers. Be prepared for difficult negotiations in securing reimbursements that cover case costs and the significant expense of the gastric band. Emphasize the current high demand for the procedure, along with successful case outcomes and low complication rates, to get paid what you deserve.