Upon completion of our fellowship in bariatric surgery, fellows will be able to provide comprehensive state-of-the-art medical and surgical care to patients with morbid obesity and obesity-related medical illnesses. This will include the initial evaluation, ordering of appropriate preoperative diagnostic studies, assessment for appropriateness of surgical therapy, and when not appropriate the referral for/conduction of medical weight loss.
The fellows will be able to safely and successfully complete the appropriate surgical intervention and the perioperative and postoperative management of patients in the routine setting and those that develop complications. In addition, for patients that have needs for revisional weight loss surgery, the fellows will be able to appropriately evaluate and recommend therapy and then carry out the procedure and manage the patient appropriately in the perioperative and postoperative setting.
The curriculum at the University of Missouri-Columbia Bariatric Surgery Fellowship will include 5 units with 3 subunits for each unit.
Units
- Unit 1: Understanding the Disease of Morbid Obesity
- Unit 2: Nonoperative Management of Morbid Obesity
- Unit 3: Primary Operative Management of Morbid Obesity
- Unit 4: Revisional Operative Management of Morbid Obesity
- Unit 5: Management of Complications of Weight Loss Surgery
Subunits
- Objectives: description of the topic the fellows must understand and the specific knowledge to acquire
- Content: description of the specific areas of study necessary to achieve the unit objectives
- Clinical Skills: description of the clinical activities and technical skills that are to be mastered
Unit 1: Understanding Morbid Obesity
Objectives
Obtain a comprehensive understanding of obesity and its related disease including surgical and non-surgical treatment of obesity.
Content
Minimum components of mastery will include
- Epidemiology of obesity both of adolescent and geriatric obesity
- Physiologic and interactive mechanisms of obesity
- Psychological issues associated with obesity and its comorbid medical illnesses
- Identification and management of nutritional deficiencies related to all surgical options
- Outcomes of bariatrics surgery aided by the use of MBSAQIP patient use files
Fellow expectations
Participation in institutional multidisciplinary conferences helps at least quarterly but often monthly. This will include chart reviews of patients interested in weight loss surgery. Key components will include the use of completed psychological evaluations, in house dietician, medical weight loss physician, as well as surgeons and ancillary staff.
Attend one support group during the year to understand the aftercare, group setting support that benefits patients.
Increase the advancement of knowledge of obesity surgery and treatment of obesity and related diseases through the completion of at least one research project that will involve the submission of at least one abstract and complete either a research manuscript or a poster presentation during the fellowship year.
Clinical Skills
Fellows will apply such knowledge in evaluating obese patients for the appropriate management.
Fellows will Understand appropriate evaluation of the obese patient including end-organ manifestations of the disease including:
- Cardiac disease
- Pulmonary disease
- Musculoskeletal disease
- Psychological disease
- Metabolic diseases
Fellows will learn to provide patients with information for informed decision making in treatment options.
Unit 2: Non-operative Management of Morbid Obesity
Objectives
Fellows will obtain and apply a comprehensive knowledge of management options for obesity without surgery
Content
- Caloric Management
- Exercise Physiology
- Pharmacologic Management
Clinical Skills
Fellows will develop an understanding of various diet and caloric management systems including how they work and short- and long-term outcomes. They will have an understanding of potential complications of low-calorie diets and the ability to monitor for adverse outcomes.
- This will be accomplished in part through work with our in house dietician as well as participation in our multi-disciplinary weight management classes
Fellows will understand the purpose of different exercise programs and the benefits/risks of each for the obese patient.
Fellows will be well versed on medications (prescription and non-prescription) for weight control including appropriate dosing and usage. This will include an understanding of outcomes, side effects, and risks.
- We have a bariatrician that treats patients prior to a surgical procedure, in the postoperative setting for weight regain. The bariatrician also runs a busy non-surgical weight management program. The fellows will spend time in his clinic to understand the non-operative management of these patients.
