Launching a new fellowship: Bariatric Anesthesia.

The dream is now real! We had started thinking of establishing "Bariatric Anesthesia Fellowship" (BAF) program in our setting since 2012. The reason was the increasing number of bariatric surgical cases for weight loss under general anesthesia (GA). The journey till establishing the BAF program consisted of two phases. Phase I started in 2012 to establish clinical practice guidelines (CPG) in "Anesthesia for Patients with Morbid Obesity undergoing weight loss surgery". Phase II started in 2015 to establish BAF program. In 2021 the first draft of BAF program was submitted to the medical education for approval. In March 2022, we got the interim approval of the program. Though the journey took sometime but ultimately it ended with success and achieving the dream. In this review, we are going to discuss a roadmap consisted of two phases in an attempt to reach our goal of establishing the BAF program. Copyright:

Introduction

The dream is now real! We had started thinking of establishing “Bariatric Anesthesia Fellowship” (BAF) program in our setting since 2012. The reason was the increasing number of bariatric surgical cases for weight loss under general anesthesia (GA). The journey till establishing the BAF program consisted of two phases. Phase I started in 2012 with clinical practice guidelines (CPG) in “Anesthesia for Patients with Obesity undergoing weight loss surgery”. Phase II started in 2015 to establish the BAF program. Though the journey took sometime but ultimately it ended with success and achieving the dream. In this review, we are going to discuss a roadmap which was in two phases to establish the BAF program.

Roadmap Phases to Establish the BAF Program

Phase I: CPG “anesthesia for patients with obesity undergoing weight loss surgery”

In 2012, we formed a committee to represent the department of anesthesia in the College of Medicine, clinical practice guidelines (CPG) committee. We have attended several meetings with the members of CPG committee in an attempt to establish guidelines for different subspecialties in the college for different subjects of interest. In one of the meetings, they requested us to select a topic to work with and establish CPG for. We have decided to work on establishing CPG in “Anesthesia for Patients with Obesity undergoing weight loss surgery”. In order to accomplish CPGs for a specific topic, the proposal has to pass into three phases: Set-up, adaptation, and finalization phases. Set-up phase which includes six steps as follow: Step 1: Feasibility of adaptation, Step 2: Establishment of an organizing committee and subcommittee, Step 3: Selection of the topic, Step 4: Identification of the necessary resources and skills, Step 5: Completion of setup tasks, and Step 6: Writing an adaptation plan. Adaptation phase is an essential part of establishing CPG. The adaptation process usually starts by defining the clinical question for which the CPGs are to be established. In our case, the clinical question was, “What are the best practice recommendations for anesthetic, perioperative care and pain management in patients with obesity undergoing weight loss surgery?” In order to define the health question, the PIPOH tool was used as follows: • Population – The population concerned are the patients with obesity undergoing weight loss surgery • Intervention – The intervention included anesthetic, perioperative management as well as postoperative pain control • Professionals – All the anesthetists as well as the technicians and nurses working in the theater are the targeted professionals • Outcome – Expected to decrease practice variation and reduce perioperative morbidity • Health care setting – Is the operation theater and immediate postoperative care areas where the guideline will be applicable.[1] The next step after identifying the clinical question was to search for the topic in the English language literature between 2005 and 2011. A comprehensive search for guidelines was done. We searched US National Guidelines Clearing House (NGCH), Guidelines International Network (GIN), PubMed, and Google Scholar. We have identified three guidelines near to our clinical search.

Guideline 1 title: Perioperative management of morbidly obese patient. This was developed by the Association of Anesthetists of Great Britain and Ireland.[2] The date of research was not mentioned, but the references supplied indicated that the search period was from 2001 to 2006. Unfortunately, these guidelines did not fulfill the clinical need of the topic under discussion. Guideline 2 title: Anesthetic considerations and management of patients with obesity presenting for bariatric surgery. This was developed by the Department of Anesthesia, Beaumont Hospital Dublin, Ireland, by Tanya O’Neil and Joanna Allam.[3] The search period was from 2001 to 2009 with no recommendations separately mentioned either as tables or appendixes. Guideline 3 title: Best practice recommendations for anesthetic perioperative care and pain management in weight loss surgery (WLS). This was developed by Roman Schumann et al.[45] They developed these guidelines within a comprehensive review of the topic for the State of Massachusetts in the USA with intended broad applicability beyond just an individual institution in 2005 and updated in 2009. The recommendations were published in the English language in the United States of America. The recommendations of this work have met most of the requirements for anesthetic, perioperative care and pain management in WLS. The above three guidelines underwent assessment via AGREE II instrument where guideline 3 scored the highest percentage. Appraisal of Guidelines for Research and Evaluation (AGREE II) is the most well-developed instrument.[6] The next step was to adapt it. We have contacted the lead author of that practice recommendation and obtained his approval regarding its adaptation in our setting. In 2015, we finally issued the final version of the CPG. Phase I has led to an established CPG for anesthesia in patients with obesity undergoing WLS. We have considered this CPG the first step forward in the journey to establish bariatric anesthesia fellowship program as we are going to discuss in phase II.

