Establishing a Laparoscopic Bariatric Surgery Program in the Nation’s Oldest Public Hospital

Bellevue Hospital Center: New York, New York

by Manish Parikh, MD; JK Saunders, MD; Marina Kurian, MD; George Fielding, MD; Christine Ren, MD; and H. Leon Pachter, MD

All from the Department of Surgery, NYU School of Medicine

Rationale for Initiation of a New Program
Of the millions of morbidly obese Americans eligible for bariatric surgery, a disproportionate number are minorities, poorly educated, or impoverished, and up to 38 percent rely on Medicare or Medicaid1 for their health insurance. Of the morbidly obese population:
• 21% are African-American
• 10% are Hispanic
• 29% live near or below the poverty line
• 54% have a high school education degree or less
• 19% have Medicaid.

Despite increasing numbers of bariatric procedures performed nationwide, (from 72,000 in 2002 to 200,000 in 2007), the subset of morbidly obese described above are underutilizing bariatric surgery, likely due to lack of healthcare access. In a recent analysis of nationwide trends of bariatric surgical procedures being performed, Hantry et al2 found that a disproportionate, higher number of patients with private insurance or who reside in wealthy zip codes seek bariatric surgery, and these proportions have been increasing over time. Contrarily, an increasingly lower percentage of patients undergoing bariatric surgery are those earning less than $25,000 or those who are Medicaid patients.

Thus there is a significant mismatch between the population needs for bariatric surgery and its availability. Nineteen percent of morbidly obese people have Medicaid insurance, yet only five percent of the bariatric operations are being done on Medicaid patients. There are clearly substantial numbers of patients who are eligible for bariatric surgery who are unable to receive this lifesaving operation due to the lack of access to obesity surgery treatment. These patients have financial limitations that preclude them from seeking bariatric surgery at private hospitals.

Bellevue Hospital Center in New York City is the oldest public hospital in the US (founded in 1736). As the flagship 900-bed facility and tertiary referral center of New York City’s Health and Hospitals Corporation (comprising 13 hospitals overall), Bellevue handles 500,000 outpatient clinic visits, 100,000 emergency patients, and 26,000 inpatients each year. The hospital has an attending physician staff of 1,800 and over 1,000 housestaff from its neighboring academic affiliate, New York University School of Medicine. Over 80 percent of Bellevue’s patients come from the city’s medically underserved populations. Demographic data of the Bellevue Hospital Adult Primary Care Clinic revealed that 41 percent of patients have BMI>30kg/m2 and 10 percent have BMI>40kg/m2. In other words, 1 out of every 10 adults seen at Bellevue fulfills National Institutes of Health (NIH) criteria for bariatric surgery! It is only fitting that Bellevue Hospital offers laparoscopic bariatric surgery in order to make a major impact on the underserved morbidly obese of New York City.

Guidelines for Starting a Laparoscopic Bariatric Program
The most critical factor for success in starting a new program is an institutional commitment at the highest level (medical and administrative). Armed with clinical and financial data, we created a blueprint of the potential program. Planning commenced in September 2007 with the creation of a Bariatric Surgery Task Force that established clinical and administrative workgroups responsible for the development of various aspects of the program. In order to ensure the delivery of bariatric surgical care with the highest levels of efficacy and safety, the Center of Excellence (COE) criteria set forth by the American Society for Metabolic and Bariatric Surgery (ASMBS) were used as guidelines (Table 1). The workgroups formed centered on fulfilling these COE criteria ranging from credentialing/privileging issues (medical staff), space preparation and support needs—including appropriate furnishings, and floor-mounted toilets (facilities management), and operating room equipment/supplies, including high-weight capacity surgical beds, long laparoscopic trays, heavy duty chairs, and larger-sized patient gowns (materials management and perioperative services).

In addition, a staff education workgroup was formed to coordinate educational in-services for clinical and non-clinical staff. Quality management developed performance-monitoring tools (based on the Bariatric Outcomes Longitudinal Database [BOLD] created by the Surgical Review Corporation) and data collection resources and established an interdisciplinary forum for the continuous review and evaluation of the bariatric program. The public relations department developed program brochures (in English and Spanish) and informational materials for patients. Fortunately, we were able to draw upon the vast experience and expertise of the highly successful NYU Program for Surgical Weight Loss (Drs. Kurian, Fielding, and Ren).