Unit 3: Primary Operative Management of Morbid Obesity
Objectives
Fellows will develop surgical competence through experience with bariatric operations. Fellows will develop the skills and knowledge to evaluate and care for patients preoperatively and postoperatively.
Content
Fellows will be exposed to multiple weight loss procedures including:
- Laparoscopic and open surgical access
- Restrictive operations
- Gastric band
- Vertical Sleeve Gastrectomy
- Gastric bypass
- Malabsorptive procedures
- Duodenal switch as well as revisional distal bypass
- Preoperative evaluation and postoperative management of the bariatric patient, including obesity-related conditions will be a key component of the surgical management of obese patients.
Achievement of competency will be attained through graded responsibility
- For each operation, the procedure is divided into components. Upon mastery of one component, the fellow will move to the next component. By the end of the fellowship, the fellow will be able to safely and efficiently complete all procedures
Clinical Skills
Fellows will participate in weight-loss operations.
The fellows will have assumed the role of the primary surgeon in the majority of cases (at least 51%), defined as having performed key components of the operation.
Fellows will participate in preoperative evaluations which include
- Order and interpret appropriate testing
- Consult with non-surgical specialists when needed
- Evaluate most appropriate surgical options
- Educate patients on the benefits and risks of each option.
- Fellows will participate in postoperative patient encounters (eg, hospital rounds) and postoperative outpatient evaluations
Unit 4: Revisional Operative Management of Morbid Obesity
Objectives
Fellows will develop an understanding of revision options, including the benefits and risks of each. Fellows will develop surgical competence through experience with revisional bariatric procedures. Fellows will develop the skills and knowledge to evaluate and care for patients preoperatively and postoperatively.
Content
Fellows will have experience with procedures for revision to treat complications or failure of previous bariatric surgery
Clinical Skills
Fellows will participate in preoperative evaluations for surgical revision including:
- Order and interpret appropriate testing
- Consult with non-surgical specialists when needed
- Evaluate most appropriate surgical options
- Educate patients on the benefits and risks of each option.
Fellows will gain appropriate operative skills through primary and revisional procedures to perform these procedures in practice.
Unit 5: Management of Complications of Weight Loss Surgery
Objectives
Fellows will gain a comprehensive understanding of the management of complications and obesity-related conditions.
Content
Early Complications
- Identification
- Management
Late Complications
- Identification
- Management
Clinical Skills
Fellows will demonstrate the ability to detect postoperative complications through history and clinical examination.
Fellows will demonstrate an understanding of the physiologic impact of delaying diagnosis or treatment of postoperative complications.
Fellows will demonstrate appropriate use and interpretation of diagnostic tests to determine the presence and magnitude of post-operative complications.
Fellows will demonstrate a safe and logical plan of action, and show expediency in implementing management of postoperative complications.
Fellows will demonstrate the operative skill to manage such complications.
ASMBS Standards
The appropriate number of necessary cases to attain competency for a given procedure remains unclear. Therefore, our program will at least meet the minimum standards as established by ASMBS. Currently, the ASMBS recommends the following case numbers:
Unit 3 - Primary Operative Management of Morbid Obesity in which the fellow is the primary surgeon:
| Procedure | # Procedures |
|---|---|
| Stapling/anastomoses of the GI tract | 51 |
| Gastric Restrictive Procedures | 10 |
| Clinical Skills | |
| Weight loss operations (role as primary surgeon in 51%) | 100 |
| Preoperative evaluations | 50 |
| Postoperative patient encounters (hospital rounds) | 100 |
| Postoperative outpatient evaluations | 100 |
Unit 4 - Revisional Operative Management of Morbid Obesity
| Procedure | # Procedures |
|---|---|
| Procedures for revision to treat complications or failure of previous bariatric surgery | 5 |
Whereas these are the minimum standards by ASMBS, our program strives for fellows to complete at least two times the number of procedures/evaluations as outline above as increase exposure and repetition will only lead to an improved skill set and therefore improved outcomes when the fellows are in independent practice.
