Specifying a bariatric surgical service for the treatment of people with severe obesity
The key components of a bariatric surgical service for the treatment of people with severe obesity are:
- ensuring appropriate referral and assessment of people with severe obesity
- developing a high-quality bariatric surgical service.
Appropriate referral and assessment of people with severe obesity
The diagnosis, assessment and general management of obesity are described in detail in NICE clinical guideline CG43 on obesity, which recommends that, for adults, referral to specialist care should be considered if bariatric surgery is being considered. The topic-specific advisory group suggests that specialist care is provided by a multidisciplinary team that comprises of physicians, surgeons, dieticians and nurses, and should ensure a joint approach to the delivery of care based on the best available evidence.
Referral to an appropriate specialist should be considered for children who are overweight or obese and have significant comorbidity or complex needs (for example, learning or educational difficulties).
NICE clinical guideline CG43 on obesity recommends that bariatric surgery is a treatment option for adults and children if all of the following criteria are fulfilled:
- the person has a BMI of 40 kg/m2 or more, or between 35 kg/m2 and 40 kg/m2 and other significant disease (for example, type 2 diabetes or high blood pressure) that could be improved if they lost weight
- all appropriate non-surgical measures have been tried but have failed to achieve or maintain adequate, clinically beneficial weight loss for at least 6 months
- the person has been receiving or will receive intensive management in a specialist obesity service
- the person is generally fit for anaesthesia and surgery
- the person commits to the need for long-term follow-up.
In addition, bariatric surgery is recommended as a first-line option (instead of lifestyle interventions or drug treatment) for adults with a BMI of more than 50 kg/m2 in whom surgical intervention is considered appropriate.
Bariatric surgery is not generally recommended for children or young people. It should be considered for young people only in exceptional circumstances, and if they have achieved or nearly achieved physiological maturity. ‘Children' refers to anyone younger than 18 years; ‘young people' is used when referring to teenagers at the older end of this age group. Young people and their families should fully understand the known risks and possible side effects of bariatric surgical procedures and should participate fully in the decision making.
NICE clinical guideline CG43 on obesity recommends that severely obese people who are considering bariatric surgery to aid weight reduction (and their families as appropriate) should discuss in detail with the clinician responsible for their treatment (that is, the hospital specialist and/or bariatric surgeon) the potential benefits and longer-term implications of surgery, as well as the associated risks, including complications and perioperative mortality.
Bariatric surgery for adults should be undertaken only after a comprehensive preoperative assessment of any psychological or clinical factors that may affect adherence to postoperative care requirements, such as changes to diet. All young people should have a comprehensive psychological, education, family and social assessment before undergoing surgery. Children and young people should have a full medical evaluation including genetic screening or assessment before surgery to exclude rare, treatable causes of the obesity.
Developing a high-quality bariatric surgical service for the treatment of people with severe obesity
NICE clinical guideline CG43 on obesity recommends that the choice of surgical intervention (see the full version of the clinical guideline on obesity) should be made jointly by the person requiring surgery and the clinician, and taking into account:
- the degree of obesity
- the best available evidence on effectiveness and long-term effects of the procedure
- the facilities and equipment available
- the experience of the surgeon who would perform the operation.
Surgery for obesity should be undertaken only by a multidisciplinary team that can provide:
- preoperative assessment, including a risk-benefit analysis that includes preventing complications of obesity, and specialist assessment for eating disorder(s)
- information on the different procedures, including potential weight loss and associated risks
- regular postoperative assessment, including specialist dietetic and surgical follow-up
- management of comorbidities
- psychological support before and after surgery
- information on, or access to, plastic surgery (such as apronectomy) where appropriate
- access to suitable equipment, including scales, theatre tables, Zimmer frames, commodes, hoists, bed frames, pressure-relieving mattresses and seating suitable for patients undergoing bariatric surgery, and staff trained to use them.
