Some bariatric cases move to outpatient arena

Special supplies, equipment needed for success

When a surgeon wants to offer a new procedure, same-day surgery program managers have to make sure that proper supplies, equipment, and staff are available for the procedure. With bariatric surgery, or weight-loss surgery, managers are in new territory.

"The bariatric patient population has specific needs related to their size that most patients don’t have," says DeNene G. Cofield, RN, BSN, CNOR, director of surgical services and orthopedic and bariatric service line manager at Medical Center East in Birmingham, AL. "Stretchers, operating tables, wheelchairs, blood pressure cuffs, scales, and gowns all have to be sized and designed to hold larger, heavier patients than normal," she explains. For example, her program stocks gowns sized 1XX to 10XX to make sure that patients don’t have to tie two gowns around themselves to be fully covered, she adds.

While most bariatric surgical procedures require at least a one-night stay in the hospital, the laparoscopic gastric bypass and the Lap-Band procedure enable some patients to undergo the procedure as an outpatient or 23-hour stay patient, Cofield says.

In June 2002, the Food and Drug Administration approved the Lap-Band Adjustable Gastric Banding System, manufactured by Inamed Health (formerly Bio-Enterics Corp.) in Santa Barbara, CA. The Lap-Band is not appropriate for all patients and does have some limitations on outcome, she says.

The Lap-Band is put into place laparoscopically, she says. The band is inflated with saline and can be adjusted over time to help patients meet their weight loss goals, she says. The adjustments are made on an outpatient basis, through a portal under the rib cage and the surgeon uses a needle to remove or add saline. Because the band limits how much the stomach can hold, patients lose weight, Cofield explains.

"The weight loss is only half of the amount of weight lost with traditional bariatric surgery," she explains. Some patients who have a body mass index that is higher than a surgeon believes is safe for traditional surgery may choose Lap-Band to lose enough weight to qualify for other surgery, she says.

"We’ve also had orthopedic surgeons ask for information on our program because they have older patients with knee or other joint problems that are difficult to treat because of the patients’ weight," Cofield says. An older patient with arthritic knees can improve the quality of life and increase the effectiveness of other treatment by reducing weight on the joints, she points out.

Not all bariatric surgeons like the Lap-Band procedure, however. "The Lap-Band trials in the United States have not duplicated the European results, so I’m not convinced of its effectiveness," says Troy LaMar, MD, a general surgeon at Arcadia (CA) Methodist Hospital. "With Lap-Band, you are placing a foreign body that can migrate or erode into a patient," he says. The laparoscopic gastric bypass is the procedure that he most often performs for bariatric patients, he says.

"Almost everyone is a candidate for laparoscopic gastric bypass, even patients with previous abdominal surgeries," LaMar says. Ninety percent of the gastric bypasses performed by LaMar and his partners are performed laparoscopically, he adds.

In a gastric bypass procedure, the surgeon creates a pouch that holds about 20 cc by dividing the stomach close to where it attaches to the esophagus. The stomach "pouch" is then connected to the small intestine, LaMar explains.

When credentialing surgeons to perform the laparoscopic gastric bypass, be sure to look for a general surgeon who successfully has performed the open procedure and also has advanced laparoscopic skills, LaMar says. "Surgeons should take courses to obtain formal training on the procedure and should be proctored as well," he adds.

Patient selection for bariatric surgery is important, Cofield says. The National Institutes of Health in Bethesda, MD, defines the ideal patient as between ages 18 and 55 and highly motivated to lose weight, she says. "Patients also undergo a complete physical, a sleep study, and a psychological evaluation," Cofield adds. Patients also attend a nutrition class and a bariatric surgery class prior to the procedure, she says.

"Unlike other surgical procedures, this is not the end of treatment for a disease," Cofield says. "This is the beginning of the treatment, so we want to make sure they are motivated and psychologically prepared for the lifestyle changes they’ll be making."

The gastric bypass generally is covered by insurance, Cofield says. The Lap-Band procedure isn’t covered at this time, she adds. That has not prevented patients from choosing the $15,000 to $20,000 procedure as a way to lose weight without the longer recovery time of the gastric bypass, she adds.

Before any surgical facility considers adding bariatric surgery, remember that unlike many same-day surgical procedures, this must be part of an overall program, Cofield says. Since the majority of procedures do require an overnight stay at this time, the program must encompass inpatient as well as outpatient surgery, radiology, lab, and nursing, she says. Support groups and nutrition counseling also are important, she adds. Staff need to develop a sensitivity to working with morbidly obese patients, she says. "All of our staff members are undergoing sensitivity training because everyone, from patient transport to cafeteria staff to all clinical staff, has contact with our bariatric patients," Cofield says.

The sensitivity training course was designed and is conducted by Rona Scott, coordinator of the bariatric surgery program at Medical Center East and a former bariatric surgery patient. The goal is to make all employees sensitive to the needs of the obese population through a general orientation, Scott says. "We offer a more in-depth course to nurses and other caregivers so they understand the specific needs of the obese," Scott says. For example, obese patients have specific hygiene issues, they tend to be very hot-natured, and they often suffer from low self-esteem, she says. "We stress that obese patients deserve the same care and respect as other patients, and point out that they should not be openly hesitant to help an obese patient move from the stretcher to the bed, or make comments about a patient’s size," Scott points out.

Once employees complete the course, they are given a blue ribbon to wear. Bariatric patients are told that the blue ribbon indicates an employee who can help them with their special needs, she adds.

No bariatric program can succeed if staff members are insensitive to patients’ needs, she says. "Our patients need to know that they can ask for information or for help without feeling embarrassed," Cofield says.

Resources

For information about setting up a bariatric surgery program, contact:

DeNene G. Cofield, RN, BSN, CNOR, Director of Surgical Services and Orthopedic and Bariatric Service Line Manager, Medical Center East, 50 Medical Park East, Birmingham, AL 35235. Telephone: (205) 838-3560. E-mail: dgcofield@ehs-inc.com.

Troy LaMar, MD, General Surgeon, Arcadia Methodist Hospital, 622 W. Duarte Road, Suite 301, Arcadia, CA 91007. Telephone: (626) 445-0600. Fax: (626) 574-8654. E-mail: cssweightloss@hotmail.com. Web: www.csscenters.com.

For information about bariatric surgery and related products, contact:

Amplestuff, Department WS, P.O. Box 116, Bearsville, NY 12409-0116. Telephone: (866) 486-1655 or (845) 679-3316. E-mail: amplestuff@aol.com. Web: www.amplestuff.com. Offers gowns and scales for obese patients.

American Society for Bariatric Surgery, 7328 W. University Ave., Suite F, Gainesville, FL 32607. Telephone: (352) 331-4900. Fax: (352) 331-4975. Web: www.asbs.org.

Inamed Health (formerly Bio-Enterics Corp.), 5540 Ekwill St., Santa Barbara, CA 93111. Telephone: (805) 683-6761. Fax: (805) 684-0812. Web: www.inamed.com.

National Institutes of Health, National Heart, Blood, and Lung Institute, Bethesda, MD 20892. Telephone: (301) 496-4000. Web: www.nhlbi.nih.gov/guidelines/obesity/ob_home.htm. Web site contains obesity guidelines for diagnosis and treatment.

National Institutes of Health, Weight Control Information Network, Bethesda, MD 20892. Telephone: (877) 946-4527 or (202) 828-1025. Web: www.niddk.nih.gov/health/nutrit/pubs/gastsurg.htm. Contains information about gastric surgery that can be used for patient education.