The goal of this program is to develop a comprehensive “Center for Obesity and Metabolic Diseases” that encompasses medical weight management, nutritional counseling, psychological therapy, and bariatric surgery. A preexisting Medical Weight Management Clinic (for patients with BMI>30) serves as the referral base for the bariatric surgery program. The medical weight management clinic receives 20 to 30 referrals monthly, has a six-month waiting list of over 200 patients, and has a payor mix of 57% Medicaid, 24% uninsured, 14% Medicare, and 5% commercial insurance. We work closely with the finance department to enroll the uninsured morbidly obese in Medicaid or a managed Medicaid program.

The weekly bariatric surgery clinic opened in November 2007. Nutritional counseling and evaluation has been provided by a nutritionist employed at Bellevue Hospital. Preoperative psychiatric evaluation has been done by an in-house psychiatrist.

We set the following guidelines to preclude adverse outcomes during the early phases of this program:
• We started with laparoscopic adjustable gastric banding only because of its known safety profile.3
• We deferred surgery on the superobese (BMI>50kg/m2) since this subset has a higher overall operative risk; they are more technically challenging and have a higher likelihood of sustaining a postoperative
complication.4
• We deferred patients 65 years and older.
• We do not offer bariatric revision surgery during the early phases— revision surgery is also associated with a higher incidence of
complications/mortality.5
• Preoperatively, all patients are placed on a very-low calorie diet (e.g. Optifast) to decrease hepatomegaly and to make the surgery less technically demanding.6
• Two laparoscopic/bariatric fellowship-trained attendings have been scrubbed on all cases to minimize operative complications.
• We created a dedicated bariatric anesthesia team and anesthesia clinical pathway to standardize intraoperative and perioperative care for the bariatric patient.
• We created a dedicated OR team (i.e. scrub techs and circulators) and have identified one operating room where these procedures take place.
• We created a clinical pathway to facilitate the standardization of perioperative care, including sending all patients to a monitored setting the first postoperative night.
• We have 24-hour access to a full complement of various consultative services required for the care of the bariatric surgical patient, including round-the-clock availability of an in-house surgical attending physician (since Bellevue Hospital is a Level 1 Trauma Center).
• We have a full-time SICU staff with extensive experience managing critically ill, morbidly obese patients with ventilators and invasive hemodynamic monitoring technologies.

We successfully performed the first laparoscopic bariatric surgery at Bellevue Hospital in January 2008. Approximately 20 cases have been done in the first three months. Our first bariatric support group met in March 2008. In order to create a bona fide comprehensive center, the Medical Weight Management Clinic and the Bariatric Surgery Clinic are in the process of merging. Furthermore, we are working closely with the hospital’s department of psychiatry to integrate behavioral therapy and psychotherapy into our postoperative support groups.

The research opportunities from this endeavor are unparalleled. Our research focus will include diabetes/metabolic disease resolution and obesity outcomes for different therapies (surgical/nonsurgical). The eventual creation of a multidisciplinary center for obesity and metabolic disease will provide the ideal setting for fruitful interdisciplinary research, including randomized-controlled trials. Furthermore, since Bellevue Hospital is the tertiary referral center for the New York City public hospital system, there are significant opportunities to expand, including adolescent bariatric surgery, post-bariatric plastic surgery, and beyond.

Conclusion
A laparoscopic bariatric surgery program can be initiated at a public hospital with the appropriate institutional commitment. COE criteria provide an ideal framework to develop a program. Certain safeguards can be instituted during the early phases of the program to help avoid adverse outcomes. Obtaining good clinical outcomes, especially at the outset, is paramount to a successful bariatric program. This program has the opportunity to make a major medical impact on the underserved morbidly obese of New York City.

References
1. Livingston E, Ko C. Socioeconomic characteristics of the population eligible for obesity surgery. Surgery. 2004;135:288–296.
2. Hantry H, Gillen D, Lauderdale D. Trends in bariatric surgical procedures. JAMA. 2005; 294:1909–1917.
3. Parikh M, Laker S, Weiner M,, et al. Objective comparison of complications resulting from laparoscopic bariatric procedures. J Am Coll Surg. 2006;202:252–261.
4. Fernandez A, Demaria E, Tichansky D, et al. Multivariate analysis of risk factors for death following gastric bypass for treatment of morbid obesity. Ann Surg. 2004;239:638–703.
5. Behrns K, Smith C, Kelly K, et al. Reoperative bariatric surgery—lessons learned to improve patient selection and results. Ann Surg. 1993; 218:643–653.
6. Lewis M, Phillips M, Slavotinek J, et al. Change in liver size and fat content after treatment with Optifast very low calorie diet. Obes Surg. 2006;16:697–701.

Tags: Bariatric Center Spotlight

Category: Bariatric Center Spotlight, Past Articles