Surgical care and follow-up for young people should be undertaken by a multidisciplinary team with paediatric expertise and should include regular postoperative assessment, specialist dietetic follow-up and psychological support. The care and follow-up should be coordinated around the young person and their family's needs and should comply with national core standards as defined in the children's national service frameworks for England and Wales.
The surgeon in the multidisciplinary team should have undertaken a relevant supervised training programme, have specialist experience in bariatric surgery and be willing to submit data for a national clinical audit scheme.
Regular, specialist postoperative dietetic monitoring should be provided, and should include:
- information on the appropriate diet for the bariatric surgical procedure
- monitoring of the person's micronutrient status
- information on patient support groups
- individualised nutritional supplementation, support and guidance to achieve long-term weight loss and weight maintenance.
Arrangements for prospective audit should be made, so that the outcomes and complications of different procedures, the impact on quality of life and nutritional status, and the effect on comorbidities can be monitored in both the short and the long term.
Revisional surgery (if the original operation has failed) should be undertaken only in specialist centres by surgeons with extensive experience because of the high rate of complications and increased mortality.
The ‘Specialised services national definitions set' definition no. 35 for morbid obesity services recommends specialist input from radiological services. These services are required in the surgical management and follow-up of patients postoperatively. In addition, centres that are providing bariatric surgery will require bariatric endoscopy support.
The ‘Specialised services national definitions set' definition no. 35 for morbid obesity services describes access to specialised obesity services throughout the country as ‘variable'. It suggests that specialised services need to be developed to provide specialist centres across the country, with each centre serving a number of primary care trusts. The centres would require specialist expertise and adequate staffing levels. The service could be delivered on a ‘hub-and-spoke' basis, using pathways of care with agreed protocols and standards. Appropriate expertise is also required in both primary care and local general hospitals.
Commissioners may wish to consider the configuration of a bariatric surgical service. This may include:
- commissioning high volume centres with surgical teams experienced in bariatric surgery with a large caseload and able to perform more than one type of operation
- making specific commissioning arrangements for revisional surgery in adults and young people, and bariatric surgery in young people
- commissioning plastic surgery once the person has reached and maintained their target weight.
The topic-specific advisory group noted that commissioners may need to bear in mind that the number of patients requiring revisional surgery, and those referred for plastic surgery (currently around 50% of people who undergo bariatric surgery), is set to rise steadily as the numbers receiving bariatric surgery increases.
Local stakeholders, including service users, should be involved in determining what is needed from a bariatric surgical service in order to meet local needs. The service should be patient-centred and integrated with other elements of care for people with obesity.
The service specification needs to consider:
- the required competencies of, and training for, staff responsible for providing the service
- the expected number of patients (this should take into account how quickly any changes in service provision are likely to take place), including young people, and the numbers that may require revisional and plastic surgery
- ease of access and service location; commissioners should engage with service users and other relevant individuals and organisations locally
- the required competencies of, and training for, staff responsible for providing the bariatric surgical service and specialist follow-up
- care and referral pathways
- information and audit requirements, including IT support and infrastructure
- planned service improvement, including redesign, quality, equitable access, and referral-to-treatment times according to the 18 week patient pathway or equitable waiting times locally for those services currently outside 18 weeks
- service monitoring criteria.
Useful sources of information may include:
- ‘Delivering the 18 week patient pathway: 18 week commissioning pathways'
- The ‘Map of medicine' provides an information resource that visually organises the latest evidence and best practice guidelines.
- The NICE ‘shared learning´ database offers examples of how organisations have implemented NICE guidance locally.
- ‘Specialised services national definition set: 35 specialised morbid obesity services (all ages)'
- NICE clinical guideline CG9 on eating disorders.
This page was last updated: 02 March 2012
- Bariatric surgical service
- Commissioning a bariatric surgical service for the treatment of people with severe obesity
- Specifying a bariatric surgical service for the treatment of people with severe obesity
- Determining local service levels for a bariatric surgical service for the treatment of people with severe obesity
- Assumptions used in estimating a population benchmark
- The commissioning and benchmarking tool
- Ensuring corporate and quality assurance