[Certification of therapy institutions, obesity trainers, and obesity trainer academies by the German Working Group on Obesity in Children and Adolescents (AGA)]. / Was hat die Arbeitsgemeinschaft Adipositas im Kindes- und Jugendalter durch die Zertifizierung von Behandlungseinrichtungen, Adipositas-Trainern und Adipositas-Trainer-Akademien erreicht?

There is a vast choice of behavioral therapy for obesity in children and adolescents, with wide differences in quality. In order to provide orientation for families, physicians, and health insurance companies, the German Working Group on Obesity in Children and Adolescents (AGA), which is affiliated with the German Obesity Society (DAG) and the German Pediatric Society (DGKJ), offers to certify institutions providing patient education programs for obese children and adolescents, obesity trainers, and academies for obesity trainers. Currently, 60 institutions offer obesity care, while 81 obesity trainers and 8 trainer academies are certified. This article summarizes requirements for certification and preliminary experience.

Evaluation of Dietary Assessment Tools Used in Bariatric Population.

Severe obesity is associated with major health issues and bariatric surgery is still the only treatment to offer significant and durable weight loss. Assessment of dietary intakes is an important component of the bariatric surgery process. OBJECTIVE: To document the dietary assessment tools that have been used with patients targeted for bariatric surgery and patients who had bariatric surgery and explore the extent to which these tools have been validated. METHODS: A literature search was conducted to identify studies that used a dietary assessment tool with patients targeted for bariatric surgery or who had bariatric surgery. RESULTS: 108 studies were included. Among all studies included, 27 used a dietary assessment tool that had been validated either as part of the study per se (n = 11) or in a previous study (n = 16). Every tool validated per se in the cited studies was validated among a bariatric population, while none of the tools validated in previous studies were validated in this population. CONCLUSION: Few studies in bariatric populations used a dietary assessment tool that had been validated in this population. Additional studies are needed to develop valid and robust dietary assessment tools to improve the quality of nutritional studies among bariatric patients.

Clinical Practice Guidelines for the Perioperative Nutrition, Metabolic, and Nonsurgical Support of Patients Undergoing Bariatric Procedures - 2019 Update: Cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic and Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists.

OBJECTIVE: The development of these updated clinical practice guidelines (CPGs) was commissioned by the American Association of Clinical Endocrinologists (AACE), The Obesity Society (TOS), American Society for Metabolic and Bariatric Surgery (ASMBS), Obesity Medicine Association (OMA), and American Society of Anesthesiologists (ASA) Boards of Directors in adherence with the AACE 2017 protocol for standardized production of CPGs, algorithms, and checklists. METHODS: Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts. RESULTS: New or updated topics in this CPG include: contextualization in an adiposity-based chronic disease complications-centric model, nuance-based and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current health care arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest). CONCLUSIONS: Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence based within the context of a chronic disease. A team approach to perioperative care is mandatory, with special attention to nutritional and metabolic issues.

Design and validation of a low cost, high-capacity weighing device for wheelchair users and bariatrics.

Accessible high-capacity weighing scales are scarce in healthcare facilities, in part due to high device cost and weight. This shortage impairs weight monitoring and health maintenance for people with disabilities and/or morbid obesity. We conducted this study to design and validate a lighter, lower cost, high-capacity accessible weighing device. A prototype featuring 360 kg (800 lbs) of weight capacity, a wheelchair-accessible ramp, and wireless data transmission was fabricated. Forty-five participants (20 standing, 20 manual wheelchair users, and five power wheelchair users) were weighed using the prototype and a calibrated scale. Participants were surveyed to assess perception of each weighing device and the weighing procedure. Weight measurements between devices demonstrated a strong linear correlation (R2 = 0.997) with absolute differences of 1.4 ± 2.0% (mean±SD). Participant preference ratings showed no difference between devices. The prototype weighed 11 kg (38%) less than the next lightest high-capacity commercial device found by author survey. The prototype's estimated commercial price range, $500-$600, is approximately half the price of the least expensive commercial device found by author survey. Such low cost weighing devices may improve access to weighing instrumentation, which may in turn help eliminate current health disparities. Future work is needed to determine the feasibility of market transition.

