As a minimally invasive, rapid recovery option for weight-loss surgery, laparoscopic adjustable gastric banding has been gaining interest among outpatient surgery facilities seeking to add bariatric services to their lineups. It's been a fairly lucrative procedure for us, and it doesn't take much longer than other laparoscopic procedures to complete. In the two years that we've hosted gastric banding, we've had two general surgeons complete about 350 cases. Here's how we built a successful program.

First steps
Each of the options for bariatric surgery involves the resizing of the patient's stomach to limit its capacity. While gastric bypass, bilio-pancreatic diversion with duodenal switch and other procedures accomplish this through the removal of a portion of the stomach (and by attaching the remainder to the middle of the small intestine), gastric banding reshapes the stomach in place. The surgeon laparoscopically wraps a saline-filled silicone ring around the upper part of the stomach to reduce its size. In the months and years following the surgery, this pouch can then be adjusted by adding or removing saline through a subcutaneous port during follow-up visits to the surgeon's office.

Our multi-specialty ASC had been open for about a year when one of our general surgeons, William Neal, MD, FACS, FASMBS, proposed bringing gastric banding to our ORs. He'd been routinely performing the surgery at the hospital with which we're joint ventured, but the schedule there didn't always allow him the time to undertake the volume he'd wanted to. So he met with our then-executive director, Paul Wilkinson, a former administrator at the hospital who'd formed a working relationship with Dr. Neal, to discuss the procedure and the possibility of offering it here.

One of Mr. Wilkinson's first concerns was whether the center was sufficiently prepared for gastric banding surgeries. Do we have the space, the staff and the equipment needed to handle it?, he asked. He ascertained what Dr. Neal required before he could begin, with one major caveat: He was not going to replace the ORs' surgical tables with heavyweight versions. Dr. Neal agreed that they wouldn't be necessary for the weight-limited patients who would be selected for the procedures.

Our center was already equipped for other laparoscopic procedures, so we already had video towers, scopes, cameras and related equipment. We had to purchase the specialized instruments required for bariatric surgery, an outlay of about $8,000. Sturdy footboard table attachments were necessary to keep patients from sliding down when the procedure required the table slightly sloped to elevate their heads. We were already purchasing new recliners for post-op, so we made sure they were rated for 475 pounds.

Two companies have the FDA's approval to market the stomach-resizing implants in the United States: Allergan, which offers the Lap-Band, and Ethicon Endo-Surgery, which offers the Realize Band. Dr. Neal purchases and supplies those for the procedure. Other than the bands, there is surprisingly little that's needed in the way of supplies. Our surgeons request large-sized thromboembolic deterrent stockings, and we supply extra-large-sized surgical gowns for patients' modesty and comfort.

We brought our medical director, an anesthesia provider, in on the planning since it's crucial for any ambulatory surgery facility that's adding services to ensure they'll be able to deliver outpatient, not inpatient, anesthesia. A combination of medications that dissipate quickly and minimize, to the extent possible, post-operative nausea and vomiting is ideal.

As with other laparoscopic procedures, gastric banding demands an OR staff that is able to operate the camera and otherwise assist the surgeon. We sent a circulator and scrub tech to observe Dr. Neal doing cases in the hospital OR before we started them here, then asked them what we'd need, how the cases proceeded and how the rooms were set up. At first we'd trained only selected members of our staff to serve as a consistent team for gastric banding cases, but before long all surgical staffers were able to step in. We kept our pre-op and PACU nurses in the loop about the upcoming new service and its demands, and made sure our central sterile department was up to speed on the proper care and handling of laparoscopic instruments.

Patient selection
Successful gastric banding in an ambulatory setting depends largely on selecting the patients who can be treated most efficiently. By the time a patient reaches our OR, the general surgeon is already well aware of his health factors. He's completed a history and physical and screened for co-morbidities during the pre-op educational seminars and counseling sessions he and his staff hold in his office.

Dr. Neal and our surgery center set a weight limit of 325 pounds for his outpatient gastric banding patients. It would have been possible for us to handle patients of 350 or even 400 pounds before we were limited by our tables' weight capacities, but Dr. Neal reasoned that beyond 325 pounds we'd be more likely to encounter airway, intubation and anesthesia management difficulties, issues that can present undue risks in a freestanding surgery center.