Phase II: Bariatric anesthesia fellowship (BAF) program

Bariatric anesthesia is one of the growing sub-specialty in anesthesia. Bariatric surgical procedures in Saudi Arabia and especially in Riyadh region became the leading surgical procedure performed in our setting. Cooperation between anesthesia and surgical teams plays a determinant factor for the bariatric surgery patient's outcome. This level of cooperation requires the anesthetist to master the anesthetic techniques performed for the surgical procedures and to know in depth respiratory physiology, pharmacology and patient's preoperative risk assessment and optimization of the patient condition as well as patient education preoperatively. It is important to understand the mechanisms of obstructive sleep apnea (OSA) among those patients and start the required respiratory therapy preoperatively. For most of the procedures protective lung ventilation strategy is preferable, requiring the knowledge of its technique, management and complications. Airway management is another important aspect in bariatric anesthesia. Awake fiberoptic intubation and use of video-laryngoscopy are among the leading techniques that the fellow will learn during BAF program. Bariatric anesthesia also permits the fellow to perform specific procedures, such as opioid free/sparing anesthesia and ultrasound truncal blocks, namely transversus abdominis plane/rectus sheath/erector spinae plane (TAP/RS/ESP) blocks.[7] The early postoperative management of these patients can be complex, requiring full knowledge of the possible complications, mainly ventilatory, circulatory, and acute pain management. Implementation of Enhanced Recovery After Surgery/Anesthesia (ERAS/ERAA) guidelines protocols became now mandatory for patients with obesity undergoing WLS.[8]

The first draft of the BAF program was submitted to the board review in the College of Medicine, King Saud Medical City (KSMC) in January 2021. In the meantime, we looked for affiliation of our program to an international society. We have contacted the International Society of Perioperative Care of patients with Obesity (ISPCOP, ) looking for mutual cooperation. We have got a positive answer with the following offer: a) all faculty of the program will become members of ISPCOP, b) complimentary fellowship certificate will be awarded to the fellows in the program, c) The fellow collaborates with one of board members for research proposal (R Schumann, P Ziemann-Gimmel, A Sultana, A Eldawlatly, S N. Kothari, S Shah, A Wadhwa). Further support to our proposal obtained in July 2019, our department was accredited a Centre of Excellence certificate by the Surgical Review Corporation (SRC). That was a milestone recognition of our setting standard of care and personnel to deal with patients with obesity undergoing WLS. In March 2022, we have got interim approval from the medical education to our BAF program (the full BAF program is available as Appendix 1 at the end of this review). That was ever the best news received this year. That mean we are going to receive applications in September and the first fellow will start on January 2023. An important aspect of our BAF program is the research. Actually, we published few articles on anesthesia for patients with obesity underwent WLS. We have studied before the hemodynamic changes and respiratory mechanics of pneumoperitoneum in patients with obesity for bariatric surgery.[910] Recently together with members of ISPCOP we have published a position statement on prophylaxis of postoperative nausea and vomiting (PONV) in bariatric surgery.[11] We believe more research is waiting for our fellows to launch. There are many areas of research interests in the perioperative care of obese patients undergoing WLS. There is good opportunity for the fellows to conduct novel research with all available supportive resources in our setting.

Conclusion

The BAF program offers career development opportunities, provides experiential training, and can be used to recruit personnel to address specific challenges facing the public health workforce in the field of perioperative care of patients with obesity undergoing WLS. Due to increasing number of subjects undergoing bariatric surgery, we must prepare our health specialists to master bariatric anesthesia. We hope the BAF program paves the way toward achieving this goal for better patient outcome.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.