Centers of Excellence in Bariatric Surgery: design, implementation, and one-year outcomes.

BACKGROUND: Bariatric surgery procedures increased from <20,000 annually in the early 1990s to >100,000 in 2003. The complications related to surgery have increased disproportionately, causing some payers to discontinue coverage for bariatric procedures and reducing patient access to an effective treatment modality. This report describes an alternative approach-the creation of a network of Centers of Excellence (COE) in Bariatric Surgery. METHODS: Blue Cross and Blue Shield of North Carolina developed a COE program by working collaboratively with the bariatric surgery community. Through systematic review, the collaborative identified bariatric surgical programs that appropriately select patients, comprehensively evaluate and prepare patients for surgery, produce superior outcomes, and provide long-term follow-up for patients. RESULTS: Seven practices were selected as Blue Cross and Blue Shield of North Carolina Bariatric Surgery COE. The short-term results comparing the 12 months before COE implementation and the 12 months after implementation included a 14% decline in the number of bariatric procedures performed (693 versus 596), a 23% decrease in the number of surgeons billing for bariatric procedures (53 versus 41), a 30-day readmission rate of 4.7% for COE providers and 8.3% for non-COE providers, and an average inpatient length of stay of 2.5 days for COE providers and 3.0 days for non-COE providers. The proportion of procedures performed by the COE providers increased from 55% to 61%. CONCLUSION: The preliminary results are encouraging, with COE providers demonstrating reduced 30-day readmission rates and, surprisingly, overall reductions in the rate and number of procedures performed and the number of physicians performing them.

The ASBS Bariatric Surgery Centers of Excellence program: a blueprint for quality improvement.

BACKGROUND: Variations in the techniques of bariatric surgery, coupled with the lack of a common database, has led to variable and, sometimes negative, outcomes from bariatric surgery. Thus, in November 2003, the American Society for Bariatric Surgery established Surgical Review Corporation (SRC) as an independent nonprofit entity for quality control of bariatric surgery and as a resource for data collection and analysis. METHODS: In November 2003, the leadership of the American Society for Bariatric Surgery founded SRC as an independent nonprofit entity for quality control of bariatric surgery and as resource for research. A national set of standards for the Bariatric Surgery Centers of Excellence program was developed using a meta-analysis of the relevant published English language data, a consensus conference at Georgetown University, and participation by stakeholders from industry, third-party payors, and malpractice carriers. A software program was developed to provide uniformity in data collection and ease of analysis. RESULTS: SRC developed standards that have been accepted by the bariatric surgical community and put in place. A system was developed for the designation of two levels for the centers, provisional and full. The growth of the Centers of Excellence program has been rapid. At present, 135 hospitals and 265 surgeons have achieved full approval. The centers for Medicare and Medicaid Services have recognized the program. On the basis of the reports of 55,567 patients from the first 176 applicants for full approval and confirmed by SRC during site inspections, the 90-day operative mortality rate was 0.35%. CONCLUSIONS: The first phase of development has gone well. Future steps include the development of a network of bariatric physicians and the development of a consortium for research.

The use and modification of clinical pathways to achieve specific outcomes in bariatric surgery.

Clinical pathways are promoted for standardizing patient care and decreasing resource use without compromising outcome. Once established, we hypothesized that clinical pathways can then be used to modify patient care to achieve specific goals. Our aim was to evaluate a clinical pathway for the bariatric surgical patient that was initially designed to standardize care and later altered to modify the postoperative course. We retrospectively reviewed 150 consecutive patients undergoing open gastric bypass by a single surgeon. The first 50 patients were managed without a formal pathway, (group I). The next 50 were managed with a pathway that standardized care in order to reduce length of stay (LOS), (group II). For the final 50 patients, the pathway was modified to shorten nasogastric decompression time (group III). Patient information, blood loss (EBL), operative time, length of stay (LOS), nasogastric decompression, 30-day complication rates, and early readmissions were reviewed. The groups were similar with respect to gender, age, body mass index, American Society of Anesthesiologists (ASA) classification, and EBL. Operative time was significantly less in groups II and III compared to group I (82% and 68% vs. 38% <180 minutes, P < 0.05). LOS was shorter in groups II and III compared to group I (62% and 42% vs. 20% with a 4-day LOS, P < 0.05). Duration of nasogastric tube decompression was successfully decreased in group III when compared to groups I and II (76% vs. 14% and 6% 1 day or less, P < 0.05). Complication rates were significantly lower in group III as well (14% vs. 36% and 28%, P < 0.05). Standardizing patient care with a clinical pathway decreases LOS after bariatric surgery. An established clinical pathway can then be used to further modify patient care in order to achieve specific goals, such as shortened time of nasogastric decompression. This goal was accomplished without compromising patient outcome.

