Bariatric and Metabolic Surgery Centre: Essential Components

Key Components of a Leading Bariatric and Metabolic Surgery Centre

Rising Incidence of Morbid Obesity

As the incidence of Morbid Obesity is rising day by day, more and more hospitals have started bariatric surgery programs. However, managing a morbidly obese patient is challenging in the way that obesity brings a lot more other diseases with it. Obstructive sleep apnea, Diabetes Mellitus type 2, Hypertension, and Hypothyroidism are a few of them.

Therefore it’s mandatory to set up a comprehensive management program for treating these patients in the best bariatric and metabolic surgery centre.

The decision to recommend bariatric surgery requires a multidisciplinary approach to evaluate the indications for surgery and to define co-morbidities properly.

Key Components of a Bariatric and Metabolic Surgery Centre

The surgeons at the best bariatric hospital must demonstrate the necessary training skills, experience, and leadership. The essential components of a bariatric surgical center include a Director, critical support, appropriate equipment and instruments, 24-hour qualified call coverage, continuous care, long-term follow-up care, and most importantly regular support groups. There must be facilities for data collection and maintaining a database. By collecting and sorting data, a well-maintained database would demonstrate past performance and help in directing future trends. Periodic evaluation and comparison will allow centers to develop improvement plans.

Role of the Bariatric and Metabolic Committee

There must be a bariatric and metabolic committee which is headed by the program director and includes the coordinator, clinical reviewer, and hospital administration staff. All the surgeons included in the committee must focus on quality improvement which includes a reduction in variation, standardization of practice, establishing selection guidelines, and quality improvements. This can result in decreasing rates of complications, re-admissions, length of stays, surgical site infections, etc. The committee also establishes pathways of care for pre-operative and post-operative management. All relevant staff must be educated in patient safety and complication recognition. The goal of the pathways is to prevent failure to rescue situations which means early recognition and treatment of the post-surgical complications.

Responsibilities of the Bariatric Surgical Care Coordinator

The Bariatric Surgical Care coordinator assists and reports to the director of the committee. The coordinator assists in center development, managing the accreditation process, maintaining relevant policies and procedures, patient education, outcomes and data collection, quality improvement efforts, and education of relevant institution staff. The coordinator supports the development of written protocols and education of nurses to recognize the critical vital signs required to minimize delays in the diagnosis of serious adverse events.

Data Management and Accreditation

The clinical reviewer enters data into relevant platforms. The reviewer should not be contributing to patient care to avoid bias.

The hospital must be accredited by relevant authorities to ensure that the care for metabolic and bariatric surgery patients is provided in a safe environment. In this respect, Apollo Hospitals New Delhi has been accredited by the JCI.

Certifications and Training

The director or the chief surgeon must have obtained a verification certificate to operate on morbidly obese patients by relevant governing bodies. These certificates are purely based on the volume of surgeries and quality of care and dedication to the practice. Similarly, there must be 24-hour call coverage for the patients attended by qualified persons.

The bariatric surgical nurse must obtain specialized training such as the Certified Bariatric Nurse certification.

Essential Support Services

There must be dedicated physicians, dieticians, psychologists and psychiatrists, social workers, and physical therapists.

Registered dieticians are absolutely essential for the success of any bariatric surgical center.

They do all the nutritional counseling and follow-up.

Psychologist and psychological evaluation is a must before any bariatric and metabolic procedure. These patients are often suffering from depression, anxiety, and other stress-related disorders. Psychological education, evaluation, and preparation are useful in achieving overall patient stability and emotional well-being.

Facilities and Equipment

Morbidly obese patients must feel welcome upon entering an institution. There must be appropriate furniture to accommodate them in the waiting room as well as the examination room. The plus size hospital clothes, beds wheelchairs, and floor-mounted toilets are a must. There must be dedicated beds or floors for bariatric surgical patients. Similarly, operating room tables and equipment are accordingly sized to the needs of such patients.

Critical Care and Anesthesia

The critical care support providers must be trained in identifying early signs of potential complications. The anesthesia team must be trained to give anesthesia to such patients taking care of DVT prevention and obstructive sleep apnea to name a few.

Various specialty consultants are also asked to give preoperative clearances to the patient in view of the existing co-morbid conditions.

Support Groups and Electronic Media

A pediatric and adolescent medical advisor is also a part of the team at the center. He/she operates on adolescent patients.

Support groups are designed for the patients who are in the recovery phase. These are primarily organized to take care of the medical, nutritional, psychological, and social issues experienced by the patients.

The development of electronic information media such as dedicated websites is an essential part of addressing various issues and reaching people in remote places.

Future Trends and Institutional Commitment

As more and more people are undergoing bariatric surgical procedures these days, the demand for safe treatment facilities will grow. According to Dr. Atul NC Peters, Senior Consultant and Head of Apollo Institute of Metabolic and Bariatric Surgery, Indraprastha Apollo Hospitals, New Delhi, India, the most important element in the best bariatric surgery center is leadership from the surgeon and integrated medical staff. They require dedication, strong fundamental infrastructure, and total institutional commitment.

Management of Diabetes After Bariatric Surgery

Effective Management of Diabetes Through Bariatric Surgery

Obesity has become the principal cause of Type 2 Diabetes Mellitus these days. Excessive fat deposition leads to insulin resistance, which results in metabolic syndrome. There are various ways to treat type 2 diabetes including lifestyle modification, weight reduction, and drugs including insulin. All these conventional methods have proved to be inefficient in achieving long-term results, highlighting the need for effective management of diabetes.