This weight limit is also intended to protect the nurses and techs charged with lifting and transporting the patients. We've purchased, and we use, patient lift assistance devices, which work wonders. But the potential risk of employee injuries increases as a patient population's weight rises.

We do our own pre-op telephone interviews and physical assessments as well. We can handle patients who suffer from diabetes and other systemic disease processes, but we always exclude patients who have recently suffered myocardial infarctions, who have significant dysrhythmia, whose lungs aren't conducive to lying flat or who have a difficult intubation history.

Our anesthesia providers were initially very hesitant about the new service, envisioning patients with no necks and impossible airways, and cautiously required every gastric banding patient with a body mass index of greater than 40 to undergo an eyes-on assessment before the day of surgery. As we successfully conducted more and more of the surgeries, however, they quickly realized that body mass index alone was not a rock-solid indicator, and that airway complications could happen to any patient. In fact, our gastric banding patients weren't showing any more problems than our laparoscopic cholecystectomy or septoplasty patients. They still do standard anesthesia reviews, as with all patients, and we avoid taking patients with ASA scores of 3 or 4.

All of our patients are self-paying, which offers the economic advantage of decreasing each case's time in accounts receivable. While most insurance companies' contracts now include provisions for bariatric surgery, their reimbursement is typically geared toward the treatment of patients over a certain weight level and who suffer from defined co-morbidities. Medicare, for instance, presently covers patients with a body mass index of 35 or higher and who suffer from at least one co-morbidity related to obesity (and the facility in which they undergo surgery must be certified by the American College of Surgeons or the American Society for Metabolic and Bariatric Surgery). But those weights and conditions are frequently not conducive to the ambulatory surgery setting.

Inside the outpatient method
Our gastric banding patients go from door to door in less than five hours. Their OR time typically ranges from one hour to 90 minutes. They spend about an hour in phase one recovery and another hour or 90 minutes in phase two recovery. Our average room turnover after a procedure is 14 minutes and no more complex than turnover for any other general surgery case.

We let Dr. Neal schedule four gastric banding cases during his regular weekly block of 7:30 a.m. to 3 p.m. When we began hosting the surgery, we limited him to two cases in a block to see how well it worked and to avoid overwhelming ourselves. Once we'd smoothed out the process, we were able to book more cases per block.

As with any procedure, and as with any patient undergoing surgery in any specialty, the outpatient method is the same: get them into the OR, successfully treat them, ensure their recovery and ambulation, and then get them home. Pre-op is standard operating procedure. We start their IV, administer antibiotics and conduct a physical assessment. But we also let patients walk from their pre-op bay to the OR, which offers them a bit of motivation. They're not sick, after all, and this helps to reinforce in them the knowledge that they're healthy now, and they're going to be healthy and recovering after the surgery.

In post-op, gastric banding patients require specialized care on account of their reshaped stomachs. We begin their recoveries with intravenous narcotics, but since they are on fluid restrictions, they cannot swallow pills. Our post-op pain management regime is hydrocodone or oxycodone elixirs and ice chips for comfort.

On occasion we've had patients who required transfers to the hospital. Some early cases saw cardiac complications, which were unpredictable, or extreme nausea, which led our anesthesia providers to adapt their methods. But there has been no commonality to our post-gastric banding admissions, and in fact they number fewer than our post-lap chole admissions.

As we've handled more of this type of case, we've come to learn that getting the patients into the post-op recliners as soon as possible helps to speed their recoveries. While most PACU wards reserve recliners for phase two recovery, we move our phase one patients into the chairs if they're alert enough. The earlier you get them into the recliners, the better they do, if only because it motivates them with the confidence that their procedure was a success and so is their recovery.

This confidence is important because we've also found that our gastric banding patients are time-intensive in post-op. As a class, they tend to require more emotional attention than the average patient, and by the end of the day it can wear a PACU nurse out. Fortunately, however, our general surgeons are very accessible to their patients and have educated them pre-emptively and thoroughly. In fact, our surgeons have even directed us not to give their patients any specific post-op instructions (other than not to drive themselves home), since they've already given their own.

Better than expected
Laparoscopic adjustable gastric banding has been a good addition to our case mix. I'll admit it took a little fine tuning, and there were a couple of rough patches, but bringing it to our center wasn't nearly as difficult as I'd originally imagined it would be. For most ASCs, a diverse case mix is a lucrative case mix, and this adds to our diversity.