[Bariatric surgery in France: results of a nationwide prospective survey]. / La chirurgie de l'obésité en France: résultats d'une enquête prospective nationale.

AIM: To compare the actual practice of bariatric surgery in France with the guidelines of scientific societies regarding surgical indications and followup. METHODS: This a prospective descriptive transversal study performed within a two month period (December 2002 - January 2003) in all patients for which a consent demand has been sent to the Medical Insurance Services (examined by an administrative consultant) and/or patients operated on for morbid obesity (with or without administrative consent). RESULTS: One thousand and three patients have been examined by an administrative consultant before obesity surgery and 1238 patients have been operated in 263 centres including 79 public (non-profit) centres and 184 private centres. In 16.7 % of the cases, there were wrong indications according to recognized criteria (BMI<35 kg/m(2) or lack of comorbidities for BMI between 35 and 39) or even contraindications because of other diseases. Patient informed consent was retrieved in only 54 % of medical files and follow up protocol was done in only 47 % of the cases. Because of several missing data, the practice of bariatric surgery followed the guidelines in only 34 % of cases. In hospital morbidity rate was 5 %. Two patients died postoperatively (mortality rate 0.2 %). CONCLUSIONS: This study demonstrates that the practice of bariatric surgery needs to be improved in France.

Bariatric and associated operations in private and academic practices.

BACKGROUND: The types of bariatric and the associated operations performed by academic and private surgeons were surveyed. METHODS: A survey containing 8 questions regarding type of practice, type of surgery, associated procedures during bariatric surgery, years in practice and bariatric training was e-mailed to all members of the American Society for Bariatric Surgery. RESULTS: 46% of the members responded and were divided between those who performed their procedures laparoscopically and those who performed open procedures. Laparoscopic adjustable gastric banding was almost exclusively performed in academic centers and encompassed 20% of their bariatric operations, while the gastric bypass was the most common operation performed (65%), followed by vertical banded gastroplasty and duodenal switch. Operations performed simultaneously indicated that cholecystectomies were performed equally in private practice (92.5%) and the academic sector (95%), with higher incidence in open procedures (95%) compared to laparoscopic (40%). Of the surgeons performing appendectomies, 20% were in private practice and 10% in academic. Liver biopsy was performed with the same incidence in private and academic practices (60%). A minority of responders had formal fellowship training (17%), and many had learned from a partner (40%). The approach was dictated by the surgical training (85%) and background. CONCLUSION: No significant difference was found between the private and academic surgeons in performing operations. Appendectomy is rarely performed academically, and cholecystectomy is mostly performed in the open procedure.

New advances in laparoscopic treatment of morbid obesity.

The prevalence of obesity in the United States (U.S.) is increasing to epidemic proportions. Currently, more than 60% of Americans and 51% of Germans are overweight. Whereas a variety of medications are available for treatment of obesity, none results in the long-term loss of more than 10% of body weight. The current standard for treatment of severe obesity, defined as a body mass index (BMI) of greater than 35 kg/m2 with comorbidities and generally greater than 40 kg/m2, is surgical. Several surgical procedures are currently available, including gastric bypass, biliopancreatic diversion (BPD) with duodenal switch, and the adjustable gastric band. These operations may be performed using laparoscopic surgical techniques to minimize perioperative morbidity and postoperative recovery time. To optimize the outcome of this type of procedure, bariatric surgery should be performed on carefully selected patients, in bariatric centers specially equipped to care for the obese, within a broadly based, multidisciplinary setting that provides lifelong postoperative care.