Surgery has evolved as the most efficient alternative to conventional treatment and results in sustained weight loss and remission or resolution of type 2 Diabetes.

Bariatric and metabolic surgery changes the anatomy of the gastrointestinal tract in a beneficial way, this alteration increases good hormones. After bariatric surgery, there is an augmented release of hormones like GLP-1 and PYY from the small intestine that leads to improvement in high blood sugar levels.

Since bariatric surgery is a highly efficient tool to reduce the blood sugar levels in an obese diabetic patient, there is a need for adjustment of anti-diabetes medicines in these patients post-surgery.

Moreover, there is decreased calorie intake after bariatric surgery for which dose adjustments of the anti-diabetes medicines are needed.

The post-operative diet schedule includes:

Phases 1 and 2 are of clear liquids to a full liquid diet for 2 weeks. At this stage, the calorie intake is about 600 to 800 kcal/day.
Phase 3 is of pureed diet.
Phase 4 consists of a soft to normal diet and the calorie intake is about 1200 to 1500 kcal/day.

Before surgery, patients are usually switched over to intravenous insulin, and blood glucose is monitored at regular intervals.

Similarly in the postoperative period, blood sugar is again maintained on intravenous insulin. On discharge, the patient is shifted to tablets along with long-acting insulin in most of cases for an initial few days.

The patient is taught to measure and chart blood sugar twice daily or in a few cases thrice daily and the doses are adjusted accordingly. Subsequently, as patients lose weight, there is a further decrease in the requirement for drugs. Most of the time, almost all of the drugs are withdrawn to avoid any hypoglycemic episode. It is advised to maintain a blood sugar level between 120 to 150 mg %. Remission of diabetes is seen in close to 80% of patients who do not need any treatment. There is a continuous need for follow-up with at least 3 monthly HbA1c levels.

In patients with poorly controlled diabetes mellitus, withdrawal of drugs may precipitate ketoacidosis in the early postoperative period. These patients are monitored carefully for symptoms and signs of diabetic ketoacidosis.

General guidelines:

To Monitor blood glucose at least twice a day with the aim of maintaining it between 110-180mg/dl.

Tab Metformin is started on day 1 of surgery. The long-acting insulin doses are reduced by 50%.

Signs and symptoms of stress hyperglycemia include frequent urination, increased thirst, blurred vision, fatigue, headache or ketoacidosis which includes fruity-smelling breath, nausea and vomiting, shortness of breath, dry mouth, weakness, confusion, coma, abdominal pain, etc. They must be addressed carefully and must be monitored by watching blood gases as well as urinary ketones.
Patients must be educated about signs and symptoms arising from hypoglycemic episodes (Blood sugar less than 70 mg%) like shakiness, dizziness, sweating, hunger, irritability or moodiness, anxiety or nervousness, and headache.
During such episodes, the patient must take 15-200 ml of fruit juice or milk if on a liquid diet. And if on solids, any sweet candy. Similarly patient can take curd or yoghurt if on a pureed diet.
Such people must take adequate protein to avoid episodes of hyper or hypoglycemia.

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Diabetes Mellitus Type 2 – The Permanent solution

Addressing the Growing Emergency of Diabetes Mellitus Type 2: The Role of Metabolic Surgery

With the increase in obesity during the last few years all over the world, type 2 diabetes mellitus has emerged as one of the largest emergencies related to obesity.

There are various treatment options for type 2 diabetes starting from lifestyle and dietary modifications to various drug schedules including insulin therapy.

The Rise of Metabolic Surgery

These days, metabolic surgery has emerged and is accepted as a new step in the therapeutic regimen for T2DM when lifestyle modifications and drugs don’t give the required sugar control.

Metabolic surgery involves food re-routing through modifications of the gastrointestinal tract by laparoscopic or Robotic approach, it is safe and effective for the treatment of diabetes mellitus type 2. Metabolic surgery is being considered as the only permanent solution for diabetes these days.

Not only Diabetes, this surgery has also been seen to reduce other cardiovascular risk factors (cholesterol and blood pressure) when compared with medical treatment.

The Importance of Cardiovascular Health

According to WHO high blood pressure and tobacco use are the greatest cause of premature deaths; therefore, it becomes more important to focus on preventing cardiovascular complications related to high blood glucose and cholesterol.

Evidence from Global Studies

Several studies done all over the world have demonstrated that metabolic surgical procedures improve blood glucose levels independently of weight loss and also have a positive impact on blood cholesterol and blood pressure, with a very good long-term effect on cardiovascular morbidity and mortality.

Gastrointestinal surgery for the specific intention to treat T2DM was first recommended at the 2007 Diabetes Surgery Summit.

Guidelines for Metabolic Surgery and Their Implications

After going through various studies, the American Diabetes Association has recommended and formed certain guidelines on metabolic surgery for adult patients with type 2 diabetes.

They have expanded the indications for metabolic surgery to include patients with inadequately controlled type 2 diabetes who have a BMI as low as 30 kg/m2 (27.5 kg/m2 in Asians).

With the present guidelines, metabolic surgery is considered a permanent solution for type 2 diabetes and metabolic disease.

Surgery Options for Non-Obese Patients

Not only in the obese, the need for control of diabetes in non-obese patients led to the development of Ileal Interposition surgery or Duodenojejunal bypass surgery. These can be performed in thin type 2 diabetics with BMI as low as 27.5 kg/m2 as well as those who had undergone supervised treatment schedules but still have poorly controlled disease.

However, these surgeries must be performed in specialized centers and in expert hands where these procedures are being performed regularly with long follow-up schedules.

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