A position statement published by the Association for Bariatric Endoscopy (ABE) and the Association of the American Society for Gastrointestinal Endoscopy (ASGE), based on appropriate care practices and a multidisciplinary approach, and outlined recommendations for the required training and privileges granted to physicians performing endoscopic bariatric therapy in clinical practice. This report was published in Gastrointestinal Endoscopy.

Overarching Principles

Management of patients with obesity

The ABE/ASGE recommends a broad and in-depth understanding of the management of patients with obesity, including knowledge and understanding of current lifestyle interventions, behavior modification, pharmacotherapy, bariatric surgery, as well as mastery of current bariatric endoscopy practices.

Endoscopic skills

The ABE/ASGE require residency or fellowship training in gastrointestinal endoscopy in which physicians must complete formal structured training in an Accreditation Council for Graduate Medical Education-accredited program in adult or pediatric gastroenterology or general surgery. Physicians must provide documentation of endoscopic skills and establish competence to be awarded privileges. These standards apply uniformly to all endoscopists, regardless of specialty.

Endoscopic bariatric therapy procedure- and device-specific knowledge

Physicians must attain comprehensive knowledge of indications, contraindications, risks, benefits, and outcomes for different endoscopic bariatric therapies as privileges are granted on a procedure-specific basis. Defined by the ASGE, endoscopic competence is the minimum level of skill and includes knowledge of endoscopic anatomy and technical features of endoscopic equipment. A minor skill is knowledge of a technique/procedure that is an extension of a widely accepted endoscopic practice (eg, placement of endoscopic balloons), and a major skill is knowledge of a technique/procedure that involves a high level of complexity (and additional risk) (eg, endoscopic sleeve gastroplasty).

Recommendations for Physician Certification

The ABE/ASGE recommends eligible physicians who wish to perform bariatric endoscopy receive certification or recognition of completion of a formal didactic curriculum and procedural exposure. The endoscopists’ knowledge following didactic and procedural education should be assessed via examination.

Development of a didactic curriculum should include courses on the objective determination of appropriate endoscopic bariatric therapies and relevant alternatives (behavioral, pharmacologic, endoscopic, and surgical); provide comprehensive knowledge regarding indications, contraindications, outcomes, risks, and benefits specific to bariatric endoscopy; and provide knowledge of endoscopic anatomy, equipment, procedural techniques, and how to manage adverse events.

Procedural education will vary according to the specific knowledge and technical demands of the specified endoscopic bariatric therapy. The ABE and ASGE are working to develop short courses dedicated to procedural exposure as well as courses integrated with larger medical meetings.

Recommendations for Physician Privileges

The ABE/ASGE recommend that privileges be awarded to endoscopists who have met training requirements and demonstrate competence in the performance of specific endoscopic bariatric therapy. Awarding of privileges should follow standardized criteria put forth by each institution; furthermore, an independent and unbiased proctor should be used to evaluate major skills. Finally, physician privileges should be subject to periodic renewal demonstrated through continuing education, quality assurance data, and clinical activity.

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Recommendations for Assessment of Quality

The ABE/ASGE recommends the use of metrics to monitor quality in the delivery of endoscopic bariatric therapies, including the rate of eating disorders in patients selected for bariatric endoscopy; early device removal, if indicated; dietary, lifestyle, and behavioral therapy during follow-up; -6 and 12-month follow-up rate, intervention-related adverse events; and weight maintenance. The ABE supports the development of a registry to track quality measures and outcomes associated with endoscopic bariatric therapies, as well as quality improvement programs that integrate nutrition and behavioral providers.

Recommendations for Program Recognition

The ASGE recommends that bariatric endoscopy units follow privileging and quality assurance guidelines in which the program should be directed by at least 1 physician with bariatric endoscopy expertise. Services provided by a bariatric endoscopy program should include comprehensive care for patients with obesity, including behavior modification by a licensed provider trained in the care of patients with overweight, obesity, and eating disorders; nutrition or obesity medicine by a registered dietitian or certified physician; physical therapy; and lifestyle modification.

Office requirements for a bariatric endoscopy program should ensure equipment (examination and procedural tables, blood pressure cuffs, compression sleeves, hospital gowns, wheelchairs, walkers, chairs, scales) and facility design (doorways, bathrooms) accommodate patient weight and size. Periprocedural care should delineate risks specific to patients with obesity such as airway management and Advanced Cardiovascular Life Support.

Conclusion

A multidisciplinary approach including endoscopic therapies will allow for a more complete spectrum of care, providing a more individualized strategy and potentially better outcomes for patients with obesity.

Disclosure: Multiple authors declare affiliations with the pharmaceutical industry. Please refer to reference for a complete list of authors’ disclosures.

Reference

Kumar N, Dayyeh BA, Dunkin BJ, et al. ABE/ASGE position statement on training and privileges for primary endoscopic bariatric therapies [published online September 23, 2019]. Gastrointest Endosc. doi: 10.1016/j.gie.2019.07.017